Journal of Pediatric Surgery 49 (2014) 460–464
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Laparoscopic inguinal hernia repair; experience with 874 children Rafik Shalaby ⁎, Maged Ismail, Abdelhady Samaha, Abdelaziz Yehya, Refaat Ibrahem, Samir Gouda, Ahmed Helal, Omar Alsamahy Department of Pediatric Surgery, Al-Azhar University Hospitals, Cairo, Egypt
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Article history: Received 1 June 2013 Received in revised form 23 October 2013 Accepted 23 October 2013 Key words: Laparoscopy Reverdin needle Congenital inguinal hernia Lateral umbilical ligament
a b s t r a c t Background: Laparoscopic inguinal hernia repair (LIHR) in children has become an alternative to the open procedure. It is gaining popularity with more and more studies supporting its feasibility, safety, and efficacy. This is a retrospective study to present our experience with children who underwent LIHR. Patients and methods: A total of 1184 inguinal hernias were repaired laparoscopically in 874 children. They were 703 boys and 171 girls. Their mean age was 2.9 ± 2.1 years (range, 6–108 months). Six-hundred and twenty four opened internal inguinal rings (IIRs) were closed by transperitoneal purse string suture technique (TPP) and 560 opened IIRs were closed by percutaneous purse string suture with lateral umbilical ligament enforcement using Reverdin Needle (RN) technique. Results: All cases were completed laparoscopically without conversion. There were no serious intraoperative complications. Mean operating time, in TPP technique, was 15 ± 2.3 minutes for unilateral and 20 ± 1.7 minutes for bilateral inguinal hernia, while the mean operating time, in RN technique, was 8.7 ±1.18 minutes for unilateral and 12.35 ± 2 minutes for bilateral hernia repair. The contralateral patent processus vaginalis (PPV) was present in 176 (20% of cases). Follow-up to date is 10–140 months (mean 80 ± 2.1 months). In the early stage of this study, the recurrence rate was 1.13%. In the last 450 cases, no recurrence occurred. Hydroceles occurred in 0.58% and no testicular atrophy or iatrogenic ascent of the testis. Conclusions: LIHR can be a routine procedure with results comparable to those of open procedures. Both recurrence and operative time are nearly equal or even less than that for the open procedure after gaining a learning curve and modifications of the techniques. © 2014 Elsevier Inc. All rights reserved.
Laparoscopic techniques have been applied widely in the management of various common pediatric surgical conditions. Laparoscopic inguinal hernia repair (LIHR) in children has become an alternative to the conventional open procedure [1–8]. However, current evidence is insufficient to justify its widespread use in children and various concerns are raised against the LIHR in children including: it is more time consuming, it has a higher recurrence rate, it violates the peritoneal cavity, and there is no overall advantage compared to the open procedure. It is important to critically evaluate the effectiveness and the potential risks of new techniques before they can be accepted as the treatment modality of choice [9,10]. The aim of this study was to present our experience with children who underwent LIHR over a period of 12 years. 1. Patients and methods This study was conducted in Al-Mishary Hospital, Riyadh, Saudi Arabia, Pediatric Surgery Unit, Al-Azhar University Hospitals and some private hospitals in Cairo, Egypt between June 2000 and June ⁎ Corresponding author at: Al-Houssain University Hospital, Darrasa, Cairo, Egypt. Tel.: +20 1000722072; fax: +20 1223975160. E-mail address: rafi[email protected] (R. Shalaby). 0022-3468/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2013.10.019
2012. A total of 1184 inguinal hernias were repaired laparoscopically in 874 children. All children were subjected to full history taking, thorough clinical examination, and routine laboratory investigations (CBC, BT, CT, FBS, liver and renal profile). The main outcome measurements of this study included; operative time, hospital stay, development of hydrocele, hernia recurrence, testicular atrophy, iatrogenic ascent of the testis and cosmetic results. The ethical committee of our hospital approved the study protocol and a written informed parental consent was obtained. 1.1. Description of the technique General endotracheal tube anesthesia was used in all cases. An open Hasson's technique through supra-umbilical incision was used for creation of pneumoperitoneum to a pressure of 8–12 mmHg. LIHR was done by 2 different techniques; namely transperitoneal purse string suture (TPP) technique and percutaneous insertion of purse string suture around IIR with lateral umbilical ligament enforcement using Reverdin Needle (RN). In both techniques, extraperitoneal saline was injected around IIR to facilitate complete encirclement of suture around IIR safely without leaving a skip area or fearing of injury of spermatic vessels and vas deferens. Patients were placed supine in the Trendelenburg’s position with tilting to the opposite side of the hernia.
R. Shalaby et al. / Journal of Pediatric Surgery 49 (2014) 460–464
TPP technique was done according to the technique described by Chan and Tam [11] with some modifications. A telescope 5-mm, 30 degree was used. Two 3-mm needle holders were inserted directly without trocars at the mid-clavicular line on both sides at the level of the umbilicus. Laparoscopy was started by inspection of both IIRs. The corresponding skin of the hernial defect was first marked by means of transabdominal illumination of the laparoscope and slight fingertip external pressure. At the marked site, a 21-gauge needle attached to a 10-cc syringe filled with saline was introduced at 12 o’clock and advanced along the preperitoneal space on the medial side of the hernia defect medial to the vas deferens. Then saline was injected while withdrawing the needle back to the starting point. Then, the same procedure was repeated along the lateral side of the hernia defect lateral to the spermatic vessels (Fig. 1). Then 17-mm needle with non-absorbable mono-filament 2–0 suture was used to close IIR by a purse string suture starting at 3 o’clock and going all around IIR. The suture mainly included the subperitoneal tissues except at the inferior border of IIR where only peritoneum was taken by carefully picking and lifting it with the tip of left hand needle holder and the needle was seen all the time beneath the peritoneum (needle sign) to avoid injury of the spermatic vessels and vas deferens (Fig. 2). Extracorporeal suture tie was used and before tightening the knot, the scrotum was squeezed and the intraperitoneal pressure was released to expel the gas in the hernial sac. RN technique (Martin Medizin-Technik, D-78501 Tuttlingen, Germany) was done according to the technique described earlier by Shalaby et al with some modifications in the form of retroperitoneal saline injection around IIR and lateral umbilical ligament enforcement [8,12]. A 3-mm Maryland forceps, holding the tip of a non-absorbable mono-filament 2–0 thread, was inserted into the abdomen without trocar at the right mid clavicular line at the level of the umbilicus for both unilateral and bilateral CIH. A stab incision of the skin was done (2 cm above and lateral to the IIR on the right side and 2 cm above and medial to the IIR on the left side) and RN was inserted into the peritoneal cavity (Fig. 3A–C). The needle was manipulated to pierce the peritoneum at 3 o’clock on IIR and was advanced to pass through the inferior margin of IIR under the peritoneum and in front of the spermatic vessels and vas deferens to pierce the peritoneum at 9 o’clock on the IIR (Fig. 3D–F). Care was taken to avoid damage of the
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vas and spermatic vessels by grasping and lifting the peritoneum away from them and the RN was seen all the time beneath the peritoneum (needle sign). Then, the side of the hole of RN was opened and the thread was inserted inside it. Then, the side of the hole was closed and the needle was withdrawn backward in the same path to the starting point at 3 o’clock. Then, RN mounted by the thread was reinserted again at 3 o’clock and was advanced along the superior margin of the IIR beneath the peritoneum and fascia transversalis to come out from the same opening at 9 o’clock. The side of the hole of RN was opened and the short end of the thread was withdrawn out. RN was withdrawn outside the abdomen and the short end of the thread was pulled outside the abdominal cavity for extracorporeal suture tie and pushed by a tie pusher for tightening of the suture around the IIR (Fig. 4). In both techniques, the airtight tightening of purse-string knot was stress-tested by raising the intraperitoneal CO2 pressure by 50%. The increase in pressure was sustained for about 30 seconds during which the patient was carefully monitored for blood pressure, pulse, and oxygen saturation. The air tightness was confirmed by the absence of hernial sac enlargement with the increased intraperitoneal pressure. In case of escape of gas into the hernial sac, a second suture was inserted around IIR 2. Results A total of 1184 inguinal hernias were repaired laparoscopically in 874 children. The reports of these patients were collected and analyzed. The demographic data of all patients are shown in (Table 1). All cases were completed laparoscopically without conversion. At operation, contralateral PPV was seen and closed in 176 (20%) of cases. Six-hundred and twenty four IIR were closed by TPP technique and 560 IIRs were closed by percutaneous RN technique. The mean operating time from skin-to-skin for both techniques is shown in (Table 1). All patients achieved full recovery without intraoperative or postoperative complications. In 2 cases, stress-test resulted in escape of gas into the hernial sac and a second suture was inserted again around IIR. Most children went home at the same day. The mean hospital stay was 7.79 ± 1.28 hours (range, 5– 19 hours). Ten percent of children stayed one night postoperatively because of parental preference, or geographical far distance. Follow-
Fig. 1. Extraperitoneal saline injection around IIR.
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Fig. 2. Needle is safely placed at the elevated peritoneum and traverses just under peritoneum, in front of the spermatic vessels and vas with complete encirclement of the IIR.
up to date is 10–140 months (mean 80 ± 2.1 months). There were 8 recurrences [8/703] (1.13%) in boys and no recurrence in girls. In the last 450 cases (350 RN and 100 TPP technique), the recurrence rate was 0%. On follow-up, there were 4 hydroceles [4/703] (0.57%), one required percutaneous aspiration, and the others responded well to conservative treatment. There were no instances of postoperative testicular atrophy or testicular malposition in our series. There was no metachronous hernia and the cosmetic results were excellent (Fig. 5). 3. Discussion Laparoscopic inguinal hernia repair is a relatively new procedure in the pediatric surgical practice. It is rapidly gaining popularity with more and more studies validating its feasibility, safety, and efficacy. It has become an alternative to the conventional open procedure [1– 8,13,14]. Advantages of LIHR include excellent visual exposure, the ability to evaluate the contralateral side, minimal dissection and avoidance of access trauma to the vas deferens and spermatic vessels, bladder injuries and iatrogenic ascent of the testis [13,15]. In addition, it is also helpful in detecting other associated pathology and other hernias with excellent cosmetic results. It has a comparable operative time and recurrence rates [7,8,16,17]. Many minimally invasive techniques for addressing pediatric inguinal hernia have mushroomed in the past two decades. These techniques vary considerably in their approaches to the internal ring (intraperitoneal or extraperitoneal), use of ports (three, two, or one), endoscopic instruments (two, one, or none), sutures (absorbable or nonabsorbable), and techniques of knotting (intracorporeal or extracorporeal). A major criticism of the laparoscopic repair remains its higher recurrence rate, as compared to the traditional open technique, ranging from 0.83% to 4.1% [7,8,18]. The reasons were versatile. These include failure to ligate the hernial sac high enough at
the IIR, tension at the closure of the internal opening, large hernia, broken purse-string thread, the suture technical problem and hematoma formation at the open wound [10]. Generally, the high recurrence rate in LIHR could possibly be owing to tension at the closure of the IIR and presence of skip area especially over the vas and spermatic vessels without complete encirclement of IIR. It appears that surgeons with more practice have fewer recurrences. Beginners may not dare to place sutures as closely as required to the vessels medially. In fact, it was found that recurrences of less experienced surgeons are high [19]. In this study, all operations were done by the first and second authors who have an extended experience with different laparoscopic techniques, specially laparoscopic hernia repair and that is why we have a very low recurrence in the beginning of this series and no recurrence in the last 450 cases. The present study proved that reducing tension on the pursestring knot when closing the IIR and the addition of the lateral umbilical ligament to enforce purse-string knot resulted in elimination of recurrence. A recurrence will not occur if the purse-string knot and umbilical ligament covering the IIR are confirmed with the stress test by an increase in the intraperitoneal CO2 pressure at the end of the operation as stated by Chan [20]. The first large series of intracorporeal repair of CIH was reported by Schier, with primary closure of the peritoneum lateral to the cord with interrupted sutures [10]. Then, he modified the technique to use 2-mm instruments without a trocar for intra-abdominal suturing of the IIR by the placement of 2 Z-sutures [5]. Other modifications include an N-suture instead of a purse-string suture [6]. Subcutaneous endoscopic assisted ligation (SEAL) of the hernial sac and other similar techniques resulted in marked reduction of operative time when compared to the transperitoneal purse string suture using standard 3-port technique [8]. Avoiding the vas deferens and gonadal vessels during the SEAL repair in boys may leave a small gap at the
Fig. 3. RN is inserted intraperitoneal at 3 o’clock and advanced through the inferior margin of IIR for picking the thread and withdrawn back (A, B, C). Then RN is passing through the superior margin of the IIR to leave the suture for encircling the IIR (D, E, F).
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Table 1 Demographic data of all patients (age, sex, presentations and operative time).
Fig. 4. The suture is tightened around IIR.
internal ring as well as leaving the hernial sac in continuity, which has the potential to contribute to a higher incidence of recurrence [21]. However, SEAL is associated with a high recurrence rate and development of granuloma, infection, and skin puckering at the site of a subcutaneously placed knot [8,22]. These drawbacks of SEAL and other similar techniques were avoided by the use of RN technique. In the beginning phase of this study, we had more recurrences (1.13%) in boys as of June 2008, excluding the last 450 cases, but this rate is lower than that reported by others (3.4%–4.1%) performing LIHR [8,10] and even lower than noted in open herniotomy (1.2%) [18]. Chan and Tam stated that injecting normal saline into the extraperitoneal space at IIR to elevate the peritoneum away from vas and spermatic vessels allows stitches to be inserted safely without any skip area for a tight purse string suture. However, care still is needed to make sure the vas deferens and testicular vessels are not included [23]. Chen et al used medial or lateral umbilical ligaments to cover the internal hernia opening region after finishing purse-string knot to prevent the recurrence. The method they developed was revolutionary in the principle of pediatric hernia repair. It includes both the security of repair offered by the watertight closure of the hernia opening and the hernia opening region covered with the umbilical ligament flap. The valve mechanism allows scrotal fluid avoiding scrotal collection. Under the stress of intra-abdominal pressure, the wall of the sac is pressed over by the flap, keeping the sac in a collapsed state. They claimed that their technique is very easy and the
No. of patients No. of opened IIR Sex Male Female Age in month 6–12 12–24 24–36 N36 Presentation Right sided hernia Left sided hernia Bilateral hernia Recurrent hernia Contralateral hernia Operative time Unilateral hernia (recurrent or fresh) Bilateral hernia
874 1184 703 171 Mean, 2.9 ± 2.1 months 314 244 140 176 460 260 134 20 176 RN 8.7 ± 1.18 minutes 12.35 ± 2 minutes
TPP 15 ± 2.3 minutes 20 ± 1.7 minutes
recurrence will not occur. They added that their technique has no severe complications and is indicated in the following cases: (1) large hernia, hernial sac N1.5 cm; (2) recurrent hernia, and (3) the patient’s age above 5 years [24]. In our pediatric surgery unit, Al-Azhar University Hospitals, the IIR is closed by purse-string suture encircling its whole circumference without any skip area either by TPP or by RN technique [8]. Both, the operative time and the recurrence rate in our series are lower than that reported in the literature because LIHR was started after gaining good experiences in different laparoscopic procedures. Recently we used an easy, safe, simple and rapid technique for repair of CIH using percutaneous insertion of purse string suture by RN and extracorporeal suture ligation which is less time consuming. Also, we followed many technical refinements such as injecting normal saline into the extraperitoneal space at IIR, including sub peritoneal tissue all around IIR without any skip area, reducing tension on the knot of purse string suture by deflation of the abdomen and squeezing the scrotum to empty the hernial sac, lateral umbilical ligament enforcement and the use of non-absorbable suture. These latest technical refinements and modifications of the techniques resulted in marked reduction of development of post-operative hydrocele, lowering the recurrence of
Fig. 5. A: Rt. Recurrent huge inguinal hernia. B: Post-operative view.
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hernia to 0% and reduced operative time. The above mentioned technical refinements have been described before by Chan and others [20,23,24]. We have no recurrence in our last 450 LIHR cases as we followed some technical refinements as described before. Also we started laparoscopic hernia repair after gaining a good experience in other laparoscopic techniques. Others have no recurrence in their series [24–27]. Marte et al stated that the incision of the peritoneum lateral to the IIR and the W-shaped suture, compared to the sole Wshaped suture, prevented hernia recurrence in their series [25]. Gorsler and Schier [28] used non-absorbable Z-sutures to close 403 inguinal rings in 279 children. The mean operating time was 14 minutes for unilateral hernias and 21 minutes for bilateral hernias. They had a recurrence hernia in 3.4% of cases and postoperative hydroceles in 1.7%. Montupet and Esposito used the laparoscopic herniorrhaphy by sectioning the sac distally to the inguinal ring and performing a purse-string suture around the periorificial peritoneum using a 4/0 nonresorbable suture with a median operating time of 19 minutes. At a follow-up between 1 and 15 years, they have only 11 recurrences (1.5%) [29]. Parelkar et al [9] reported a recurrence rate of 2.9% in the early phase of their study. They claim that the high recurrence rate could possibly be owing to tension at the closure of the internal opening and the use of absorbable suture materials. However, they did not have a recurrence in their last 100 cases and they presume that this might be attributed to improved learning skills over time and technical modifications [9]. Methods that allow complete encircling of the PPV, such as the intraperitoneal purse string stitch passing between the peritoneum and the cord and vessel structures so as not to leave any skipped area, or a laparoscopic technique that produces every step of the open procedure involving complete division and stitching up of the PPV at the IIR, achieved the lowest recurrence rate from 0 to 1.3% [25,28]. LIHR in children is known to take longer operative time than open herniotomy. Many reports showed that it ranged from 25 to 74 minutes. However, the operative time is reduced gradually with the training curve [5,15,28]. Schier stated that LIHR is not more time consuming than open techniques. He added that LIHR is quicker than the open approach especially in male newborns and in bilateral hernias [10]. It has been stated that after unilateral open herniotomy, metachronous hernia may occur in up to 30% of cases [30]. Today, publications are still quoted from the 50s and 60s reporting contralateral openings in up to 60% [22]. After LIHR, we have never seen a metachronous hernia within the last 9 years that is because any open IIR detected during laparoscopy is closed at the same setting. There is always a risk of intra-abdominal adhesions in open technique as seen by Schier during the laparoscopic repair of a metachronous hernia. They found dense intraperitoneal adhesions in the area of the previously surgically repaired CIH on the other side. The objection that laparoscopy has a higher risk of adhesions has not been substantiated. However we did not have a single case of adhesive obstruction in our series of LIHR and the laparoscopic view of recurrent right sided hernia after bilateral laparoscopic hernia repair showed no adhesion on both sides. This disprove the objection that laparoscopy has high risk of adhesion formation owing to violation of peritoneal cavity. These observations coincided with that of Schier [10]. 4. Conclusion LIHR is technically easier and safe owing to better visualization of all anatomical structures, thus minimizing chances of injury of the vas deferens and spermatic vessels. Although both recurrences and
operative time were slightly higher in the early stages, now they are nearly equal or even less than with the open procedure. The risk of metachronous hernia is reduced. The cosmetic results are excellent and there are virtually no scars. LIHR can be adopted routinely in pediatric centers and it can be considered good training for residents in pediatric surgery because it helps to improve their ability with both intracorporeal and extracorporeal suture tying. References [1] Akansel G, Guvenc BH, Ekingen G, et al. Ultrasonographic findings after laparoscopic repair of paediatric female inguinal hernias: the vanishing rosebud. Pediatr Radiol 2003;33:693–6. [2] Chan KL, Hui WC, Tam PK. Prospective, randomized, single-center, single-blind comparison of laparoscopic versus open repair of pediatric inguinal hernia. Surg Endosc 2005;19:927–32. [3] Esposito C, Montupet P. Laparoscopic treatment of recurrent inguinal hernia in children. Pediatr Surg Int 1998;14:182–4. [4] Prasad R, Lovvorn 3rd HN, Wadie GM, et al. Early experience with needlescopic inguinal herniorrhaphy in children. J Pediatr Surg 2003;38:1055–8. [5] Schier F. Laparoscopic herniorrhaphy in girls. J Pediatr Surg 1998;33:1495–7. [6] Schier F. Laparoscopic surgery of inguinal hernias in children: initial experience. J Pediatr Surg 2000;35:1331–5. [7] Schier F, Montupet P, Esposito C. Laparoscopic inguinal herniorrhaphy in children: a three-center experience with 933 repairs. J Pediatr Surg 2002;37:395–7. [8] Shalaby R, Ismail M, Dorgham A, et al. Laparoscopic hernia repair in infancy and childhood: evaluation of 2 different techniques. J Pediatr Surg 2010;45:2210–6. [9] Parelkar SV, Oak S, Gupta R, et al. Laparoscopic inguinal hernia repair in the pediatric age group–experience with 437 children. Pediatr Surg 2010;45:789–92. [10] Schier F. Laparoscopic inguinal hernia repair-a prospective personal series of 542 children. J Pediatr Surg 2006;41:1081–4. [11] Chan KL, Tam PK. A safe laparoscopic technique for repair of inguinal hernia in boys. J Am Coll Surg 2003;196:987–9. [12] Shalaby RY, Fawy M, Soliman SM, et al. A new simplified technique for needlescopic inguinal herniorrhaphy in children. J Pediatr Surg 2006;41:863–7. [13] Lee Y, Liang J. Experience with 450 cases of microlaparoscopic herniotomy in infants and children. Pediatr Endosurg Innov Technol 2002;6:25–8. [14] Bharathi RS, Dabas AK, Arora M, et al. Laparoscopic ligation of internal ring-three ports versus single-port technique: are working ports necessary? J Laparoendosc Adv Surg Tech A 2008;18:891–4. [15] Saranga Bharathi R, Arora M, Baskaran V. Pediatric inguinal hernia: laparoscopic versus open surgery. JSLS 2008;12:277–81. [16] De Caluwe D, Cherti B, Puri P, et al. Childhood femoral hernia: a commonly misdiagnosed condition. Pediatr Surg Int 2003;19:608–9. [17] Schier F. Direct inguinal hernia in children, the laparoscopic aspect. Pediatr Surg Int 2000;16:562–4. [18] Ein SH, Njere I, Ein A, et al. Six thousand three hundred sixty-one pediatric inguinal hernias: a 35 year review. Pediatr Surg 2006;41:980–6. [19] Treef W, Schier F. Characteristics of laparoscopic inguinal hernia recurrences. Pediatr Surg Int 2009;25:149–52. [20] Chan KL. Laparoscopic repair of recurrent childhood inguinal hernias after open herniotomy. Hernia 2007;11:37–40. [21] Ozgediz D, Roayaie K, Lee H, et al. Subcutaneous endoscopically assisted ligation (SEAL) of the internal ring for repair of inguinal hernias in children: report of a new technique and early results. Surg Endosc 2007;21:1327–31. [22] Cushieri A, Szabo Z. Intracorporeal knots in endoscopic surgery. In: Giles GR, Moossa AR, editors. Essential Surgical Practice. 3rd ed. Oxford, United Kingdom: Isis Medical Media; 1995. p. 42 [Chap 4]. [23] Chan KL, Tam PK. Technical refinements in laparoscopic repair of childhood inguinal hernias. Surg Endosc 2004;18:957–60. [24] Chen K, Xiang G, Wang H, et al. Towards a Near-Zero Recurrence Rate in Laparoscopic Inguinal Hernia Repair for Pediatric Patients. J Laparoendosc Adv Surg Tech A 2011;21:445–8. [25] Marte A, Sabatino MD, Borrelli M, et al. Decreased recurrence rate in the laparoscopic herniorraphy in children: comparison between two techniques. J Laparoendosc Adv Surg Tech A 2009;19:259–62. [26] Becmeur F, Philippe P, Lemandat-Schultz A, et al. A continuous series of 96 laparoscopic inguinal hernia repairs in children by a new technique. Surg Endosc 2004;18:1738–41. [27] Riquelme M, Aranda A, Riquelme-Q M. Laparoscopic pediatric inguinal hernia repair: no ligation, just resection. J Laparoendosc Adv Surg Tech A 2010;20:77–80. [28] Gorsler CM, Schier F. Laparoscopic herniorrhaphy in children. Surg Endosc 2003;17:571–3. [29] Montupet P, Esposito C. Fifteen years experience in laparoscopic inguinal hernia repair in pediatric patients. Results and considerations on a debated procedure. Surg Endosc 2011;25:450–3. [30] Burd RS, Heffington SH, Teague JL. The optimal approach for management of metachronous hernias in children: a decision analysis. J Pediatr Surg 2001;36: 1190–5.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Laparoscopic inguinal hernia repair; experience with 874 children Rafik Shalaby ⁎, Maged Ismail, Abdelhady Samaha, Abdelaziz Yehya, Refaat Ibrahem, Samir Gouda, Ahmed Helal, Omar Alsamahy Department of Pediatric Surgery, Al-Azhar University Hospitals, Cairo, Egypt
a r t i c l e
i n f o
Article history: Received 1 June 2013 Received in revised form 23 October 2013 Accepted 23 October 2013 Key words: Laparoscopy Reverdin needle Congenital inguinal hernia Lateral umbilical ligament
a b s t r a c t Background: Laparoscopic inguinal hernia repair (LIHR) in children has become an alternative to the open procedure. It is gaining popularity with more and more studies supporting its feasibility, safety, and efficacy. This is a retrospective study to present our experience with children who underwent LIHR. Patients and methods: A total of 1184 inguinal hernias were repaired laparoscopically in 874 children. They were 703 boys and 171 girls. Their mean age was 2.9 ± 2.1 years (range, 6–108 months). Six-hundred and twenty four opened internal inguinal rings (IIRs) were closed by transperitoneal purse string suture technique (TPP) and 560 opened IIRs were closed by percutaneous purse string suture with lateral umbilical ligament enforcement using Reverdin Needle (RN) technique. Results: All cases were completed laparoscopically without conversion. There were no serious intraoperative complications. Mean operating time, in TPP technique, was 15 ± 2.3 minutes for unilateral and 20 ± 1.7 minutes for bilateral inguinal hernia, while the mean operating time, in RN technique, was 8.7 ±1.18 minutes for unilateral and 12.35 ± 2 minutes for bilateral hernia repair. The contralateral patent processus vaginalis (PPV) was present in 176 (20% of cases). Follow-up to date is 10–140 months (mean 80 ± 2.1 months). In the early stage of this study, the recurrence rate was 1.13%. In the last 450 cases, no recurrence occurred. Hydroceles occurred in 0.58% and no testicular atrophy or iatrogenic ascent of the testis. Conclusions: LIHR can be a routine procedure with results comparable to those of open procedures. Both recurrence and operative time are nearly equal or even less than that for the open procedure after gaining a learning curve and modifications of the techniques. © 2014 Elsevier Inc. All rights reserved.
Laparoscopic techniques have been applied widely in the management of various common pediatric surgical conditions. Laparoscopic inguinal hernia repair (LIHR) in children has become an alternative to the conventional open procedure [1–8]. However, current evidence is insufficient to justify its widespread use in children and various concerns are raised against the LIHR in children including: it is more time consuming, it has a higher recurrence rate, it violates the peritoneal cavity, and there is no overall advantage compared to the open procedure. It is important to critically evaluate the effectiveness and the potential risks of new techniques before they can be accepted as the treatment modality of choice [9,10]. The aim of this study was to present our experience with children who underwent LIHR over a period of 12 years. 1. Patients and methods This study was conducted in Al-Mishary Hospital, Riyadh, Saudi Arabia, Pediatric Surgery Unit, Al-Azhar University Hospitals and some private hospitals in Cairo, Egypt between June 2000 and June ⁎ Corresponding author at: Al-Houssain University Hospital, Darrasa, Cairo, Egypt. Tel.: +20 1000722072; fax: +20 1223975160. E-mail address: rafi[email protected] (R. Shalaby). 0022-3468/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2013.10.019
2012. A total of 1184 inguinal hernias were repaired laparoscopically in 874 children. All children were subjected to full history taking, thorough clinical examination, and routine laboratory investigations (CBC, BT, CT, FBS, liver and renal profile). The main outcome measurements of this study included; operative time, hospital stay, development of hydrocele, hernia recurrence, testicular atrophy, iatrogenic ascent of the testis and cosmetic results. The ethical committee of our hospital approved the study protocol and a written informed parental consent was obtained. 1.1. Description of the technique General endotracheal tube anesthesia was used in all cases. An open Hasson's technique through supra-umbilical incision was used for creation of pneumoperitoneum to a pressure of 8–12 mmHg. LIHR was done by 2 different techniques; namely transperitoneal purse string suture (TPP) technique and percutaneous insertion of purse string suture around IIR with lateral umbilical ligament enforcement using Reverdin Needle (RN). In both techniques, extraperitoneal saline was injected around IIR to facilitate complete encirclement of suture around IIR safely without leaving a skip area or fearing of injury of spermatic vessels and vas deferens. Patients were placed supine in the Trendelenburg’s position with tilting to the opposite side of the hernia.
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TPP technique was done according to the technique described by Chan and Tam [11] with some modifications. A telescope 5-mm, 30 degree was used. Two 3-mm needle holders were inserted directly without trocars at the mid-clavicular line on both sides at the level of the umbilicus. Laparoscopy was started by inspection of both IIRs. The corresponding skin of the hernial defect was first marked by means of transabdominal illumination of the laparoscope and slight fingertip external pressure. At the marked site, a 21-gauge needle attached to a 10-cc syringe filled with saline was introduced at 12 o’clock and advanced along the preperitoneal space on the medial side of the hernia defect medial to the vas deferens. Then saline was injected while withdrawing the needle back to the starting point. Then, the same procedure was repeated along the lateral side of the hernia defect lateral to the spermatic vessels (Fig. 1). Then 17-mm needle with non-absorbable mono-filament 2–0 suture was used to close IIR by a purse string suture starting at 3 o’clock and going all around IIR. The suture mainly included the subperitoneal tissues except at the inferior border of IIR where only peritoneum was taken by carefully picking and lifting it with the tip of left hand needle holder and the needle was seen all the time beneath the peritoneum (needle sign) to avoid injury of the spermatic vessels and vas deferens (Fig. 2). Extracorporeal suture tie was used and before tightening the knot, the scrotum was squeezed and the intraperitoneal pressure was released to expel the gas in the hernial sac. RN technique (Martin Medizin-Technik, D-78501 Tuttlingen, Germany) was done according to the technique described earlier by Shalaby et al with some modifications in the form of retroperitoneal saline injection around IIR and lateral umbilical ligament enforcement [8,12]. A 3-mm Maryland forceps, holding the tip of a non-absorbable mono-filament 2–0 thread, was inserted into the abdomen without trocar at the right mid clavicular line at the level of the umbilicus for both unilateral and bilateral CIH. A stab incision of the skin was done (2 cm above and lateral to the IIR on the right side and 2 cm above and medial to the IIR on the left side) and RN was inserted into the peritoneal cavity (Fig. 3A–C). The needle was manipulated to pierce the peritoneum at 3 o’clock on IIR and was advanced to pass through the inferior margin of IIR under the peritoneum and in front of the spermatic vessels and vas deferens to pierce the peritoneum at 9 o’clock on the IIR (Fig. 3D–F). Care was taken to avoid damage of the
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vas and spermatic vessels by grasping and lifting the peritoneum away from them and the RN was seen all the time beneath the peritoneum (needle sign). Then, the side of the hole of RN was opened and the thread was inserted inside it. Then, the side of the hole was closed and the needle was withdrawn backward in the same path to the starting point at 3 o’clock. Then, RN mounted by the thread was reinserted again at 3 o’clock and was advanced along the superior margin of the IIR beneath the peritoneum and fascia transversalis to come out from the same opening at 9 o’clock. The side of the hole of RN was opened and the short end of the thread was withdrawn out. RN was withdrawn outside the abdomen and the short end of the thread was pulled outside the abdominal cavity for extracorporeal suture tie and pushed by a tie pusher for tightening of the suture around the IIR (Fig. 4). In both techniques, the airtight tightening of purse-string knot was stress-tested by raising the intraperitoneal CO2 pressure by 50%. The increase in pressure was sustained for about 30 seconds during which the patient was carefully monitored for blood pressure, pulse, and oxygen saturation. The air tightness was confirmed by the absence of hernial sac enlargement with the increased intraperitoneal pressure. In case of escape of gas into the hernial sac, a second suture was inserted around IIR 2. Results A total of 1184 inguinal hernias were repaired laparoscopically in 874 children. The reports of these patients were collected and analyzed. The demographic data of all patients are shown in (Table 1). All cases were completed laparoscopically without conversion. At operation, contralateral PPV was seen and closed in 176 (20%) of cases. Six-hundred and twenty four IIR were closed by TPP technique and 560 IIRs were closed by percutaneous RN technique. The mean operating time from skin-to-skin for both techniques is shown in (Table 1). All patients achieved full recovery without intraoperative or postoperative complications. In 2 cases, stress-test resulted in escape of gas into the hernial sac and a second suture was inserted again around IIR. Most children went home at the same day. The mean hospital stay was 7.79 ± 1.28 hours (range, 5– 19 hours). Ten percent of children stayed one night postoperatively because of parental preference, or geographical far distance. Follow-
Fig. 1. Extraperitoneal saline injection around IIR.
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Fig. 2. Needle is safely placed at the elevated peritoneum and traverses just under peritoneum, in front of the spermatic vessels and vas with complete encirclement of the IIR.
up to date is 10–140 months (mean 80 ± 2.1 months). There were 8 recurrences [8/703] (1.13%) in boys and no recurrence in girls. In the last 450 cases (350 RN and 100 TPP technique), the recurrence rate was 0%. On follow-up, there were 4 hydroceles [4/703] (0.57%), one required percutaneous aspiration, and the others responded well to conservative treatment. There were no instances of postoperative testicular atrophy or testicular malposition in our series. There was no metachronous hernia and the cosmetic results were excellent (Fig. 5). 3. Discussion Laparoscopic inguinal hernia repair is a relatively new procedure in the pediatric surgical practice. It is rapidly gaining popularity with more and more studies validating its feasibility, safety, and efficacy. It has become an alternative to the conventional open procedure [1– 8,13,14]. Advantages of LIHR include excellent visual exposure, the ability to evaluate the contralateral side, minimal dissection and avoidance of access trauma to the vas deferens and spermatic vessels, bladder injuries and iatrogenic ascent of the testis [13,15]. In addition, it is also helpful in detecting other associated pathology and other hernias with excellent cosmetic results. It has a comparable operative time and recurrence rates [7,8,16,17]. Many minimally invasive techniques for addressing pediatric inguinal hernia have mushroomed in the past two decades. These techniques vary considerably in their approaches to the internal ring (intraperitoneal or extraperitoneal), use of ports (three, two, or one), endoscopic instruments (two, one, or none), sutures (absorbable or nonabsorbable), and techniques of knotting (intracorporeal or extracorporeal). A major criticism of the laparoscopic repair remains its higher recurrence rate, as compared to the traditional open technique, ranging from 0.83% to 4.1% [7,8,18]. The reasons were versatile. These include failure to ligate the hernial sac high enough at
the IIR, tension at the closure of the internal opening, large hernia, broken purse-string thread, the suture technical problem and hematoma formation at the open wound [10]. Generally, the high recurrence rate in LIHR could possibly be owing to tension at the closure of the IIR and presence of skip area especially over the vas and spermatic vessels without complete encirclement of IIR. It appears that surgeons with more practice have fewer recurrences. Beginners may not dare to place sutures as closely as required to the vessels medially. In fact, it was found that recurrences of less experienced surgeons are high [19]. In this study, all operations were done by the first and second authors who have an extended experience with different laparoscopic techniques, specially laparoscopic hernia repair and that is why we have a very low recurrence in the beginning of this series and no recurrence in the last 450 cases. The present study proved that reducing tension on the pursestring knot when closing the IIR and the addition of the lateral umbilical ligament to enforce purse-string knot resulted in elimination of recurrence. A recurrence will not occur if the purse-string knot and umbilical ligament covering the IIR are confirmed with the stress test by an increase in the intraperitoneal CO2 pressure at the end of the operation as stated by Chan [20]. The first large series of intracorporeal repair of CIH was reported by Schier, with primary closure of the peritoneum lateral to the cord with interrupted sutures [10]. Then, he modified the technique to use 2-mm instruments without a trocar for intra-abdominal suturing of the IIR by the placement of 2 Z-sutures [5]. Other modifications include an N-suture instead of a purse-string suture [6]. Subcutaneous endoscopic assisted ligation (SEAL) of the hernial sac and other similar techniques resulted in marked reduction of operative time when compared to the transperitoneal purse string suture using standard 3-port technique [8]. Avoiding the vas deferens and gonadal vessels during the SEAL repair in boys may leave a small gap at the
Fig. 3. RN is inserted intraperitoneal at 3 o’clock and advanced through the inferior margin of IIR for picking the thread and withdrawn back (A, B, C). Then RN is passing through the superior margin of the IIR to leave the suture for encircling the IIR (D, E, F).
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Table 1 Demographic data of all patients (age, sex, presentations and operative time).
Fig. 4. The suture is tightened around IIR.
internal ring as well as leaving the hernial sac in continuity, which has the potential to contribute to a higher incidence of recurrence [21]. However, SEAL is associated with a high recurrence rate and development of granuloma, infection, and skin puckering at the site of a subcutaneously placed knot [8,22]. These drawbacks of SEAL and other similar techniques were avoided by the use of RN technique. In the beginning phase of this study, we had more recurrences (1.13%) in boys as of June 2008, excluding the last 450 cases, but this rate is lower than that reported by others (3.4%–4.1%) performing LIHR [8,10] and even lower than noted in open herniotomy (1.2%) [18]. Chan and Tam stated that injecting normal saline into the extraperitoneal space at IIR to elevate the peritoneum away from vas and spermatic vessels allows stitches to be inserted safely without any skip area for a tight purse string suture. However, care still is needed to make sure the vas deferens and testicular vessels are not included [23]. Chen et al used medial or lateral umbilical ligaments to cover the internal hernia opening region after finishing purse-string knot to prevent the recurrence. The method they developed was revolutionary in the principle of pediatric hernia repair. It includes both the security of repair offered by the watertight closure of the hernia opening and the hernia opening region covered with the umbilical ligament flap. The valve mechanism allows scrotal fluid avoiding scrotal collection. Under the stress of intra-abdominal pressure, the wall of the sac is pressed over by the flap, keeping the sac in a collapsed state. They claimed that their technique is very easy and the
No. of patients No. of opened IIR Sex Male Female Age in month 6–12 12–24 24–36 N36 Presentation Right sided hernia Left sided hernia Bilateral hernia Recurrent hernia Contralateral hernia Operative time Unilateral hernia (recurrent or fresh) Bilateral hernia
874 1184 703 171 Mean, 2.9 ± 2.1 months 314 244 140 176 460 260 134 20 176 RN 8.7 ± 1.18 minutes 12.35 ± 2 minutes
TPP 15 ± 2.3 minutes 20 ± 1.7 minutes
recurrence will not occur. They added that their technique has no severe complications and is indicated in the following cases: (1) large hernia, hernial sac N1.5 cm; (2) recurrent hernia, and (3) the patient’s age above 5 years [24]. In our pediatric surgery unit, Al-Azhar University Hospitals, the IIR is closed by purse-string suture encircling its whole circumference without any skip area either by TPP or by RN technique [8]. Both, the operative time and the recurrence rate in our series are lower than that reported in the literature because LIHR was started after gaining good experiences in different laparoscopic procedures. Recently we used an easy, safe, simple and rapid technique for repair of CIH using percutaneous insertion of purse string suture by RN and extracorporeal suture ligation which is less time consuming. Also, we followed many technical refinements such as injecting normal saline into the extraperitoneal space at IIR, including sub peritoneal tissue all around IIR without any skip area, reducing tension on the knot of purse string suture by deflation of the abdomen and squeezing the scrotum to empty the hernial sac, lateral umbilical ligament enforcement and the use of non-absorbable suture. These latest technical refinements and modifications of the techniques resulted in marked reduction of development of post-operative hydrocele, lowering the recurrence of
Fig. 5. A: Rt. Recurrent huge inguinal hernia. B: Post-operative view.
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hernia to 0% and reduced operative time. The above mentioned technical refinements have been described before by Chan and others [20,23,24]. We have no recurrence in our last 450 LIHR cases as we followed some technical refinements as described before. Also we started laparoscopic hernia repair after gaining a good experience in other laparoscopic techniques. Others have no recurrence in their series [24–27]. Marte et al stated that the incision of the peritoneum lateral to the IIR and the W-shaped suture, compared to the sole Wshaped suture, prevented hernia recurrence in their series [25]. Gorsler and Schier [28] used non-absorbable Z-sutures to close 403 inguinal rings in 279 children. The mean operating time was 14 minutes for unilateral hernias and 21 minutes for bilateral hernias. They had a recurrence hernia in 3.4% of cases and postoperative hydroceles in 1.7%. Montupet and Esposito used the laparoscopic herniorrhaphy by sectioning the sac distally to the inguinal ring and performing a purse-string suture around the periorificial peritoneum using a 4/0 nonresorbable suture with a median operating time of 19 minutes. At a follow-up between 1 and 15 years, they have only 11 recurrences (1.5%) [29]. Parelkar et al [9] reported a recurrence rate of 2.9% in the early phase of their study. They claim that the high recurrence rate could possibly be owing to tension at the closure of the internal opening and the use of absorbable suture materials. However, they did not have a recurrence in their last 100 cases and they presume that this might be attributed to improved learning skills over time and technical modifications [9]. Methods that allow complete encircling of the PPV, such as the intraperitoneal purse string stitch passing between the peritoneum and the cord and vessel structures so as not to leave any skipped area, or a laparoscopic technique that produces every step of the open procedure involving complete division and stitching up of the PPV at the IIR, achieved the lowest recurrence rate from 0 to 1.3% [25,28]. LIHR in children is known to take longer operative time than open herniotomy. Many reports showed that it ranged from 25 to 74 minutes. However, the operative time is reduced gradually with the training curve [5,15,28]. Schier stated that LIHR is not more time consuming than open techniques. He added that LIHR is quicker than the open approach especially in male newborns and in bilateral hernias [10]. It has been stated that after unilateral open herniotomy, metachronous hernia may occur in up to 30% of cases [30]. Today, publications are still quoted from the 50s and 60s reporting contralateral openings in up to 60% [22]. After LIHR, we have never seen a metachronous hernia within the last 9 years that is because any open IIR detected during laparoscopy is closed at the same setting. There is always a risk of intra-abdominal adhesions in open technique as seen by Schier during the laparoscopic repair of a metachronous hernia. They found dense intraperitoneal adhesions in the area of the previously surgically repaired CIH on the other side. The objection that laparoscopy has a higher risk of adhesions has not been substantiated. However we did not have a single case of adhesive obstruction in our series of LIHR and the laparoscopic view of recurrent right sided hernia after bilateral laparoscopic hernia repair showed no adhesion on both sides. This disprove the objection that laparoscopy has high risk of adhesion formation owing to violation of peritoneal cavity. These observations coincided with that of Schier [10]. 4. Conclusion LIHR is technically easier and safe owing to better visualization of all anatomical structures, thus minimizing chances of injury of the vas deferens and spermatic vessels. Although both recurrences and
operative time were slightly higher in the early stages, now they are nearly equal or even less than with the open procedure. The risk of metachronous hernia is reduced. The cosmetic results are excellent and there are virtually no scars. LIHR can be adopted routinely in pediatric centers and it can be considered good training for residents in pediatric surgery because it helps to improve their ability with both intracorporeal and extracorporeal suture tying. References [1] Akansel G, Guvenc BH, Ekingen G, et al. Ultrasonographic findings after laparoscopic repair of paediatric female inguinal hernias: the vanishing rosebud. Pediatr Radiol 2003;33:693–6. [2] Chan KL, Hui WC, Tam PK. Prospective, randomized, single-center, single-blind comparison of laparoscopic versus open repair of pediatric inguinal hernia. Surg Endosc 2005;19:927–32. [3] Esposito C, Montupet P. Laparoscopic treatment of recurrent inguinal hernia in children. Pediatr Surg Int 1998;14:182–4. 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