Journal of Pediatric Surgery xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Operative Techniques
Laparoscopic single instrument closure of inguinal hernia in female children: A novel technique Ahmed AbdElgaffar Helal ⁎ Pediatric Surgery Department, Al-Azhar University, Cairo, Egypt
a r t i c l e
i n f o
Article history: Received 1 December 2014 Received in revised form 23 April 2015 Accepted 17 May 2015 Available online xxxx Key words: Minimal access surgery Single instrument closure Female hernia
a b s t r a c t Background: Inguinal hernia repair is the most common operation performed by pediatric surgeons, and herniotomy through a groin incision is the gold standard. Recently minimal access surgery (MAS) has challenged this conventional surgery. At the moment, cosmesis became the target of all MAS especially in female. So, MAS techniques have developed to become more minimally invasive, from 3 to 2 and now single port technique. However, most recent emerging techniques show a tendency for simple extracorporeal suturing with subcutaneous knotting, which has many drawbacks. We introduce a novel technique for laparoscopic repair of inguinal hernia in female children using laparoscopic single instrument closure (LSIC) with intracorporeal knotting. Patients and methods: This prospective study was conducted at Al-Azhar University Hospital, between February 2012 and August 2014. Sixty girls with 68 congenital inguinal hernias were subjected to LSIC. Criteria for enrollment include: female gender, unilateral or bilateral inguinal hernia. Exclusion criteria include: recurrent hernia, hernia in morbid obese children, complicated hernia, girls who could not tolerate pneumoperitoneum. The main outcome measurements include: operative time, feasibility of the procedure, complications and cosmesis. Results: A total of 60 girls with 68 congenital inguinal hernias were subjected to LSIC, with a mean age of 2.2 ± 2.25 years (range = 0.58–10.00 years). Complete purse string of internal inguinal ring (IIR) with intracorporeal knotting was done for all cases. All cases were completed laparoscopically without conversion. The mean operative time was 10.5 ± 2.2 minutes for unilateral hernia repair and 20 ± 4.3 for bilateral cases. All patients achieved full recovery without intraoperative or postoperative complications. Conclusion: LSIC of inguinal hernia in female children is feasible, simple, secure and more cosmetic. It avoids the drawbacks of extracorporeal knotting. © 2015 Elsevier Inc. All rights reserved.
The incidence of female inguinal hernia is 1.9%. It is interesting that 1 in 50 females will eventually develop inguinal hernia in her life time [1]. Although, laparoscopic inguinal hernia repair in children is gaining ground as a safe, feasible, and popular method [2], MAS for inguinal hernia repair in children is still a controversial topic, and many pediatric surgeons continue to debate its safety, efficacy, cosmesis as well as cost effectiveness [3]. Recently, many centers perform laparoscopic hernia repair in children with excellent visual exposure, minimal dissection, less postoperative pain, and better cosmetic results especially in female children. Traditionally, the two needle holder (TNH) technique is the most common technique used to close the IIR by either purse string or Z-shaped suture and there are some reports describing the insertion of a purse string suture by percutaneous techniques using conventional needle holder or endoscopically under laparoscopic guidance (subcutaneous endoscopically assisted ligation of the internal ring). However, the use of extracorporeal knotting causes many drawbacks, as undue tensions
⁎ Al-Houssain University Hospital, Darrasa, Cairo, Egypt. Tel.: +20 1005107647, +20 1110773436. E-mail address: [email protected].
on the tissues, loosening of the suture with high recurrence rate, development of granuloma, sinus, infection, and skin puckering at the site of a subcutaneously placed knot. All these drawbacks can be avoided with intracorporeal knot tying [4–6]. We introduce a novel technique for laparoscopic repair of inguinal hernia in female children, by using LSIC, with intracorporeal knotting [7]. The goal of this study is to describe the feasibility, safety and efficacy of LSIC of inguinal hernia in female children. 1. Patients and methods This prospective study was conducted at the Pediatric Surgery Unit of Al-Azhar University Hospitals, Cairo, Egypt, between February 2012 and June 2014. A total of 68 inguinal hernias were repaired with LSIC in 60 girls. Criteria for enrollment included: female gender, unilateral or bilateral inguinal hernia. Exclusion criteria included: recurrent hernia, hernia in morbid obese female, complicated hernia (e.g., incarcerated ovary), patients who could not tolerate pneumoperitoneum (e.g., congenital heart disease). All children were subjected to full history taking, thorough clinical examination, and routine laboratory investigations (CBC, BT, CT, liver and renal profile). The main outcome measurements include: operative time, feasibility of the procedure, complications and
http://dx.doi.org/10.1016/j.jpedsurg.2015.05.003 0022-3468/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Helal AA, Laparoscopic single instrument closure of inguinal hernia in female children: A novel technique, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.05.003
2
A.A. Helal / Journal of Pediatric Surgery xxx (2015) xxx–xxx
Fig. 1. a–c, The direction and position of the needle are adjusted by the needle holder, by pushing it against the peritoneum around the ring.
Fig. 2. a–c, The needle is advanced along the lateral margin and the floor of IIR under the peritoneum.
cosmesis. Ethical committee of our hospital approved the study protocol and a written informed parental consent was obtained.
1.1. Surgical technique The principle of our repair is closure of the IIR in female children with complete purse string suture using single laparoscopic needle holder instrument, with intracorporeal suture knotting. The procedure was begun by positioning the patient supine in Trendelenburg's position with tilting to the opposite side of the hernia. Through a supraumbilical incision, 5-mm 30 degree angled telescope, was inserted via a 5-mm port. Pneumoperitoneum was created to pressure of 8–12 mmHg (according to age). The pelvis was carefully inspected. The uterus was identified, and the inguinal rings were evaluated. If a contralateral hernia was identified, it will be repaired at the same time with only few minutes added to the procedure, with no additional instruments or incisions. A 3 mm stab incision was made in the ipsilateral mid clavicular line (according to the hernia side) at the level of the umbilicus, to introduce 3-mm laparoscopic needle holder directly through the abdominal wall, holding the end of the thread just before its junction with the needle (2-0 polyester, round needle), while the long end of the thread was held outside the abdomen. The direction and position of the needle were adjusted by the needle holder
Fig. 3. a and b, Backward movement of the needle holder along the medial margin of IIR.
manipulating it against the posterior abdominal wall (Fig. 1A–C). We started our repair by introducing the needle at 3 o'clock meridian (on both sides) in the peritoneal leaflet at the level of IIR and then the needle was advanced along the inferior margin of IIR (Fig. 2A–C). Then we take it out again into the peritoneal cavity at 9 o'clock meridian (Fig. 3A and B). To reintroduce it again through this last point, to encircle the superior half of the IIR, and to come out again from the same opening at 3 o'clock meridian (Fig. 4A and B) encircling the IIR completely without any skip areas (Fig. 5A and B). We used the single instrument intracorporeal knot tie described by Ismail and Shalaby [7].
2. Results Overall, 60 girls with 68 inguinal hernias underwent laparoscopic hernia repair using LSIC technique. Demographic, preoperative, intraoperative, and postoperative data were collected and analyzed. They were 60 females, with 68 hernia with a mean age of 2.2 ± 2.25 years (range = 0.58–10.00 years). The demographic data of all patients were shown in Table 1. LSIC technique has been used for closure of IIR with intracorporeal knot tie and all cases were completed laparoscopically without conversion. The mean operating time was 10.5 ± 2.3 minutes for unilateral cases and 20 ± 4.3 minutes for bilateral cases. All patients achieved full recovery without intraoperative or postoperative
Fig. 4. a and b, Then along the superior margin of the IIR to complete the purse suture.
Please cite this article as: Helal AA, Laparoscopic single instrument closure of inguinal hernia in female children: A novel technique, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.05.003
A.A. Helal / Journal of Pediatric Surgery xxx (2015) xxx–xxx
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Fig. 5. a and b, Closure of the IIR completely without any skips areas with single instrument intracorporeal knotting. c, Excellent cosmetic results.
complications. There was 1 recurrence (1/68; 1.47%). All children went home at the same day. The mean hospital stay was 7.79 ± 1.28 hours (range, 5–19 hours). The cosmetic results were excellent (Fig. 5C). The mean follow-up period was 12 months (range 6–24 months).
3. Discussion The standard repair of inguinal hernia in females involves a small groin incision on the affected side, with or without incision of the external oblique muscle and opening of the external ring, dissection of the hernia sac, and high ligation and excision of the sac. Reconstruction of the inguinal ring is not routinely necessary [8]. Open herniotomy is an excellent method of repair in the pediatric population. However, it carries the potential risk of tubal or ovarian damage which may cause infertility [9,10]. Laparoscopic approach is rapidly gaining popularity with more and more studies validating its feasibility, safety, and efficacy [11,3]. Advantages of laparoscopic inguinal hernia repair include excellent visual exposure, the ability to approach IIR from within, leaving the outer abdominal wall intact, evaluation of the contralateral side, minimal dissection, avoidance of access trauma and decreased operative time especially in recurrent and obese cases [12]. Many minimally invasive approaches have been proposed for pediatric inguinal hernia repair, and become the procedure of choice in most institutions including subcutaneous endoscopically assisted ligation, and percutaneous internal ring suturing [13,14]. In the open operation, the incisions are small, the operation is easy, and there is a low cost, with minimal postoperative pain [15]. In addition, laparoscopic approaches have a troubling rate of recurrence and a prolonged learning curve [16]. There is also justifiable concern that the spermatic cord
Table 1 Demographic data of all patients. Demographic data
Number
Number of patient Sex Age Mean Range
60
% 100% Female 2.2 ± 2.25 years 0.58–10.00 years
Presentation Clinical Left inguinal hernia. Right inguinal hernia Operative Bilateral inguinal hernia (OPPV)
42 18
70% 30%
8 (of clinically left)
13.3%
Nil 1 recurrence
Nil 1.47%
Complications Type Intraoperative Postoperative
structures cannot be protected as well as in the open approach [17]. On the other hand, female pediatric inguinal hernias are inherently simpler to repair because there is no need to dissect and protect the structures in the spermatic cord [18]. From the author view, one of the advantages of LSIC is the ability to pick up OPPV, thus preventing metachronous hernias. The reported rates of OPPV in literature are 23–37%. Using the LSIC approach, these defects were easily repaired at the same operation without any need for additional instruments or additional incisions and with minimal additional time (9 minutes). An alternative method of assessing for OPPV is the use of transinguinal diagnostic laparoscopy with an angled scope. However, there is occasionally a peritoneal fold on the medial side of the inguinal ring that obscures the view. In addition, if an OPPV is encountered, a contralateral incision is required [19,20]. Inguinal hernia in females should raise the surgeons' suspicion about the child's nuclear sex, particularly if the condition is bilateral. About 2% of the girls with inguinal hernia have been reported to be having an intersex differentiation syndrome. Approximately 1.6% of these children presenting with inguinal hernia and having apparent female genitalia prove to be of male nuclear sex [21]. LSIC allows careful inspection of the uterus, ovaries, and fallopian tubes, to detect any disorder of sexual differentiation. Also, closure of opened IIR in that child was not advisable owing to the possibility of further treatment of sex differentiation disorders. One of the major drawbacks of laparoscopic inguinal hernia repairs in children has been the high rate of recurrences. This is unacceptable, as open inguinal hernia repairs have a very low recurrence rate (less than 1%). Yang et al. [22] in their meta-analysis stated that the recurrence rate after laparoscopic hernia when compared to conventional open hernia is the matter of controversy, they reported that the recurrence was higher after laparoscopic surgery in two of their meta-analysis studies, lower in other three studies and they reported no deference in other two studies. In the present study, we had only 1 recurrence, and occurred very early (the first case in our series, and recurrence occurred in the immediate postoperative period). At that time, we were in the learning curve, and it may be owing to skip area in the IIR. The redo surgery for this case was performed with open herniotomy (as the parent refused redo laparoscopy). After that no recurrence or complications have been observed to date. We started LSIC technique for repair of female inguinal hernia in our department after gaining large experiences in different laparoscopic procedures for inguinal hernia repair. Complete encirclement of the neck of the sac at the IIR without skip areas, and without dissecting or protecting spermatic cord structures in female children, prevents recurrence. It also may result in preventing the development of hydrops of Nuck's canal. Becmeur et al. [16] asked a question about which of the following laparoscopic techniques is the most efficient for pediatric inguinal hernia cases: ligature alone of the hernia sac, dividing the peritoneum at the IIR, without ligature of the hernia sac, or complete separation of the sac at IIR by dissection method. They concluded that, patent processus vaginalis (PPV) must be treated as that done by an open
Please cite this article as: Helal AA, Laparoscopic single instrument closure of inguinal hernia in female children: A novel technique, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.05.003
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A.A. Helal / Journal of Pediatric Surgery xxx (2015) xxx–xxx
approach. This was achieved with complete separation of the sac at IIR, which remained in the scrotal pouch or in the labia majora, and suturing the peritoneum at the IIR. From their opinion this technique requires no more time than an open operation, and that pain and discomfort resolved very quickly [16]. Giseke et al. [23] reported that, laparoscopic hernia repair should stay as close as possible to the open approach. So, they considered the use of laparoscopic reproduction of the inguinal approach, in their series on 385 children (178 girls and 207 boys). He incised the peritoneum circumferentially at the IIR and the distal processus vaginalis was partially resected or dropped in the inguinal canal and the peritoneum was closed with nonabsorbable sutures. Despite his use of dissection technique, he had 4 recurrent hernias (1 girl and 3 boys) in his series (1.04% of his treated children and 0.76% of his hernia repairs). He considered his rate of recurrence being in the lower average when compared to that reported in the literature (recurrence rate after laparoscopic repair has been reported at between 0 and 4.4%) [23]. Recently, Lee et al. [24] raised again the following question “A pursestring suture at the level of internal inguinal ring, taking only the peritoneum leaving the distal sac: is it enough for inguinal hernia in pediatric patients?” They performed their series on 98 children (67 males, 31 females). The PPV was encircled laparoscopically with nonabsorbable suture, by purse-string suture at the level of the IIR taking only the peritoneum leaving the distal sac, and the knot was tied intracorporeally. They did not report any recurrence in their patients during the followup period. The only two postoperative complications were, one boy had a mild hydrocele in the immediate postoperative period, and it was resolved 7 days later. The second was an umbilical port site infection, and it was fixed via wound dressing. He concludes that the laparoscopic purse-string suture of internal inguinal opening of hernia sac could be a safe, effective, and reliable alternative for management of pediatric inguinal hernia [24]. The use of intracorporeal knotting in LSIC is more superior to other MAS techniques, which use extracorporeal, with many disadvantages as the undue tensions on the tissues, losing of the suture with high recurrence rate, development of granuloma or sinus, infection, and skin puckering at the site of a subcutaneously placed knot. Intracorporeal knotting avoids the undue tension on tissues as does the extracorporeal tie. Although extracorporeal suture tie is a good method for tying sutures, however it needs extra instrument (tie pusher) in addition, repeated entry and removal of the tie pusher through the portless opening may result in increased operative time and difficulty of repeated negotiation of the opening. Some reports claimed that extracorporeal knot may result in undue tension on tissue [25]. If we look at the simplicity of this procedure, it no doubt has a learning curve but in the opinion of the author, it is a relatively short one. Especially for pediatric surgeons who are accustomed to using the needle holder to dissect or purse the internal ring with intracorporeal knotting. An indicator of the learning curve gradient will be the decreased operative times and recurrence rates as the number of cases increases. In our department, we trained the junior pediatric surgeon on how to use the LSIC and that the movement of the hand is from the wrist joint not from elbow.
4. Conclusions LSIC of female inguinal hernia is feasible, simple, secure and more cosmetic. It permits extension of benefits of MAS. It reduces operative time in bilateral cases (unlike open surgery in which time is twice as long, as it consists of two separate procedures with actually no common parts beyond cleaning the surgical field). It allows for quick return to normal activity of children. References [1] Tan HL. Laparoscopic repair of inguinal hernias in children. J Pediatr Surg 2001;36: 833–8. [2] Lukong CS. Surgical techniques of laparoscopic inguinal hernia repair in childhood: a critical appraisal. J Surg Tech Case Rep 2012;4:1–5. [3] 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. [4] Chow A, Purkayastha S, Paraskeva P. Appendicectomy and cholecystectomy using single-incision laparoscopic surgery (SILS): the first UK experience. Surg Innov 2009;16:211–7. [5] de Armas IA, Garcia I, Pimpalwar A. Laparoscopic single port surgery in children using Triport: our early experience. Pediatr Surg Int 2011;27:985–9. [6] Mcclain L, Streck C, Leshar A. Laparoscopic needle assisted inguinal hernia repair in 495 children. Surg Endosc 2014;29:781–6. [7] Ismail M, Shalaby R. Single instrument intracorporeal knot tying during single port laparoscopic hernia repair in children: a new simplified technique. J Pediatr Surg 2014;49:1044–8. [8] Weber TR, Tracy TF, Keller MS. Groin hernias and hydroceles. Ashcraft Pediatric surgery. Philadelphia: Elsevier Saunders; 2005. p. 697–705. [9] 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. [10] Cam C, Celik C, Sancak A, et al. Inguinal herniorrhaphy in childhood may result in tubal damage and future infertility. Arch Gynecol Obstet 2009;279:175–6. [11] Lee Y, Liang J. Experience with 450 cases of micro laparoscopic herniotomy in infants and children. Pediatr Endosurgery Innovative Tech 2002;6:25–8. [12] Saranga Bharathi R, Arora M, Baskaran V. Pediatric inguinal hernia: laparoscopic versus open surgery. JSLS 2008;12:277–81. [13] El-Gohary MA. Laparoscopic ligation of inguinal of inguinal hernia in girls. Pediatr Endocrinol Surg Innov Technol 1997;1:185–7. [14] Zallen G, Glick PL. Laparoscopic inversion and ligation inguinal hernia repair in girls. J Laparoendosc Adv Surg Tech 2007;17:143–5. [15] Schier F. Laparoscopic herniorrhaphy in girls. J Pediatr Surg 1998;33:1495–7. [16] Becmeur F, Philippe P, Lemandat SA, et al. A continuous series of 96 laparoscopic inguinal hernia repairs in children by a new technique. Surg Endosc 2004;18:1738–41. [17] Schier F. Laparoscopic inguinal hernia repair—a prospective personal series of 542 children. J Pediatr Surg 2006;41:1081–4. [18] Chinnaswamy P, Malladi V, Jani KV, et al. Laparoscopic inguinal hernia repair in children. JSLS 2005;9:393–8. [19] Harrison MR, Lee H, Albanese CT, et al. Subcutaneous endoscopically assisted ligation (SEAL) of the internal ring for repair of inguinal hernias in children: a novel technique. J Pediatr Surg 2005;40:1177–80. [20] Dorsey JH, Sharp HT, Chovan JD, et al. Laparoscopic knot strength: a comparison with conventional knots. Obstet Gynecol 1995;86:536–40. [21] George EK, Qudesluys MAM, Madern GC, et al. Inguinal hernia containing the uterus, fallopian tube and ovary in premature female infants. J Paediatr 2000;136:696–703. [22] Yang C, Zhang H, Pu J, et al. Laparoscopic vs open herniorrhaphy in the management of pediatric inguinal hernia: a systemic review and meta-analysis. J Pediatr Surg 2011;46:1824–34. [23] Giseke S, Glass M, Priyanka TP, et al. True laparoscopic herniotomy in children evaluation of long-term outcome. J Laparoendoscopic Adv Surg Tech A 2010;20:191–4. [24] Lee DY, Baik YH, Kwak BS, et al. A purse-string suture at the level of internal inguinal ring, taking only the peritoneum leaving the distal sac: is it enough for inguinal hernia in pediatric patients? Hernia 2015:1348-7. [25] Kumar A, Ramakrishnan TS. Single port laparoscopic repair of paediatric inguinal hernias: our experience at a secondary care centre. J Minim Access Surg 2013;9:7–12.
Please cite this article as: Helal AA, Laparoscopic single instrument closure of inguinal hernia in female children: A novel technique, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.05.003
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Operative Techniques
Laparoscopic single instrument closure of inguinal hernia in female children: A novel technique Ahmed AbdElgaffar Helal ⁎ Pediatric Surgery Department, Al-Azhar University, Cairo, Egypt
a r t i c l e
i n f o
Article history: Received 1 December 2014 Received in revised form 23 April 2015 Accepted 17 May 2015 Available online xxxx Key words: Minimal access surgery Single instrument closure Female hernia
a b s t r a c t Background: Inguinal hernia repair is the most common operation performed by pediatric surgeons, and herniotomy through a groin incision is the gold standard. Recently minimal access surgery (MAS) has challenged this conventional surgery. At the moment, cosmesis became the target of all MAS especially in female. So, MAS techniques have developed to become more minimally invasive, from 3 to 2 and now single port technique. However, most recent emerging techniques show a tendency for simple extracorporeal suturing with subcutaneous knotting, which has many drawbacks. We introduce a novel technique for laparoscopic repair of inguinal hernia in female children using laparoscopic single instrument closure (LSIC) with intracorporeal knotting. Patients and methods: This prospective study was conducted at Al-Azhar University Hospital, between February 2012 and August 2014. Sixty girls with 68 congenital inguinal hernias were subjected to LSIC. Criteria for enrollment include: female gender, unilateral or bilateral inguinal hernia. Exclusion criteria include: recurrent hernia, hernia in morbid obese children, complicated hernia, girls who could not tolerate pneumoperitoneum. The main outcome measurements include: operative time, feasibility of the procedure, complications and cosmesis. Results: A total of 60 girls with 68 congenital inguinal hernias were subjected to LSIC, with a mean age of 2.2 ± 2.25 years (range = 0.58–10.00 years). Complete purse string of internal inguinal ring (IIR) with intracorporeal knotting was done for all cases. All cases were completed laparoscopically without conversion. The mean operative time was 10.5 ± 2.2 minutes for unilateral hernia repair and 20 ± 4.3 for bilateral cases. All patients achieved full recovery without intraoperative or postoperative complications. Conclusion: LSIC of inguinal hernia in female children is feasible, simple, secure and more cosmetic. It avoids the drawbacks of extracorporeal knotting. © 2015 Elsevier Inc. All rights reserved.
The incidence of female inguinal hernia is 1.9%. It is interesting that 1 in 50 females will eventually develop inguinal hernia in her life time [1]. Although, laparoscopic inguinal hernia repair in children is gaining ground as a safe, feasible, and popular method [2], MAS for inguinal hernia repair in children is still a controversial topic, and many pediatric surgeons continue to debate its safety, efficacy, cosmesis as well as cost effectiveness [3]. Recently, many centers perform laparoscopic hernia repair in children with excellent visual exposure, minimal dissection, less postoperative pain, and better cosmetic results especially in female children. Traditionally, the two needle holder (TNH) technique is the most common technique used to close the IIR by either purse string or Z-shaped suture and there are some reports describing the insertion of a purse string suture by percutaneous techniques using conventional needle holder or endoscopically under laparoscopic guidance (subcutaneous endoscopically assisted ligation of the internal ring). However, the use of extracorporeal knotting causes many drawbacks, as undue tensions
⁎ Al-Houssain University Hospital, Darrasa, Cairo, Egypt. Tel.: +20 1005107647, +20 1110773436. E-mail address: [email protected].
on the tissues, loosening of the suture with high recurrence rate, development of granuloma, sinus, infection, and skin puckering at the site of a subcutaneously placed knot. All these drawbacks can be avoided with intracorporeal knot tying [4–6]. We introduce a novel technique for laparoscopic repair of inguinal hernia in female children, by using LSIC, with intracorporeal knotting [7]. The goal of this study is to describe the feasibility, safety and efficacy of LSIC of inguinal hernia in female children. 1. Patients and methods This prospective study was conducted at the Pediatric Surgery Unit of Al-Azhar University Hospitals, Cairo, Egypt, between February 2012 and June 2014. A total of 68 inguinal hernias were repaired with LSIC in 60 girls. Criteria for enrollment included: female gender, unilateral or bilateral inguinal hernia. Exclusion criteria included: recurrent hernia, hernia in morbid obese female, complicated hernia (e.g., incarcerated ovary), patients who could not tolerate pneumoperitoneum (e.g., congenital heart disease). All children were subjected to full history taking, thorough clinical examination, and routine laboratory investigations (CBC, BT, CT, liver and renal profile). The main outcome measurements include: operative time, feasibility of the procedure, complications and
http://dx.doi.org/10.1016/j.jpedsurg.2015.05.003 0022-3468/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Helal AA, Laparoscopic single instrument closure of inguinal hernia in female children: A novel technique, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.05.003
2
A.A. Helal / Journal of Pediatric Surgery xxx (2015) xxx–xxx
Fig. 1. a–c, The direction and position of the needle are adjusted by the needle holder, by pushing it against the peritoneum around the ring.
Fig. 2. a–c, The needle is advanced along the lateral margin and the floor of IIR under the peritoneum.
cosmesis. Ethical committee of our hospital approved the study protocol and a written informed parental consent was obtained.
1.1. Surgical technique The principle of our repair is closure of the IIR in female children with complete purse string suture using single laparoscopic needle holder instrument, with intracorporeal suture knotting. The procedure was begun by positioning the patient supine in Trendelenburg's position with tilting to the opposite side of the hernia. Through a supraumbilical incision, 5-mm 30 degree angled telescope, was inserted via a 5-mm port. Pneumoperitoneum was created to pressure of 8–12 mmHg (according to age). The pelvis was carefully inspected. The uterus was identified, and the inguinal rings were evaluated. If a contralateral hernia was identified, it will be repaired at the same time with only few minutes added to the procedure, with no additional instruments or incisions. A 3 mm stab incision was made in the ipsilateral mid clavicular line (according to the hernia side) at the level of the umbilicus, to introduce 3-mm laparoscopic needle holder directly through the abdominal wall, holding the end of the thread just before its junction with the needle (2-0 polyester, round needle), while the long end of the thread was held outside the abdomen. The direction and position of the needle were adjusted by the needle holder
Fig. 3. a and b, Backward movement of the needle holder along the medial margin of IIR.
manipulating it against the posterior abdominal wall (Fig. 1A–C). We started our repair by introducing the needle at 3 o'clock meridian (on both sides) in the peritoneal leaflet at the level of IIR and then the needle was advanced along the inferior margin of IIR (Fig. 2A–C). Then we take it out again into the peritoneal cavity at 9 o'clock meridian (Fig. 3A and B). To reintroduce it again through this last point, to encircle the superior half of the IIR, and to come out again from the same opening at 3 o'clock meridian (Fig. 4A and B) encircling the IIR completely without any skip areas (Fig. 5A and B). We used the single instrument intracorporeal knot tie described by Ismail and Shalaby [7].
2. Results Overall, 60 girls with 68 inguinal hernias underwent laparoscopic hernia repair using LSIC technique. Demographic, preoperative, intraoperative, and postoperative data were collected and analyzed. They were 60 females, with 68 hernia with a mean age of 2.2 ± 2.25 years (range = 0.58–10.00 years). The demographic data of all patients were shown in Table 1. LSIC technique has been used for closure of IIR with intracorporeal knot tie and all cases were completed laparoscopically without conversion. The mean operating time was 10.5 ± 2.3 minutes for unilateral cases and 20 ± 4.3 minutes for bilateral cases. All patients achieved full recovery without intraoperative or postoperative
Fig. 4. a and b, Then along the superior margin of the IIR to complete the purse suture.
Please cite this article as: Helal AA, Laparoscopic single instrument closure of inguinal hernia in female children: A novel technique, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.05.003
A.A. Helal / Journal of Pediatric Surgery xxx (2015) xxx–xxx
3
Fig. 5. a and b, Closure of the IIR completely without any skips areas with single instrument intracorporeal knotting. c, Excellent cosmetic results.
complications. There was 1 recurrence (1/68; 1.47%). All children went home at the same day. The mean hospital stay was 7.79 ± 1.28 hours (range, 5–19 hours). The cosmetic results were excellent (Fig. 5C). The mean follow-up period was 12 months (range 6–24 months).
3. Discussion The standard repair of inguinal hernia in females involves a small groin incision on the affected side, with or without incision of the external oblique muscle and opening of the external ring, dissection of the hernia sac, and high ligation and excision of the sac. Reconstruction of the inguinal ring is not routinely necessary [8]. Open herniotomy is an excellent method of repair in the pediatric population. However, it carries the potential risk of tubal or ovarian damage which may cause infertility [9,10]. Laparoscopic approach is rapidly gaining popularity with more and more studies validating its feasibility, safety, and efficacy [11,3]. Advantages of laparoscopic inguinal hernia repair include excellent visual exposure, the ability to approach IIR from within, leaving the outer abdominal wall intact, evaluation of the contralateral side, minimal dissection, avoidance of access trauma and decreased operative time especially in recurrent and obese cases [12]. Many minimally invasive approaches have been proposed for pediatric inguinal hernia repair, and become the procedure of choice in most institutions including subcutaneous endoscopically assisted ligation, and percutaneous internal ring suturing [13,14]. In the open operation, the incisions are small, the operation is easy, and there is a low cost, with minimal postoperative pain [15]. In addition, laparoscopic approaches have a troubling rate of recurrence and a prolonged learning curve [16]. There is also justifiable concern that the spermatic cord
Table 1 Demographic data of all patients. Demographic data
Number
Number of patient Sex Age Mean Range
60
% 100% Female 2.2 ± 2.25 years 0.58–10.00 years
Presentation Clinical Left inguinal hernia. Right inguinal hernia Operative Bilateral inguinal hernia (OPPV)
42 18
70% 30%
8 (of clinically left)
13.3%
Nil 1 recurrence
Nil 1.47%
Complications Type Intraoperative Postoperative
structures cannot be protected as well as in the open approach [17]. On the other hand, female pediatric inguinal hernias are inherently simpler to repair because there is no need to dissect and protect the structures in the spermatic cord [18]. From the author view, one of the advantages of LSIC is the ability to pick up OPPV, thus preventing metachronous hernias. The reported rates of OPPV in literature are 23–37%. Using the LSIC approach, these defects were easily repaired at the same operation without any need for additional instruments or additional incisions and with minimal additional time (9 minutes). An alternative method of assessing for OPPV is the use of transinguinal diagnostic laparoscopy with an angled scope. However, there is occasionally a peritoneal fold on the medial side of the inguinal ring that obscures the view. In addition, if an OPPV is encountered, a contralateral incision is required [19,20]. Inguinal hernia in females should raise the surgeons' suspicion about the child's nuclear sex, particularly if the condition is bilateral. About 2% of the girls with inguinal hernia have been reported to be having an intersex differentiation syndrome. Approximately 1.6% of these children presenting with inguinal hernia and having apparent female genitalia prove to be of male nuclear sex [21]. LSIC allows careful inspection of the uterus, ovaries, and fallopian tubes, to detect any disorder of sexual differentiation. Also, closure of opened IIR in that child was not advisable owing to the possibility of further treatment of sex differentiation disorders. One of the major drawbacks of laparoscopic inguinal hernia repairs in children has been the high rate of recurrences. This is unacceptable, as open inguinal hernia repairs have a very low recurrence rate (less than 1%). Yang et al. [22] in their meta-analysis stated that the recurrence rate after laparoscopic hernia when compared to conventional open hernia is the matter of controversy, they reported that the recurrence was higher after laparoscopic surgery in two of their meta-analysis studies, lower in other three studies and they reported no deference in other two studies. In the present study, we had only 1 recurrence, and occurred very early (the first case in our series, and recurrence occurred in the immediate postoperative period). At that time, we were in the learning curve, and it may be owing to skip area in the IIR. The redo surgery for this case was performed with open herniotomy (as the parent refused redo laparoscopy). After that no recurrence or complications have been observed to date. We started LSIC technique for repair of female inguinal hernia in our department after gaining large experiences in different laparoscopic procedures for inguinal hernia repair. Complete encirclement of the neck of the sac at the IIR without skip areas, and without dissecting or protecting spermatic cord structures in female children, prevents recurrence. It also may result in preventing the development of hydrops of Nuck's canal. Becmeur et al. [16] asked a question about which of the following laparoscopic techniques is the most efficient for pediatric inguinal hernia cases: ligature alone of the hernia sac, dividing the peritoneum at the IIR, without ligature of the hernia sac, or complete separation of the sac at IIR by dissection method. They concluded that, patent processus vaginalis (PPV) must be treated as that done by an open
Please cite this article as: Helal AA, Laparoscopic single instrument closure of inguinal hernia in female children: A novel technique, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.05.003
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approach. This was achieved with complete separation of the sac at IIR, which remained in the scrotal pouch or in the labia majora, and suturing the peritoneum at the IIR. From their opinion this technique requires no more time than an open operation, and that pain and discomfort resolved very quickly [16]. Giseke et al. [23] reported that, laparoscopic hernia repair should stay as close as possible to the open approach. So, they considered the use of laparoscopic reproduction of the inguinal approach, in their series on 385 children (178 girls and 207 boys). He incised the peritoneum circumferentially at the IIR and the distal processus vaginalis was partially resected or dropped in the inguinal canal and the peritoneum was closed with nonabsorbable sutures. Despite his use of dissection technique, he had 4 recurrent hernias (1 girl and 3 boys) in his series (1.04% of his treated children and 0.76% of his hernia repairs). He considered his rate of recurrence being in the lower average when compared to that reported in the literature (recurrence rate after laparoscopic repair has been reported at between 0 and 4.4%) [23]. Recently, Lee et al. [24] raised again the following question “A pursestring suture at the level of internal inguinal ring, taking only the peritoneum leaving the distal sac: is it enough for inguinal hernia in pediatric patients?” They performed their series on 98 children (67 males, 31 females). The PPV was encircled laparoscopically with nonabsorbable suture, by purse-string suture at the level of the IIR taking only the peritoneum leaving the distal sac, and the knot was tied intracorporeally. They did not report any recurrence in their patients during the followup period. The only two postoperative complications were, one boy had a mild hydrocele in the immediate postoperative period, and it was resolved 7 days later. The second was an umbilical port site infection, and it was fixed via wound dressing. He concludes that the laparoscopic purse-string suture of internal inguinal opening of hernia sac could be a safe, effective, and reliable alternative for management of pediatric inguinal hernia [24]. The use of intracorporeal knotting in LSIC is more superior to other MAS techniques, which use extracorporeal, with many disadvantages as the undue tensions on the tissues, losing of the suture with high recurrence rate, development of granuloma or sinus, infection, and skin puckering at the site of a subcutaneously placed knot. Intracorporeal knotting avoids the undue tension on tissues as does the extracorporeal tie. Although extracorporeal suture tie is a good method for tying sutures, however it needs extra instrument (tie pusher) in addition, repeated entry and removal of the tie pusher through the portless opening may result in increased operative time and difficulty of repeated negotiation of the opening. Some reports claimed that extracorporeal knot may result in undue tension on tissue [25]. If we look at the simplicity of this procedure, it no doubt has a learning curve but in the opinion of the author, it is a relatively short one. Especially for pediatric surgeons who are accustomed to using the needle holder to dissect or purse the internal ring with intracorporeal knotting. An indicator of the learning curve gradient will be the decreased operative times and recurrence rates as the number of cases increases. In our department, we trained the junior pediatric surgeon on how to use the LSIC and that the movement of the hand is from the wrist joint not from elbow.
4. Conclusions LSIC of female inguinal hernia is feasible, simple, secure and more cosmetic. It permits extension of benefits of MAS. It reduces operative time in bilateral cases (unlike open surgery in which time is twice as long, as it consists of two separate procedures with actually no common parts beyond cleaning the surgical field). It allows for quick return to normal activity of children. References [1] Tan HL. Laparoscopic repair of inguinal hernias in children. J Pediatr Surg 2001;36: 833–8. [2] Lukong CS. Surgical techniques of laparoscopic inguinal hernia repair in childhood: a critical appraisal. J Surg Tech Case Rep 2012;4:1–5. [3] 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. [4] Chow A, Purkayastha S, Paraskeva P. Appendicectomy and cholecystectomy using single-incision laparoscopic surgery (SILS): the first UK experience. Surg Innov 2009;16:211–7. [5] de Armas IA, Garcia I, Pimpalwar A. Laparoscopic single port surgery in children using Triport: our early experience. Pediatr Surg Int 2011;27:985–9. [6] Mcclain L, Streck C, Leshar A. Laparoscopic needle assisted inguinal hernia repair in 495 children. Surg Endosc 2014;29:781–6. [7] Ismail M, Shalaby R. Single instrument intracorporeal knot tying during single port laparoscopic hernia repair in children: a new simplified technique. J Pediatr Surg 2014;49:1044–8. [8] Weber TR, Tracy TF, Keller MS. Groin hernias and hydroceles. Ashcraft Pediatric surgery. Philadelphia: Elsevier Saunders; 2005. p. 697–705. [9] 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. [10] Cam C, Celik C, Sancak A, et al. Inguinal herniorrhaphy in childhood may result in tubal damage and future infertility. Arch Gynecol Obstet 2009;279:175–6. [11] Lee Y, Liang J. Experience with 450 cases of micro laparoscopic herniotomy in infants and children. Pediatr Endosurgery Innovative Tech 2002;6:25–8. [12] Saranga Bharathi R, Arora M, Baskaran V. Pediatric inguinal hernia: laparoscopic versus open surgery. JSLS 2008;12:277–81. [13] El-Gohary MA. Laparoscopic ligation of inguinal of inguinal hernia in girls. Pediatr Endocrinol Surg Innov Technol 1997;1:185–7. [14] Zallen G, Glick PL. Laparoscopic inversion and ligation inguinal hernia repair in girls. J Laparoendosc Adv Surg Tech 2007;17:143–5. [15] Schier F. Laparoscopic herniorrhaphy in girls. J Pediatr Surg 1998;33:1495–7. [16] Becmeur F, Philippe P, Lemandat SA, et al. A continuous series of 96 laparoscopic inguinal hernia repairs in children by a new technique. Surg Endosc 2004;18:1738–41. [17] Schier F. Laparoscopic inguinal hernia repair—a prospective personal series of 542 children. J Pediatr Surg 2006;41:1081–4. [18] Chinnaswamy P, Malladi V, Jani KV, et al. Laparoscopic inguinal hernia repair in children. JSLS 2005;9:393–8. [19] Harrison MR, Lee H, Albanese CT, et al. Subcutaneous endoscopically assisted ligation (SEAL) of the internal ring for repair of inguinal hernias in children: a novel technique. J Pediatr Surg 2005;40:1177–80. [20] Dorsey JH, Sharp HT, Chovan JD, et al. Laparoscopic knot strength: a comparison with conventional knots. Obstet Gynecol 1995;86:536–40. [21] George EK, Qudesluys MAM, Madern GC, et al. Inguinal hernia containing the uterus, fallopian tube and ovary in premature female infants. J Paediatr 2000;136:696–703. [22] Yang C, Zhang H, Pu J, et al. Laparoscopic vs open herniorrhaphy in the management of pediatric inguinal hernia: a systemic review and meta-analysis. J Pediatr Surg 2011;46:1824–34. [23] Giseke S, Glass M, Priyanka TP, et al. True laparoscopic herniotomy in children evaluation of long-term outcome. J Laparoendoscopic Adv Surg Tech A 2010;20:191–4. [24] Lee DY, Baik YH, Kwak BS, et al. A purse-string suture at the level of internal inguinal ring, taking only the peritoneum leaving the distal sac: is it enough for inguinal hernia in pediatric patients? Hernia 2015:1348-7. [25] Kumar A, Ramakrishnan TS. Single port laparoscopic repair of paediatric inguinal hernias: our experience at a secondary care centre. J Minim Access Surg 2013;9:7–12.
Please cite this article as: Helal AA, Laparoscopic single instrument closure of inguinal hernia in female children: A novel technique, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.05.003
