World J Urol DOI 10.1007/s00345-014-1259-8
Original Article
Modified single‑port minilaparoscopic extraperitoneal repair for pediatric hydrocele: a single‑center experience with 279 surgeries Zhifeng Wang · Le Xu · Zhi Chen · Cong Yao · Zexuan Su
Received: 5 October 2013 / Accepted: 29 January 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose The purpose of the study is to introduce our experience of a modified single-port minilaparoscopic technique for the treatment of pediatric hydrocele. Methods Between June 2008 and May 2012, 279 boys (115 communicating hydrocele and 164 “non-communicating” hydrocele, diagnosis based on preoperative physical examination and scrotal ultrasound) underwent the modified single-port minilaparoscopic repair in our institution. During surgery, a 3-mm laparoscope was inserted into the
Zhifeng Wang and Le Xu contributed equally to this study. Electronic supplementary material The online version of this article (doi:10.1007/s00345-014-1259-8) contains supplementary material, which is available to authorized users. Z. Wang · Z. Su Institute of Clinical Anatomy, Southern Medical University, Guangzhou 510515, Guangdong, China e-mail: [email protected] Z. Wang · L. Xu · C. Yao Department of Urology, The Affiliated Hexian Memorial Hospital of Southern Medical University, Guangzhou 511400, Guangdong, China e-mail: [email protected] C. Yao e-mail: [email protected] Z. Chen Department of Urology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China e-mail: [email protected] Z. Su (*) Department of Urology, The First Affiliated Hospital of JINAN University, Guangzhou 510630, Guangdong, China e-mail: [email protected]
abdomen through a mini-umbilical incision. The hydrocele sac orifice was closed by an extraperitoneal purse-string suture placed around the internal ring with an ordinary taper needle and an endoclose needle. Results Of all the 279 patients, 16 (5.7 %) were found to have a potential patent processus vaginalis (PPV) on the contralateral side. Of the 164 boys diagnosed with “non-communicating” hydrocele preoperatively, 5 (3.0 %) had no PPV identified in laparoscope and the other 159 (97.0 %) had PPV actually. A total of 274 single-port minilaparoscopic procedures were performed, and all cases were successful without serious complications. The mean operative time was 19.5 and 24.8 min for unilateral and bilateral operations, respectively. Postoperative complications were noted in 4 cases, 2 (0.7 %) patients with scrotal edema, 1 (0.4 %) patient experienced an umbilical hernia, and 1 (0.4 %) patient with suture site abscess. During a median follow-up period of 9 months (range 6–24 months), postoperative hydrocele recurrence was seen in 2 patients (0.7 %). Conclusions This modified single-port minilaparoscopic technique is a safe, effective, and reliable procedure for pediatric hydroceles. Keywords Pediatric hydrocele · Single port · Minilaparoscopic technique
Introduction Hydrocele is a common congenital anomaly in children, occurring in 1–5 % of newborn males [1–3]. A hydrocele is a collection of fluid between the visceral and parietal layers of the tunica vaginalis. Traditionally, open surgery for a pediatric hydrocele is performed through an inguinal
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incision [4]. However, this approach requires wide muscle separation and carries the risk of damaging the vas deferens and spermatic vessel as well as the architecture of the inguinal canal [5–7]. Minimal access surgery is challenging the conventional surgical management of pediatric hydroceles. The clinical studies of laparoscopic pediatric hernia repair have been reported [8–11], but the literature on laparoscopic repair of hydroceles was sparse. In 1994, Janetschek et al. [12] first reported their experience with laparoscopic repair of pediatric hydroceles. The difference between hernia and communicating hydrocele was attributed to the caliber of the connection. But the channel to abdominal cavity in hydrocele was always thin, and this made the open surgery process relatively difficult. On the contrary, the narrow PPV made the laparoscopic repair technique relatively easy to operate. So, the laparoscopic repair technique may be more suitable for pediatric hydrocele patients. We modified a kind of single-port minilaparoscopic technique for the repair of pediatric hydroceles since 2008. Over a 4-year period, 279 boys underwent this minilaparoscopic technique and received follow-up in our center. In this study, we review the outcomes of these patients to assess this technique.
Materials and methods This was a retrospective review. From June 2008 and May 2012, a consecutive series of 279 boys with hydroceles underwent the single-port minilaparoscopic repair in our institution. The diagnosis was based on clinical presentation, physical examination, and ultrasound findings (to exclude inguinal hernia). Communicating hydrocele can change the size during the periods of increased intraabdominal pressure. “Non-communicating” hydroceles was present with no change in size. Ultrasound detection of the channel to abdominal cavity also was a diagnosis index. The principal outcome parameters included age, the side of the hydrocele, operative time, presence of contralateral PPV, length of hospital stay, and postoperative complications (Table 1). All patients were followed for more than 6 months. Data were collected from medical records and personal interviews. The hospital Institutional Review Board (IRB) approved the study protocol. All patients were placed in the supine position under general anesthesia. Local anesthesia (Lidocaine 0.5 %, about 2–3 ml) to the incision part was applied on the basis of general anesthesia. The surgeon operated standing on the contralateral side to the hydrocele. The monitor was placed at the patient’s feet. A single 3.0-mm incision was made at the lower part of the umbilicus using the open technique, and a 3-mm trocar was inserted. Pneumoperitoneum was
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World J Urol Table 1 Patient clinical characteristics and surgical results of the Sing-incision minilaproscopic technique Parameters (279 cases) The type in the preoperative diagnosis n (%) Communicating “Non-communicating” Median age (range), months Side of presentation, n (%) Right Left Contralateral PPV, n (%) No PPV, n (%) Median operative time, min (range) Unilateral Bilateral Hospital stay, days (range) Complications, n (%) Recurrence Scrotal edema Suture site abscess Umbilical hernia
115 (41.2) 164 (58.8) 39 (12–139) 127 (45.5) 152 (54.5) 16 (5.7) 5 (3.0) 19.5 (14–31) 24.8 (19–40) 2.1 (2–3) 2 (0.7) 2 (0.7) 1 (0.4) 1 (0.4)
PPV patent processus vaginalis
established, and insufflation pressure was maintained between 6 and 12 mmHg. A 3-mm laparoscope was introduced (Olympus Optical Co., Ltd., Shinjukuku, Tokyo, Japan). The entire abdominal cavity was examined, and the PPV could be clearly identified. The middle of the PPV shadow on the skin was the optimal location for the needle suture (Fig. 1b). The location was chosen by pressing the outside of the inguinal region with the tip of the endoclose needle. A 1.5-mm incision was made at the marked site by a sharp knife. A taper needle (1/2Arc 11 × 34 mm) (Fig. 1b) with non-absorbable 2–0 monofilament thread was introduced into the extraperitoneal space through the skin incision and moved forward until the tip of the needle reached the peritoneum. Under laparoscopic visualization, the vas deferens and vessels can be easily distinguished. The needle was moved along the preperitoneal space just outside the PPV from lateral to medial. It was kept extraperitoneal until it strided over the gonadal vessels and the vas deferens (Fig. 1c). The needle was removed from the abdominal cavity, leaving the suture in the peritoneal cavity. Through the previous stab incision, an endoclose needle was introduced along the opposite side of the PPV into the extraperitoneal space and moved forward to meet the previous suture. The endoclose needle tip was blunt, and there was a hook in the lateral of the tip. When the endoclose needle was inserted into the intra-abdominal space, the hook could be opened or closed by pushing the switch in needle’s end. The free end of the suture was picked up
World J Urol
Fig. 1 Single-port minilaparoscopic extraperitoneal hydrocele repair in a 26-month-old boy. a Instruments required: endoclose needle (Auto Suture, USA). b Extracorporeal suturing with a standard needle holder and an ordinary taper needle (1/2 Arc 11 × 34). c Suturing the PPV under laparoscopic visualization. d Endoclose needle was
inserted into the intra-abdominal space to retrieve the suture. e PPV was completely encircled and prepared to be ligated with extracorporeal tie. f Release of residual hydrocele fluid with a syringe and the cosmetic result of the single-port minilaparoscopic technique
and pulled out by the endoclose needle (Fig. 1d). The PPV then was completely encircled (Fig. 1e) and closed when the knot was tied subcutaneously. In the cases with large PPV or peritoneum fold, lifting up the abdominal wall over the internal ring may help the suture. Endoclose needle and taper needle also can be inserted simultaneously. Endoclose needle can be used to smoothing the peritoneum fold. If these failed, an additional port was recommended. Making the incision exceeding subcutaneous tissue and lifting up the abdominal wall could reduce the bunching of subcutaneous tissue when swiping a needle. All the suture procedures were performed in the preperitoneal space and under laparoscopic visualization. Care was taken to avoid damage to the gonadal vessels, epigastric vessels and the vas deferens. At the end of the operation, the umbilical incision was closed by suturing the peritoneum and fascia. Sometimes, it was necessary to release the residual hydrocele fluid with a syringe when the hydrocele sac was large (Fig. 1f). Lifting up the skin around the needle wound by toothed forceps could help the knot deeply seated under the skin and fat. The needle wound just needed a piece of skin bond. If a contralateral potential PPV was present, it was simultaneously repaired using the same procedure.
Perioperative psychological nursing care was taken to reduce the postoperative discomfort, and the patients were discharged when clinically appropriate. Patients were followed by physical examination or a scrotal ultrasound when scrotal edema was present. Parents were advised to contact us immediately if their children had any complication. The patients who lost follow-up were ruled out from our study.
Results Table 1 shows the demographics of the patients and the surgical results. The median age was 39 months (range 12–139 months). There were 115 boys with communicating hydrocele and 164 boys with “non-communicating” hydrocele diagnosed preoperatively. The hydrocele was right-sided in 127 (45.5 %) and left-sided in 152 (54.5 %). Of the 164 patients with “non-communicating” hydrocele, 5 (3.0 %) had no PPV identified at laparoscopy and were converted to open surgery through a scrotal incision. The other 159 patients were found to have PPV and were communicating style actually. Of all the 279 patients, 16 (5.7 %) were found to have a potential PPV on the contralateral side and subsequent repair was performed. A
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total of 274 single-incision minilaparoscopic procedures were performed, and all cases were successful without serious complications. The mean operative time was 19.5 and 24.8 min for unilateral (range 14–31 min) and bilateral (range 19–40 min), respectively. The mean hospital stay was 2.1 days (range 2–3 days). There are five cases which need an additional port to assist the suture of peritoneum. During a median follow-up period of 9 months (range 6–29 months), there were 2 (0.7 %) recurrences and no testicular atrophy. The two recurrences occurred in 2 and 5 months postoperatively, respectively. The two recurrent hydroceles underwent open trans-inguinal repair and was followed up for 12 months; no recurrence was detected. Postoperative complications were noted in 4 cases: 2 (0.8 %) patients with scrotal edema, 1 patient experienced an umbilical hernia; and 1 patient suffered suture site abscess. The 2 patients with scrotal edema occurred within 1 week postoperatively. Mild edema of scrotum was the only symptom, and it did not company with any red, hot or pain. They both had complete resolution of the edema after 1 month without any treatment. The patients experienced umbilical hernia within 1 h. We reduced the hernia content and made a simple suture of the umbilicus under local anesthesia. The ulcerative wound of suture site (occurring within 1 month postoperatively) did not heal until we dislodged the tie knot. The patient was followed up for 12 months, and no recurrence was detected. Postoperative pain was slight, and no narcotic analgesia was necessary. The cosmetic results were excellent with only one invisible scar in the umbilicus (Fig. 1f).
Discussion Hydrocele is a common clinical problem in boys. Complete patency with a narrow opening at the internal ring that allows only fluid passage is referred to as a communicating hydrocele. In actual, most infant hydroceles are communicating, but the channel to abdominal cavity was thin and cannot be detected by ultrasound. In addition, most infant hydroceles do resolve without surgical treatment [13]. Hussein et al. [14] reported that 89 % of patients with infantile hydroceles had spontaneous resolution due to ongoing changes in the PPV. But there is no study that clearly demonstrates an inverse relationship between the likelihood of encountering a PPV and patient age. In the current study, there was no PPV identified in patients older than 12 years without suspecting its presence based on preoperative history and physical examination [4, 15]. In general, surgical intervention for pediatric hydrocele is recommended if it remains unresolved after the age of 12–24 months [15–17]. We recommend an age from 2 to 12 years as appropriate for considering this technique. The mean age of our
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World J Urol
patients was 39 months. In our series, 159 (97.0 %) boys diagnosed with “non-communicating” hydrocele preoperatively had PPV and were characteristic of the communicating hydrocele actually under the laparoscope. There were only five boys indeed without PPV and were converted to open surgery through a scrotal incision instead of inguinal incision. For these boys without PPV, we thought the singleport minilaparoscopy technique still had some significance because a scrotal approach could give a better cosmetic result and less complication than an inguinal incision [4]. There are many traditional methods for hydrocele repair described in the literature [18–20]. The application of laparoscopy for inguinal hernia repair in pediatric surgery is progressively gaining acceptance [8–11, 21]. But experiences of laparoscopic repair of pediatric hydrocele have been rarely reported. Laparoscopic procedures for repair of pediatric hydroceles differ in their approach to the internal ring, number of ports (one to three), suture methods, and techniques of knot tying [9, 22, 23]. This single-port minilaparoscopic technique was developed based on the principle of the traditional cut-down technique and the experience of laparoscopic hernia repair that utilizes complete extraperitoneal high ligation of the PPV. To achieve a better cosmetic result, we made some improvements and placed only one port through a 3-mm umbilical incision. Using this minimally invasive technique, we obtained a better cosmetic result (Fig. 2). By the use of the minilaparoscope, we were able to visualize the PPV before and during repair. It has been estimated that 3–30 % of patients present later with symptomatic hydrocele on the contralateral side, and examining the contralateral internal ring simultaneously was necessary [24]. In our series, 16 patients (5.7 %) were identified with a contralateral PPV that was repaired simultaneously. In addition, although this modified single-port technique uses only one port for laparoscopy, the mean operative time was similar to other reports [8–11, 23]. This technique simplifies the surgical manipulation. The semicircular radius of ordinary taper needle can match the physiologic curve of the PPV when there are no folds. In our series, the patients experienced minimal postoperative pain, and the cosmetic outcomes were outstanding. However, the mean hospitalization time was 2.1 days, more than other’s reports [8–11]. Actually, we thought this technique could be considered an ambulatory surgery. But the Chinese parent’s traditional concept regards the hospital as the safest place for recovery and hoped their boys to stay in hospital longer. There were two recurrences in our series, a recurrence rate of 0.7 %, which is similar to previous reports [12, 23]. The recurrent hydroceles were treated with traditional surgery through an inguinal incision. During open surgery, suture threads were found in situ along with part of the
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Fig. 2 Schematic illustration of the single-port minilaparoscopic technique. a The clinical anatomy of a hydrocele. b Under laparoscopic visualization, the needle sutures the PPV in the extraperitoneal space lateral to medial, astride the gonadal vessels, and the vas deferens. The needle is removed from the abdominal cavity, leaving the suture inside the peritoneal cavity. c Through the previous stab incision, an endoclose needle is introduced along the opposite side of the
PPV into the extraperitoneal space and moved forward to meet the previous suture. d Endoclose needle is inserted into the intra-abdominal space and picks up the suture; e the free end of the suture is pulled out by the endoclose needle, and the PPV is completely encircled. f The knot is tied subcutaneously, and the PPV is completely ligated
PPV. The cause may have been that the PPV was not completely sealed or the PPV was inadvertently cut by the knot. We believed the integrity of the PPV suture was the key to minimizing recurrences. Therefore, it was necessary to use a grasping forceps through another 3-mm incision for some cases with large PPV. Scrotal edema following laparoscopic hydrocele surgery was sparse in the reports. But scrotal edema following laparoscopic hernia repair surgery was a common complication [25]. In the study of laparoscopic hernia, clinical factors associated with scrotal edema formation were old age, large hernial defect, and the presence of distal indirect sac [26]. However, we thought the invisible pull, squeezing or injury to lymphatic vessels or vascular during operation process might be the most possible cause in our study. The follow-up period in our study was relatively short, although the minimum follow-up time in other studies ranged from 1 to 6 months [4, 23]. The frequent population
mobility in our area made the follow-up difficult. To meet both the requirements of surgery evaluation and the number of study cases, we chose 6 months as the minimum followup time. It is theoretically possible that the vas deferens or vessels can be pulled into the closure, and the purse-string suture may inflict pressure on them [27]. In addition, the deferens or vessels may be damaged by the encroachment of postoperative scar tissue [28]. These possible reasons might be potential risks on fertility. A long-term outcomes of fertility remained to be defined.
Conclusions This modified single-port minilaparoscopic technique is a safe, effective, and reliable procedure for pediatric hydroceles.
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Acknowledgments The authors thank Mr. Weizhao Zhou for his assistance in the drawing of schematic illustration. Conflict of interest No competing financial interests exist.
References 1. Drew JH, Parkinson P, Walstab JE et al (1977) Incidences and types of malformations in newborn infants. Med J Aust 1:945 2. Osifo OD, Osaigbovo EO (2008) Congenital hydrocele: prevalence and outcome among male children who underwent neonatal circumcision in Benin City, Nigeria. J Pediatr Urol 43:178–182 3. Marden PM, Smith DW, McDonald MJ (1964) Congenital anomalies in the newborn infant, including minor variations. A study of 4,412 babies by surface examination for anomalies and buccal smear for sex chromatin. J Pediatr Urol 64:357–371 4. Jason M, Wilson David S et al (2008) Hydrocele in the pediatric patient: inguinal or scrotal approach? J Urol 180:1724–1728 5. Partrick DA, Bensard DD, Karrer FM et al (1998) Is routine pathological evaluation of pediatric hernia sacs justified? J Pediatr Surg 33:1090–1094 6. Steigman CK, Sotelo-Avila C, Weber TR (1999) The incidence of spermatic cord structures in inguinal hernia sacs from male children. Am J Surg Pathol 23:880 7. Cam C, Celik C, Sancak A et al (2009) Inguinal herniorrhaphy in childhood may result in tubal damage and future infertility. Arch Gynecol Obstet 279:175–176 8. Schier F (2006) Laparoscopic inguinal hernia repair: a prospective personal series of 542 children. J Pediatr Surg 41:1081–1084 9. Bharathi RS, Arora M, Baskaran V (2008) Minimal access surgery of pediatric inguinal hernias: a review. Surg Endosc 22:1751–1762 10. Schier F, Montupet P, Esposito C (2002) Laparoscopic inguinal herniorrhaphy in children: a three-center experience with 933 repairs. J Pediatr Surg 37:395–397 11. Takehara H, Yakabe S, Kameoka K (2006) Laparoscopic percutaneous extraperitoneal closure for inguinal hernia in children: clinical outcome of 972 repairs done in 3 pediatric surgical institutions. J Pediatr Surg 41:1999–2003 12. Janetschek G, Reissigl A, Bartsch G (1994) Laparoscopic repair of pediatric hydroceles. J Endourol 8:415–417 13. Koski ME, Makari JH, Adams MC et al (2010) Infant communicating hydroceles-do they need immediate repair or might some clinically resolve? J Pediatr Surg 45:590–593
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World J Urol 14. Naji H, Ingolfsson I, Isacson D et al (2012) Decision making in the management of hydroceles in infants and children. Eur J Pediatr 171:807–810 15. Hall NJ, Ron O, Eaton S, Pierro A (2011) Surgery for hydrocele in children-an avoidable excess? J Pediatr Surg 46:2401–2405 16. Fried AH, Epstein MH (1994) Childhood hydrocephalus: clinical features, treatment, and the slit-ventricle syndrome. Neurosurg Q 4:51–65 17. Kapur P, Caty MG, Glick PL (1998) Pediatric hernias and hydroceles. Pediatr Clin North Am 45:773–789 18. Sweeney DD, Smaldone MC, Docimo SG (2007) Minimally invasive surgery for urologic disease in children. Nat Clin Pract Urol 4:26–38 19. Jahnson S, Sandblom D, Holmäng S (2011) A randomized trial comparing 2 doses of polidocanol sclerotherapy for hydrocele or spermatocele. J Urol 186:1319–1323 20. Agbakwuru EA, Salako AA, Olajide AO et al (2008) Hydrocelectomy under local anaesthesia in a Nigerian adult population. Afr Health Sci 8:160–162 21. Endo M, Watanabe T, Nakano M et al (2009) Laparoscopic completely extraperitoneal repair of inguinal hernia in children: a single-institute experience with 1,257 repairs compared with cutdown herniorrhaphy. Surg Endosc 23:1706–1712 22. Ron O, Eaton S, Pierro A (2007) Systematic review of the risk of developing a metachronous contralateral inguinal hernia in children. Br J Surg 94:804–811 23. Wang D, Qiu J, Fang Y et al (2011) Laparoscopic extraperitoneal repair of symptomatic hydrocele in children: a single-center experience with 73 surgeries. J Endourol 25:1221–1225 24. Wulkan ML, Wiener ES, VanBalen N et al (1996) Laparoscopy through the open ipsilateral sac to evaluate presence of contralateral hernia. J Pediatr Surg 31:1174–1177 25. Misra MC, Kumar S, Bansal VK (2008) Total extraperitoneal (TEP) mesh repair of inguinal hernia in the developing world: comparison of low-cost indigenous balloon dissection versus direct telescopic dissection: a prospective randomized controlled study. Surg Endosc 22:1947–1958 26. Choi YY, Kim Z, Hur KY (2011) Swelling after laparoscopic total extraperitoneal repair of inguinal hernias: review of one surgeon’s experience in 1,065 cases. World J Surg 35:43–46 27. Schier F, Turial S, Hückstädt T et al (2008) Laparoscopic inguinal hernia repair does not impair testicular perfusion. J Pediatr Surg 43:131–135 28. Ridgway PF, Shah J, Darzi AW (2002) Male genital tract injuries after contemporary inguinal hernia repair. BJU Int 90:272–276
Original Article
Modified single‑port minilaparoscopic extraperitoneal repair for pediatric hydrocele: a single‑center experience with 279 surgeries Zhifeng Wang · Le Xu · Zhi Chen · Cong Yao · Zexuan Su
Received: 5 October 2013 / Accepted: 29 January 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose The purpose of the study is to introduce our experience of a modified single-port minilaparoscopic technique for the treatment of pediatric hydrocele. Methods Between June 2008 and May 2012, 279 boys (115 communicating hydrocele and 164 “non-communicating” hydrocele, diagnosis based on preoperative physical examination and scrotal ultrasound) underwent the modified single-port minilaparoscopic repair in our institution. During surgery, a 3-mm laparoscope was inserted into the
Zhifeng Wang and Le Xu contributed equally to this study. Electronic supplementary material The online version of this article (doi:10.1007/s00345-014-1259-8) contains supplementary material, which is available to authorized users. Z. Wang · Z. Su Institute of Clinical Anatomy, Southern Medical University, Guangzhou 510515, Guangdong, China e-mail: [email protected] Z. Wang · L. Xu · C. Yao Department of Urology, The Affiliated Hexian Memorial Hospital of Southern Medical University, Guangzhou 511400, Guangdong, China e-mail: [email protected] C. Yao e-mail: [email protected] Z. Chen Department of Urology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China e-mail: [email protected] Z. Su (*) Department of Urology, The First Affiliated Hospital of JINAN University, Guangzhou 510630, Guangdong, China e-mail: [email protected]
abdomen through a mini-umbilical incision. The hydrocele sac orifice was closed by an extraperitoneal purse-string suture placed around the internal ring with an ordinary taper needle and an endoclose needle. Results Of all the 279 patients, 16 (5.7 %) were found to have a potential patent processus vaginalis (PPV) on the contralateral side. Of the 164 boys diagnosed with “non-communicating” hydrocele preoperatively, 5 (3.0 %) had no PPV identified in laparoscope and the other 159 (97.0 %) had PPV actually. A total of 274 single-port minilaparoscopic procedures were performed, and all cases were successful without serious complications. The mean operative time was 19.5 and 24.8 min for unilateral and bilateral operations, respectively. Postoperative complications were noted in 4 cases, 2 (0.7 %) patients with scrotal edema, 1 (0.4 %) patient experienced an umbilical hernia, and 1 (0.4 %) patient with suture site abscess. During a median follow-up period of 9 months (range 6–24 months), postoperative hydrocele recurrence was seen in 2 patients (0.7 %). Conclusions This modified single-port minilaparoscopic technique is a safe, effective, and reliable procedure for pediatric hydroceles. Keywords Pediatric hydrocele · Single port · Minilaparoscopic technique
Introduction Hydrocele is a common congenital anomaly in children, occurring in 1–5 % of newborn males [1–3]. A hydrocele is a collection of fluid between the visceral and parietal layers of the tunica vaginalis. Traditionally, open surgery for a pediatric hydrocele is performed through an inguinal
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incision [4]. However, this approach requires wide muscle separation and carries the risk of damaging the vas deferens and spermatic vessel as well as the architecture of the inguinal canal [5–7]. Minimal access surgery is challenging the conventional surgical management of pediatric hydroceles. The clinical studies of laparoscopic pediatric hernia repair have been reported [8–11], but the literature on laparoscopic repair of hydroceles was sparse. In 1994, Janetschek et al. [12] first reported their experience with laparoscopic repair of pediatric hydroceles. The difference between hernia and communicating hydrocele was attributed to the caliber of the connection. But the channel to abdominal cavity in hydrocele was always thin, and this made the open surgery process relatively difficult. On the contrary, the narrow PPV made the laparoscopic repair technique relatively easy to operate. So, the laparoscopic repair technique may be more suitable for pediatric hydrocele patients. We modified a kind of single-port minilaparoscopic technique for the repair of pediatric hydroceles since 2008. Over a 4-year period, 279 boys underwent this minilaparoscopic technique and received follow-up in our center. In this study, we review the outcomes of these patients to assess this technique.
Materials and methods This was a retrospective review. From June 2008 and May 2012, a consecutive series of 279 boys with hydroceles underwent the single-port minilaparoscopic repair in our institution. The diagnosis was based on clinical presentation, physical examination, and ultrasound findings (to exclude inguinal hernia). Communicating hydrocele can change the size during the periods of increased intraabdominal pressure. “Non-communicating” hydroceles was present with no change in size. Ultrasound detection of the channel to abdominal cavity also was a diagnosis index. The principal outcome parameters included age, the side of the hydrocele, operative time, presence of contralateral PPV, length of hospital stay, and postoperative complications (Table 1). All patients were followed for more than 6 months. Data were collected from medical records and personal interviews. The hospital Institutional Review Board (IRB) approved the study protocol. All patients were placed in the supine position under general anesthesia. Local anesthesia (Lidocaine 0.5 %, about 2–3 ml) to the incision part was applied on the basis of general anesthesia. The surgeon operated standing on the contralateral side to the hydrocele. The monitor was placed at the patient’s feet. A single 3.0-mm incision was made at the lower part of the umbilicus using the open technique, and a 3-mm trocar was inserted. Pneumoperitoneum was
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World J Urol Table 1 Patient clinical characteristics and surgical results of the Sing-incision minilaproscopic technique Parameters (279 cases) The type in the preoperative diagnosis n (%) Communicating “Non-communicating” Median age (range), months Side of presentation, n (%) Right Left Contralateral PPV, n (%) No PPV, n (%) Median operative time, min (range) Unilateral Bilateral Hospital stay, days (range) Complications, n (%) Recurrence Scrotal edema Suture site abscess Umbilical hernia
115 (41.2) 164 (58.8) 39 (12–139) 127 (45.5) 152 (54.5) 16 (5.7) 5 (3.0) 19.5 (14–31) 24.8 (19–40) 2.1 (2–3) 2 (0.7) 2 (0.7) 1 (0.4) 1 (0.4)
PPV patent processus vaginalis
established, and insufflation pressure was maintained between 6 and 12 mmHg. A 3-mm laparoscope was introduced (Olympus Optical Co., Ltd., Shinjukuku, Tokyo, Japan). The entire abdominal cavity was examined, and the PPV could be clearly identified. The middle of the PPV shadow on the skin was the optimal location for the needle suture (Fig. 1b). The location was chosen by pressing the outside of the inguinal region with the tip of the endoclose needle. A 1.5-mm incision was made at the marked site by a sharp knife. A taper needle (1/2Arc 11 × 34 mm) (Fig. 1b) with non-absorbable 2–0 monofilament thread was introduced into the extraperitoneal space through the skin incision and moved forward until the tip of the needle reached the peritoneum. Under laparoscopic visualization, the vas deferens and vessels can be easily distinguished. The needle was moved along the preperitoneal space just outside the PPV from lateral to medial. It was kept extraperitoneal until it strided over the gonadal vessels and the vas deferens (Fig. 1c). The needle was removed from the abdominal cavity, leaving the suture in the peritoneal cavity. Through the previous stab incision, an endoclose needle was introduced along the opposite side of the PPV into the extraperitoneal space and moved forward to meet the previous suture. The endoclose needle tip was blunt, and there was a hook in the lateral of the tip. When the endoclose needle was inserted into the intra-abdominal space, the hook could be opened or closed by pushing the switch in needle’s end. The free end of the suture was picked up
World J Urol
Fig. 1 Single-port minilaparoscopic extraperitoneal hydrocele repair in a 26-month-old boy. a Instruments required: endoclose needle (Auto Suture, USA). b Extracorporeal suturing with a standard needle holder and an ordinary taper needle (1/2 Arc 11 × 34). c Suturing the PPV under laparoscopic visualization. d Endoclose needle was
inserted into the intra-abdominal space to retrieve the suture. e PPV was completely encircled and prepared to be ligated with extracorporeal tie. f Release of residual hydrocele fluid with a syringe and the cosmetic result of the single-port minilaparoscopic technique
and pulled out by the endoclose needle (Fig. 1d). The PPV then was completely encircled (Fig. 1e) and closed when the knot was tied subcutaneously. In the cases with large PPV or peritoneum fold, lifting up the abdominal wall over the internal ring may help the suture. Endoclose needle and taper needle also can be inserted simultaneously. Endoclose needle can be used to smoothing the peritoneum fold. If these failed, an additional port was recommended. Making the incision exceeding subcutaneous tissue and lifting up the abdominal wall could reduce the bunching of subcutaneous tissue when swiping a needle. All the suture procedures were performed in the preperitoneal space and under laparoscopic visualization. Care was taken to avoid damage to the gonadal vessels, epigastric vessels and the vas deferens. At the end of the operation, the umbilical incision was closed by suturing the peritoneum and fascia. Sometimes, it was necessary to release the residual hydrocele fluid with a syringe when the hydrocele sac was large (Fig. 1f). Lifting up the skin around the needle wound by toothed forceps could help the knot deeply seated under the skin and fat. The needle wound just needed a piece of skin bond. If a contralateral potential PPV was present, it was simultaneously repaired using the same procedure.
Perioperative psychological nursing care was taken to reduce the postoperative discomfort, and the patients were discharged when clinically appropriate. Patients were followed by physical examination or a scrotal ultrasound when scrotal edema was present. Parents were advised to contact us immediately if their children had any complication. The patients who lost follow-up were ruled out from our study.
Results Table 1 shows the demographics of the patients and the surgical results. The median age was 39 months (range 12–139 months). There were 115 boys with communicating hydrocele and 164 boys with “non-communicating” hydrocele diagnosed preoperatively. The hydrocele was right-sided in 127 (45.5 %) and left-sided in 152 (54.5 %). Of the 164 patients with “non-communicating” hydrocele, 5 (3.0 %) had no PPV identified at laparoscopy and were converted to open surgery through a scrotal incision. The other 159 patients were found to have PPV and were communicating style actually. Of all the 279 patients, 16 (5.7 %) were found to have a potential PPV on the contralateral side and subsequent repair was performed. A
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total of 274 single-incision minilaparoscopic procedures were performed, and all cases were successful without serious complications. The mean operative time was 19.5 and 24.8 min for unilateral (range 14–31 min) and bilateral (range 19–40 min), respectively. The mean hospital stay was 2.1 days (range 2–3 days). There are five cases which need an additional port to assist the suture of peritoneum. During a median follow-up period of 9 months (range 6–29 months), there were 2 (0.7 %) recurrences and no testicular atrophy. The two recurrences occurred in 2 and 5 months postoperatively, respectively. The two recurrent hydroceles underwent open trans-inguinal repair and was followed up for 12 months; no recurrence was detected. Postoperative complications were noted in 4 cases: 2 (0.8 %) patients with scrotal edema, 1 patient experienced an umbilical hernia; and 1 patient suffered suture site abscess. The 2 patients with scrotal edema occurred within 1 week postoperatively. Mild edema of scrotum was the only symptom, and it did not company with any red, hot or pain. They both had complete resolution of the edema after 1 month without any treatment. The patients experienced umbilical hernia within 1 h. We reduced the hernia content and made a simple suture of the umbilicus under local anesthesia. The ulcerative wound of suture site (occurring within 1 month postoperatively) did not heal until we dislodged the tie knot. The patient was followed up for 12 months, and no recurrence was detected. Postoperative pain was slight, and no narcotic analgesia was necessary. The cosmetic results were excellent with only one invisible scar in the umbilicus (Fig. 1f).
Discussion Hydrocele is a common clinical problem in boys. Complete patency with a narrow opening at the internal ring that allows only fluid passage is referred to as a communicating hydrocele. In actual, most infant hydroceles are communicating, but the channel to abdominal cavity was thin and cannot be detected by ultrasound. In addition, most infant hydroceles do resolve without surgical treatment [13]. Hussein et al. [14] reported that 89 % of patients with infantile hydroceles had spontaneous resolution due to ongoing changes in the PPV. But there is no study that clearly demonstrates an inverse relationship between the likelihood of encountering a PPV and patient age. In the current study, there was no PPV identified in patients older than 12 years without suspecting its presence based on preoperative history and physical examination [4, 15]. In general, surgical intervention for pediatric hydrocele is recommended if it remains unresolved after the age of 12–24 months [15–17]. We recommend an age from 2 to 12 years as appropriate for considering this technique. The mean age of our
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patients was 39 months. In our series, 159 (97.0 %) boys diagnosed with “non-communicating” hydrocele preoperatively had PPV and were characteristic of the communicating hydrocele actually under the laparoscope. There were only five boys indeed without PPV and were converted to open surgery through a scrotal incision instead of inguinal incision. For these boys without PPV, we thought the singleport minilaparoscopy technique still had some significance because a scrotal approach could give a better cosmetic result and less complication than an inguinal incision [4]. There are many traditional methods for hydrocele repair described in the literature [18–20]. The application of laparoscopy for inguinal hernia repair in pediatric surgery is progressively gaining acceptance [8–11, 21]. But experiences of laparoscopic repair of pediatric hydrocele have been rarely reported. Laparoscopic procedures for repair of pediatric hydroceles differ in their approach to the internal ring, number of ports (one to three), suture methods, and techniques of knot tying [9, 22, 23]. This single-port minilaparoscopic technique was developed based on the principle of the traditional cut-down technique and the experience of laparoscopic hernia repair that utilizes complete extraperitoneal high ligation of the PPV. To achieve a better cosmetic result, we made some improvements and placed only one port through a 3-mm umbilical incision. Using this minimally invasive technique, we obtained a better cosmetic result (Fig. 2). By the use of the minilaparoscope, we were able to visualize the PPV before and during repair. It has been estimated that 3–30 % of patients present later with symptomatic hydrocele on the contralateral side, and examining the contralateral internal ring simultaneously was necessary [24]. In our series, 16 patients (5.7 %) were identified with a contralateral PPV that was repaired simultaneously. In addition, although this modified single-port technique uses only one port for laparoscopy, the mean operative time was similar to other reports [8–11, 23]. This technique simplifies the surgical manipulation. The semicircular radius of ordinary taper needle can match the physiologic curve of the PPV when there are no folds. In our series, the patients experienced minimal postoperative pain, and the cosmetic outcomes were outstanding. However, the mean hospitalization time was 2.1 days, more than other’s reports [8–11]. Actually, we thought this technique could be considered an ambulatory surgery. But the Chinese parent’s traditional concept regards the hospital as the safest place for recovery and hoped their boys to stay in hospital longer. There were two recurrences in our series, a recurrence rate of 0.7 %, which is similar to previous reports [12, 23]. The recurrent hydroceles were treated with traditional surgery through an inguinal incision. During open surgery, suture threads were found in situ along with part of the
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Fig. 2 Schematic illustration of the single-port minilaparoscopic technique. a The clinical anatomy of a hydrocele. b Under laparoscopic visualization, the needle sutures the PPV in the extraperitoneal space lateral to medial, astride the gonadal vessels, and the vas deferens. The needle is removed from the abdominal cavity, leaving the suture inside the peritoneal cavity. c Through the previous stab incision, an endoclose needle is introduced along the opposite side of the
PPV into the extraperitoneal space and moved forward to meet the previous suture. d Endoclose needle is inserted into the intra-abdominal space and picks up the suture; e the free end of the suture is pulled out by the endoclose needle, and the PPV is completely encircled. f The knot is tied subcutaneously, and the PPV is completely ligated
PPV. The cause may have been that the PPV was not completely sealed or the PPV was inadvertently cut by the knot. We believed the integrity of the PPV suture was the key to minimizing recurrences. Therefore, it was necessary to use a grasping forceps through another 3-mm incision for some cases with large PPV. Scrotal edema following laparoscopic hydrocele surgery was sparse in the reports. But scrotal edema following laparoscopic hernia repair surgery was a common complication [25]. In the study of laparoscopic hernia, clinical factors associated with scrotal edema formation were old age, large hernial defect, and the presence of distal indirect sac [26]. However, we thought the invisible pull, squeezing or injury to lymphatic vessels or vascular during operation process might be the most possible cause in our study. The follow-up period in our study was relatively short, although the minimum follow-up time in other studies ranged from 1 to 6 months [4, 23]. The frequent population
mobility in our area made the follow-up difficult. To meet both the requirements of surgery evaluation and the number of study cases, we chose 6 months as the minimum followup time. It is theoretically possible that the vas deferens or vessels can be pulled into the closure, and the purse-string suture may inflict pressure on them [27]. In addition, the deferens or vessels may be damaged by the encroachment of postoperative scar tissue [28]. These possible reasons might be potential risks on fertility. A long-term outcomes of fertility remained to be defined.
Conclusions This modified single-port minilaparoscopic technique is a safe, effective, and reliable procedure for pediatric hydroceles.
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Acknowledgments The authors thank Mr. Weizhao Zhou for his assistance in the drawing of schematic illustration. Conflict of interest No competing financial interests exist.
References 1. Drew JH, Parkinson P, Walstab JE et al (1977) Incidences and types of malformations in newborn infants. Med J Aust 1:945 2. Osifo OD, Osaigbovo EO (2008) Congenital hydrocele: prevalence and outcome among male children who underwent neonatal circumcision in Benin City, Nigeria. J Pediatr Urol 43:178–182 3. Marden PM, Smith DW, McDonald MJ (1964) Congenital anomalies in the newborn infant, including minor variations. A study of 4,412 babies by surface examination for anomalies and buccal smear for sex chromatin. J Pediatr Urol 64:357–371 4. Jason M, Wilson David S et al (2008) Hydrocele in the pediatric patient: inguinal or scrotal approach? J Urol 180:1724–1728 5. Partrick DA, Bensard DD, Karrer FM et al (1998) Is routine pathological evaluation of pediatric hernia sacs justified? J Pediatr Surg 33:1090–1094 6. Steigman CK, Sotelo-Avila C, Weber TR (1999) The incidence of spermatic cord structures in inguinal hernia sacs from male children. Am J Surg Pathol 23:880 7. Cam C, Celik C, Sancak A et al (2009) Inguinal herniorrhaphy in childhood may result in tubal damage and future infertility. Arch Gynecol Obstet 279:175–176 8. Schier F (2006) Laparoscopic inguinal hernia repair: a prospective personal series of 542 children. J Pediatr Surg 41:1081–1084 9. Bharathi RS, Arora M, Baskaran V (2008) Minimal access surgery of pediatric inguinal hernias: a review. Surg Endosc 22:1751–1762 10. Schier F, Montupet P, Esposito C (2002) Laparoscopic inguinal herniorrhaphy in children: a three-center experience with 933 repairs. J Pediatr Surg 37:395–397 11. Takehara H, Yakabe S, Kameoka K (2006) Laparoscopic percutaneous extraperitoneal closure for inguinal hernia in children: clinical outcome of 972 repairs done in 3 pediatric surgical institutions. J Pediatr Surg 41:1999–2003 12. Janetschek G, Reissigl A, Bartsch G (1994) Laparoscopic repair of pediatric hydroceles. J Endourol 8:415–417 13. Koski ME, Makari JH, Adams MC et al (2010) Infant communicating hydroceles-do they need immediate repair or might some clinically resolve? J Pediatr Surg 45:590–593
13
World J Urol 14. Naji H, Ingolfsson I, Isacson D et al (2012) Decision making in the management of hydroceles in infants and children. Eur J Pediatr 171:807–810 15. Hall NJ, Ron O, Eaton S, Pierro A (2011) Surgery for hydrocele in children-an avoidable excess? J Pediatr Surg 46:2401–2405 16. Fried AH, Epstein MH (1994) Childhood hydrocephalus: clinical features, treatment, and the slit-ventricle syndrome. Neurosurg Q 4:51–65 17. Kapur P, Caty MG, Glick PL (1998) Pediatric hernias and hydroceles. Pediatr Clin North Am 45:773–789 18. Sweeney DD, Smaldone MC, Docimo SG (2007) Minimally invasive surgery for urologic disease in children. Nat Clin Pract Urol 4:26–38 19. Jahnson S, Sandblom D, Holmäng S (2011) A randomized trial comparing 2 doses of polidocanol sclerotherapy for hydrocele or spermatocele. J Urol 186:1319–1323 20. Agbakwuru EA, Salako AA, Olajide AO et al (2008) Hydrocelectomy under local anaesthesia in a Nigerian adult population. Afr Health Sci 8:160–162 21. Endo M, Watanabe T, Nakano M et al (2009) Laparoscopic completely extraperitoneal repair of inguinal hernia in children: a single-institute experience with 1,257 repairs compared with cutdown herniorrhaphy. Surg Endosc 23:1706–1712 22. Ron O, Eaton S, Pierro A (2007) Systematic review of the risk of developing a metachronous contralateral inguinal hernia in children. Br J Surg 94:804–811 23. Wang D, Qiu J, Fang Y et al (2011) Laparoscopic extraperitoneal repair of symptomatic hydrocele in children: a single-center experience with 73 surgeries. J Endourol 25:1221–1225 24. Wulkan ML, Wiener ES, VanBalen N et al (1996) Laparoscopy through the open ipsilateral sac to evaluate presence of contralateral hernia. J Pediatr Surg 31:1174–1177 25. Misra MC, Kumar S, Bansal VK (2008) Total extraperitoneal (TEP) mesh repair of inguinal hernia in the developing world: comparison of low-cost indigenous balloon dissection versus direct telescopic dissection: a prospective randomized controlled study. Surg Endosc 22:1947–1958 26. Choi YY, Kim Z, Hur KY (2011) Swelling after laparoscopic total extraperitoneal repair of inguinal hernias: review of one surgeon’s experience in 1,065 cases. World J Surg 35:43–46 27. Schier F, Turial S, Hückstädt T et al (2008) Laparoscopic inguinal hernia repair does not impair testicular perfusion. J Pediatr Surg 43:131–135 28. Ridgway PF, Shah J, Darzi AW (2002) Male genital tract injuries after contemporary inguinal hernia repair. BJU Int 90:272–276
