Open inguinal hernia repair in children with bladder exstrophy can be a challenging operation and is associated with a high rate of recurrence (15%-22%) (1-2).
We report our initial experience with laparoscopic repair of 4 inguinal hernias in two children with bladder exstrophy. This should be the second attempt at describing laparoscopic repair of inguinal hernia (1a-c)in bladder exstrophy patients in literature after reviewing several research Indexes such as pubmed, google scholar and cochrane.

Over a one year period, two boys with repaired bladder exstrophy presented with huge bilateral inguinal hernias during follow up.
Under general anathesia ‚ pneumoperitoneum of 10 mmHg was raised with a Hasson technique at the umbilicus ‚ two working instruments were inserted in the right and left flanks with ports (2b), the repair (1a-d) includes peritoneal dissection around the ring followed by narrowing of the ring by approximating the conjoint tendon to the iliopubic tract which is the part of fascia transversalis below the internal ring, this is facilitated by use of sliding knot.
The sutures used were vicryl  4/0 in the first patient and Ethibond 4/0 in the 2nd patient followed by usual peritoneal  purse string closure.

The children had an uneventful recovery and discharged within 24 hours. There were no complications or recurrence over 14 months follow up.(2a-c)

Bladder exstrophy patients present with a very high incidence of inguinal hernia up to 67% and increased recurrence up to 22%.(2)
Predisposing factors include weakly developed abdominal wall musculature and lack of obliquity of the inguinal canal that causes the superficial and deep ring to overlap, as well as the elevation of the abdominal pressure after bladder closure(1).

The recurrence rate of inguinal hernia following repair is significantly elevated in patient who had bladder exstrophy repair compared to the general Pediatric  population.(3)

The original inguinal repair recommended tightening of the wide deep ring to reduce recurrence by placing an interrupted suture between the transversus arch and the iliopubic tract hence increasing the obliquity of the inguinal canal(2), in our approach we reproduce the same steps laparoscopically with good provisional results (2c).

Another laparoscopic approach described hitch stitch (1)to increase the obliquity of the canal using purse string closure for the defect without disconnection of the peritoneal sac.

male fertility (1)is shown to be reduced on long term follow up, which is possibly due to multiple difficult open operations in the groin. With the laparoscopic approach the trauma to the vas and vessels is minimal even when operating for recurrence.

Long term follow up and more patients is needed to draw stronger conclusions at least 5 years follow up for recurrence and follow up into adulthood to check for fertility.
Our provisional study, is an incentive for bigger long term study in our Center.

Laparoscopic inguinal herniotomy is a technically feasible procedure and an effective way to manage inguinal hernias in children with bladder exstrophy.

Lopez PJ, Mushtaq I, Curry JI. Laparoscopic inguinal herniotomy in bladder exstrophy: a new solution to an old problem? J Pediatr Urol. 2007 Feb;3(1):28-31. doi: 10.1016/j.jpurol.2006.03.001. Epub 2006 May 5. PMID: 18947694.
Connolly JA, Peppas DS, Jeffs RD, Gearhart JP. Prevalence and repair of inguinal hernias in children with bladder exstrophy. J Urol. 1995 Nov;154(5):1900-1. PMID: 7563380.
Lee T, Vasquez E, Logvinenko T, Venna A, Frazier J, Lingongo M, Roth E, Weiss D, Groth T, Shukla A, Kryger JV, Canning DA, Mitchell ME, Borer JG. Timing of inguinal hernia following complete primary repair of bladder exstrophy. J Pediatr Urol. 2021 Feb;17(1):87.e1-87.e6. doi: 10.1016/j.jpurol.2020.11.025. Epub 2020 Nov 23. PMID: 33317945.