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Treatment of inguinal hernias in children: review of laparoscopic techniques, or history of «hooks and needles»
... Однако при большинстве существующих форм наложение лигатуры пр оисходит не изолированно на шейку влагалищного отростка брюшины. В лигатуру также попада-ют все слои передней брюшной стенки, что создает риск их прорезывания в будущем и послабления лигатуры, что в свою очередь может привести к рецидиву грыжи или развитию водянки оболочек яичка [15,16]. ...
Background. Inguinal hernias are very important problem in pediatric surgery. It appears in 520 cases in every 1000 newborns, approximately 10 times prevalence in males. However, the incidence of inguinal hernia is bigger by 1.52 times in group of premature infants. Materials and methods. In prospective study, that was performed in 20192020, 90 pediatric patients diagnosed inguinal hernia were included. All patients had open herniotomy (Duhamel method), subcutaneous endoscopic-assisted ligation of inguinal hernia using Tuohy needle, or video-assisted percutaneous hernial sac suturing (VIPS). Results. The mean operating time in VIPS group was 13 13.46 min in patients with unilateral inguinal hernia and 20 6.12 min in patients with bilateral variant. In the 6-month follow-up period, any complications or recurrences were not observed. VIPS group included two extremely premature infant with uni- and bilateral inguinal hernia. Minimally invasive herniotomy was performed in 50 weeks post-conceptual age, with unremarkable postoperative period. A difference was found in the operating time between groups of minimally invasive herniotomy and group of Duhamel repair. No difference was found in the operating time of bilateral hernia between all groups. Conclusion. Considered all things, assuming that announced method of video-assisted percutaneous hernial sac ligation to be a perspective minimal invasive way of treatment for inguinal hernia in children is reasonable. However, for final conclusions, further study of this surgical technique, also in a cohort of premature infants, is required, with the possible organization of multicenter clinical trials.
Introduction. Currently the surgical treatment of inguinal hernias in children is usually a high ligation of the hernia sac without the separation of its distal portion or plastic reconstruction of the inguinal canal. This technique is considered the treatment of choice as it has brought down the incidence of post-operative hernias and testicular atrophy. However, the issues of approach to the selection of a conservative treatment strategy and the role played by instrumental examination methods used to determine indications for surgical treatment remain controversial.
Materials and methods. This paper presents a retrospective analysis of 684 clinical cases followed up at the Yaroslavl Regional Children’s Teaching Hospital. The study included boys aged one month to 17 years who were treated for inguinal and inguinoscrotal hernias in 2011-2015.
Results and discussion. 89 patients (10.3%) were hospitalised with incarcerated inguinal and inguinoscrotal hernias in the period under review. Of these, in 86 patients, when the incarceration lasted under 12 hours, conservative treatment attempts were undertaken. Hernia reduction was achieved without any direct manipulation on the hernia sac in 10 boys (11.6%). Attempts of manual hernia reduction were undertaken in the remaining 56 children (65.1%); these resulted in successful outcomes in 47 patients (83.9%). Emergency surgical repair of incarcerated hernias was performed in 23 cases (3.1%). No patients with incarcerated hernias were older than seven years. 45 out of 183 boys (29.5%) had scrotal oedemas and haematomas in the early post-operative period following planned hernia repair surgeries.
Conclusion. In the majority of patients hospitalised early the conservative hernia reduction approach was effective and resulted in fewer emergency hernia repair surgeries. Ultrasound examination of inguinal canal may be considered as a method of screening for asymptomatic hernias.
Between 1993 and 1997, 28 girls with inguinal hernia were managed laparoscopically at our hospital. Their age ranged between 5 months and 10 years. Clinically, 15 of the hernias were on the right side, 9 were on the left, and 4 were bilateral. At laparoscopy, one of the suspected cases of bilateral hernia had a hernia only on one side. Two patients with a suspected left-sided unilateral hernia and one with a suspected right-sided unilateral hernia were found to have hernias on the contralateral side. All hernial sacs were ligated laparoscopically by applying endoscopic loops around the base of the inverted hernia sac. This procedure proves to be simple, safe, and effective.
Conventional open herniorrhaphy in children has been reported to have 0.3-3.8% recurrence and 5.6-30% postoperative contralateral hernia rates. We developed a unique technique to achieve completely extraperitoneal ligation of PPV without any skip areas under laparoscopic control. This report introduces our technique and results compared with the cut-down herniorrhaphy.
A consecutive series of 1,585 children with inguinal hernia/hydrocele (1996-2006) was analyzed. In laparoscopic patent processus vaginalis (PPV) closure (LPC), an orifice of PPV was encircled with a 2-0 suture extraperitoneally by a specially devised Endoneedle and tied up from outside of the body achieving completely extraperitoneal ligation of the ring. The round ligament was included in the ligation, whereas the spermatic cord and testicular vessels were excluded by advancing the needle across them behind the peritoneum. Cut-down herniorrhaphy (CD), with or without diagnostic laparoscopy, or LPC was selected according to parental preference under informed consent.
Parents gave more preference to LPC (LPC in 1,257 children, CD in 308, and miscellaneous in 20). Age ranges were equal for both groups. Sex distribution showed female preponderance in the LPC group (44.8% vs. 26.6%, p < 0.001) and umbilical hernia/cysts were predominantly included in the LPC group (11.9% vs. 2.9%, p < 0.001). Mean operation times were equal for both groups for unilateral repair (28.2 +/- 9.2 for LPC vs. 27.8 +/- 13.5 for CD) and were shorter for bilateral repair in the LPC group (35.8 +/- 11.6 vs. 46.7 +/- 17.7). The incidence of postoperative hernia recurrence and contralateral hernia in the LPC group was 0.2% and 0.8%. Two children in the CD group had injuries to their reproductive system during the operation (0.6%).
The advantages of our technique include following: technically simple, short operation time, inspection of bilateral IIRs with simultaneous closure of cPPV, reproductive systems remain intact, routine addition of umbilicoplasty if desired, and essentially indiscernible wounds.
Inguinal hernia is one of the most common surgical conditions in infants and children. Over the past few decades, inguinal exploration with clear dissection of the hernial sac off the vas deferens and spermatic vessels, and secure high ligation of the patent processus vaginalis (PPV), i.e. inguinal herniotomy, has remained the standard treatment. The procedure has stood the test of time with very low recurrence rates in experienced hands. However, there are continuing controversies regarding the management strategy for a possible contralateral patent processus vaginalis that may develop into a subsequent hernia. Routine exploration of the contralateral side, as has been adopted by some workers, may result in a significant proportion of unnecessary inguinal explorations, along with the potential complications (Wiener et al. 1996). Recently, it has become increasingly popular to examine the contralateral side laparoscopically through the open hernial sac and perform contralateral inguinal herniotomy should a patent processus vaginalis be present (Geisler et al. 2001; Holcomb et al. 1996; Miltenburg et al. 1998; Wulkan et al. 1996). However, at times the hernial sac may be too small or thin to allow passage of a laparoscope. A prominent peritoneal fold at the medial side of the contralateral deep ring may also significantly obscure the view of the laparoscope passed through the ipsilateral hernial sac. Transumbilical laparoscopy without doubt provides a better way to assess the status of the deep ring. We describe a new technique of endoscopic repair of inguinal hernia in children under the guidance of transumbilical laparoscopy. The technique is easy to learn and does not require expensive laparoscopic instruments.
Background:
Many different laparoscopic techniques for pediatric inguinal hernia (PIH) have been developed, with a trend toward increasing use of extracorporeal knotting and decreasing use of working ports. Single-port laparoscopic percutaneous extraperitoneal closure is one of the most simple and reliable methods. We describe our modifications of laparoscopically assisted simple suturing obliteration (LASSO) using an epidural needle with preperitoneal hydrodissection.
Materials and methods:
Two hundred and seven patients with PIH were treated with single-port LASSO from February 2010 to July 2013. Under laparoscopic visualization, an 18-gauge epidural needle was inserted at the corresponding point of the internal ring. The hernia defect was obliterated extraperitoneally by a nonabsorbable suture that was introduced into the abdomen on one side and withdrawn on the opposite side in an identical subcutaneous path around the internal ring using the hydrodissection-lasso technique.
Results:
A total of 251 PIHs were successfully performed by LASSO, 163 patients had unilateral inguinal hernia repair, and 44 patients underwent repair of bilateral inguinal hernias. Mean operating time for unilateral and bilateral inguinal hernia repairs was 18.1±5.4min and 26.6±4.8min, respectively. There were no perioperative complications. Only one recurrence was observed to date.
Conclusions:
LASSO using an epidural needle with preperitoneal hydrodissection as a handy technique has proved to be a safe and effective procedure. It is easy to perform with high parent satisfaction, invisible scarring, and good cosmetic results, and therefore is a worthy choice for PIH.
Purpose: To introduce a suture needle (Endoneedle) designed for laparoscopic extraperitoneal closure of patent processus vaginalis (PPV). Methods: The Endoneedle consists of 19-gauge hollow needle with a notch near the tip and 2-0 nonabsorbable suture and a plastic sheath. The procedures are performed with the help of a 5-mm telescope inserted through the umbilicus, and a 2-mm Endograsp placed below the umbilicus. Results: Since July 1998, this procedure has been carried out in 61 girls aged 3 months to 14 years. There have been no postoperative complications, and no recurrent hernia. The surgical wounds completely disappeared. In the most recent 10 cases, the mean operative time was 21 minutes for unilateral and 28 minutes for bilateral closure. Conclusion: This procedure is easy and safe, and it has excellent cosmetic results.
Development of laparoscopic or minimally invasive surgery (MIS) in infants and children has taken a tremendous pace over the past decade. With the availability of appropriately sized fine instruments tailored made for small paediatric patients, together with significant improvement in surgical technique and anaesthetic experience, a wide range of operations can now be performed by the laparoscopic approach even in small newborn infants. These include a whole spectrum of gastrointestinal tract operations, herniotomy and even more complicated thoracoscopic and laparoscopic reconstructive procedures, e.g. oesophageal anastomosis for oesophageal atresia and surgery for choledochal cyst and biliary atresia. Evidence so far suggests that minimal access surgery results in a more rapid recovery, shorter hospital stay and much better wound cosmesis. The advent of MIS has revolutionised the overall management strategy for certain diseases such as Hirschsprung's disease, imperforate anus and gastro-oesophageal reflux. There is no age limit to its application. With further improvement in technology and advances in surgical experience and skills, there is little doubt that laparoscopic surgery would gain a much wider acceptance and become the treatment of choice in place of conventional open surgery for the great majority of surgical conditions in infants and young children in this new millennium.
Introduction:
High ligation and division of the hernia sac are the two important steps in open pediatric indirect inguinal hernia repair. We describe a laparoscopically assisted method of delivering the hernia sac through a 5-mm micro-incision with complete division and high ligation of the hernia sac similar to the open repair method.
Method:
A new laparoscopic technique of pediatric inguinal hernia repair which allows high ligation, complete division and removal of the indirect inguinal hernia sac is described.
Results:
Twenty-six patients (15 boys, 11 girls) underwent laparoscopic inguinal hernia repair. The mean age was 40 months. 13 patients had bilateral inguinal hernia repair. There were no intra-operative complications and at mean follow-up of 6 months, there was 1 recurrence. No other complications (wound infection, suture granuloma formation, hydrocele) were seen post-operatively.
Conclusion:
This new laparoscopically assisted inguinal hernia repair technique combines the advantages of standard open method and laparoscopy. The efficacy of this repair will need confirmation with a longer follow-up and a larger patient series. The effect of traction on cord structure will need to be monitored.
Inguinal hernia repair is the most common procedure in pediatric surgery. Suture techniques for laparoscopic inguinal hernia repair in children are easy to perform and popular with a low recurrence rate. The aim of this study was to evaluate the effect of laparoscopic preperitoneal injection of three-dimensional gel on closing of the inguinal hernia sac (IHS) in laboratory animals.
With the animals under general anesthesia, we performed peritoneoscopy in 12 male Chinchilla rabbits weighing 1200-1400 g. The endoscope was introduced into the abdominal cavity, and bilateral deep inguinal rings were identified. A Tuohy needle with the injectable polymeric bulking agent DAM+™ (three-dimensional polyacrylamide gel with silver ions [Argiform(®) from Bioform(®)]) was introduced preperitoneally. The implant was then injected across the entire orifice of the deep inguinal rings and draped over the cord structures. After completion of bilateral repairs, the rabbits were extubated and observed in the animal laboratory. Then the second laparoscopy was performed 6 months later, and the deep inguinal rings were inspected.
The postoperative course was uneventful in all the animals. At the second laparoscopy no reopening of the entire orifice of the deep inguinal rings was noted. Accurate placement of the polymeric agent and adequate coverage of the vas deferens were accomplished in all the animals.
This study demonstrates that the biopolymeric implant gives good postoperative results and a stable trend of closing the IHS in long-term follow-up. In conclusion, we hope that injectable polymeric bulking agents can be used for treatment of inguinal hernias of pediatric patients after additional animal and human research.
To describe our results of laparoscopic transperitoneal division of the hernia sac with purse string closure of the proximal peritoneum for inguinal hernia repair in children.
A retrospective case review of all patients undergoing laparoscopic herniorrhaphy with herniotomy by a single surgeon between January and August 2007 was performed evaluating perioperative and postoperative outcomes.
A complete intracorporeal laparoscopic technique was utilized to inspect bilateral inguinal canals followed by circumferential division of the peritoneum at the deep ring (patent processus vaginalis) followed by purse string closure of the proximal peritoneum.
31 inguinal hernias were repaired laparoscopically in 26 patients (23 boys, 3 girls). Median age was 36 months (range 1-168 months). 22 children had unilateral inguinal hernia repairs including 2 recurrent hernias; 4 children underwent repair of bilateral inguinal hernias. Mean operating time for unilateral and bilateral inguinal hernia repairs were 48.5 ± 14 min and 61 ± 13.8 min, respectively. 2 patients with a preoperative unilateral inguinal hernia were found to have bilateral inguinal hernias upon laparoscopic examination which were repaired. Postoperative pain was minimal in 20 (77%) patients at discharge. Mean telephone follow-up at 8 ± 9.6 months demonstrated no recurrences to date.
Laparoscopic inguinal hernia repair with transperitoneal division of the hernia sac and purse string closure of the proximal peritoneum allows for a minimally invasive option for pediatric inguinal hernia repair that mimics open inguinal hernia repair. At medium term follow-up there have been no recurrences to date, high parent satisfaction, minimal scarring and good cosmetic results.
Many different techniques for laparoscopic inguinal hernia repair have been introduced recently, using either an intraperitoneal [1–3] or an extraperitoneal [4–6] approach. One of the main challenges is to obtain a complete circumferential closure of the sack at the level of the internal ring without injury to the adjacent vas deferens or spermatic vessels. In an effort to separate these structures from the peritoneum before passing a suture around the base of the sack, we developed the hydrodissection-lasso technique, which is performed using a single-incision endosurgical approach.
With the patient in Trendelenburg position, an 8-mm skin incision is made in the umbilicus, and a 5-mm trocar is placed in the inferior aspect for the endoscope. A 3-mm Maryland grasper is placed directly through the fascia in the upper part of the incision. Using a 22-gauge needle inserted percutaneously over the internal inguinal ring, saline is injected into the subperitoneal plane circumferentially, hydrodissecting the peritoneum off the vas deferens and vessels and creating a safe space through which the suture can pass without compromising these structures. A 2-mm stab incision is made directly over the internal inguinal ring, and a lasso technique is used to pass two strands of braided polyester suture around the hernia sack, as demonstrated in the video. Both sutures are tied tightly, leaving the knots under the skin. No direct or indirect manipulation of the vas deferens or vessels takes place during any part of the procedure.
In contrast to other described techniques [7], the hydrodissection-lasso technique can be used for all indirect inguinal hernias in both girls and boys, and hydrodissection itself may be a useful adjunct to any of the other aforementioned techniques. Although an age limit for exclusive high ligation of the hernia sack for indirect inguinal hernias has not been established, the recurrence rate may be higher for adults if the procedure is not combined with inguinal floor reconstruction [8]. At this time, we therefore limit the proposed technique to prepubertal patients.
We have performed the described procedure for 22 patients without any recurrences during a maximum follow-up period of 12 months (Table 1). The patients had minimal postoperative pain. There were no complications except for a transient genitofemoral nerve paresis experienced by one girl in whom the hydrodissection was performed using 1% lidocaine instead of the usual normal saline solution. Although the sack was not resected, there were no cases of postoperative hydroceles.
To evaluate whether this novel technique is an adequate long-term solution, a prospective clinical trial comparing standard open and single-incision endosurgical inguinal hernia repair using hydrodissection should be performed.
Laparoscopic evaluation of the contralateral side (LECS) in children with unilateral inguinal hernia (UIH) has been criticized because of the abdominal trocar risk and costs. LECS was modified to avoid abdominal trocar insertion by using the open hernia sac for instrumentation (OHLECS). This study was performed to determine the utility, safety, and effectiveness of this technique.
During a 15-month period, 80 children with unilateral hernia underwent attempted OHLECS. All ordinarily would have undergone open contralateral exploration. The indications were UIH in boys < or = 2 years of age and girls < or = 4 years of age (n = 53) or high clinical suspicion (but not certainty) of contralateral hernia in older children with UIH (n = 27). Endotracheal intubation was not used unless otherwise indicated. Reusable 3-mm blunt trocars and 3-mm 30 degrees or 70 degrees laparoscopes were employed, with and 6 to 8 mm of insufflation pressure. No urethral catheter was used. The ipsilateral hernia sac was dissected, opened, and instrumented, and the contralateral side was evaluated for patency. Concurrent external palpation of the contralateral inguinal canal is an important diagnostic adjunct. Positive results were visible patency of processus vaginalis or bubbles or fluid and/or gas expressed from the processus by palpation. Only if the evaluation was positive was contralateral incision and repair performed. OHLECS added no more than 2 minutes of operating time. The operating room cost is similar to that of opening the contralateral side. Only reusable laparoscopic instruments are used, and less operating time, anesthetic time, suture material, and dressings are required if the contralateral side is not opened.
In 10 patients (all < 6 months old) OHLECS was aborted because the hernia sac was smaller than 3 mm at the internal ring. OHLECS was successful in 70 (88%) patients-56 boys and 14 girls, aged 2 mo to 12 years (mean, 2.6 years). The presenting hernia was right-sided in 46 (66%) and left-sided in 24 (34%). Overall, 43 (61%) OHLECS results were negative and 27 (39%) were positive. The OHLECS results were positive for 22 (39%) boys and 5 (36%) girls. Their mean age was 1.9 years (range, 2 months to 10 years). There were no false-positives and one false-negative. There have been no complications during follow-up (mean, 1.14 years; range, 6 months to 2 years). No additional costs were incurred because nondisposable equipment was used.
Laparoscopic evaluation of the contralateral side via the open ipsilateral hernia sac is feasible, quick, safe, cost effective, and requires no additional incisions. The rate of positive findings is comparable with that of open exploration. Long-term follow-up is required to determine the ultimate effectiveness of the technique.
Laparoscopy has been used to evaluate the contralateral side in inguinal hernias. Once a hernia was identified in such procedures, laparoscopy was terminated and a conventional groin exploration was undertaken. This study presents a purely laparoscopic approach using miniature instruments without the use of a groin incision.
The technique was applied in 14 girls (median age, 6.5 years). The laparoscope was inserted via the umbilicus. Two 1.7- or 2-mm instruments were advanced (without a trocar) trough the abdominal wall for intraabdominal suturing of the open inguinal rings by the placement of two to three Z-sutures.
With this procedure the diagnosis is easy, although the placing of miniature suturing needs practice. When there is doubt about an inguinal ring during laparoscopy, an open processus vaginalis also can be sutured using the same approach. There were no recurrences or complications. The longest follow-up period is 1 year.
A purely laparoscopic approach using miniature instruments combines diagnosis and immediate treatment without the need for conversion to another technique. There is rapid recovery and excellent cosmetic results.
The authors report their experience in the laparoscopic treatment of congenital inguinal hernia in children.
Between September 1994 and September 1995, 45 boys between 8 months and 13 years of age (mean, 4 years) were treated laparoscopically for hydroceles, spermatic cord cysts, or hernias. Twenty-six (57.8%) boys showed a right inguinal hernia, 17 (37.8%) a left hernia, and two cases (4.4%) presented the clinical data of a bilateral pathology. The approach used for small hernias was the placement of purse-string suture around the internal orifice of the inguinal canal (28 cases). As to hernias exceeding 4 to 5 mm in diameter, the external hemicircumference of the neck was opened to bring the conjoined tendon closer to the crural arch with a nonresorbable suture (17 cases). There was never need to use a prosthesis.
Surgery lasted from 15 to 45 minutes with the duration decreasing with experience. There were no intra- or postsurgical complications. Two patients (4.4%) experienced a recurrent inguinal hernia, which was successfully operated on again with laparoscopy.
The early results of these authors suggest that laparoscopic surgery is a feasible and safe technique for the treatment of patent peritoneal vaginal canal (PVC) and inguinal hernia in children.
The aim of this study was to document the authors' experience with laparoscopy in the treatment of inguinal hernia in girls and boys.
The internal inguinal ring was closed with 1 or 2 stitches of 4-0 monofilamentous material. Two 2-mm needle holders were inserted through the inferolateral abdominal wall. The laparoscope was advanced through the umbilicus. A total of 129 children underwent surgery.
Once the technique of intracorporeal suturing is mastered, the procedure is straightforward, requiring 22 minutes for bilateral and 16 minutes for unilateral hernias. Age and size are not factors because of the magnifying effect of the laparoscope. In almost half our patients, the preoperative diagnosis could not be matched unequivocally with the intraoperative findings. There was 1 recurrence of hernia in a boy. No serious complications and no hydroceles occurred. Five direct hernias were found in this group (5%).
The technique is easy for experienced laparoscopists. Bilaterality is of no concern. Cosmesis is superb. For recurrences, the technique is preferable to the open technique.
We report our clinical experience with 403 inguinal hernias in 279 children. They were treated via a purely laparoscopic approach using 2-mm instruments, obviating the need for a groin incision.
Laparoscopic herniorrhaphy was performed in children ages 4 days to 15 years. A 5-mm laparoscope was inserted through the umbilicus, and two 2-mm needle holders were inserted through the inferolateral abdominal wall. The open inner inguinal rings were closed by placing Z-sutures of monofilamentous nonabsorbable material.
The mean operating time was 14 min for unilateral hernias and 21 min for bilateral hernias. We found 3.9% direct hernias. Hydroceles occurred in 1.7% of patients, testicular atrophy was noted in one patient, and no hernia was found in 2.3%. In girls with inguinal hernias, a contralateral asymptomatic patent processus vaginalis (PPV) was found in 45.2%, regardless of whether the hernia was on the right or the left side. In boys with inguinal hernias, contralateral PPVs were found on the right side in 21.9% and on the left in 8%. There were no major complications. One conversion to an open procedure was necessary because of a dilated bowel. The mean follow-up period was 23 months. There were 2.7% hernia recurrences; this rate was slightly higher than that seen with the open technique. The incidence of direct inguinal hernias was higher than has been previously reported.
Laparoscopic herniorrhaphy allows the surgeon to identify the type of defect and proceed with immediate treatment. This technique is safe, reproducible, and technically easy for experienced laparoscopists. Bilaterality is of no concern. The cosmetic results are excellent; and in patients with recurrence of a hernia, this procedure is preferable to the open technique.
To validate its safety and efficacy, the authors evaluated their early experience with needleoscopic inguinal herniorrhaphy in children.
Twelve consecutive children, older than 6 months, with unilateral (n = 8) or bilateral (n = 4) inguinal hernias underwent a needleoscopic herniorrhaphy. A 1.7-mm needle laparoscope was introduced through the umbilicus, and a grasper placed laterally was used for traction. A curved stainless steel awl introduced percutaneously anterolateral to the internal ring was used to pass a ligature circumferentially to complete an extraperitoneal high ligation of the sac (without handling the vas deferens and spermatic vessels in males). Four of 12 patients underwent their repair combined with other procedures. Children who underwent herniorrhaphy only were allowed immediate return to unrestricted activity. Data recorded with IRB approval included operating time, postoperative discomfort, recurrence, and complications.
For herniorrhaphy only the mean operating time was 23 minutes (unilateral, n = 5) or 46 minutes (bilateral, n = 3). All were able to return to immediate unrestricted activity. None required any analgesics other than acetaminophen. There were no recurrences or complications.
Needleoscopic inguinal herniorrhaphy in children is safe and effective. This technique potentially offers less risk of injury to cord structures with a superior cosmetic result.
Laparoscopic hernia repair is especially advantageous for bilateral or recurrent diseases in children because it avoids vas injury. However, it is more technically demanding, and the recurrent rate has been higher than with the open method. The authors developed a method of laparoscopic hernia repair that is easy and secure.
The hernia opening was repaired with a peritoneal flip-flap anchored with a single tension-free intracorporeal suture. The vas and testicular vessel were completely untouched. The valve mechanism of the flip-flap helped to avoid scrotal collection and prevent hernia recurrence.
In 32 patients ages 1 month to 17 years 43 repairs were performed. The early result was promising, and no recurrence was noticed in a median follow-up period of 4 months.
Laparoscopic flip-flap hernioplasty is easy to perform and has a number of theoretical advantages, although the long-term result still needs to be evaluated.
The aim of this study was evaluate a novel technique of laparoscopic hernia repair in children.
Eighty two consecutive patients aged >or=2 years old were operated on for hernia repair using a laparoscopic technique that reproduced every step of the conventional open procedure. Technical details and clinical results are reported.
Ninety six sacs were divided in 82 patients (15 girls and 67 boys). Fourteen bilateral hernias that had been diagnosed before operation in nine cases and during laparoscopy in five cases were repaired. Nine controplateral dimples were left and not repaired. Mean operative time was 23 min in girls and 28 min in boys for unilateral hernias, and 30 min in girls and 40 min in boys for bilateral hernias. Sixty-seven of the children were followed up 6 months later. None of them suffered recurrences. No unsightly scars were observed at the port sites. Discomfort did not extend beyond 48 h after the operation, enabling a rapid return to normal activities.
Dividing the sac and suturing the peritoneum is feasible and efficient by laparoscopy. Compared with the other techniques that have previously been reported, either without any dissection of the sac or any ligature, our technique seems to be advantageous. It is not time consuming and does not require any special laparoscopic skill.
Subcutaneous endoscopically assisted ligation (SEAL) is a technique for high ligation of the patent processus at the internal ring without a groin incision or dissection of the vas and vessels. Under endoscopic visualization through a single umbilical port, a suture is guided extraperitoneally around the internal ring, avoiding the vas and vessels. The safety, efficacy (recurrence risk), and cost-effectiveness of this unproven procedure must be tested against standard open repair in a trial. (c) 2005 Elsevier Inc. All rights reserved.
Needlescopic techniques have been used recently in repairing inguinal hernias (IHs), which made this type of surgery more feasible and less invasive. The technique is being developed further.
The objective of this study was to describe and assess the results that can be achieved by using a new simplified technique (Reverdin needle) in needlescopic inguinal herniorrhaphy in children.
All patients with symptomatic IH confirmed by clinical examination were subjected to elective needlescopic herniorrhaphy. One hundred fifty patients with 186 groin hernias, from 2 hospitals in Egypt and Saudi Arabia, in the period from October 1999 to May 2002, were assigned to needlescopic inguinal herniorrhaphy using Reverdin needle. Reverdin needle was used to insert a purse-string suture around the internal inguinal ring to be tied extracorporeally.
A total of 186 inguinal hernial defects in 150 children were repaired successfully. There were 130 males and 20 females with a mean age of 20.58 +/- 21 months (range, 8-96 months). Right-sided IH was present in 86 patients (57.33%); among these patients, an opened internal inguinal ring was found and repaired in 12 cases (8%). Left-sided IH was present in 30 (20%), bilateral hernia in 19 cases (12.67%), and recurrent IH in 20 cases (10%). The mean duration of surgery was 8.7 +/- 1.18 minutes for unilateral and 12.35 +/- 2 minutes for bilateral hernia repair. There were no intraoperative or postoperative complications. The mean hospital stay was 6 +/- 1.21 hours.
The new technique had all the advantages of needlescopic herniorrhaphy in children (less invasive, less pain, short hospital stay) combined with the advantages of reduced operating time, simplicity, and feasibility. It may be preferable to the intracorporeal suturing and knot tying. However, it needs long-term follow-up.
Laparoscopic herniorrhaphy in pediatric surgery is usually performed through three ports in the abdominal wall with intraperitoneal suturing. Our technique of percutaneous internal ring suturing (PIRS) requires only one umbilical port and needle puncture point. We describe the technique and evaluate the efficacy of percutaneous internal ring suturing for inguinal hernia repair in children.
We performed percutaneous internal ring suturing on 106 children (ages 28 days-14.5 years) with 140 hernias. The procedures were performed under general endotracheal anesthesia. Pneumoperitoneum was established with an open technique. Under laparoscopic-guided vision an 18-gauge injection needle with a nonabsorbable thread inside the barrel of the needle was placed through the abdominal wall into the peritoneal cavity. By moving the injection needle, the thread passed under the peritoneum around the entrance into the hernia sac. The knot was tightened from outside and placed in the subcutaneous space. The contralateral open inguinal ring was closed in the same procedure.
The average operative time was 19 minutes for unilateral and 24 minutes for bilateral hernias. Follow-up ranged between 18 and 29 months. Cosmetic results are excellent with almost invisible scars. There were 3 cases of intraoperative complication: incidental puncture of the iliac vein that required no treatment. There were 4 cases of postoperative complications: one case of ileus adhesion with bowel strangulation, and hernia recurrence in 3 boys, one of whom was reoperated with percutaneous internal ring suturing. In 5 boys, transient hydroceles were observed that disappeared spontaneously after 3 to 5 months.
The percutaneous internal ring suturing method seems to be a simple and effective minimally invasive procedure with excellent cosmetic results. The rate of complications is comparable to other laparoscopic techniques of inguinal hernia repair in children. According to our experience, percutaneous internal ring suturing should be considered as a treatment alternative.
In 1995, we developed laparoscopic percutaneous extraperitoneal closure (LPEC) to treat inguinal hernias in children. This study evaluated LPEC's safety, efficacy, and reliability in 3 hospitals.
In 2 hospitals, LPEC was the standard procedure used to repair inguinal hernias in children, and in 1 hospital, it was done optionally in girls. During LPEC, a 4.5-mm laparoscope was placed through an umbilical incision, a 2-mm grasping forceps was inserted on the left side of the umbilicus, and a 19-gauge LPEC needle with suture material was inserted at the midpoint of the right or left inguinal line. The hernial sac orifice was closed extraperitoneally by circuit suturing around the internal inguinal ring using the LPEC needle.
Nine hundred seventy-two LPECs were performed on 711 children (age range, 18 days to 19 years): 384 boys had 500 internal inguinal rings closed and 327 girls had 472 internal inguinal rings closed. Operating time for uni- or bilateral inguinal hernias ranged from 10 to 30 minutes. No complications occurred during surgery. The recurrence rate was 0.73% during follow-up (range, 5 months to 10 years). No hydroceles or testicular atrophy occurred after surgery.
Laparoscopic percutaneous extraperitoneal closure for inguinal hernia in children appears to be safe, effective, and reliable.
"Subcutaneous endoscopically assisted ligation" is a novel technique in minimal access surgery of pediatric inguinal hernias. We describe our modifications of subcutaneous endoscopically assisted ligation, which confer greater ease, safety, speed, and success to this operation.
Laparoscopic Pediatric Inguinal Hernia Repair: BURNIA Technique - J Godoy
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- V A Novozhilov
- A V Podkamenev
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