JSLS Intraoperative Laparoscopy by a Flexible Scope: Is it Reliable in Contralateral Childhood Hernias? M. Harun Gursoy, Assist. Prof. MD, Mehmet Gurel, Prof. MD, Ugur Koltuksuz,Assist. Prof. MD, Sema Uguralp, MD, Mustafa Aydinc, MD ABSTRACT Background and Objectives: Negative contralateral groin exploration for childhood hernias raises the question of whether contralateral groin exploration is necessary or not. To find out whether a contralateral processus vaginalis was patent, we performed laparoscopy with a flexible scope. Methods: After carbon dioxide insufflation, a flexible laparoscope was inserted through the opened hernia sac and the contralateral processus vaginalis orifice was exam- ined. We considered a patent processus vaginalis as a potential hernia. The study involved 20 children: 16 boys and 4 girls. The symptomatic side was explored in acon- ventional manner and laparoscopy was performed through the opened hernia sac. Results: A contralateral processus vaginalis was found in 6 children: 4 boys and 2 girls. These results were con- firmed by exploring the opposite groin. We did not explore if the laparoscopic examination was within normal limits. There was one false-positive result in a female patient. Conclusions: Intraoperative non-puncture laparoscopy utilizing a flexible laparoscope through the hernia opening is an uncomplicated, reliable and precise method for iden- tifying a patent contralateral processus vaginalis. It may represent a satisfactory alternative to routine bilateral inguinal exploration. Also, use of the flexible laparoscope may be more beneficial than use of a rigid laparoscope passed through the umbilicus or hernia sac. Key Words: Laparoscopy, Hernia, Inguinal, Pediatric. Inonu University Turgut Ozal Medical Center, Malatya, TURKEY. Address reprint request to: M. Harun Gursoy, Turgut Ozal Tip Merkezi, Cocuk Cerrahisi Ana Bilim Dali, 44069 Malatya, TURKEY. INTRODUCTION Evaluation of the contralateral side in children who have manifest unilateral inguinal hernias is still controversial. The incidence of contralateral hernias is not low, and pediatric surgeons need to re-evaluate their policies on this issue. If there is no evidence of a patent processus vaginalis at the contralateral side, it does not seem reasonable to explore these patients. If one could evaluate the contralateral side for the existence of a patent processus vaginalis before operating on it, it would help in avoiding unnecessary inter- ventions and avoid the risk of injury to the contralateral spermatic cord elements. Methods such as intraoperative pneumoperitoneum, transperitoneal probing, and herniog- raphy have been advocated in the past to detect contralat- eral hernias but none have developed into routineuse.1 Recently, laparoscopy, using rigid scopes of various sizes and angles, has been reported to be used with success by several authors.1,4,5 Using the laparoscopic concept, we first searched for limi- tations of the described techniques and then looked for a way to improve the examination. A flexible scope seemed to offer several potential advantages. MATERIALS AND METHODS The study involved 20 children, 16 boys and 4 girls, whose ages ranged from nine months to four years. Approval was obtained from the Institutional Ethics Committee. The symptomatic side was explored under epidural anesthesia through a transverse inguinal incision. The hernia sac was carefully dissected and the sac opened. A 5 mm cannula was introduced into the peritoneal cavity through the sac in patients above one year of age. The flexible scope was introduced through the cannula (Storz Endoscopy Systems, Cat # 11272AA). In younger patients we inserted the scope directly without a cannula. The abdomen was insufflated with CO2 and the contralateral side was examined. The contralateral processus vaginalis was visualized lateral to the lateral umbilical fold. The contralateral processus vaginalis was considered to be patent if an open, funnel-shaped internal ring was observed in the contralateral groin. A high ligation of the opened sac was performed and the other side JSLS (1997) 1:225-226 225