Long-term absorbable versus non-absorbable suture in laparoscopic percutaneous extraperitoneal closure of internal ring for inguinal hernia in children

Modifications of surgical techniques in laparoscopic percutaneous extraperitoneal closure of inguinal ring for childhood inguinal hernia to achieve zero recurrence and zero subcutaneous stitch granuloma

PURPOSE

To present our technical modifications of single incision laparoscopic percutaneous extraperitoneal closure (SILPEC) of the internal inguinal ring (IIR) for pediatric inguinal hernia (PIH).

METHODS

The prospectively collected data of all children diagnosed with PIH undergoing SILPEC at our center from 2016 to 2023 were reviewed and divided into two groups for result comparison: Group A: before and Group B: after the implementation of full modifications. Our modifications included using a nonabsorbable monofilament suture, creating a peritoneal thermal injury at the internal inguinal ring (IIR), employing a cannula to ensure the suture at the IIR ligates only the peritoneum, and double ligation of the IIR in selected cases.

RESULTS

1755 patients in group A and in group B (1 month to 14 years old) were enrolled. There were no significant differences regarding baseline patient characteristics between the two groups. At a median follow-up of 40 months, the rate of recurrent CIH and subcutaneous stitch granuloma (SSG) was 2.3% and 1.5% in group A vs. 0% and 0% in group B (p < 0.001). There were no hydroceles, no ascended or atrophic testis.

CONCLUSIONS

Our SILPEC technical modifications can achieve zero recurrence and zero SSG for PIH.

A novel technique for the single-port laparoscopic percutaneous extraperitoneal closure (SLPEC) of paediatric isolated giant inguinal hernias using double-modified hernia needles

The objective was to explore the efficacy of single-port laparoscopic percutaneous extraperitoneal closure using double-modified hernia needles with hydrodissection (SLPEC group) and two-port laparoscopic percutaneous extraperitoneal closure (TLPEC group) for the treatment of giant indirect inguinal hernias in children. We performed a retrospective review of all children with giant indirect inguinal hernias (inner ring orifice diameter ≥ 1.5 cm) who underwent laparoscopic high ligation of the hernia sac at FuJian Children's Hospital from January 2019 to December 2021. We collected data from the medical records of all the children and analysed their clinical characteristics and operation-related and follow-up information. Overall, this study included a cohort of 219 patients with isolated giant inguinal hernias who had complete clinical data and who had undergone laparoscopic high ligation of the hernia sac at our centre. All procedures were successfully performed for the 106 patients who underwent SLPEC and for the 113 patients who underwent TLPEC at our centre. There were no statistically significant differences in patient age, sex, body weight, follow-up time or the side of inguinal hernia between the SLPEC group and the TLPEC group (P = 0.123, 0.613, 0.121, 0.076 and 0.081, respectively). However, there were significant differences in the bleeding volume, visual analogue scale (VAS) score, and postoperative activity time between the two groups (P ≤ 0.001). The operation times in the TLPEC group were significantly longer than those in the SLPEC group (P = 0.048), but there were no significant differences in hospital length of stay or hospitalization costs between the two groups (P = 0.244 and 0.073, respectively). Incision scars were found in 2 patients in the SLPEC group and 9 patients in the TLPEC group, and there was a significant difference between the two groups (P = 0.04). However, the incidence of ipsilateral hernia recurrence, surgical site infection, suture-knot reactions and chronic inguinodynia did not significantly differ between the two groups (P = 0.332, 0.301, 0.332 and 0.599, respectively). Postoperative hydrocele occurred in only 1 male child in the SLPEC group and in no male children in the TLPEC group, and there was no difference between the two groups (P = 0.310). In this study, there were no cases of testicular atrophy or iatrogenic ascent of the testis. Compared with the TLPEC group, the SLPEC group had the advantages of a concealed incision, light scarring, minimal invasiveness, a reduced operation time, minimal bleeding, mild pain and rapid recovery. In conclusion, SLPEC using double-modified hernia needles with hydrodissection and high ligation of the hernia sac is a safe, effective and minimally invasive surgery. The cosmetic results are impressive, and the follow-up results are promising.

Reduction of recurrence by peritoneal thermal injury in laparoscopic percutaneous extraperitoneal closure of internal ring for inguinal hernia in children

PURPOSE

To evaluate the impact of peritoneal thermal injury (PTI) in the reduction of recurrence incidence in laparoscopic percutaneous extra-peritoneal closure of internal ring (LPEC) for pediatric inguinal hernia (PIH) in children.

METHODS

Medical records of patients undergoing LPEC for PIH at our center were reviewed and divided into 2 groups: Group A (period from June 2017 to December 2017)-without PTI and Group B (period from January 2018 to December 2018) with PTI. The surgical technique and the type of suture used for LPEC were the same for both groups. The outcomes of the two groups were analyzed and compared.

RESULTS

277 patients with 283 IHs in group A were compared to 376 patients with 389 IHs in group B. There were no significant differences between the two groups in terms of age, gender, uni- or bilateral hernia. At a median follow-up period of 48 months, there was no hydrocele, suture granuloma, testicular atrophy, or iatrogenic cryptorchidism in both groups. The recurrence rate in group A was 6.4%, significantly higher than 1.8% in group B (p = 0.002).

CONCLUSIONS

Our study showed that PTI in LPEC for PIH is safe and associated with a significant reduction of recurrence incidence.

Laparoscopic percutaneous closure of patent processus vaginalis without hydrocelectomy for childhood primary hydrocele

PURPOSE

To present our surgical technique and the outcome of single-incision laparoscopic percutaneous extraperitoneal closure (SILPEC) of patent processus vaginalis (PPV) without hydrocelectomy for childhood primary hydrocele (CPH).

METHODS

A prospective study was conducted on all cases of CPH treated with SILPEC at our center between June 2016 and December 2021. In our SILPEC procedure, PPV was closed extraperitoneally using a percutaneous needle with a wire lasso. No hydrocelectomy or fenestration of the hydrocele was performed. Percutaneous aspiration was performed when the hydrocele fluid could not be pushed back to the peritoneal cavity.

RESULTS

553 patients were enrolled, with a median age of 34 months (range from 22 months to 13 years). Ipsilateral PPV was present in all cases. There were no intraoperative complications and no conversion. At follow-up 6-72 months, recurrent hydrocele occurred in 0.36%, and subcutaneous stitch inflammatory reaction was noted in 0.7%. There was no case of testicular atrophy or iatrogenic cryptorchidism. Postoperative cosmesis was excellent as all patients were virtually scarless.

CONCLUSIONS

Ipsilateral PPV was present in all cases of CPH in our series. Our technique of SILPEC of PPV without hydrocelectomy is feasible and safe, with excellent postoperative cosmesis in the management of CPH.

Comparing Outcomes of Single-Incision Laparoscopic Herniorrhaphy in Newborns and Infants

BACKGROUND

As surgical techniques progress, laparoscopic herniorrhaphy is now performed more often in premature babies. The aim of this study was to analyze the outcomes of newborns and infants who underwent single-incision laparoscopic herniorrhaphy (SILH) at our center.

METHODS

We retrospectively reviewed patients younger than 12 months old who received SILH at our department from 2016 to 2020. SILH involved a 5 mm 30-degree scope and 3 mm instruments with a 3-0 Silk purse-string intracorporeal suture for closure of the internal ring. At the time of surgery, Group 1 newborns, whose corrected age was 2 months and below, were compared to the Group 2 infants, whose age was above 2 months. We assessed the patients' characteristics, anesthesia, surgical data, and complications.

RESULTS

A total of 197 patients were included (114 newborns in Group 1 and 83 infants in Group 2). The mean age and body weight in Group 1 were 1.2 months and 3.8 kg, respectively, whereas in Group 2, they were 3.2 months and 6.7 kg, respectively. There were no significant differences in operative time (Group 1 = 34.1 min vs. Group 2 = 32.3 min, p = 0.26), anesthetic time (Group 1 = 80.0 min vs. Group 2 = 76.3 min, p = 0.07), length of hospitalization (Group 1 = 2.3 days vs. Group 2 = 2.4 days, p = 0.88), postoperative complications including omphalitis (Group 1 = 5.3% vs. Group 2 = 1.2%, p = 0.13), wound infection (Group 1 = 0.9% vs. Group 2 = 1.2%, p = 0.81), and hydrocele (Group 1 = 0.35% vs. Group 2 = 8.4%, p = 0.14). No recurrence, testicular ascent or atrophy, or mortality was observed in either group during the 2-year follow-up period.

CONCLUSIONS

Single-incision laparoscopic herniorrhaphy is a safe and effective operation for inguinal hernia repair in infants, even those with prematurity, lower body weight at the time of surgery, or cardiac and/or pulmonary comorbidities. Comparable results revealed no significant differences in perioperative complications despite younger ages and lower body weights.

Comparison of Two Laparoscopic Techniques in Management of Pediatric Inguinal Hernias

Introduction: Many studies focus on comparing outcomes of the open method for inguinal hernia repair (IHR) and the laparoscopic method. However, few studies compare different laparoscopic techniques. With over a dozen different techniques described in the literature for laparoscopic IHR, significant opportunities exist to study the efficacy of each technique. We investigated outcomes of a subcutaneous endoscopically assisted transfixion ligation (SEATL) technique and a percutaneous internal ring suturing (PIRS). Materials and Methods: After receiving institutional review board approval, we completed a retrospective chart review of IHR performed at our pediatric tertiary care center between September 2015 and May 2020. We included all patients under the age of 18 years. We separated laparoscopic repairs from total repairs. Laparoscopic repairs were further divided into their respective techniques. Factors involving patient demographics, operative details, and postoperative complications were statistically analyzed using SPSS. Results: There was a total of 131 IHRs performed with SEATL and 124 IHRs performed with PIRS. Median operative time (minutes) differed significantly (P = .001) with SEATL at 49 (28-66) and PIRS at 55 (37-76)] minutes. Significantly more incarcerated hernias were repaired with PIRS (n = 13) than with SEATL (n = 3, P = .006). SEATL had a higher number of postoperative complications; the most significant were granulomas (n = 3, P = .09) and recurrent hernias (n = 12, P < .001). Conclusion: SEATL had a significantly higher number of postoperative complications. This may be a result of multiple factors including but not limited to the absence of electrocautery, a shorter median operative time, and utilization of absorbable suture. Modifications have been made to this technique to reduce risk of postoperative complications.

Optimizing the Working Space for Single-Port Laparoscopic Totally Extraperitoneal Closure of Inguinal Hernia with TPV Protocol in Infants and Young Children

Purpose: To evaluate the outcomes of single-port laparoscopic internal ring closure of inguinal hernia, optimized according to TPV (tilt, pad, and void) protocol, in infants and young children. Methods: From August 2018 to March 2021, a prospective cohort study was conducted including 400 patients younger than 3 years with either left- or right-side inguinal hernia treated with single-port laparoscopic totally extraperitoneal (TEP) closure of the internal ring using a two-hooked core needle apparatus. Patients whose hospitalization ID ended with an odd number were included in group A (n = 200). They were surgically treated with single-port laparoscopy optimized according to TPV protocol, in which the operating table was placed at a 30° head-down tilt position (tilt), the hip was padded by 4-5 cm (pad), and the bladder was voided (void). The remaining patients in group B (n = 200) were conventionally treated with single-port laparoscopic TEP closure of the internal ring. Success rate of surgery, surgery duration, and postoperative complications of two groups were compared. Results: A significantly higher success rate of surgery was detected in group A than in group B (198/200 versus 182/200, P < .05). Regardless of unilateral or bilateral inguinal hernia, surgery duration was significantly shorter in group A than in group B (unilateral inguinal hernia, 14.38 ± 2.85 minutes versus 21.17 ± 4.47 minutes; bilateral inguinal hernia, 20.73 ± 4.58 minutes versus 28.99 ± 4.12 minutes, both P < .05). In addition, the incidence of postoperative complications was significantly lower in group A (1/200 versus 8/200). Conclusions: TPV protocol to optimize working space for single-port laparoscopic TEP closure of inguinal hernia can increase the success rate, shorten surgery duration, and decrease the incidence of postoperative complications.