Hernia DOI 10.1007/s10029-013-1181-9
ORIGINAL ARTICLE
Single-port laparoscopic extraperitoneal repair of pediatric inguinal hernias and hydroceles by using modified Kirschner pin: a novel technique W. Liu • R. Wu • G. Du
Received: 14 July 2013 / Accepted: 31 October 2013 Ó Springer-Verlag France 2013
Abstract Background The development of laparoscopic processus vaginalis repair has provided an alternative approach to the management of inguinal hernia and hydroceles in children. Here we describe our new technique for laparoscopic extraperitoneal ligation of processus vaginalis with subumbilical single-port using a modified Kirschner pin. Methods A 5-mm trocar for an operative laparoscope was placed through an infraumbilical incision. A Kirschner pin with a hole in one flat terminal was inserted at the point of the internal inguinal ring. The processus vaginalis was closed extracorporeally by a non-absorbable suture, which was introduced into the abdomen through the Kirschner pin performing dissection within the extraperitoneal space in a series of movements. When a contralateral patent processus vaginalis is present, laparoscopic-assisted extracorporeal ligation is performed during the same operation. Results Between September 2010 and September 2012, 211 children (130 cases of inguinal hernia and 81 cases of hydrocele) underwent processus vaginalis repair using this novel technique. A contralateral patent processus vaginalis was present and thus simultaneously closed in 20 patients with unilateral inguinal hernias and 12 patients with unilateral hydroceles. The mean operative time was 18 min (8–35 min). The mean follow-up period is 12 months (range 5–24 months), and no recurrence and complications has been observed to date. W. Liu R. Wu (&) Department of Pediatric Surgery, Provincial Hospital Affiliated to Shandong University, Jinan 250021, China e-mail: [email protected] G. Du Department of Pediatric Surgery, The People’s Hospital of Linyi City, Linyi 276003, China
Conclusions This article describes a unique technique of extracorporeal circuit ligation of processus vaginalis using a minimally invasive technique as afforded by a reused modified Kirschner pin. Single-port laparoscopic processus vaginalis repair using this instrument is feasible and seems to be safe. Keywords Single-incision laparoscopy Inguinal hernia Hydrocele Repair Children Technique
Introduction Inguinal hernias and hydroceles, because of failure to close the processus vaginalis, are common conditions of infancy and childhood [1]. The principle for the repair of pediatric inguinal hernias and hydroceles is the complete ligation of patent processus vaginalis [2, 3]. With the advent of laparoscopic era, laparoscopic repair of processus vaginalis is regarded as a safe and effective technique [4]. It has been established that laparoscopic hernia repair has the advantages over open procedure, such as better cosmesis, faster recovery, less postoperative pain, and simultaneous repair of contralateral patent processus vaginalis [4, 5]. Recently, it has been described that laparoscopic hernia repair with extracorporeal ligation, as compared with intracorporeal suturing, resulted in a marked reduction in operative time, low comparative recurrence rates, and excellent cosmetic results [6]. This article presents a unique technique of extracorporeal ligation of processus vaginalis in a series of movements performed using a modified Kirschner pin with a cannula and preperitoneal dissection with minimal injury to the subcutaneous tissues, nerves, and muscles.
123
Hernia
Patients and methods Between September 2010 and September 2012, a total of 130 consecutive children (age range, 10 months to 11 years; median 2.5 years; 113 boys, 17 girls) with inguinal hernias (38 left sided, 82 right sided, 10 bilateral; not including incarcerated hernia and sliding hernia) and a total of 81 male infants or children (age range, 1–9 years; median 3.3 years) with hydroceles (18 left sided, 50 right sided, 13 bilateral) underwent processus vaginalis repair using this novel technique. The diagnosis of inguinal hernia and hydrocele was based on clinical presentation and physical examination. This study was approved by our institutional review board. A retrospective chart review of all patients undergoing repair of their symptomatic hernias and hydroceles using this new technique was carried out. Data collection included demographics, unilateral vs. bilateral hernia or hydroceles, operative time, recurrence rate, and complications. The surgical technique is as follows: After the induction of general anesthesia, patients were placed in the supine position. The television screen was placed at the affected side and the surgeon operated by standing on the other side. A 5-mm port was inserted at the infraumbilical region for insertion of a 5-mm laparoscope and carbon dioxide pneumoperitoneum was maintained at 10–12 mmHg. An 18-mm Kirschner pin (Fig. 1) with a hole in one flat terminal (22-mm width), which a 2-0 nonabsorbable suture was threaded through the hole, was inserted at the point of the internal inguinal ring (Fig. 2a). The pin was then advanced extraperitoneally over the testicular vessels/spermatic duct or under the round ligament by performing dissection within the preperitoneal space (Fig. 2b). After this dissection, the pin penetrated the peritoneum on the opposite side, and a small opening was made in the peritoneum (Fig. 2c). The laparoscope was inserted into the loop of suture and the Kirschner pin was withdrawn with the end loop of the suture remaining in the abdominal cavity (Fig. 2e) and the ends remaining above the skin. A cannula was set outside the Kirschner pin into preperitoneal space before withdrawing the pin first to guarantee the second insertion of the pin through the same space (Fig. 2d). Then the Kirschner pin with another non-absorbable suture easily reached the upper half of the internal inguinal ring extraperitoneally along the cannula and was advanced on the same opening of the peritoneum and entered the loop (Fig. 2f–i). Using the same method, the Kirschner pin was withdrawn leaving the second suture loop in the abdominal cavity (Fig. 2j). The first suture was then removed from the abdomen together with the second suture. The processus vaginalis was closed and the circuit ligation was tied extracorporeally using the second suture (Fig. 2k). Before tying the
123
Fig. 1 The picture of the modified Kirschner pin with the cannula
knot of the suture, the scrotum was squeezed to expel the gas in the hernia sac while at the same time intraperitoneal pressure was reduced. After tying the knot, the ring closure was checked to see if it was air-tight by reinsufflation and was confirmed by the absence of hernial sac enlargement. The same procedure was performed on the contralateral side if there was patent processus vaginalis. No stitching was required for the pin puncture wound (Fig. 2l). The residual effusion in the hernia sac could be eliminated by puncture in the scrotum. Postoperatively, patients were discharged when it was clinically appropriate. All returned to the outpatient clinic 1 month after discharge and received a regular follow-up thereafter. All were followed with physical examinations to detect any recurrence of inguinal hernia or hydrocele.
Results The demographic and clinical characteristics of the patients are shown in Table 1. In 30 of the 211 patients, repair of hernia or hydrocele was performed using single-port laparoscopic surgery with forceps through another 3-mm trocar placed in the subumbilical incision because it was difficult to safely maneuver the Kirschner pin in the preperitoneal space without forceps. In 20 of the 120 unilateral inguinal hernias, a contralateral patent processus vaginalis was present and thus simultaneously closed, as was the case with a total of 12 unilateral hydroceles.
Hernia
Fig. 2 Intraoperative findings in a male patient with left inguinal hernia. a–c A modified Kirschner pin with a cannula navigated along the lower half of the internal inguinal ring, extraperitoneally crossed over the testicular vessels/spermatic duct (arrow in b), and penetrating the peritoneum to create a small opening. d A cannula was inserted into preperitoneal space along the pin. e The loop of the suture was left in the abdominal cavity (arrow: the cannula). f–i The
pin was reintroduced along the cannula into the same space, then was directed toward the upper half of the internal inguinal ring into the same small opening of the peritoneum and entered the loop. j The pin was withdrawn leaving the second suture loop in the abdominal cavity. k The processus vaginalis was closed after tying the sutures percutaneously. l External appearance after surgery
The median operation time (from skin incision to wound closure) was 18 min (8–35 min). All postoperative courses were uneventful without any complication, such as hematoma, infection, or anything related to laparoscopy or pneumoperitoneum. Children were discharged on the same day after surgery. The mean follow-up period is 12 months (range
5–24 months), and no patient had an ipsilateral recurrence or a metachronous contralateral occurrence of hydrocele or hernia to date. Meanwhile, none had chronic wound pain, abdominal pain, or any gastrointestinal symptom during this period. In operated boys, all the testes were correctly positioned in the scrotum and we have no testicular atrophy in this study.
123
Hernia Table 1 Data for the 211 children undergoing laparoscopic extraperitoneal repair of inguinal hernias and hydroceles Variables
Inguinal hernia
Hydrocele
Period
September 2010 and September 2012
No. of patients
130
81
Age
2.5 years (10 months to 11 years)
3.3 years (1 to 9 years)
No. of boys
113
81
No. of girls
17
0
Right (%)
82(63.1 %)
50(61.7 %)
Left (%)
38(29.2 %)
18(22.2 %)
Bilateral (%)
10(7.7 %)
13(16.1 %)
No. of contralateral patent processus vaginalis(%)
20(16.7 %)
12(17.6 %)
OP time, mins
8–35 min
Hospital stay
1 day
Follow-up
12 months (5–24 months)
Recurrence
0
Postoperative hydrocele
0
0
Postoperative testicular atrophy
0
0
0
Data are expressed as median (range) or count (percentage)
Discussion Inguinal hernia and hydrocele are the most common pediatric surgical operations and classically treated with an inguinal incision, followed by dissection and high ligation of the patent processus vaginalis to completely obliterate intestine and fluid drainage into the sac [1, 3]. Although an inguinal approach is familiar to most urological or pediatric surgeons, it may carry a risk of injury to the cord structures, such as the vas deferens, testicular vessels, or the ilioinguinal nerve [7]. In addition to an iatrogenic resection, these vital cord structures may also be damaged by electrocautery, suturing, or postoperative scarring [8]. Compared with the traditional inguinal approach, the minilaparoscopic high ligation is characterized by several advantages. The laparoscopic technique has the advantage that it is simple, feasible, and safe. Also, the contralateral internal inguinal ring and other hernia sites such as femoral, obturator, or internal hernia can be diagnosed and treated at same sitting and other occult pathologies may be diagnosed [9, 10]. The risk of injury to the vas deferens and cord structures in this procedure is lesser when compared to the conventional open technique [11–14]. Studies by Schier and Parelkar et al. have shown that laparoscopic inguinal hernia repair in children does not affect testicular perfusion or growth [15, 16]. The general advantages of laparoscopic technique such as cosmesis, low wound infection, less pain, and short hospital stay, all apply here [17]. Indeed, it is fast becoming the gold
123
standard for the treatment of inguinal hernia and hydrocele in children. With increasing interest, there has been a proliferation of various techniques in the laparoscopic repair of inguinal hernia in children. This proliferation has been orchestrated by refinements in methods of ligation of the patent processus vaginalis at the internal inguinal ring in order to improve results and the outcome of treatment. The various techniques are: extracorporeal or intracorporeal suturing and knotting, three- or single-port procedure, sac inversion and ligation technique in girls, flip-flap technique, and use of tissue adhesives. Studies show preference for extracorporeal technique because it is simple, safe, reproducible, and has low recurrent rates [18]. The other trend is toward the single-port technique because it results in virtually scarless abdomen as the surgical incision is hidden within the umbilicus [19, 20]. In laparoscopic extracorporeal hernia repair, it is important to prevent injury to nerves and muscles which could occur by their inclusion in the circuit suturing. At this point, as a modification of single-port endoscopic-assisted ligation with a homemade holed Kirschner pin and a cannula, dissection of the preperitoneal space becomes easier using the longer and flat Kirschner pin without injury of upper subcutaneous tissues and spermatic cord structures than using the epidural needle described in other report [21]. Furthermore, the fact that the Kirschner pin is passed through the cannula without complete removal of the cannula minimizes the chance of injury to subcutaneous tissues, nerves, and muscles in the upper portion of the circuit suturing. In a few cases with more wrinkles of patent processus vaginalis, damage to spermatic cord structures is also prevented by using additional forceps as the pin is advanced. As demonstrated in the present study, no patients experienced any recurrence or complications after a median follow-up of 12 months. Overall, we have shown this procedure with its incorporation of the modified Kirschner pin in conjunction with a one-port laparoscopic scheme to be simple, safe, and effective in managing inguinal hernias and hydroceles in the pediatric population. Further studies are required to determine whether this approach would benefit patient compared with the standard laparoscopic techniques and long-term outcomes remain to be defined. Conflict of interest All authors declare that they have no competing interest and no relevant financial interest.
References 1. Kapur P, Caty MG, Glick PL (1998) Pediatric hernias and hydroceles. Pediatr Clin North Am 45:773–789 2. Potts WJ, Riker WL, Lewis JE (1950) The treatment of inguinal hernia in infants and children. Ann Surg 132:566–576
Hernia 3. Rodriguez WC, Rodriguez DD, Fortuno RF (1981) The operative treatment of hydrocele: a comparison of 4 basic techniques. J Urol 125:804–805 4. Tsai Y, Wu C, Yang S (2007) Minilaparoscopic herniorrhaphy with hernia sac transection in children and young adults: a preliminary report. Surg Endosc 21:1623–1625 5. Tsai YC, Wu CC, Yang SS (2008) Is local anesthesia or oral analgesics necessary after mini-laparoscopic functional surgery in children and young adults?: a prospective randomized trial. Surg Laparosc Endosc Percutan Tech 18:344–347 6. Shalaby R, Ismail M, Dorgham A, Hefny K, Alsaied G, Gabr K, Abdelaziz M (2010) Laparoscopic hernia repair in infancy and childhood: evaluation of 2 different techniques. J Pediatr Surg 45:2210–2216 7. Wilson JM, Aaronson DS, Schrader R, Baskin LS (2008) Hydrocele in the pediatric patient: inguinal or scrotal approach? J Urol 180:1724–1727 8. Zahalsky MP, Berman AJ, Nagler HM (2004) Evaluating the risk of epididymal injury during hydrocelectomy and spermatocelectomy. J Urol 171:2291–2292 9. Schier F (2007) The laparoscopic spectrum of inguinal hernias and their recurrences. Pediatr Surg Int 23:1209–1213 10. Gorsler CM, Schier F (2003) Laparoscopic herniorrhaphy in children. Surg Endosc 17:571–573 11. SarangaBharathi R, Arora M, Baskaran V (2008) Pediatric inguinal hernia: laparoscopic versus open surgery. JSLS 12:277–281 12. Niyogi A, Tahim AS, Sherwood WJ, De Caluwe D, Madden NP, Abel RM, Haddad MJ, Clarke SA (2010) A comparative study
13.
14.
15. 16.
17. 18. 19.
20.
21.
examining open inguinal herniotomy with or without hernioscopy to laparoscopic inguinal hernia repair in a paediatric population. Pediatr Surg Int 20:387–392 Kuhry E, Van Veen RN, Langeveld HR, Steyerberg EW, Jeckel J, Bonjer H (2007) Open or total extraperitoneal inguinal hernia repair? A systemic review. Surg Endosc 21:161–166 Nah SA, Glacomello L, Eaton S, de Coppi P, Curry JI, Drake DP, Kiely EM, Pierro A (2011) Surgical repair of incarcerated inguinal hernia in children. Laparoscopic or open? Eur J Pediatr Surg 2:8–11 Schier F (2006) Laparoscopic inguinal hernia repair- a prospective series of 542 children. J Pediatr Surg 41:1081–1084 Parelkar SV, Oak S, Gupta R, Sanghvi B, Shimoga PH, Kaltari D, Prakash A, Shekhar R, Gupta A, Bachani M (2010) Laparoscopic inguinal hernia repair in a pediatric age group-experience with 437 children. J Pediatr Surg 45:789–792 Chan KL (2007) Laparoscopic repair of recurrent childhood inguinal hernias after open herniotomy. Hernia 11:37–40 SarangaBharathi R, Arora M, Baskaran V (2008) Minimal access surgery of pediatric hernia: a review. Surg Endosc 22:1751–1762 Rothenberg SS, Shipman K, Yoder S (2009) Experience with modified single port laparoscopic procedures in children. J Laparoendosc Adv Surg Tech A 19:695–698 Chang YT (2010) Technical refinements in single port laparoscopic surgery of inguinal hernia in infants and children. Diag Ther Endosc 2010:392847 Tatekawa Y (2012) Laparoscopic extracorporeal ligation of hernia defects using an epidural needle and preperitoneal hydrodissection. J Endourol 26:474–477
123
ORIGINAL ARTICLE
Single-port laparoscopic extraperitoneal repair of pediatric inguinal hernias and hydroceles by using modified Kirschner pin: a novel technique W. Liu • R. Wu • G. Du
Received: 14 July 2013 / Accepted: 31 October 2013 Ó Springer-Verlag France 2013
Abstract Background The development of laparoscopic processus vaginalis repair has provided an alternative approach to the management of inguinal hernia and hydroceles in children. Here we describe our new technique for laparoscopic extraperitoneal ligation of processus vaginalis with subumbilical single-port using a modified Kirschner pin. Methods A 5-mm trocar for an operative laparoscope was placed through an infraumbilical incision. A Kirschner pin with a hole in one flat terminal was inserted at the point of the internal inguinal ring. The processus vaginalis was closed extracorporeally by a non-absorbable suture, which was introduced into the abdomen through the Kirschner pin performing dissection within the extraperitoneal space in a series of movements. When a contralateral patent processus vaginalis is present, laparoscopic-assisted extracorporeal ligation is performed during the same operation. Results Between September 2010 and September 2012, 211 children (130 cases of inguinal hernia and 81 cases of hydrocele) underwent processus vaginalis repair using this novel technique. A contralateral patent processus vaginalis was present and thus simultaneously closed in 20 patients with unilateral inguinal hernias and 12 patients with unilateral hydroceles. The mean operative time was 18 min (8–35 min). The mean follow-up period is 12 months (range 5–24 months), and no recurrence and complications has been observed to date. W. Liu R. Wu (&) Department of Pediatric Surgery, Provincial Hospital Affiliated to Shandong University, Jinan 250021, China e-mail: [email protected] G. Du Department of Pediatric Surgery, The People’s Hospital of Linyi City, Linyi 276003, China
Conclusions This article describes a unique technique of extracorporeal circuit ligation of processus vaginalis using a minimally invasive technique as afforded by a reused modified Kirschner pin. Single-port laparoscopic processus vaginalis repair using this instrument is feasible and seems to be safe. Keywords Single-incision laparoscopy Inguinal hernia Hydrocele Repair Children Technique
Introduction Inguinal hernias and hydroceles, because of failure to close the processus vaginalis, are common conditions of infancy and childhood [1]. The principle for the repair of pediatric inguinal hernias and hydroceles is the complete ligation of patent processus vaginalis [2, 3]. With the advent of laparoscopic era, laparoscopic repair of processus vaginalis is regarded as a safe and effective technique [4]. It has been established that laparoscopic hernia repair has the advantages over open procedure, such as better cosmesis, faster recovery, less postoperative pain, and simultaneous repair of contralateral patent processus vaginalis [4, 5]. Recently, it has been described that laparoscopic hernia repair with extracorporeal ligation, as compared with intracorporeal suturing, resulted in a marked reduction in operative time, low comparative recurrence rates, and excellent cosmetic results [6]. This article presents a unique technique of extracorporeal ligation of processus vaginalis in a series of movements performed using a modified Kirschner pin with a cannula and preperitoneal dissection with minimal injury to the subcutaneous tissues, nerves, and muscles.
123
Hernia
Patients and methods Between September 2010 and September 2012, a total of 130 consecutive children (age range, 10 months to 11 years; median 2.5 years; 113 boys, 17 girls) with inguinal hernias (38 left sided, 82 right sided, 10 bilateral; not including incarcerated hernia and sliding hernia) and a total of 81 male infants or children (age range, 1–9 years; median 3.3 years) with hydroceles (18 left sided, 50 right sided, 13 bilateral) underwent processus vaginalis repair using this novel technique. The diagnosis of inguinal hernia and hydrocele was based on clinical presentation and physical examination. This study was approved by our institutional review board. A retrospective chart review of all patients undergoing repair of their symptomatic hernias and hydroceles using this new technique was carried out. Data collection included demographics, unilateral vs. bilateral hernia or hydroceles, operative time, recurrence rate, and complications. The surgical technique is as follows: After the induction of general anesthesia, patients were placed in the supine position. The television screen was placed at the affected side and the surgeon operated by standing on the other side. A 5-mm port was inserted at the infraumbilical region for insertion of a 5-mm laparoscope and carbon dioxide pneumoperitoneum was maintained at 10–12 mmHg. An 18-mm Kirschner pin (Fig. 1) with a hole in one flat terminal (22-mm width), which a 2-0 nonabsorbable suture was threaded through the hole, was inserted at the point of the internal inguinal ring (Fig. 2a). The pin was then advanced extraperitoneally over the testicular vessels/spermatic duct or under the round ligament by performing dissection within the preperitoneal space (Fig. 2b). After this dissection, the pin penetrated the peritoneum on the opposite side, and a small opening was made in the peritoneum (Fig. 2c). The laparoscope was inserted into the loop of suture and the Kirschner pin was withdrawn with the end loop of the suture remaining in the abdominal cavity (Fig. 2e) and the ends remaining above the skin. A cannula was set outside the Kirschner pin into preperitoneal space before withdrawing the pin first to guarantee the second insertion of the pin through the same space (Fig. 2d). Then the Kirschner pin with another non-absorbable suture easily reached the upper half of the internal inguinal ring extraperitoneally along the cannula and was advanced on the same opening of the peritoneum and entered the loop (Fig. 2f–i). Using the same method, the Kirschner pin was withdrawn leaving the second suture loop in the abdominal cavity (Fig. 2j). The first suture was then removed from the abdomen together with the second suture. The processus vaginalis was closed and the circuit ligation was tied extracorporeally using the second suture (Fig. 2k). Before tying the
123
Fig. 1 The picture of the modified Kirschner pin with the cannula
knot of the suture, the scrotum was squeezed to expel the gas in the hernia sac while at the same time intraperitoneal pressure was reduced. After tying the knot, the ring closure was checked to see if it was air-tight by reinsufflation and was confirmed by the absence of hernial sac enlargement. The same procedure was performed on the contralateral side if there was patent processus vaginalis. No stitching was required for the pin puncture wound (Fig. 2l). The residual effusion in the hernia sac could be eliminated by puncture in the scrotum. Postoperatively, patients were discharged when it was clinically appropriate. All returned to the outpatient clinic 1 month after discharge and received a regular follow-up thereafter. All were followed with physical examinations to detect any recurrence of inguinal hernia or hydrocele.
Results The demographic and clinical characteristics of the patients are shown in Table 1. In 30 of the 211 patients, repair of hernia or hydrocele was performed using single-port laparoscopic surgery with forceps through another 3-mm trocar placed in the subumbilical incision because it was difficult to safely maneuver the Kirschner pin in the preperitoneal space without forceps. In 20 of the 120 unilateral inguinal hernias, a contralateral patent processus vaginalis was present and thus simultaneously closed, as was the case with a total of 12 unilateral hydroceles.
Hernia
Fig. 2 Intraoperative findings in a male patient with left inguinal hernia. a–c A modified Kirschner pin with a cannula navigated along the lower half of the internal inguinal ring, extraperitoneally crossed over the testicular vessels/spermatic duct (arrow in b), and penetrating the peritoneum to create a small opening. d A cannula was inserted into preperitoneal space along the pin. e The loop of the suture was left in the abdominal cavity (arrow: the cannula). f–i The
pin was reintroduced along the cannula into the same space, then was directed toward the upper half of the internal inguinal ring into the same small opening of the peritoneum and entered the loop. j The pin was withdrawn leaving the second suture loop in the abdominal cavity. k The processus vaginalis was closed after tying the sutures percutaneously. l External appearance after surgery
The median operation time (from skin incision to wound closure) was 18 min (8–35 min). All postoperative courses were uneventful without any complication, such as hematoma, infection, or anything related to laparoscopy or pneumoperitoneum. Children were discharged on the same day after surgery. The mean follow-up period is 12 months (range
5–24 months), and no patient had an ipsilateral recurrence or a metachronous contralateral occurrence of hydrocele or hernia to date. Meanwhile, none had chronic wound pain, abdominal pain, or any gastrointestinal symptom during this period. In operated boys, all the testes were correctly positioned in the scrotum and we have no testicular atrophy in this study.
123
Hernia Table 1 Data for the 211 children undergoing laparoscopic extraperitoneal repair of inguinal hernias and hydroceles Variables
Inguinal hernia
Hydrocele
Period
September 2010 and September 2012
No. of patients
130
81
Age
2.5 years (10 months to 11 years)
3.3 years (1 to 9 years)
No. of boys
113
81
No. of girls
17
0
Right (%)
82(63.1 %)
50(61.7 %)
Left (%)
38(29.2 %)
18(22.2 %)
Bilateral (%)
10(7.7 %)
13(16.1 %)
No. of contralateral patent processus vaginalis(%)
20(16.7 %)
12(17.6 %)
OP time, mins
8–35 min
Hospital stay
1 day
Follow-up
12 months (5–24 months)
Recurrence
0
Postoperative hydrocele
0
0
Postoperative testicular atrophy
0
0
0
Data are expressed as median (range) or count (percentage)
Discussion Inguinal hernia and hydrocele are the most common pediatric surgical operations and classically treated with an inguinal incision, followed by dissection and high ligation of the patent processus vaginalis to completely obliterate intestine and fluid drainage into the sac [1, 3]. Although an inguinal approach is familiar to most urological or pediatric surgeons, it may carry a risk of injury to the cord structures, such as the vas deferens, testicular vessels, or the ilioinguinal nerve [7]. In addition to an iatrogenic resection, these vital cord structures may also be damaged by electrocautery, suturing, or postoperative scarring [8]. Compared with the traditional inguinal approach, the minilaparoscopic high ligation is characterized by several advantages. The laparoscopic technique has the advantage that it is simple, feasible, and safe. Also, the contralateral internal inguinal ring and other hernia sites such as femoral, obturator, or internal hernia can be diagnosed and treated at same sitting and other occult pathologies may be diagnosed [9, 10]. The risk of injury to the vas deferens and cord structures in this procedure is lesser when compared to the conventional open technique [11–14]. Studies by Schier and Parelkar et al. have shown that laparoscopic inguinal hernia repair in children does not affect testicular perfusion or growth [15, 16]. The general advantages of laparoscopic technique such as cosmesis, low wound infection, less pain, and short hospital stay, all apply here [17]. Indeed, it is fast becoming the gold
123
standard for the treatment of inguinal hernia and hydrocele in children. With increasing interest, there has been a proliferation of various techniques in the laparoscopic repair of inguinal hernia in children. This proliferation has been orchestrated by refinements in methods of ligation of the patent processus vaginalis at the internal inguinal ring in order to improve results and the outcome of treatment. The various techniques are: extracorporeal or intracorporeal suturing and knotting, three- or single-port procedure, sac inversion and ligation technique in girls, flip-flap technique, and use of tissue adhesives. Studies show preference for extracorporeal technique because it is simple, safe, reproducible, and has low recurrent rates [18]. The other trend is toward the single-port technique because it results in virtually scarless abdomen as the surgical incision is hidden within the umbilicus [19, 20]. In laparoscopic extracorporeal hernia repair, it is important to prevent injury to nerves and muscles which could occur by their inclusion in the circuit suturing. At this point, as a modification of single-port endoscopic-assisted ligation with a homemade holed Kirschner pin and a cannula, dissection of the preperitoneal space becomes easier using the longer and flat Kirschner pin without injury of upper subcutaneous tissues and spermatic cord structures than using the epidural needle described in other report [21]. Furthermore, the fact that the Kirschner pin is passed through the cannula without complete removal of the cannula minimizes the chance of injury to subcutaneous tissues, nerves, and muscles in the upper portion of the circuit suturing. In a few cases with more wrinkles of patent processus vaginalis, damage to spermatic cord structures is also prevented by using additional forceps as the pin is advanced. As demonstrated in the present study, no patients experienced any recurrence or complications after a median follow-up of 12 months. Overall, we have shown this procedure with its incorporation of the modified Kirschner pin in conjunction with a one-port laparoscopic scheme to be simple, safe, and effective in managing inguinal hernias and hydroceles in the pediatric population. Further studies are required to determine whether this approach would benefit patient compared with the standard laparoscopic techniques and long-term outcomes remain to be defined. Conflict of interest All authors declare that they have no competing interest and no relevant financial interest.
References 1. Kapur P, Caty MG, Glick PL (1998) Pediatric hernias and hydroceles. Pediatr Clin North Am 45:773–789 2. Potts WJ, Riker WL, Lewis JE (1950) The treatment of inguinal hernia in infants and children. Ann Surg 132:566–576
Hernia 3. Rodriguez WC, Rodriguez DD, Fortuno RF (1981) The operative treatment of hydrocele: a comparison of 4 basic techniques. J Urol 125:804–805 4. Tsai Y, Wu C, Yang S (2007) Minilaparoscopic herniorrhaphy with hernia sac transection in children and young adults: a preliminary report. Surg Endosc 21:1623–1625 5. Tsai YC, Wu CC, Yang SS (2008) Is local anesthesia or oral analgesics necessary after mini-laparoscopic functional surgery in children and young adults?: a prospective randomized trial. Surg Laparosc Endosc Percutan Tech 18:344–347 6. Shalaby R, Ismail M, Dorgham A, Hefny K, Alsaied G, Gabr K, Abdelaziz M (2010) Laparoscopic hernia repair in infancy and childhood: evaluation of 2 different techniques. J Pediatr Surg 45:2210–2216 7. Wilson JM, Aaronson DS, Schrader R, Baskin LS (2008) Hydrocele in the pediatric patient: inguinal or scrotal approach? J Urol 180:1724–1727 8. Zahalsky MP, Berman AJ, Nagler HM (2004) Evaluating the risk of epididymal injury during hydrocelectomy and spermatocelectomy. J Urol 171:2291–2292 9. Schier F (2007) The laparoscopic spectrum of inguinal hernias and their recurrences. Pediatr Surg Int 23:1209–1213 10. Gorsler CM, Schier F (2003) Laparoscopic herniorrhaphy in children. Surg Endosc 17:571–573 11. SarangaBharathi R, Arora M, Baskaran V (2008) Pediatric inguinal hernia: laparoscopic versus open surgery. JSLS 12:277–281 12. Niyogi A, Tahim AS, Sherwood WJ, De Caluwe D, Madden NP, Abel RM, Haddad MJ, Clarke SA (2010) A comparative study
13.
14.
15. 16.
17. 18. 19.
20.
21.
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