Intraoperative Laparoscopyby a Flexible Scope: Is it Reliable in Contralateral Childhood Hernias?, Harun Gursoy M. explored if the processus vaginalis was patent. An explo- ration was not performed if a contralateral patent processus vaginalis was not visualized. All patients were discharged on the day of the procedure. Intraoperative laparoscopy averaged approximately 25 minutes. RESULTS An open contralateral processus vaginalis was found by flexible endoscopy in 6 children: 4 boys and 2 girls. Positive results were confirmed by exploring the opposite groin. There was one false-positive result in a girl in whom we did not find a patent processus vaginalis in the con- tralateral side. The other girl and 4 boys had patent proces- sus vaginalis. There were no early complications associated with this laparoscopic technique. The postoperative course was uneventful. No patient experienced postoperative pain due to laparoscopy. Those who did not demonstrate a patent processus vaginalis were followed for at least one year to determine whether they would develop a contralateral her- nia. None of them have developed a hernia to date. DISCUSSION A patent processus vaginalis does not always mean a her- nia. The processus vaginalis is patent in 80% to 94% of infants at birth, and in 57% of infants between the ages of four months and one year.2 The incidence of patent processus vaginalis is 20% among adults.3 Intraoperative laparoscopy can only identify whether there is a patent processus vaginalis, however, in this way it helps the sur- geon make a choice regarding contralateral exploration. Non-puncture laparoscopy with a flexible scope proved to be a satisfactory method for evaluating the contralateral side in this study. It added less than half an hour to the procedure even during our learning curve and we believe it was effective in preventing unnecessary contralateral exploration. No unexpected contralateral hernia occurred in this study and we believe the laparoscopic technique to be quite reliable. It has been suggested by many authors that contralateral groin exploration be employed if an accurate and safe tech- nique is available to determine patency of the processus vaginalis.4 A major advantage of this laparoscopic tech- nique is that there is no need for a puncture wound or inci- sion. The opened hernia sac is all that is needed for the cannula to be inserted into the abdomen. Authors who have used rigid scopes for this purpose advocate a 30- degree or wider laparoscope to better evaluate the internal inguinal ring. The internal ring lies just beside the lateral umbilical fold and can be difficult to visualize with a 0- degree laparoscope. Non-puncture laparoscopic techniques, with either rigid or flexible scopes, seem to be effective in detecting the paten- cy of a contralateral processus vaginalis. However, Chin et al., in a series with rigid scopes using a non-puncture inguinal technique, experienced difficulties which included a tear of the hernia sac and tear of a distended urinary blad- der.5 In another series by Holcomb et al., after initial inser- tion through the hernia sac, had to convert to an umbilical site because they were unable to identify the internal inguinal ring or the sac was too thin to cannulate.4 In our series, we did not face such problems because the flexible scope was easy to manipulate, and if the sac was thin, we inserted the laparoscope directly though the sac and per- formed an examination while insufflating the abdomen. For this reason, we believe that the flexible laparoscopic technique is superior to a rigid scope technique and advo- cate its use in evaluating the contralateral groin during pediatric inguinal hernia repair. References: 1. Wolf SA, Hopkins JW. Laparoscopic incidence of contralateral patent processus vaginalis in boys with clinical unilateral inguinal hernias.J Pediatr Surg. 1994;29:1118-1120. 2. Snyder WH Jr, Greaney EM Jr. Inguinal hernia. In Mustard WT, Ravitch MM, Snyder WH Jr, et al. eds. Pediatric Surgery (ed 2). Chicago: Year Book Medical; 1969:692-704. 3. Morgan EH, Anson BJ. Anatomy of region of inguinal hernia. IV. The internal surface of parietal layers. Q Bull Northwest Univ. Med. School. 1942;l6:20-37. 4. Holcomb GW III , Morgan WM III, Brock JW III. Laparoscopic evaluation for contralateral patent processus vaginalis: part II. J Pediatr Surg. 1996;31:1170-1173. 5. Chin T, Liu C, Wei C. The morphology of the contralateral internal inguinal rings is age-dependent in children with unilater- al inguinal hernia. J Pediatr Surg. 1995;30:l663-l665. 226 JSLS (1997) 1:225-226