Subcutaneous endoscopically assisted ligation (SEAL) of the internal ring for repair of inguinal hernias in children: report of a new technique and early results

Background: Open inguinal hernia repair with high ligation is an excellent method of repair in the pediatric population. Advantages of endoscopic repairs include the ability to evaluate the contralateral side, avoidance of access trauma to the vas deferens and gonadal vessels, and decreased operative time. We now report our experience with subcutaneous endoscopically assisted ligation (SEAL), a novel technique that has proved to be a safe and effective in the treatment of inguinal hernia in the pediatric population. Methods: The study is based on a retrospective review of 204 pediatric patients with 300 inguinal hernias treated with the SEAL technique from November 2001 to August 2003 at a tertiary referral center. Patient age ranged from 30 days to 16 years at the time of operation, with a mean follow-up of 235 days (median follow-up, 189 days). Statistical analysis was done with chi(2) test, with the main outcome measures being intraoperative and postoperative complications including recurrence rate, suture abscesses, and postoperative hydroceles. Results: There were 13 recurrences in 300 SEAL repairs, for a recurrence rate of 4.3% (95% C.I. 2.01%-6.65%), with only two recurrences in the last 100 repairs (2%). There were 10 suture abscesses or granulomas and 7 postoperative hydroceles. There was no statistically significant association between recurrence and gender, age at operation, history of prematurity, bilaterality, or kind of suture used. Conclusions: Our 4.3% (95% C.I. 2.01-6.65%) recurrence rate is comparable to prior series of laparoscopic repairs citing recurrence rates of 0%-5.7%. The majority of recurrences occurred within the first 4 months of developing this new procedure, with only two recurrences in the last 100 repairs. These pilot data suggest that SEAL is a safe and effective technique for inguinal hernia repair in the pediatric population. A prospective study is planned to compare this laparoscopic technique with open herniorrhaphy.