Pediatric Inguinal Hernia Repair with Laparoscopy (PIHRL)-trial: A multicenter study comparing extra-corporeal Percutaneous Internal Ring Suturing (PIRS) and intra-corporeal purse-string suture for inguinal hernia

Introduction: Techniques for inguinal hernia repair (IHR) in children are continuously being improved. Open repair is increasingly giving way to laparoscopy, with two possible approaches for laparoscopy: extra-peritoneally (Percutaneous Internal Ring Suturing, PIRS) or intra-peritoneally (conventional laparoscopy with purse-string suture). The aim of this trial is to compare outcomes, e.g. recurrence and anesthesia times, of PIRS with intra-corporeal laparoscopy using a purse-string suture (LIHR). Methods: Subjects were prospectively, non-randomly included in the multicenter ‘Pediatric Inguinal Hernia Repair with Laparoscopy’ (PIHRL)-trial, to undergo surgery with PIRS or LIHR. The choice of method was based on shared-decision making between parents and surgeon. Follow-up was conducted one year after surgery. Data concerning post-operative complications and anesthesia times were collected. Parents were asked to complete two questionnaires (POSAS and TAPQoL/TACQoL) to assess cosmetic results and quality of life one year postoperatively. Results: 177 subjects were included (PIRS n = 126, LIHR n = 51). There was a baseline difference in age between the groups from the different centers (1.4 ± 2.8 and 1.5 ± 2.5 years for PIRS and LIHR respectively in the MUMC + vs. 3.6 ± 3.5 years for PIRS in UCHW, p = <0.001). Total anesthesia time was significantly shorter with PIRS (62.1 ± 24.6min vs. 84.7 ± 21.7min, p = 0.001). Net surgical time was also shorter; however, this difference was not significant. One readmittance within 30 days occurred in the LIHR group due to subcutaneous hemorrhage of the surgical site. This resolved spontaneously without the need for intervention. There was a significant difference in recurrence rate (PIRS n = 2 (2 %), LIHR n = 4 (8 %), p = 0.038). One patient in the PIRS group suffered from testicular atrophy (p = 0.523) and five re-interventions were necessary after PIRS due to wound complications (p = 0.984). Discussion: PIRS is safe and effective for pediatric IHR, with shorter anesthesia times and a lower recurrence rate compared to LIHR at one-year follow-up. However, even though not significant, there were more re-interventions in the PIRS group necessary. Longer follow-up and a larger sample size are necessary to confirm these results.