A simple single-port laparoscopic-assisted technique for completely enclosing inguinal hernia in children

Outcomes from a new modified single needle laparoscopic percutaneous extraperitoneal closure and cut off for pediatric inguinal hernia

Inguinal hernia is a prevalent surgical condition in pediatric patients. Despite the efficacy of current treatment modalities, a certain recurrence rate still persists. Hence, our objective in this study is to introduce an innovative surgical technique designed to minimize surgical complications. We conducted a retrospective analysis on 809 pediatric cases that underwent laparoscopic repair with our innovative technique for inguinal hernia from June 2020 to June 2022. Demographic information, perioperative details, and postoperative follow-up outcomes were thoroughly assessed. All surgeries were conducted laparoscopically under general anesthesia. The procedure commenced by encircling the hernia sac with two sutures under laparoscopic guidance. Subsequently, the sac was exteriorized from the body using the two sutures, followed by ligation and excision of the hernia sac. The research findings demonstrate that the duration of unilateral and bilateral procedures was recorded as 15.9 ± 4.8 and 21.7 ± 3.9 min, respectively. Incision infection occurred in 7 patients (0.87%), and Male Complicated Inguinal Hernia (MCIH) was observed in 2 patients (0.23%). Notably, there were no occurrences of iatrogenic cryptorchidism, testicular atrophy, or recurrence (0%) during the follow-up period. In conclusion, our novel modification shows a notable reduction in postoperative recurrence rates and alleviates the impact of the procedure on the positioning of the testis or uterus. This modified technique is both safe and valuable, thus warranting broader adoption and promotion.

Single-port Laparoscopy with Modified Needle Hook-assisted Extracorporeal High Ligation of Hernia Defects (Suwardi’s Technique): An Experience from Single-center Hospital

BACKGROUND: Laparoscopy has long been used for the evaluation of hernia defects on the contralateral side when performing herniated tears in children. In 1997, El Gohary first reported laparoscopic treatment of hernia repair in a female patient. Since then, laparoscopic inguinal hernia ligation has been performed in various medical institutions with a variety of methods including closing the defect intraperitoneally and extracorporeal ligation of the herniated ring defect. CASE PRESENTATION: Data were taken from January 2016 to December 2020 in the Pediatric Surgery Department of Dr. Moewardi General Hospital, Surakarta. A total of 22 cases, consisting of 19 boys and 3 girls aged 1–14 years (mean 5 years), underwent single-port laparoscopy with modified extracorporeal ligation of hernial defects using an epidural needle. From the results of surgery from January 2016 to December 2020, there were 22 patients with a follow-up period of 6 months who were carried out with a single port without the assistance of forceps and hydrodissection with a single-port laparoscopic technique that had been modified extracorporeally using an epidural needle and were able to evaluate the contralateral side. Thus, it shortened the operating period and the patient was able to be discharged 24 h postoperatively without any complications. CONCLUSION: From 22 patients who used single-port technique with modified extracorporeal ligation of hernia defects using epidural needles, the results were shorter operation time, without complications and satisfying cosmetic results.

Indirect inguinal hernia repair conducted with single conventional port intracorporeal conventional equipment-endoscopic surgery

PURPOSE

Laparoscopic or laparoscopy-assisted inguinal hernia repair (IHR) can be performed using one port plus two stab wounds. We herein present our experience with laparoscopic IHR conducted using a single conventional port and a single working instrument.

METHODS

The records patients who underwent single conventional port intracorporeal IHR during November 2013-December 2018 were evaluated. The main outcome measurements were patient's demographic characteristics, hernia side, presence of incarceration, operative time, and complications.

RESULTS

A total of 132 inguinal hernias (52 right, 40 left, and 20 bilateral) were repaired in 112 patients (76 boys, 36 girls). The mean ages of the patients were 69.8 ± 53.4 months (3 months to 17 years). In six patients, contralateral processus vaginalis was found to be patent during operation. Incarcerated inguinal hernia was present in two patients. Mean operative time was 17.9 ± 3.8 min (9-30 min) in unilateral hernias and 28.9 ± 6.5 min (24-45 min) in bilateral hernias. No intraoperative and postoperative complications were encountered. The mean hospital stay of the patients was 8.8 ± 5.0 h (4-36 h). Postoperative follow-up was 16.5 ± 5.1 months (6-24 months). No recurrent inguinal hernias were detected during follow-up.

CONCLUSION

Single conventional port intracorporeal IHR obviates additional stab wounds. Additionally, present technique eliminates the risk of skin puckering, subcutaneous granuloma, infection, nerve, and muscle damage development induced by the subcutaneously placed knot in laparoscopy-assisted IHR. Single conventional port intracorporeal IHR in children is a feasible and safe operative technique with low complication rates.

A 9-year experience study of single-port micro-laparoscopic repair of pediatric inguinal hernia using a simple needle

Purpose

As laparoscopic techniques and equipments improve, laparoscopic inguinal hernia repair has been gaining popularity. The objective of the study was to summarize 9 years of experience using a single-port micro-laparoscopic approach to repair pediatric inguinal hernias with a simple hernia needle.

Methods

1880 children with inguinal hernias were enrolled using micro-laparoscopic surgery between June 2009 and 2018. All patients underwent high ligation surgery using a single-port micro-laparoscopic technique. The clinical data were retrospectively analyzed.

Results

All micro-laparoscopic surgeries were successfully performed in the 1880 patients, who ranged in age from 2 months to 14 years (3.66 ± 2.96 years) including 1622 males and 258 females. Among them, 1299 cases were unilateral hernias and 581 cases were bilateral hernias. The average operating time was 12.5 ± 3.5 min for a unilateral hernia and 20.5 ± 4.5 min for bilateral hernias. All patients were discharged 1–2 days after surgery, and the average length of their hospital stay was 2–4 days. Complications of knot reaction and pneumoscrotum occurred in 5 cases (0.27%) and 54 cases (2.87%), respectively, but these cases were properly managed, with no major impact on the operational outcomes. All patients were followed up for 3–65 months; there were 13 recurrent cases (0.69%).

Conclusions

Single-port micro-laparoscopic herniorrhaphy in children using a simple hernia needle is a reliable and minimally invasive procedure.

Needlescopic assisted internal ring suturing; a novel application of low-cost home-made instruments for pediatric inguinal hernia repair

BACKGROUND

Congenital inguinal hernia (CIH) is a commonly performed surgical procedure in infants and children. Single port laparoscopic hernia repair using percutaneous internal inguinal ring (IIR) suturing procedure is a widely employed technique for indirect inguinal hernia repair in children. The majority of extracorporeal techniques use extracorporeal knotting and burying the knot subcutaneously. This may result in many drawbacks. The aim of this multicenter study is to introduce a new technique for pediatric inguinal hernia repair using only needles without any laparoscopic instruments.

PATIENTS AND METHODS

This is a multicenter study which was conducted at Pediatric Surgical Departments of Al-Azhar, Mansoura, Alexandria and Tanta Universities during the period from January 2015 to June 2017. 314 patients with CIH underwent Needlescopic Assisted Internal Ring Suturing (NAIRS) after cauterization of the hernia sac at its neck. The main outcome measures were: feasibility, safety of the technique, operative time, recurrence rate, hydrocele and cosmetic results.

RESULTS

A total of 314 patients with CIH were corrected by NAIRS. They were 232 males and 82 females. The mean age was 28.12 ± 1.3 months (range 6-120 months). The mean operative time was 12.6 ± 1.7 min (range 8-15 min) for unilateral cases and 18.6 ± 1.7 min (range 14-20 min) for the bilateral repairs. All cases were completed laparoscopically without major intraoperative complications. No recurrence was detected in this study. No wound complications or umbilical hernias developed. Hydrocele occurred in five males (2.16%), without detection of testicular atrophy or iatrogenic ascent of the testis.

CONCLUSION

This preliminary study showed that NAIRS after cauterization of the neck of the hernia sac in infants and children is safe, feasible, reproducible with excellent cosmetic results.

Single-center, retrospective study of the outcome of laparoscopic inguinal herniorrhaphy in children

Laparoscopic hernia repairs are used increasingly in children.The purpose of this single-center cohort observational research study was to analyze the outcome of children treated surgically for unilateral or bilateral inguinal hernia using laparoscopy.We did a STROBE-compliant retrospective outcome analysis of pediatric, laparoscopic hernia repair. Consecutive laparoscopic herniorrhaphies in 123 children done between March 2, 2010, and March 1, 2014, were included in this analysis. Data analysis was based on reviewing the hospital records and a prospective questionnaire. We evaluated postoperative hernia recurrence rate, occurrence of postoperative complications, duration of postoperative pain medication, and wound cosmesis.We first performed laparoscopic inguinal herniorrhaphy according to the techniques described by Schier et al and Becmeur et al in March 2010. We treated 46 girls and 77 boys with laparoscopically confirmed inguinal hernias, and their ages ranged from 0 to 16 years. Of these, 77 children suffered from unilateral hernias, 30 from unilateral hernias with contralateral patency of the vaginal process, and 16 from indirect bilateral hernias. The median follow-up interval was 38 months (range: 13-58 months). Overall, 8 (6.5%) of these 123 patients experienced a recurrence of the inguinal hernia. Two patients (1.6%) suffered a postoperative infection. Postoperative pain medication was administered by parents for 1 to 3 days in 67 (63.8%) of the 105 families who answered the question, and no pain medication was administered by 5 (4.0%) parents. Wound cosmesis was rated by the parents as invisible or barely visible in 106 (86.2%) of 123 patients and esthetically disturbing in 4 (3.2%) children.Laparoscopic inguinal hernia repair carries a learning curve and is safe and efficient in children thereafter. Further prospective studies are required to evaluate the long-term outcome of laparoscopic inguinal hernia repair in children.

One trocar needlescopic assisted inguinal hernia repair in children: a novel technique

BACKGROUND

Inguinal hernia repair using a percutaneous internal ring suturing technique is an effective alternative technique to conventional laparoscopic hernia repair. It is one of the most commonly used approaches for laparoscopic hernia repair in children. However, most percutaneous techniques have utilized extracorporeal knotting of the suture and burying the knot subcutaneously. This approach has several drawbacks. The aim of this study is to present a modified technique for single cannula needlescopic assisted hernia repair in children.

PATIENTS AND METHODS

Three-hundred and fifty-seven patients with 397 indirect inguinal hernias underwent a one port needlescopic assisted inguinal hernia repair. The open internal inguinal ring [IIR] was closed using an 18-gauge epidural needle [EN], a 14-gauge venous access cannula [VAC], and a homemade suture device. Saline was injected extraperitoneally around the IIR for hydrodissection. The main outcome measurements were: feasibility, safety of the technique, operative time, recurrence rate, and cosmetic results.

RESULTS

This prospective study was conducted on 357 patients at Al-Azhar, Alexandria, and Mansoura University Hospitals during the period from June 2012 to October 2015. There were 286 males and 71 females. The mean age was 2.6±1.3years (range=4months to 6years). One-hundred and ninety-eight patients presented with a right-sided inguinal hernia, 119 patients with a left-sided hernia, and 40 patients with bilateral inguinal hernia. The mean operative time was 12.6±1.7min (range=8-15min) for unilateral cases and 18.6±1.7min (range=14-20min) for the bilateral repairs. No wound complications or umbilical hernias developed. The mean follow-up period was 18.6±1.2months (range=11-36months). During the follow-up period, no recurrence was detected, and the scars were nearly invisible.

CONCLUSION

This preliminary study shows that a single port needlescopic assisted hernia repair in infants and children is a very promising technique to achieve nearly scarless surgery. The procedure is very safe, rapid, easy to learn, and reproducible.

A systematic review and meta-analysis concerning single-site laparoscopic percutaneous extraperitoneal closure for pediatric inguinal hernia and hydrocele

BACKGROUND

Single-site laparoscopic percutaneous extraperitoneal closure (SLPEC) of hernia sac/processus vaginalis has been widely performed for repair of inguinal hernia/hydrocele in children. However, a variety of surgical instruments and techniques were used, and significant differences existed among the SLPEC reports.

METHODS

A literature search was performed for all available studies concerning SLPEC for pediatric inguinal hernia/hydrocele in PubMed, Embase and Cochrane library. The surgical details and operative outcomes were pooled and analyzed with software StataSE 12.0.

RESULTS

49 studies fulfilled the predefined inclusion criteria of this review and 37 studies were finally included in the meta-analysis. The mean incidence of CPPV was 29.1% (range 5.73-43.0%). The average of mean operative time was 19.56 min (range 8.30-41.19 min) for unilateral SLPEC and 27.23 min (range 12.80-48.19 min) for bilateral SLPEC. The total incidence of injury, conversion, recurrence, hydrocele formation, knot reaction, severe pain, and scrotal swelling was 0.32% (range 0-3.24%), 0.05% (range 0-0.89%), 0.70% (range 0-15.5%), 0.23% (range 0-3.57%), 0.33% (range 0-3.33%), 0.05% (range 0-4.55%), and 0.03% (range 0-1.52%), respectively. There was no development of testicular atrophy. Subgroup analyses showed an inverse correlation between the injury incidence and adoption of assisted forceps, hydrodissection, and blunt puncture device, between the conversion rate and adoption of hydrodissection, between the recurrence/hydrocele incidence and adoption of assisted forceps, hydrodissection, nonabsorbable suture and the preventive measures to avoid ligating the unnecessary subcutaneous tissues, and between the rate of knot reaction and adoption of assisted forceps, hydrodissection, and the preventive measures.

CONCLUSIONS

SLPEC was a well-developed procedure for repair of pediatric inguinal hernia/hydrocele. Adoption of assisted forceps, hydrodissection, nonabsorbable suture, and the preventive measures to avoid ligating the unnecessary subcutaneous tissues could significantly reduce the intra- and postoperative complications.

Transumbilical endoscopic technique for complete closure of inguinal hernias in female pediatric patients

Laparoscopic percutaneous extraperitoneal closure of inguinal hernia with variable devices as an effective technique in minimal-access surgery for pediatric inguinal hernias in children was investigated in the present study. A Veress needle was inserted into the abdomen. Trocars, laparoscope and needle holder were placed through the umbilical incision. Under laparoscopic monitoring, a round needle was introduced into the peritoneal cavity through the anterior abdominal wall. The end of the suture inside the peritoneal cavity was left outside the peritoneal cavity in favor of ligation. The needle was passed through the peritoneum to place an extraperitoneal purse-string suture around the internal inguinal ring, counterclockwise on the left and clockwise on the right. The needle was then passed back into the peritoneal cavity and out through the abdominal wall, and the needle ends of the stitch were cut. The ends of the suture were tied. We described a technique used for transumbilical endoscopic closure of pediatric inguinal hernias in girls. This technique is simple and can be performed quickly. The cosmetic result is excellent because the two umbilical incisions are only 5-mm long, which make it possible to perform surgery without a visible scar. We performed this procedure in over 96 patients and have had no recurrences. Thus, this method may become the laparoscopic repair of choice for females with inguinal hernias.

A Modified Technique with a New Device of Laparoscopic Percutaneous Extraperitoneal Closure for Pediatric Inguinal Hernia

INTRODUCTION

Laparoscopic percutaneous extraperitoneal closure (LPEC) in boys is more complex than in girls, because the vas deferens and testicular vessels must be separated from the peritoneum. We therefore developed a needle-shaped surgical instrument that enables blunt separation. Here, we report the effectiveness of this new device.

SURGICAL TECHNIQUE

The new device is a ligature carrier consisting of (1) an inner tube (19-G blunt needle) through which slides a rod with a loop wire at its tip that can catch and release suture materials and (2) an outer tube (17-G needle) with a cutting edge. The blunt-structured inner tube enables blunt separation. All actions (stabbing, separation, and catching) in the LPEC procedure that are required to close the hernia orifice using a thread are facilitated through a simple small incision by switching between the inner and outer tubes.

SUBJECTS AND METHODS

From January 2013 to September 2015, 73 boys with inguinal hernia or hydrocele underwent LPEC, and the new device was used in 45 of these cases. We compared surgical results between cases wherein the new (group A) and conventional devices (LPEC needle; group B) were used.

RESULTS

The mean surgery duration was 33.4 and 34.8 min for groups A and B, respectively. Neither group experienced complications during or after surgery.

CONCLUSION

Our findings suggest that the newly developed needle device may improve the safety of the LPEC procedure for boys, although further investigation involving more cases and long-term follow-up is needed in the future.

Effects of single-port laparoscopic percutaneous extraperitoneal closure on the orientation of the vas deferens and testicular perfusion and volume: Experience from a single center

OBJECTIVE

To investigate the influence of single-port laparoscopic percutaneous extraperitoneal closure (LPEC) on the orientation of the vas deferens and testicular perfusion and volume in pediatric patients undergoing inguinal hernia repair.

METHODS

A total of 92 consecutively enrolled boys preoperatively diagnosed with a unilateral inguinal hernia underwent single-port LPEC between June 2013 and June 2014. The orientation of the vas deferens and the testicular perfusion and volume of these patients were ultrasonographically assessed preoperatively, one month after surgery and six months after surgery.

RESULTS

The surgical procedures were performed successfully without conversion or serious perioperative complications. Ultrasonography showed no angulation or distortion of the vas deferens on the surgical side during a six-month follow-up period. Similarly, there were no perioperative changes in testicular perfusion or volume.

CONCLUSION

Our experience suggests that the single-port LPEC technique can be safe and effective in pediatric patients with an inguinal hernia and that this technique does not affect the orientation of the vas deferens or testicular perfusion or volume.

Laparoscopic percutaneous inguinal hernia repair in children: review of technique and comparison with open surgery

INTRODUCTION

Minimally-invasive approaches for inguinal hernia repair have evolved from conventional laparoscopy requiring placement of three ports and intracorporeal suturing to simple, one and two port extraperitoneal closure techniques. We utilize a single port laparoscopic percutaneous repair (LPHR) technique for selected children requiring operative intervention for inguinal hernia. We suspect that compared to open surgery, LPHR offers shorter operative duration with comparable safety and efficacy. Our objectives are to (1) illustrate this technique and (2) compare operative times and surgical outcomes in patients undergoing LPHR versus traditional open repair.

METHODS

We reviewed operative times, complications, and recurrence rates in 38 patients (49 hernias) who underwent LPHR at our institution between January 2010 and September 2013. These data were compared with an age-, gender-, weight-, and laterality-matched cohort undergoing open repair during the same 3 year period. All cases were performed by a pediatric urologist or pediatric surgeon.

RESULTS

Thirty-eight patients with a median age of 21.5 months underwent LPHR, and 38 patients with a median age of 23 months underwent open repair. In both groups, 27/38 patients (71%) had unilateral repairs, and 11/38 patients (29%) had bilateral repairs. For unilateral procedures, average operative duration was 25 min for LPHR and 59 min for OHR (p < 0.001). For bilateral procedures, average operative duration was 31 min for LPHR and 79 min for OHR (p < 0.001). There were no intraabdominal injuries in either group. In the LPHR group, there were no vascular or cord structure injuries and no conversions to open technique. Median follow-up was 51 days for the LPHR group and 47 days for the OHR group (p = 0.346). No hernia recurrence was observed in either group.

CONCLUSIONS

In select patients, LPHR is an efficient, safe, and effective minimally invasive alternative to OHR, with reduced operative times but without increased rates of complications or recurrences. The technique has a short learning curve and is a practical alternative to OHR for pediatric urologists who infrequently utilize pure laparoscopic technique.

Single-port laparoscopic percutaneous double ligation for pediatric inguinal hernias: report of a new technique and early results

PURPOSE

Several single-port laparoscopic hernial repair methods have been designed to treat inguinal hernia in children, but reliable and safe ligation of the hernial sac should be further investigated. This study aimed to investigate a new technique for laparoscopic percutaneous double ligation for pediatric inguinal hernias with a set of home-made instruments.

METHODS

Before each operation, a set of home-made instruments were prepared, including a curved puncture needle, a lasso suture, a dual ligation suture, and occasionally, a flat-headed puncture needle for obese patients. After a series of operational steps, the hernial sac was doubly extracorporeally ligated, leaving only one puncture point in the inguinal region and one incision in the navel.

RESULTS

Between October 2011 and September 2013, 236 children (211 boys and 25 girls) underwent hernial repair using this novel technique. In 38.8 % (85/219) of patients with the preoperative diagnosis of unilateral inguinal hernia, contralateral patent processus vaginalis was confirmed during the laparoscopic surgery and subsequent repair was performed. In 134 cases of unilateral repair, the mean operative time was 11 min (range 5-16 min), and it was 19 min (range 13-29 min) in 102 cases of bilateral repair. No recurrence or complications have been observed to date.

CONCLUSIONS

This study shows a unique technique of percutaneous double ligation of the hernial sac using a minimally invasive technique with the aid of a transabdominal 5-mm telescope and a set of home-made instruments. Single-port laparoscopic hernial repair using this technique is feasible and appears to be safe.

A novel technique for laparoscopic inguinal hernia repair in children: single-port laparoscopic percutaneous extraperitoneal closure assisted by an optical forceps

AIM

The aim of this study was to describe and report the results of our new pediatric inguinal hernia repair technique, in which single-port laparoscopic percutaneous extraperitoneal closure (SPEC) technique was modified by using optical foreign-body forceps (OFF) of the rigid bronchoscope.

MATERIALS AND METHODS

Between January 2012 and January 2014, a total of 79 children who were operated using SPEC assisted with OFF (SPEC-OFF) were included in this study. Demographic and clinical features of the children were obtained and reviewed retrospectively.

RESULTS

Ninety-nine hernia repairs were performed on a total of 79 children (51 boys, 28 girls). All of the patients were operated by SPEC-OFF without the need of introducing extra forceps, with or without an additional trocar. The mean operating time was 17.6 ± 5.5 min. The mean follow-up period was 17.5 ± 7.1 months. There were six recurrences (two boys, four girls). No wound infection, hydroceles or testicular atrophy occurred in any patients during post-surgery follow-up. The technique left a very small scar with excellent cosmesis in the umbilicus and groin area.

CONCLUSIONS

SPEC-OFF is a simple, safe and effective technique for laparoscopic inguinal hernia repair, and for determining contralateral hernia. There is no need to use additional working forceps for the technique and the surgeon can perform the procedure without any assistance for laparoscope.

Single-port laparoscopic percutaneous extraperitoneal closure using an innovative apparatus for pediatric inguinal hernia

BACKGROUND

Laparoscopic procedures for pediatric inguinal hernia (PIH) have numerous techniques and continue to evolve, with a trend toward increasing use of extracorporeal knotting and decreasing use of working ports and endoscopic instruments. Single-port laparoscopic percutaneous extraperitoneal closure (SPLPEC) with variable devices seems to be one of the most simple and reliable methods. Here the authors describe and evaluate the applicable effects of SPLPEC using an innovative two-hooked core hernia apparatus.

MATERIALS AND METHODS

Between June 2008 and October 2011, 72 children with indirect inguinal hernia underwent SPLPEC with an innovative two-hooked core hernia apparatus. A 5-mm laparoscope was placed through a transumbilical port. Without an assistant working port, the two-hooked core hernia apparatus with a 2-0 nonabsorbable suture was inserted at the point of the internal inguinal ring. It could be readily kept in an identical subcutaneous path for introducing and withdrawing the suture. The extraperitoneal knot-tying could tautly enclose the hernia defect without peritoneal gaps and upper subcutaneous tissues. During the same period, 63 cases with PIH underwent SPLPEC with a single-hooked hernia device. Technical essentials, mean operation time, and intra- and postoperative complications were compared.

RESULTS

The internal orifice was closed faster by SPLPEC with the innovative two-hooked core apparatus than with a single-hooked device (unilateral, 13.21±3.86 versus 17.92±4.37 minutes [P<.05]; bilateral, 17.18±4.69 versus 25.36±7.38 minutes [P<.01]). There were no postoperative complications or evidence of early recurrence in the two-hooked group. However, one recurrence and one subcutaneous knot granuloma were postoperatively observed in the single-hooked group.

CONCLUSIONS

SPLPEC with the two-hooked core apparatus was proved to be a successful procedure without leaving a peritoneal gap and ligating subcutaneous tissues. It is safe, feasible, and reliable for PIH.

Transumbilical endoscopic surgery for incarcerated inguinal hernias in infants and children

PURPOSE

To describe transumbilical laparoscopic herniorrhaphy after unsuccessful attempted manual reduction of incarcerated inguinal hernias in infants and children.

METHODS

In our two hospitals, two-trocar transumbilical endoscopic surgery (TUES) is the standard technique used to repair incarcerated inguinal hernias in infants and children. Seventeen patients (aged 8months to 2.5years; median, 15months; 15 boys, 2 girls) with incarcerated inguinal hernias underwent urgent laparoscopy after unsuccessful attempted manual reduction. Two 3- or 5-mm trocars were inserted into the abdomen through two intraumbilical incisions, under laparoscopic guidance. The hernia was reduced by combined external manual pressure and internal pulling with bowel forceps. After inspection of the bowel, a round needle with a 2-0 nonabsorbable suture was introduced into the peritoneal cavity through the anterior abdominal wall near the internal inguinal ring. The hernial orifice was closed with an extraperitoneal purse-string suture around the internal inguinal ring, and tied with an intraperitoneal knot. A similar procedure was performed on the contralateral side if the processus vaginalis was patent.

RESULTS

The TUES procedure was successful in all patients. No conversions to open surgery were required. The mean operating time was 30min (range, 25-40min). All patients were discharged on the second postoperative day. No complications such as postoperative bleeding, hydrocele, or scrotal edema were observed. The mean follow-up period was 15months. No cases of testicular atrophy, hypotrophy, or hernia recurrence were reported.

CONCLUSIONS

Our preliminary experience with using TUES for the treatment of incarcerated inguinal hernias in infants and children had satisfactory outcomes. This technique appeared to be safe, effective, and reliable, and had excellent cosmetic results.

Transumbilical two-port laparoscopic percutaneous extraperitoneal closure: a new technique for inguinal hernia repair in children

BACKGROUND AND PURPOSE

Since laparoscopic hernia repair was reported a few decades ago, many techniques have been developed. A simplified and safe procedure with a low recurrence rate and good cosmetic result is the main concern. In this study, we introduced a new method, transumbilical two-port laparoscopic percutaneous extraperitoneal closure (TTPLPEC), and evaluated the safety and feasibility of this method.

PATIENTS AND METHODS

Five hundred thirty-six patients who accepted the TTPLPEC procedure in our hospital from July 2008 to January 2012 were analyzed retrospectively. During the TTPLPEC procedure, a laparoscope was placed through a supraumbilical incision. A 3-mm grasping forceps was inserted into the peritoneal cavity through a 3-mm infraumbilical incision. Using a hooked needle, the hernia sac was closed extraperitoneally.

RESULTS

In total, 731 inguinal repairs were performed in 536 children with an age range from 3 months to 14 years. All operations were completed successfully by TTPLPEC. Contralateral patent processus vaginalis was found in 43.0%. For female patients, the mean operation time was 8.3 minutes for the unilateral procedure and 12.8 minutes for the bilateral procedure; for male patients, the mean operation time was 12.5 minutes and 18.6 minutes, respectively. At follow-up, there were two recurrences (0.37%) and 2 missed cases of contralateral patent processus vaginalis that developed a metachronous hernia. No other postoperative complication was noted. Six months after the operation, most patients had no obvious signs of a previous operation.

CONCLUSIONS

The preliminary results showed satisfactory outcomes with TTPLPEC in the treatment of inguinal hernia in children. This technique for inguinal hernia repair in children appears to be safe and feasible, has good cosmetics, and has a low recurrence rate.

Comparative mid-term results between inguinal herniotomy and single-port laparoscopic herniorrhaphy for pediatric inguinal hernia

BACKGROUND

Some recent papers have advocated single-port laparoscopic herniorrhaphy and obtained satisfactory results. The aim of this study was to compare the mid-term outcomes of conventional inguinal herniotomy and single-port laparoscopic herniorrhaphy.

METHODS

Between April 2007 and March 2009, 202 records of infants and children with inguinal hernia treated were retrospectively reviewed. Of them, 86 patients were treated by conventional inguinal herniotomy (IH group), and 116 patients by single-port laparoscopic herniorrhaphy with preperitoneal hydrodissection, a totally extraperitoneal enclosing suture and extracorporeal knot tying (LH group). Follow-up data were collected using a telephone questionnaire and last outpatient follow-up.

RESULTS

Mean follow-up was 35.7±7.2 months. Both procedures could achieve compete repair without recurrence. Operation time of unilateral repair was significantly longer in the LH group than in the IH group (40.1 vs. 20.0 min; P<0.001); however, operation time of bilateral repairs was comparable in both groups (46.0 vs. 37.5 min; P=0.291). Metachronous hernia developed in 6 of 80 patients (7.5%) initially presenting with unilateral hernia in the IH group and in no patient in the LH group (P=0.005).

CONCLUSIONS

Accompanied by the method of preperitoneal hydrodissection and a totally extraperitoneal enclosing suture, single-port laparoscopic herniorrhaphy would be an effective procedure as conventional inguinal herniotomy. Single-port laparoscopic herniorrhaphy was associated with long operation time and a reduction in contralateral hernia development. However, every 4 patent processus vaginalis would require intervention to prevent 1 metachronous hernia.

A new, easy, and safe suturing technique for laparoscopic repair of Morgagni hernias

Laparoscopic repair is gaining attention as a minimally invasive surgical option for children with Morgagni hernias. There are very few reports in the literature in which different suturing techniques are described. In this report, the authors detail a new, easy, and safe suturing technique used in the laparoscopic repair of a Morgagni hernia in a five-and-a-half-month-old baby.

Laparoscopic extracorporeal ligation of hernia defects using an epidural needle and preperitoneal hydrodissection

PURPOSE

This article presents the extracorporeal ligation of inguinal hernia defects using an epidural needle and preperitoneal hydrodissection.

PATIENTS AND METHODS

Thirteen children underwent laparoscopic extracorporeal ligation of their hernia defect using an epidural needle and preperitoneal hydrodissection. A 5-mm trocar for an operative laparoscope was placed through an infraumbilical incision, a Veress needle for forceps was inserted halfway between the umbilicus and the anterior superior iliac spine on the contralateral side of the hernia, and a 17-gauge epidural needle was inserted at the point of the internal inguinal ring. The hernia defect was closed extracorporeally by a nonabsorbable suture, which was introduced into the abdomen through the epidural needle on the lower half of the hernia defect and withdrawn on the opposite side by a wire-loop through the epidural needle going along the upper half side of the hernia defect in a series of movements. When a contralateral hernia defect is present, laparoscopic-assisted extracorporeal ligation of the contralateral hernia defect is performed during the same operation.

RESULTS

All patients were discharged uneventfully from the hospital within 24 hours postoperatively. The mean follow-up period is 6.1 months (range 2-12 mos), and no recurrence has been observed to date.

CONCLUSIONS

This article describes a unique technique of extracorporeal circuit suturing of inguinal hernia defects using a minimally invasive technique as afforded by an epidural needle.

Transumbilical endoscopic surgery for completely enclosing inguinal hernias in children

BACKGROUND/PURPOSE

There has been great interest in natural orifice transluminal endoscopic surgery in recent years. We report another new approach for pediatric inguinal hernia repair: transumbilical endoscopic surgery (TUES). Compared with the natural orifice transluminal endoscopic surgery technique, TUES can obtain similar scarless results on the abdomen.

METHODS

In our hospital, 2-trocar TUES was the standard procedure used to repair pediatric inguinal hernias. Through 2 intraumbilical incisions, two 5-mm trocars were inserted into the abdomen under laparoscopic guidance. With the use of a needle-holding forceps, a round needle with 2-0 nonabsorbable suture material was introduced into the peritoneal cavity through the anterior abdominal wall near the internal inguinal ring. The orifice of the hernial sac was closed extraperitoneally with a purse-string suture around the internal inguinal ring, and intraperitoneal knot-tying was performed.

RESULTS

A total of 76 inguinal repairs were performed in 64 children (age range, 6 months to 9 years; median, 3.8 years; 44 boys, 20 girls). All operations were completed successfully by TUES, with the exception of one case of intraoperative bleeding because the inferior epigastric vein was punctured. The mean operating time was 20 minutes (range, 15-30 minutes). No postoperative bleeding, hydrocele, or scrotal edema in this group of patients was found, and there were no known cases of postoperative testicular atrophy or hypotrophy nor hernia recurrence on the symptomatic side.

CONCLUSIONS

Our preliminary experience shows satisfactory outcomes with TUES for completely enclosing inguinal hernias in children. This technique appears to be safe, effective, and reliable. The cosmetic result is excellent.

Single-site laparoscopic herniorrhaphy using needle instruments for inguinal hernias in children: a novel technique

We describe our new technique for laparoscopic herniorrhaphy with subumbilical single-site access to treat inguinal hernias in children. First, we inserted a transparent 3-mm trocar and a 2-mm minitrocar at the umbilicus. We then inserted a 3-mm 45° camera through the 3-mm trocar and needle-grasping forceps through the 2-mm trocar. We closed the hernia defect by using a 19-gauge hooked injection needle with a nonabsorbable suture. We treated 11 consecutive female children with inguinal hernia using this operation. The mean operating time was 26.7 min (range 21-36 min) and the procedure was technically successful, without the need for additional trocars, in all 11 patients. There were no intraoperative complications and all the patients were discharged on the same day after the surgery. Single-site laparoscopic herniorrhaphy using needle instruments is feasible and seems to be safe. Further studies are required to determine whether this approach would benefit patient compared with standard laparoscopic herniorrhaphy.

Laparoscopic inguinal hernia repair by the hook method in emergency setting in children presenting with incarcerated inguinal hernia

BACKGROUND

The development of laparoscopic hernia repair has provided an alternative approach to the management of incarcerated inguinal hernia in children. Different laparoscopic techniques for hernia repair have been described. However, we hereby review the role of laparoscopic hernia repair using the hook method in the emergency setting for incarcerated inguinal hernias in children.

METHODS

A retrospective review was conducted of all children who presented with incarcerated inguinal hernia and underwent laparoscopic hernia repair using the hook method in emergency setting between 2004 and 2010.

RESULTS

There were a total of 15 boys and 1 girl with a mean age of 30 ± 36 months (range, 4 months to 12 years). The hernia was successfully reduced after sedation in 7 children and after general anesthesia in 4 children. In 5 children, the hernia was reduced by a combined manual and laparoscopic-assisted approach. Emergency laparoscopic inguinal hernia repair using the hook method was performed after reduction of the hernia. The presence of preperitoneal fluid secondary to recent incarceration facilitated the dissection of the preperitoneal space by the hernia hook. All children underwent successful reduction and hernia repair. The median operative time was 37 minutes. There was no postoperative complication. The median hospital stay was 3 days. At a median follow-up of 40 months, there was no recurrence of the hernia or testicular atrophy.

CONCLUSIONS

Emergency laparoscopic inguinal hernia repair by the hook method is safe and feasible. Easier preperitoneal dissection was experienced, and repair of the contralateral patent processus vaginalis can be performed in the same setting.

Laparoscopic extraperitoneal repair of symptomatic hydrocele in children: a single-center experience with 73 surgeries

PURPOSE

To introduce a novel, two-port laparoscopic technique for treatment of hydrocele in children, which allows completely extraperitoneal closure of the patent processus vaginalis (PPV) and does not necessitate laparoscopic suturing skills.

PATIENTS AND METHODS

We describe a consecutive series of 56 boys with a median age of 36 months (range 12-144 mos) who presented with a presumably communicating hydrocele. Laparoscopic repair of these hydroceles was performed between July 2009 and June 2010. During surgery, a 5-mm laparoscope and a 3-mm grasping forceps were inserted through an identical umbilical incision (10 mm). The hydrocele sac orifice was closed extraperitoneally by circuit suturing around the internal inguinal ring.

RESULTS

All cases were preoperatively diagnosed to be unilaterally based on physical examination and ultrasonography. During surgery, 17 of the 56 (30%) patients presented a contralateral PPV. A total of 73 laparoscopic procedures were achieved, with a success rate of 100%. The mean operative time was 25±6 and 36±5 minutes for unilateral and bilateral operations, respectively. During a median follow-up period of 6 months (range 1-12 mos), neither recurrence nor other postoperative complication was encountered.

CONCLUSIONS

Our limited experiences suggest that the two-port, totally extraperitoneal laparoscopic technique could be a safe, effective, and reliable alternative for management of pediatric hydrocele.

Single-incision laparoscopic surgery: hernia repair

In most countries, inguinal hernia repair is the most frequent procedure performed in a surgical practice. Different approaches have been developed during the last decades, with a strong tendency towards tension-free techniques. The laparoscopic approach offers advantages in terms of less postoperative pain and faster recovery with a low incidence in recurrence. In the last few years, single-incision laparoscopic surgery (SILS) has been introduced to further improve surgical outcome and cosmetic results. For SILS inguinal hernia repair, there is little data available so far, but both totally extraperitoneal hernia repair and transabdominal preperitoneal hernia repair have been succesfully performed without complications in a limited number of patients. In our experience, totally extraperitoneal hernia repair seems to be an ideal indication for the application of SILS.

Inguinal hernia repair in children using single-incision laparoscopic-assisted percutaneous extraperitoneal closure

BACKGROUND/PURPOSE

There are numerous techniques of minimally invasive surgery for pediatric inguinal hernia. However, laparoscopic percutaneous extraperitoneal closure (LPEC) is one of the most simple and reliable methods. Single-incision laparoscopic surgery has recently been developed to reduce the invasiveness of traditional laparoscopy. This study aimed to assess the safety and feasibility of the single-incision approach for LPEC.

MATERIALS AND METHODS

Between June 2009 and March 2010, 117 conventional LPEC and 60 single-incision LPEC (SILPEC) procedures were performed. A laparoscope was placed through a transumbilical incision. A 3-mm grasping forceps was inserted in the lower abdomen in LPEC and through the same transumbilical incision with a different entrance in SILPEC. Using the LPEC needle, the hernia sac was closed extraperitoneally. We compared the short-term outcomes of 177 children operated on using either technique.

RESULTS

Visualization and tissue manipulation were good in both methods. There were no complications or evidence of early recurrence. Cosmetically, SILPEC proved to be superior to LPEC because the scar resulting from surgical incision is hidden within the umbilicus.

CONCLUSION

Single-incision LPEC proved to be as successful an operative procedure as LPEC and produced excellent cosmetic results. Single-incision LPEC for inguinal hernia in children is safe and feasible.

A modified single-port technique for the minimally invasive treatment of pediatric inguinal hernias with high ligation of the vaginal process: the initial experience

The aim of this study is to evaluate a modified single-port technique for treating pediatric inguinal hernias (PIH) with high ligation of the vaginal process by combining the use of a ureteroscope and a custom-made puncture guide under pneumoperitoneum. The cases of 86 patients with PIH who underwent the procedure in our institution were reviewed. All of the operations were completed uneventfully. The median operative times for unilateral and bilateral lesions were 11 min (range, 8-15 min) and 16 min (range, 12-20 min), respectively. All of the patients were discharged from the hospital on the day of surgery. No massive hemorrhages or infections were reported. The median follow-up was 15 months (range, 12-24 months), during which no recurrences were reported. In conclusion, with the aid of a ureteroscope and a modified custom-made puncture suit, the described single-port technique allowed easier induction of the ligation suture and a shorter operative time than other methods reported previously. However, the determination of long-term efficacy requires additional studies with larger sample sizes and longer follow-up times.

Technical refinements in single-port laparoscopic surgery of inguinal hernia in infants and children

The techniques of minimal access surgery for pediatric inguinal hernia are numerous and they continue to evolve, with a trend toward increasing use of extracorporeal knotting and decreasing use of working ports and endoscopic instruments. Single-port endoscopic-assisted percutaneous extraperitoneal closure seems to be the ultimate attainment, and numerous techniques have mushroomed in the past decade. This article comprehensively reviews and compares the various single-port techniques. These techniques mainly vary in their approaches to the hernia defect with different devices, which are designed to pass a suture to enclose the orifice of the defect. However, most of these emerging techniques fail to entirely enclose the hernia defect and have the potential to lead to higher incidence of hernia recurrence. Accompanying preperitoneal hydrodissection and keeping identical subcutaneous path for introducing and withdrawing the suture, the suture could tautly enclose the hernia defect without upper subcutaneous tissues and a lower peritoneal gap, and a trend towards achieving a near-zero recurrence rate.