Full text of DOI:10.1007/s004649900078

Surg Endosc (2000) 14: 114–116
DOI: 10.1007/s004649900078
© Springer-Verlag New York Inc. 2000
A new technique for laparoscopic exploration to find contralateral
patent processus vaginalis
E. P. Owings, K. E. Georgeson
University of Alabama School of Medicine, Children’s Hospital of Alabama, 1600 Seventh Avenue South, ACC 300
Birmingham, AL 35233, USA
Received: 15 May 1998/Accepted: 15 June 1999
Abstract
Key words: Contralateral — Hernia — Exploration — Pro-
cessus vaginalis
Background: Contralateral inguinal exploration in an infant
with a symptomatic unilateral hernia is controversial. A
patent processus vaginalis (PPV) may be found in up to
60% of term infants, and even in a greater number of pre-
term infants. However, only 10% to 30% of children will
subsequently develop a contralateral hernia when only the
symptomatic side is repaired. Standard contralateral laparo-
scopic inguinal exploration (CLIE) usually is performed
through the ipsilateral groin with an angled scope or through
the umbilicus with a 0° scope. A significant number of
children have a peritoneal veil shrouding the internal ring.
To enhance the accuracy of contralateral groin exploration,
we have used a laparoscopic technique of directly visualiz-
ing the internal ring through a lateral abdominal approach.
Methods: From January 1993 through June 1997, we per-
formed 141 CLIE on infants younger than 1 year of age with
symptomatic unilateral inguinal hernia. After routine dis-
section on the symptomatic side, the sac was used to insuf-
flate the abdominal cavity. A needle catheter was inserted
on the contralateral abdominal wall and used to introduce a
1.2-mm scope. If a PPV was identified, the potential hernia
was repaired using standard techniques.
Results: Of the 141 CLIEs performed on patients younger
than 1 year of age, 39 (27.6%) were positive. There were no
false-positives. In all, 42 CLIEs (29.7%) were performed on
infants born at less than 36 weeks gestation, and 14 of these
infants (33.3%) had a positive exploration. The patients
were followed for 3 to 57 months. No complications re-
sulted from the technique. One patient had a recurrence on
the repaired side. No patients who had a negative CLIE
subsequently developed a contralateral hernia.
Controversy over exploration of the contralateral groin dur-
ing surgery for an apparent unilateral hernia in children has
continued for decades. Studies have found patent processus
vaginalis (PPV) by open exploration at rates ranging from
20% to 100%, with rates of 40% to 50% most commonly
quoted [2, 13–17]. This has prompted many surgeons to
advocate contralateral explorations in all young children,
with the advantage of exposing the child to only one opera-
tion and anesthetic event.
Several reasons exist for avoiding contralateral explo-
ration. Despite the large number of patients with a PPV at
open exploration, only 10% to 29% of patients with a clini-
cally unilateral hernia will develop a subsequent symptom-
atic contralateral hernia [2, 11–13, 17–19]. In an uncompli-
cated hernia repair, the incidence of testicular trauma caus-
ing reduction in testicle size may be as high as 3% [7], and
the incidence of atrophy may be as high as 2% [11, 19].
Damage to the vas deferens may result from an operation
for hernia [18] or even a negative exploration [7]. High-
riding testis also has been reported as a postoperative com-
plication [8, 9].
The advent of laparoscopic surgery has revived the con-
troversy surrounding contralateral exploration. Laparoscop-
ic exploration avoids the potential trauma to the testis or
cord structures reported with open exploration. Most au-
thors have used either the umbilicus [4–6, 10, 20] or the
opened ipsilateral sac for insufflation and examination [1,
21]. Positive rates of laparoscopic exploration in infants
younger than 1 year of age range from 46% [6] to 50% [20],
and one report cites a 42% positive rate in infants younger
than 2 years of age [21]. Studies commonly have excluded
premature infants because it is accepted that the rate of
positive exploration associated with increasing prematurity
approaches 100%.
Conclusions: The lateral abdominal approach for laparo-
scopic evaluation of the contralateral groin is safe and ac-
curate, requiring no additional incisions. Longer follow-up
is necessary to determine the true false-negative rate.
Presented at the annual meeting of the Society of American Gastrointes-
tinal Endoscopic Surgeons (SAGES), Seattle, Washington, 1–4 April 1998
Correspondence to: E. P. Owings
We described our “in-line” technique for examining the

115
Fig. 1. An apparent processus vaginalis in a
10-year-old girl photographed during a
fundoplication from an umbilical port camera.
Fig. 2. When the peritoneal veil is taken down
in the same patient, it is apparent that a patent
processus vaginalis does not exist. Patent
processus vaginalis would have been easily ruled
out with an “in line” view.
contralateral side and our positive finding of 27% contra-
lateral PPV in children younger than 2 years of age in an
earlier article [3]. Recently, we have reviewed our experi-
ence with full-term and premature infants younger than 1
year of age using this technique.
Discussion
We have found the CLIE safe and easy to perform. The
operative camera is reusable, so the procedure does not
necessarily result in any increased cost to the patient. There
are no extra incisions.
The incidence of positive explorations in our study was
similar to that seen in long-term clinical follow-up without
contralateral exploration (up to 29%) [11], and lower than
for any other reported technique of contralateral explora-
tion, even though 30% of our patients were premature in-
fants. The reasons for these differences are probably varied.
Open exploration, for example, may distort any potential
hernia sac during dissection. We have discovered in using
the in-line technique that there frequently is a peritoneal veil
that obscures the area of potential hernia or may actually
appear to be a hernia when other techniques of exploration
are used (Fig. 1). If this veil is removed, the accuracy in
detecting a PPV is improved significantly (Fig. 2). This
same accuracy can be achieved with an in-line evaluation of
the internal ring.
Materials and methods
Between January 1993 and June 1997, two experienced pediatric surgeons
at the Children’s Hospital of Alabama performed 141 contralateral lapa-
roscopic inguinal explorations (CLIEs) on infants younger than 1 year of
age. In this group were 120 boys and 21 girls ranging in age from 13 days
to 11 months. There were 42 infants whose gestational ages at birth ranged
from 29 weeks to 36 weeks.
Operations were performed as same-day procedures with the patients
under general anesthesia. After the bladder was emptied by Crede’s ma-
neuver and the patient was placed in the Trendelenberg position, the hernia
sac of the symptomatic groin was dissected in the standard fashion. A
14-gauge catheter without a needle then was placed through the open
hernia sac, secured with a silk tie, and connected to a carbon dioxide (CO2)
insufflator to produce a pneumoperitoneum.
When an intra-abdominal pressure of 15 cm H2O was attained, a 14-
gauge needle catheter was inserted through the abdominal wall above the
contralateral (asymptomatic) groin at the level of the umbilicus in the
anterior axillary line. A 1.2-mm laparoscope (Stortz, 600 Corporate Pointe,
Culver City, CA, USA, catalogue No. S11503) was placed through the
catheter and used to visualize the internal inguinal ring. If a PPV was seen,
the tip of the laparoscope was passed into it and the depth measured by
noting the difference in scope length remaining outside as the scope was
withdrawn. The processus was considered “patent” if its depth exceeded
1.0 cm from the internal ring, in which case a standard open repair was
performed.
References
1. Chu C, Chou C, Hsu T, Yang T, Ma C, Cywes S (1993) Intraoperative
laparoscopy in unilateral hernia repair to detect a contralateral patent
processus vaginalis. Pediatr Surg Int 8: 385–388
2. Clausen EG, Jake RJ, Binkley FM (1958) Contralateral inguinal ex-
ploration of unilateral hernia in infants and children. Surgery 44: 735–
740
3. Fuenfer M, Pitts R, Georgeson K (1996) Laparoscopic exploration of
the contralateral groin in children: an improved technique. J Laparo-
endosc Surg 6(Suppl 1): S1–S4
Results
4. Grossmann P, Wolf S, Hopkins J, Paradise N (1995) The efficacy of
laparoscopic examination of the internal inguinal ring in children. J
Pediatr Surg 30: 214–218
5. Holcomb G III (1993) Laparoscopic evaluation for a contralateral
inguinal hernia or a nonpalpable testis. Pediatr Ann 22: 678–684
6. Holcomb G III (1994) Laparoscopic evaluation for a contralateral
patent processus vaginalis. J Pediatr Surg 29: 970–974
7. Janik J, Shandling B (1982) The vulnerability of the vas deferens (II):
the case against routine bilateral inguinal exploration. J Pediatr Surg
17: 585–588
Of the 141 CLIE performed on infants younger than 1 year
of age, 39 (27.6%) were positive. There were no false-
positives. Of the 42 (29.7%) CLIE’s performed on infants
younger than 36 weeks gestation, 14 (33.3%) were positive.
There was one recurrence on the ipsilateral side. No patients
with negative explorations subsequently developed hernias
during the follow-up period. There were no deaths or anes-
thetic complications.

116
8. Kaplan GW (1976) Iatrogenic cryptorchidism resulting from hernia
15. Rowe M, Clatworthy HW (1971) The other side of the pediatric in-
guinal hernia. Surg Clin North Am 51: 1371–1376
repair. Surg Gynecol Obstet 142: 671–672
9. Kiesewetter WB, Parenzan L (1959) When should hernia in the infants
be treated bilaterally? JAMA 171: 287
10. Lobe T, Schropp K (1992) Inguinal hernias in pediatrics: initial expe-
rience with laparoscopic inguinal exploration of the asymptomatic
contralateral side. J Laparoendosc Surg 2: 135–140
16. Rowe M, Copelson L, Clatworthy HW (1969) The patent processus
vaginalis and the inguinal hernia. J Pediatr Surg 4: 102–107
17. Santulli T, Shaw A (1961) Inguinal hernia: infancy and childhood.
JAMA 176: 110–113
11. McGregor D, Halverson K, McVay C (1980) The unilateral pediatric
inguinal hernia: should the contralateral side be explored? J Pediatr
Surg 15: 313–317
12. McVay CB (1965) Inguinal hernioplasty in infancy: the case against
exploration of the contralateral side. In: Mulholland JH, Ellison EH,
Friesen SR, (eds) Current surgical management III. Saunders, Phila-
delphia pp 482–486
13. Minton J, Clatworthy H (1961) Incidence of patency of the processus
vaginalis. Ohio State Med J 57: 530–532
14. Rothenberg R, Barnett T (1955) Bilateral herniotomy in infants and
children. Surgery 37: 947–950
18. Sparkman R (1962) Bilateral exploration in inguinal hernia in juvenile
patients. Pediatr Surg 51: 393–406
19. Surana R, Puri P (1993) Is contralateral exploration necessary in in-
fants with unilateral inguinal hernia? J Pediatr Surg 28: 1026–1027
20. Wolf S, Hopkins J (1994) Laparoscopic incidence of contralateral
patent processus vaginalis in boys with clinical unilateral inguinal
hernias. J Pediatr Surg 29: 1118–1121
21. Wulkan M, Wiener E, VanBalen N, Vescio P (1996) Laparoscopy
through the open ipsilateral sac to evaluate presence of contralateral
hernia. J Pediatr Surg 31: 1174–1177