JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 24, Number 3, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/lap.2013.0288
Single-Port Laparoscopic Percutaneous Extraperitoneal Closure Using an Innovative Apparatus for Pediatric Inguinal Hernia Suolin Li, MD, Lin Liu, MD, and Meng Li, MD
Abstract
Background: Laparoscopic procedures for pediatric inguinal hernia (PIH) have numerous techniques and continue to evolve, with a trend toward increasing use of extracorporeal knotting and decreasing use of working ports and endoscopic instruments. Single-port laparoscopic percutaneous extraperitoneal closure (SPLPEC) with variable devices seems to be one of the most simple and reliable methods. Here the authors describe and evaluate the applicable effects of SPLPEC using an innovative two-hooked core hernia apparatus. Materials and Methods: Between June 2008 and October 2011, 72 children with indirect inguinal hernia underwent SPLPEC with an innovative two-hooked core hernia apparatus. A 5-mm laparoscope was placed through a transumbilical port. Without an assistant working port, the two-hooked core hernia apparatus with a 2-0 nonabsorbable suture was inserted at the point of the internal inguinal ring. It could be readily kept in an identical subcutaneous path for introducing and withdrawing the suture. The extraperitoneal knot-tying could tautly enclose the hernia defect without peritoneal gaps and upper subcutaneous tissues. During the same period, 63 cases with PIH underwent SPLPEC with a single-hooked hernia device. Technical essentials, mean operation time, and intra- and postoperative complications were compared. Results: The internal orifice was closed faster by SPLPEC with the innovative two-hooked core apparatus than with a single-hooked device (unilateral, 13.21 – 3.86 versus 17.92 – 4.37 minutes [P < .05]; bilateral, 17.18 – 4.69 versus 25.36 – 7.38 minutes [P < .01]). There were no postoperative complications or evidence of early recurrence in the two-hooked group. However, one recurrence and one subcutaneous knot granuloma were postoperatively observed in the single-hooked group. Conclusions: SPLPEC with the two-hooked core apparatus was proved to be a successful procedure without leaving a peritoneal gap and ligating subcutaneous tissues. It is safe, feasible, and reliable for PIH.
Introduction
O
pen inguinal hernia repair with pure high ligation is a classical procedure for pediatric inguinal hernia (PIH). With the development of minimally invasive surgery, many techniques of laparoscopic-assisted high ligation of hernias have developed consistently and evolved gradually. The trend for pediatric surgeons is to perform laparoscopic percutaneous extraperitoneal closure (LPEC), which does not require dissection of the hernia sac, and no peritoneal gaps were left.1 LPEC as a new simplified method was first introduced in 1995 and published in 2006 by Takehara et al.2 to manage PIH. However, an additional grasping forceps was required during the LPEC procedure.
In order to reduce the number of multiple skin incisions of conventional laparoscopic surgery and to improve cosmesis, single-port LPEC (SPLPEC) has been widely used, and numerous techniques have mushroomed in the past decade.3–7 Nowadays, SPLPEC with various devices seems to be the ultimate attainment, but the various SPLPEC methods have their own limitations in which some upper subcutaneous tissues, including nerves and muscles, may cause injury by their inclusion in the upper portion of the circuit suturing. The inclusion of unnecessary subcutaneous tissues in the ligature may lead to a propensity for subsequent loosening of the knot, causing later recurrence.8 Here we report that SPLPEC with an innovative twohooked core hernia apparatus brings its advantages into full
Department of Pediatric Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, China.
188
LAPAROSCOPIC PERCUTANEOUS EXTRAPERITONEAL CLOSURE
play and overcomes the limitations of existing single-port techniques. With just one puncture, using an hernia apparatus could perform both the sending and retrieving of the suture loop along the internal hernia orifice. Without preperitoneal hydrodissection and the assistance of grasping forceps, we thoroughly closed the internal orifice of the hernia sac while not leaving a peritoneal gap and ligating the tissues of the abdominal wall. Materials and Methods Clinical data
Between June 2008 and October 2011, 135 cases of SPLPEC for PIH were performed by the same surgeon in our department. There were 63 children who underwent SPLPEC with a single-hooked device, and 72 children were treated using an innovative two-hooked core hernia apparatus. Patient demographics, clinical data, operating techniques, operating time, intraoperative findings, postoperative course, and recurrence were retrospectively collected and analyzed. This study was approved by the hospital’s Institutional Review Board. All children underwent SPLPEC after providing informed consent.
189
pushing the proximal end of the core, and then the hernia suture was safely locked inside the sheath by the core returning back inside the sheath. The innovative two-hooked core hernia apparatus was prepared as follows: On the basis of the single-hooked hernia device described above, we further modified this apparatus by making two slots on the greater curvature of the core instead of the one over the lesser curvature in the singlehooked core. The first shallow slot is 0.5 cm away from the distal end for sending the loop of the hernia suture into the peritoneal cavity, and the second deep slot is 0.5 cm proximal from the first slot for pulling out the indwelling intraabdominal suture loop (Fig. 2). A patent of invention has been authorized in China (number ZL 2013 2 0013865.2). At present, prototypes of both the single hook-pin device and the innovative twohooked core hernia apparatus are being manufactured by Huida Biomedical Instrument (Tonglu, China) under the consent agreement of collaboration. Surgical procedure
The single-hooked hernia device used in the control group, composed of a stainless steel sheath and core, was modified from the one previously described (Fig. 1).6 It is similar to the 18-gauge Tuohy epidural needle with a length of 15 cm. The distal segment is slightly curved (5 cm away from the Tuohy point). It makes the device easier to pass through along the internal hernia orifice and also to bluntly dissect the spermatic cord and vas deferens from the peritoneum. There is a hub male screw and spring adaptor for locking the core of the device on the proximal end of the sheath. A hook-like slot was made on the lesser curvature of the core 0.5 cm away from the distal end for retrieving the hernia suture. The proximal end of the core was equipped with a spring and female screw. After the sheath and core were screwed together, the hernia suture was placed in the core slot by
SPLPEC with a single-hooked hernia device. After endotracheal anesthesia, the patients were placed in the Trendelenburg position and oblique to the healthy side at 20–30. A 5.5-mm trocar was placed through the umbilicus in an open method. The abdomen was insufflated with CO2 to 8–10 mm Hg pressure, and a 5-mm, 30 laparoscope was introduced into the peritoneal cavity. Both internal orifices were inspected for hernia defects. The surface marker of the inner ring of the hernia defect was located, and a skin stab wound was made. The single-hooked hernia device was inserted through this stab; it penetrated the subcutaneous tissues and muscles of the abdominal wall, extending into the extraperitoneal space. The device further advanced along the medial side of the internal orifice of the hernia defect. The Tuohy point of the device separated the vas deferens from the peritoneum, and finally the device tip breached the peritoneum between the vas deferens and spermatic vessels into the intraabdominal cavity. The core of the device was withdrawn, and a 2-0 silk suture (5–8 cm long) was introduced into the
FIG. 1. The single-hook hernia device: (a) the sheath with the Tuohy point; (b) core with the single hook; (c) silk suture; (d) epidural catheter (guidewire); (e) magnifying diagram of the hook in the distal end of the core; (f ) tagged silk suture with the epidural catheter and introduced into the peritoneal cavity through the sheath; and (g) the suture locked inside the sheath by the core returning back into the sheath.
FIG. 2. The innovative two-hooked core hernia apparatus: (a) the sheath with the Tuohy point; (b) double slots on the larger curvature of the core; (c) folding silk suture; (d) magnifying diagram of the double slots in the core distal end of the apparatus; (e) introducing the folding suture placed in the distal shallow slot of the core; and (f ) the silk suture loop captured by the proximal deep slot of the core.
Production of the innovative hernia apparatus
190
peritoneal cavity with a thread-guidewire through the sheath of the device. The guidewire detached from the suture with the assistance of the laparoscope, and then the sheath of the single-hooked hernia device was pulled out. The other end of the suture was above the skin. The device sheath was remounted with the core to perform another puncture. The hernia device was again introduced at the original skin stab site and advanced along the internal ring laterally. After dissecting and crossing between the spermatic vessels and the peritoneum, the single-hooked hernia device was re-introduced into the abdominal cavity through the previous peritoneal puncture point. The initialized silk suture was placed into the core slot and locked inside the sheath by sequentially pressing and releasing the proximal end of the core (Fig. 1f and g). In that moment, the single-hooked hernia device with the suture was pulled out through the abdominal wall. The inner ring of the hernia was closed by knotting the silk suture extracorporeally. The trocar was removed after the intraperitoneal CO2 was vented out, and the umbilical incision was sutured. SPLPEC with an innovative two-hooked core hernia apparatus. After a laparoscope was introduced into the intra-
abdominal cavity (Fig. 3), the middle of a folding suture (2-0 silk) was placed in the distal slot and then locked inside the sheath by pressing and releasing the proximal end of the core sequentially. The suture-loaded apparatus was introduced 5–8 cm into the intraabdominal cavity in the same way as the single-hooked device described above (Fig. 4). With the assistance of the laparoscope and pushing the core slot out of the sheath, the folding suture loop was released and left in the peritoneal cavity. The apparatus was gently withdrawn until its tip was within the preperitoneal space on the roof of the inner ring (Fig. 5) and re-introduced along the lateral side of the hernia defect, separating the gonadal vessels into the intraabdominal space at the same peritoneal puncture point (Fig. 6). The initialized folding suture loop was placed in the proximal slot by pressing and holding the proximal end of the core and then locked inside the sheath by releasing the core (Fig. 7). The rest of the steps were the same as for the singlehooked device method. The extracorporeal knot-tying could
FIG. 3. A laparoscope is introduced into the abdominal cavity through a 5.5-mm trocar after induction of pneumoperitoneum.
LI ET AL.
FIG. 4. The two-hooked apparatus loaded with the folding suture is introduced along the preperitoneal space on the medial side of the hernia inner ring, over the vas deferens and into the abdominal cavity. (a) The apparatus is inserted through the abdominal wall into the operative field. (b) The apparatus is introduced along the hernia sac before reaching the vas deferens. (c) Blunt dissection of the vas deferens from the peritoneum. (d) The apparatus with the suture crossing over the vas deferens and entering the peritoneal cavity. be pushed using the sheath or modified Kirschner pin knotpusher into the preperitoneal space through the identical abdominal path in a child with thick subcutaneous fat to guarantee a pure ligation of the inner ring without redundant tissues. Results
The SPLPEC procedures were performed uneventfully in 135 patients. The perioperative data of children are summarized
FIG. 5. (a) The loop of the folding suture is formed by withdrawing the apparatus back about 4–6 cm. (b) The distal slot of the core is exposed by pushing the core out of the sheath. (c) The folding suture is detached from the slot itself during the withdrawal of the apparatus or by pulling the loop of the suture with the head of the laparoscope. (d) The apparatus is returned back to the 12 o’clock position of the inner ring and kept in the extraperitoneal space.
LAPAROSCOPIC PERCUTANEOUS EXTRAPERITONEAL CLOSURE
191
Table 1. Comparison of the Single-Hooked Device and the Two-Hooked Apparatus During Single-Port Laparoscopic Percutaneous Extraperitoneal Closure Parameter
FIG. 6. (a and b) The two-hooked apparatus is re-introduced along the preperitoneal space on the opposite side of the inner ring. (c) The apparatus to cross over the spermatic vessels reaches the previous puncture site where the suture was placed. (d) Passing through the same site and re-entering the peritoneal cavity. in Table 1. Eighty-two SPLPECs with the single-hooked hernia device were done in 63 patients (53 unilateral, 10 bilateral, and 9 insidious contralateral hernias). In this group, 1 patient who had a recurrent hernia 1 month postprocedure was reoperated on by the same technique due to knot slippage, and another patient had a foreign body reaction to the suture knot 2 months after the procedure and was treated with removal of the stitch. Ninety-six SPLPECs with an innovative two-hooked core hernia apparatus were performed in 72 patients (59 unilateral, 13 bilateral, and 11 insidious contralateral hernias). No significant differences were observed between the two groups in terms of sex ratio, mean age, unilateral or bilateral repairs, or contralateral asymptomatic repairs. The mean operation time was shorter in SPLPEC with
FIG. 7. (a) Pushing out the proximal slot of the core and entering the initialized suture loop where the suture is captured. (b) The suture is firmly locked inside the sheath by the core retracting back to the sheath. (c and d) The suture is withdrawn by the hernia apparatus, and the inner ring is ligated extraperitoneally.
One-hooked
Two-hooked
P
Number of patients 63 Age (years) 3.12 – 1.37 Gender (boy:girl) 52:11 Unilateral 53 Bilateral 10 Contralateral 9 Operative time (minutes) Unilateral 17.92 – 4.37 Bilateral 25.36 – 7.38 Follow-up interval 19.7 – 2.1 (months) Knots response 1 Recurrence 1 Testicular atrophy 0
72 3.26 – 1.39 58:14 59 13 11
.58 .77 .73 .73 .87
13.21 – 3.86 17.18 – 4.69 8.6 – 1.8
.032 .008 .002
0 0 0
.28 .28 1
the innovative two-hooked core hernia apparatus (unilateral versus bilateral lesions, 13.21 versus 17.18 minutes) compared with the single-hooked device (unilateral versus bilateral lesions, 17.92 versus 25.36 minutes). P values were .032 and .008, respectively. There were no perioperative complications, and all patients could be discharged within 24 hours after the operation. In addition, the mean follow-up interval was much shorter in patients using the innovative two-hooked core hernia apparatus (8.6 months) compared with the single-hook pin (19.7 months) (P = .002), during which there were no recurrence, no testicular atrophy, and no hydrocele. Discussion
PIH is the result of persistent patency of the processus vaginalis, and there are no defects of any other anatomical structures in the inguinal area. Thus, the treatment of PIH can be reached with high ligation of the hernia sac. Laparoscopy as a minimal invasive surgery is recently well developed for it has clear advantages related to the evaluation of a contralateral insidious hernia and avoidance of dissecting spermatic vessels and the vas deferens.9 Numerous laparoscopic techniques for PIH have mushroomed from the initial intraperitoneal three-port techniques to extraperitoneal two-port techniques to, recently, SPLEPC or single-incision LPEC.10–13 However, there are several reported issues that need to be addressed before considering SPLEPC or single-incision LPEC as a standard procedure for PIH. (1) The dissection of the hernia sac is limited without an accessory instrument. (2) A small gap of the peritoneum is left untouched during the ligation of the inner ring in order to avoid damage to spermatic vessels and the vas deferens, and this gap might contribute to the postoperative recurrence or hydrocele formation. (3) The possible ligation of partial abdominal wall tissue, including nerve and muscles, might lead to long-term abdominal discomfort due to the introduction of the hernia device twice for placing, pulling, and knotting the hernia suture extracorporeally.1,3–6 In the single-hooked group, we had problems similar to the others reported. One case with
192
postoperative recurrence after 1 month was due to knotting slippage. In this case of recurrence reoperated on by the same SPLEPC, the suture was not found in situ, and a review of the original records identified shrinking and partial scarring of his hernia ring defect, which may indicate that the reason for the recurrence was due to extraabdominal tissues of the anterior loop of the encircling suture and the knot in the subcutaneous plane instead of the preperitoneal space, which may subsequently leading to the suture/knot slippage when the inner ring tissues are cut through,5 because the singlehooked device was not guaranteed to pass through the same path for introducing and withdrawing the hernia suture thread. Another case had a foreign body reaction or granuloma subcutaneously due to extra knots that could not be properly embedded under the muscular layer. We removed the suture, and the wound healed; no recurrence has been detected in this case in the subsequent 24-month follow-up. In the group of SPLPEC using an innovative two-hooked core hernia apparatus, however, the unique design of the apparatus punctured the abdominal wall only once and remained in the external peritoneal space for bluntly dissecting the hernia sac and placing and withdrawing the hernia suture in the same passage. We did not encounter the abovementioned problems. The present study used an innovative two-hooked core hernia apparatus, a uniquely designed hernia apparatus, in SPLPEC to treat PIH. The Tuohy point of the apparatus makes it easier to dissect spermatic vessels and the vas deferens immediately beneath the peritoneum without injection of normal saline, and even easier in the relative larger inner ring of the hernia or the vas deferens with little tension by pulling the ipsilateral testis. Of the two slots on the larger curvature of the core in the apparatus, the design of its distal shallow slot makes it easier to detach the suture loop from the core with the assistance of the laparoscope and to keep the suture loop in the peritoneal cavity. The initialized suture loop can easily be captured by the proximal deep slot alone and firmly locked inside the sheath after the core is retracted back into the sheath. The newly designed double slots of the core in the apparatus, capturing the suture and retracting back into the sheath, conquer the defect of tissue damage due to the hook in the external sheath during the procedure.8 With the innovative two-hooked core hernia apparatus, the inner ring ligation can be performed safely by puncturing the anterior abdominal wall only once. Therefore, we reduced the surgical damage to a minimum, avoided ligating additional tissues, and decreased the procedure time significantly (Table 1), and we have had no recurrent cases in this group so far. Using SPLPEC, we never had to convert any case to open surgery, but it was proved harder in children with a very wide ring ( > 15 mm). In this instance the addition of introducing a working port might be necessary.11 In our present series, an extra assistant grasping instrument through the umbilicus alongside the laparoscope was necessary in three giant hernias. Using the hernia apparatus with the aid of the forceps, the huge orifice of the hernia sac was completely closed extraperitoneally, and the medial umbilical bladder fold was meanwhile tied up to the lateral–posterior peritoneum to further strengthen the ligated hernia inner ring, preventing recurrence.14 The grasping forceps and telescope could be inserted through the same umbilical incision, which could
LI ET AL.
also provide better cosmetics and reach the state of minimally invasive surgery (Fig. 8). In comparison with the single-hooked hernia device, SPLPEC using an innovative two-hooked core hernia apparatus no doubt has more advantages. In SPLPEC using a single-hooked hernia device requiring two abdominal punctures, simultaneous ligation of subcutaneous tissues between the skin and hernia defect is inevitable. This might possibly increase the recurrence rate when subsequent loosening of the knot takes place. Especially in children with an excess thickness of abdominal wall and obesity, extracorporeal ligation is more difficult to safely enclose the hernia defect without any subcutaneous tissues (including nerves and muscles) in the upper portion of the circuit suturing. As demonstrated in the present study, our modified SPLPEC using an innovative two-hooked core hernia apparatus can be done with only one puncture, suture knots were located in the extraperitoneal space, and it is almost impossible to ligate additional tissues of the abdominal wall. With only one umbilical wound and another puncture point, SPLPEC cosmetic outcomes were outstanding. All of the parents were satisfied with the scarless results in postoperative follow-up. This unique procedure can be performed in a day-surgery setting. The majority of patients could be discharged on the same day of admission. Those kept in the hospital overnight were due to logistics, such as geographic distance, parental concerns, and administrative delays.11 In summary, with our own design for an innovative twohooked core hernia apparatus, the SPLPEC procedure was safely performed in PIH. Because the two-hooked apparatus may be readily kept in an identical subcutaneous path for introducing and withdrawing the suture, this technique could eliminate the necessity of using an additional assistant port and enclose the inner ring tensionless without a peritoneal gap and inclusion of subcutaneous tissues in the suture. The present data suggest SPLPEC is a better, more feasible, and reliable procedure for PIH. However, determination of further advantages and disadvantages would be required to decide whether this procedure would benefit children compared with the standard laparoscopic techniques.
FIG. 8. The umbilical incision for the trocar is hidden in the umbilical folds, and only a 1.5-mm skin puncture is evident with the innovative two-hooked core hernia apparatus.
LAPAROSCOPIC PERCUTANEOUS EXTRAPERITONEAL CLOSURE Disclosure Statement
No competing financial interests exist. References
1. Ozgediz D, Roayaie K, Lee H, Nobuhara KK, Farmer DL, Bratton B, Harrison MR. 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;21:1327–1331. 2. Takehara H, Yakabe S, Kameoka K. Laparoscopic percutaneous extraperitoneal closure for inguinal hernia in children: Clinical outcome of 972 repairs done in 3 pediatric surgical institutions. J Pediatr Surg 2006;41:1999–2003. 3. Harrison MR, Lee H, Albanese CT, Farmer DL. Subcutaneous endoscopically assisted ligation (SEAL) of the internal ring for repair of inguinal hernias in children: A novel technique. J Pediatr Surg 2005;40:1177–1180. 4. Patkowski D, Czernik J, Chrzan R, Jaworski W, Apoznan´ski W. Percutaneous internal ring suturing: A simple minimally invasive technique for inguinal hernia repair in children. J Laparoendosc Adv Surg Tech A 2006;16:513–517. 5. Bharathi RS, Arora M, Baskaran V. How we ‘‘SEAL’’ internal ring in pediatric inguinal hernias. Surg Laparosc Endosc Percutan Tech 2008;18:192–194. 6. Chang YT, Wang JY, Lee JY, Chiou CS, Hsieh JS. Onetrocar laparoscopic transperitoneal closure of inguinal hernia in children. World J Surg 2008;32:2459–2463. 7. Saranga Bharathi R, Arora M, Baskaran V. Minimal access surgery of pediatric inguinal hernias: A review. Surg Endosc 2008;22:1751–1762. 8. Chang YT, Wang JY, Lee JY, Chiou CS. A simple singleport laparoscopic-assisted technique for completely enclosing inguinal hernia in children. Am J Surg 2009; 198:e13–e16.
193
9. Chan KL, Tam PK.A safe laparoscopic technique for the repair of inguinal hernias in boys. J Am Coll Surg 2003; 196:987–989. 10. Shalaby R, Shams AM, Mohamed S, el-Leathy M, Ibrahem M, Alsaed G. Two-trocar needlescopic approach to incarcerated inguinal hernia in children. J Pediatr Surg 2007;42: 1259–1262. 11. Bharathi RS, Dabas AK, Arora M, Baskaran V. Laparoscopic ligation of internal ring-three ports versus single-port technique: Are working ports necessary? J Laparoendosc Adv Surg Tech A 2008;18:891–894. 12. Uchida H, Kawashima H, Goto C, Sato K, Yoshida M, Takazawa S, Iwanaka T. Inguinal hernia repair in children using single-incision laparoscopic-assisted percutaneous extraperitoneal closure. J Pediatr Surg 2010;45:2386– 2389. 13. Yamoto M, Morotomi Y, Yamamoto M, Suehiro S. Singleincision laparoscopic percutaneous extraperitoneal closure for inguinal hernia in children: An initial report. Surg Endosc 2011;25:1531–1534. 14. Liu J, Baird M, Tang Y, Bi J, Tian H, Chen Y, Li M. Medial umbilical ligament flap reinforcement of the internal ring in children with indirect inguinal hernia. J Laparoendosc Adv Surg Tech A 2011;21:561–565.
Address correspondence to: Suolin Li, MD Department of Pediatric Surgery The Second Hospital of Hebei Medical University No. 215, Hepingxi Road Xinhua District, Shijiazhuang, Hebei Province, 050000 China E-mail: [email protected]
Single-Port Laparoscopic Percutaneous Extraperitoneal Closure Using an Innovative Apparatus for Pediatric Inguinal Hernia Suolin Li, MD, Lin Liu, MD, and Meng Li, MD
Abstract
Background: Laparoscopic procedures for pediatric inguinal hernia (PIH) have numerous techniques and continue to evolve, with a trend toward increasing use of extracorporeal knotting and decreasing use of working ports and endoscopic instruments. Single-port laparoscopic percutaneous extraperitoneal closure (SPLPEC) with variable devices seems to be one of the most simple and reliable methods. Here the authors describe and evaluate the applicable effects of SPLPEC using an innovative two-hooked core hernia apparatus. Materials and Methods: Between June 2008 and October 2011, 72 children with indirect inguinal hernia underwent SPLPEC with an innovative two-hooked core hernia apparatus. A 5-mm laparoscope was placed through a transumbilical port. Without an assistant working port, the two-hooked core hernia apparatus with a 2-0 nonabsorbable suture was inserted at the point of the internal inguinal ring. It could be readily kept in an identical subcutaneous path for introducing and withdrawing the suture. The extraperitoneal knot-tying could tautly enclose the hernia defect without peritoneal gaps and upper subcutaneous tissues. During the same period, 63 cases with PIH underwent SPLPEC with a single-hooked hernia device. Technical essentials, mean operation time, and intra- and postoperative complications were compared. Results: The internal orifice was closed faster by SPLPEC with the innovative two-hooked core apparatus than with a single-hooked device (unilateral, 13.21 – 3.86 versus 17.92 – 4.37 minutes [P < .05]; bilateral, 17.18 – 4.69 versus 25.36 – 7.38 minutes [P < .01]). There were no postoperative complications or evidence of early recurrence in the two-hooked group. However, one recurrence and one subcutaneous knot granuloma were postoperatively observed in the single-hooked group. Conclusions: SPLPEC with the two-hooked core apparatus was proved to be a successful procedure without leaving a peritoneal gap and ligating subcutaneous tissues. It is safe, feasible, and reliable for PIH.
Introduction
O
pen inguinal hernia repair with pure high ligation is a classical procedure for pediatric inguinal hernia (PIH). With the development of minimally invasive surgery, many techniques of laparoscopic-assisted high ligation of hernias have developed consistently and evolved gradually. The trend for pediatric surgeons is to perform laparoscopic percutaneous extraperitoneal closure (LPEC), which does not require dissection of the hernia sac, and no peritoneal gaps were left.1 LPEC as a new simplified method was first introduced in 1995 and published in 2006 by Takehara et al.2 to manage PIH. However, an additional grasping forceps was required during the LPEC procedure.
In order to reduce the number of multiple skin incisions of conventional laparoscopic surgery and to improve cosmesis, single-port LPEC (SPLPEC) has been widely used, and numerous techniques have mushroomed in the past decade.3–7 Nowadays, SPLPEC with various devices seems to be the ultimate attainment, but the various SPLPEC methods have their own limitations in which some upper subcutaneous tissues, including nerves and muscles, may cause injury by their inclusion in the upper portion of the circuit suturing. The inclusion of unnecessary subcutaneous tissues in the ligature may lead to a propensity for subsequent loosening of the knot, causing later recurrence.8 Here we report that SPLPEC with an innovative twohooked core hernia apparatus brings its advantages into full
Department of Pediatric Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, China.
188
LAPAROSCOPIC PERCUTANEOUS EXTRAPERITONEAL CLOSURE
play and overcomes the limitations of existing single-port techniques. With just one puncture, using an hernia apparatus could perform both the sending and retrieving of the suture loop along the internal hernia orifice. Without preperitoneal hydrodissection and the assistance of grasping forceps, we thoroughly closed the internal orifice of the hernia sac while not leaving a peritoneal gap and ligating the tissues of the abdominal wall. Materials and Methods Clinical data
Between June 2008 and October 2011, 135 cases of SPLPEC for PIH were performed by the same surgeon in our department. There were 63 children who underwent SPLPEC with a single-hooked device, and 72 children were treated using an innovative two-hooked core hernia apparatus. Patient demographics, clinical data, operating techniques, operating time, intraoperative findings, postoperative course, and recurrence were retrospectively collected and analyzed. This study was approved by the hospital’s Institutional Review Board. All children underwent SPLPEC after providing informed consent.
189
pushing the proximal end of the core, and then the hernia suture was safely locked inside the sheath by the core returning back inside the sheath. The innovative two-hooked core hernia apparatus was prepared as follows: On the basis of the single-hooked hernia device described above, we further modified this apparatus by making two slots on the greater curvature of the core instead of the one over the lesser curvature in the singlehooked core. The first shallow slot is 0.5 cm away from the distal end for sending the loop of the hernia suture into the peritoneal cavity, and the second deep slot is 0.5 cm proximal from the first slot for pulling out the indwelling intraabdominal suture loop (Fig. 2). A patent of invention has been authorized in China (number ZL 2013 2 0013865.2). At present, prototypes of both the single hook-pin device and the innovative twohooked core hernia apparatus are being manufactured by Huida Biomedical Instrument (Tonglu, China) under the consent agreement of collaboration. Surgical procedure
The single-hooked hernia device used in the control group, composed of a stainless steel sheath and core, was modified from the one previously described (Fig. 1).6 It is similar to the 18-gauge Tuohy epidural needle with a length of 15 cm. The distal segment is slightly curved (5 cm away from the Tuohy point). It makes the device easier to pass through along the internal hernia orifice and also to bluntly dissect the spermatic cord and vas deferens from the peritoneum. There is a hub male screw and spring adaptor for locking the core of the device on the proximal end of the sheath. A hook-like slot was made on the lesser curvature of the core 0.5 cm away from the distal end for retrieving the hernia suture. The proximal end of the core was equipped with a spring and female screw. After the sheath and core were screwed together, the hernia suture was placed in the core slot by
SPLPEC with a single-hooked hernia device. After endotracheal anesthesia, the patients were placed in the Trendelenburg position and oblique to the healthy side at 20–30. A 5.5-mm trocar was placed through the umbilicus in an open method. The abdomen was insufflated with CO2 to 8–10 mm Hg pressure, and a 5-mm, 30 laparoscope was introduced into the peritoneal cavity. Both internal orifices were inspected for hernia defects. The surface marker of the inner ring of the hernia defect was located, and a skin stab wound was made. The single-hooked hernia device was inserted through this stab; it penetrated the subcutaneous tissues and muscles of the abdominal wall, extending into the extraperitoneal space. The device further advanced along the medial side of the internal orifice of the hernia defect. The Tuohy point of the device separated the vas deferens from the peritoneum, and finally the device tip breached the peritoneum between the vas deferens and spermatic vessels into the intraabdominal cavity. The core of the device was withdrawn, and a 2-0 silk suture (5–8 cm long) was introduced into the
FIG. 1. The single-hook hernia device: (a) the sheath with the Tuohy point; (b) core with the single hook; (c) silk suture; (d) epidural catheter (guidewire); (e) magnifying diagram of the hook in the distal end of the core; (f ) tagged silk suture with the epidural catheter and introduced into the peritoneal cavity through the sheath; and (g) the suture locked inside the sheath by the core returning back into the sheath.
FIG. 2. The innovative two-hooked core hernia apparatus: (a) the sheath with the Tuohy point; (b) double slots on the larger curvature of the core; (c) folding silk suture; (d) magnifying diagram of the double slots in the core distal end of the apparatus; (e) introducing the folding suture placed in the distal shallow slot of the core; and (f ) the silk suture loop captured by the proximal deep slot of the core.
Production of the innovative hernia apparatus
190
peritoneal cavity with a thread-guidewire through the sheath of the device. The guidewire detached from the suture with the assistance of the laparoscope, and then the sheath of the single-hooked hernia device was pulled out. The other end of the suture was above the skin. The device sheath was remounted with the core to perform another puncture. The hernia device was again introduced at the original skin stab site and advanced along the internal ring laterally. After dissecting and crossing between the spermatic vessels and the peritoneum, the single-hooked hernia device was re-introduced into the abdominal cavity through the previous peritoneal puncture point. The initialized silk suture was placed into the core slot and locked inside the sheath by sequentially pressing and releasing the proximal end of the core (Fig. 1f and g). In that moment, the single-hooked hernia device with the suture was pulled out through the abdominal wall. The inner ring of the hernia was closed by knotting the silk suture extracorporeally. The trocar was removed after the intraperitoneal CO2 was vented out, and the umbilical incision was sutured. SPLPEC with an innovative two-hooked core hernia apparatus. After a laparoscope was introduced into the intra-
abdominal cavity (Fig. 3), the middle of a folding suture (2-0 silk) was placed in the distal slot and then locked inside the sheath by pressing and releasing the proximal end of the core sequentially. The suture-loaded apparatus was introduced 5–8 cm into the intraabdominal cavity in the same way as the single-hooked device described above (Fig. 4). With the assistance of the laparoscope and pushing the core slot out of the sheath, the folding suture loop was released and left in the peritoneal cavity. The apparatus was gently withdrawn until its tip was within the preperitoneal space on the roof of the inner ring (Fig. 5) and re-introduced along the lateral side of the hernia defect, separating the gonadal vessels into the intraabdominal space at the same peritoneal puncture point (Fig. 6). The initialized folding suture loop was placed in the proximal slot by pressing and holding the proximal end of the core and then locked inside the sheath by releasing the core (Fig. 7). The rest of the steps were the same as for the singlehooked device method. The extracorporeal knot-tying could
FIG. 3. A laparoscope is introduced into the abdominal cavity through a 5.5-mm trocar after induction of pneumoperitoneum.
LI ET AL.
FIG. 4. The two-hooked apparatus loaded with the folding suture is introduced along the preperitoneal space on the medial side of the hernia inner ring, over the vas deferens and into the abdominal cavity. (a) The apparatus is inserted through the abdominal wall into the operative field. (b) The apparatus is introduced along the hernia sac before reaching the vas deferens. (c) Blunt dissection of the vas deferens from the peritoneum. (d) The apparatus with the suture crossing over the vas deferens and entering the peritoneal cavity. be pushed using the sheath or modified Kirschner pin knotpusher into the preperitoneal space through the identical abdominal path in a child with thick subcutaneous fat to guarantee a pure ligation of the inner ring without redundant tissues. Results
The SPLPEC procedures were performed uneventfully in 135 patients. The perioperative data of children are summarized
FIG. 5. (a) The loop of the folding suture is formed by withdrawing the apparatus back about 4–6 cm. (b) The distal slot of the core is exposed by pushing the core out of the sheath. (c) The folding suture is detached from the slot itself during the withdrawal of the apparatus or by pulling the loop of the suture with the head of the laparoscope. (d) The apparatus is returned back to the 12 o’clock position of the inner ring and kept in the extraperitoneal space.
LAPAROSCOPIC PERCUTANEOUS EXTRAPERITONEAL CLOSURE
191
Table 1. Comparison of the Single-Hooked Device and the Two-Hooked Apparatus During Single-Port Laparoscopic Percutaneous Extraperitoneal Closure Parameter
FIG. 6. (a and b) The two-hooked apparatus is re-introduced along the preperitoneal space on the opposite side of the inner ring. (c) The apparatus to cross over the spermatic vessels reaches the previous puncture site where the suture was placed. (d) Passing through the same site and re-entering the peritoneal cavity. in Table 1. Eighty-two SPLPECs with the single-hooked hernia device were done in 63 patients (53 unilateral, 10 bilateral, and 9 insidious contralateral hernias). In this group, 1 patient who had a recurrent hernia 1 month postprocedure was reoperated on by the same technique due to knot slippage, and another patient had a foreign body reaction to the suture knot 2 months after the procedure and was treated with removal of the stitch. Ninety-six SPLPECs with an innovative two-hooked core hernia apparatus were performed in 72 patients (59 unilateral, 13 bilateral, and 11 insidious contralateral hernias). No significant differences were observed between the two groups in terms of sex ratio, mean age, unilateral or bilateral repairs, or contralateral asymptomatic repairs. The mean operation time was shorter in SPLPEC with
FIG. 7. (a) Pushing out the proximal slot of the core and entering the initialized suture loop where the suture is captured. (b) The suture is firmly locked inside the sheath by the core retracting back to the sheath. (c and d) The suture is withdrawn by the hernia apparatus, and the inner ring is ligated extraperitoneally.
One-hooked
Two-hooked
P
Number of patients 63 Age (years) 3.12 – 1.37 Gender (boy:girl) 52:11 Unilateral 53 Bilateral 10 Contralateral 9 Operative time (minutes) Unilateral 17.92 – 4.37 Bilateral 25.36 – 7.38 Follow-up interval 19.7 – 2.1 (months) Knots response 1 Recurrence 1 Testicular atrophy 0
72 3.26 – 1.39 58:14 59 13 11
.58 .77 .73 .73 .87
13.21 – 3.86 17.18 – 4.69 8.6 – 1.8
.032 .008 .002
0 0 0
.28 .28 1
the innovative two-hooked core hernia apparatus (unilateral versus bilateral lesions, 13.21 versus 17.18 minutes) compared with the single-hooked device (unilateral versus bilateral lesions, 17.92 versus 25.36 minutes). P values were .032 and .008, respectively. There were no perioperative complications, and all patients could be discharged within 24 hours after the operation. In addition, the mean follow-up interval was much shorter in patients using the innovative two-hooked core hernia apparatus (8.6 months) compared with the single-hook pin (19.7 months) (P = .002), during which there were no recurrence, no testicular atrophy, and no hydrocele. Discussion
PIH is the result of persistent patency of the processus vaginalis, and there are no defects of any other anatomical structures in the inguinal area. Thus, the treatment of PIH can be reached with high ligation of the hernia sac. Laparoscopy as a minimal invasive surgery is recently well developed for it has clear advantages related to the evaluation of a contralateral insidious hernia and avoidance of dissecting spermatic vessels and the vas deferens.9 Numerous laparoscopic techniques for PIH have mushroomed from the initial intraperitoneal three-port techniques to extraperitoneal two-port techniques to, recently, SPLEPC or single-incision LPEC.10–13 However, there are several reported issues that need to be addressed before considering SPLEPC or single-incision LPEC as a standard procedure for PIH. (1) The dissection of the hernia sac is limited without an accessory instrument. (2) A small gap of the peritoneum is left untouched during the ligation of the inner ring in order to avoid damage to spermatic vessels and the vas deferens, and this gap might contribute to the postoperative recurrence or hydrocele formation. (3) The possible ligation of partial abdominal wall tissue, including nerve and muscles, might lead to long-term abdominal discomfort due to the introduction of the hernia device twice for placing, pulling, and knotting the hernia suture extracorporeally.1,3–6 In the single-hooked group, we had problems similar to the others reported. One case with
192
postoperative recurrence after 1 month was due to knotting slippage. In this case of recurrence reoperated on by the same SPLEPC, the suture was not found in situ, and a review of the original records identified shrinking and partial scarring of his hernia ring defect, which may indicate that the reason for the recurrence was due to extraabdominal tissues of the anterior loop of the encircling suture and the knot in the subcutaneous plane instead of the preperitoneal space, which may subsequently leading to the suture/knot slippage when the inner ring tissues are cut through,5 because the singlehooked device was not guaranteed to pass through the same path for introducing and withdrawing the hernia suture thread. Another case had a foreign body reaction or granuloma subcutaneously due to extra knots that could not be properly embedded under the muscular layer. We removed the suture, and the wound healed; no recurrence has been detected in this case in the subsequent 24-month follow-up. In the group of SPLPEC using an innovative two-hooked core hernia apparatus, however, the unique design of the apparatus punctured the abdominal wall only once and remained in the external peritoneal space for bluntly dissecting the hernia sac and placing and withdrawing the hernia suture in the same passage. We did not encounter the abovementioned problems. The present study used an innovative two-hooked core hernia apparatus, a uniquely designed hernia apparatus, in SPLPEC to treat PIH. The Tuohy point of the apparatus makes it easier to dissect spermatic vessels and the vas deferens immediately beneath the peritoneum without injection of normal saline, and even easier in the relative larger inner ring of the hernia or the vas deferens with little tension by pulling the ipsilateral testis. Of the two slots on the larger curvature of the core in the apparatus, the design of its distal shallow slot makes it easier to detach the suture loop from the core with the assistance of the laparoscope and to keep the suture loop in the peritoneal cavity. The initialized suture loop can easily be captured by the proximal deep slot alone and firmly locked inside the sheath after the core is retracted back into the sheath. The newly designed double slots of the core in the apparatus, capturing the suture and retracting back into the sheath, conquer the defect of tissue damage due to the hook in the external sheath during the procedure.8 With the innovative two-hooked core hernia apparatus, the inner ring ligation can be performed safely by puncturing the anterior abdominal wall only once. Therefore, we reduced the surgical damage to a minimum, avoided ligating additional tissues, and decreased the procedure time significantly (Table 1), and we have had no recurrent cases in this group so far. Using SPLPEC, we never had to convert any case to open surgery, but it was proved harder in children with a very wide ring ( > 15 mm). In this instance the addition of introducing a working port might be necessary.11 In our present series, an extra assistant grasping instrument through the umbilicus alongside the laparoscope was necessary in three giant hernias. Using the hernia apparatus with the aid of the forceps, the huge orifice of the hernia sac was completely closed extraperitoneally, and the medial umbilical bladder fold was meanwhile tied up to the lateral–posterior peritoneum to further strengthen the ligated hernia inner ring, preventing recurrence.14 The grasping forceps and telescope could be inserted through the same umbilical incision, which could
LI ET AL.
also provide better cosmetics and reach the state of minimally invasive surgery (Fig. 8). In comparison with the single-hooked hernia device, SPLPEC using an innovative two-hooked core hernia apparatus no doubt has more advantages. In SPLPEC using a single-hooked hernia device requiring two abdominal punctures, simultaneous ligation of subcutaneous tissues between the skin and hernia defect is inevitable. This might possibly increase the recurrence rate when subsequent loosening of the knot takes place. Especially in children with an excess thickness of abdominal wall and obesity, extracorporeal ligation is more difficult to safely enclose the hernia defect without any subcutaneous tissues (including nerves and muscles) in the upper portion of the circuit suturing. As demonstrated in the present study, our modified SPLPEC using an innovative two-hooked core hernia apparatus can be done with only one puncture, suture knots were located in the extraperitoneal space, and it is almost impossible to ligate additional tissues of the abdominal wall. With only one umbilical wound and another puncture point, SPLPEC cosmetic outcomes were outstanding. All of the parents were satisfied with the scarless results in postoperative follow-up. This unique procedure can be performed in a day-surgery setting. The majority of patients could be discharged on the same day of admission. Those kept in the hospital overnight were due to logistics, such as geographic distance, parental concerns, and administrative delays.11 In summary, with our own design for an innovative twohooked core hernia apparatus, the SPLPEC procedure was safely performed in PIH. Because the two-hooked apparatus may be readily kept in an identical subcutaneous path for introducing and withdrawing the suture, this technique could eliminate the necessity of using an additional assistant port and enclose the inner ring tensionless without a peritoneal gap and inclusion of subcutaneous tissues in the suture. The present data suggest SPLPEC is a better, more feasible, and reliable procedure for PIH. However, determination of further advantages and disadvantages would be required to decide whether this procedure would benefit children compared with the standard laparoscopic techniques.
FIG. 8. The umbilical incision for the trocar is hidden in the umbilical folds, and only a 1.5-mm skin puncture is evident with the innovative two-hooked core hernia apparatus.
LAPAROSCOPIC PERCUTANEOUS EXTRAPERITONEAL CLOSURE Disclosure Statement
No competing financial interests exist. References
1. Ozgediz D, Roayaie K, Lee H, Nobuhara KK, Farmer DL, Bratton B, Harrison MR. 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;21:1327–1331. 2. Takehara H, Yakabe S, Kameoka K. Laparoscopic percutaneous extraperitoneal closure for inguinal hernia in children: Clinical outcome of 972 repairs done in 3 pediatric surgical institutions. J Pediatr Surg 2006;41:1999–2003. 3. Harrison MR, Lee H, Albanese CT, Farmer DL. Subcutaneous endoscopically assisted ligation (SEAL) of the internal ring for repair of inguinal hernias in children: A novel technique. J Pediatr Surg 2005;40:1177–1180. 4. Patkowski D, Czernik J, Chrzan R, Jaworski W, Apoznan´ski W. Percutaneous internal ring suturing: A simple minimally invasive technique for inguinal hernia repair in children. J Laparoendosc Adv Surg Tech A 2006;16:513–517. 5. Bharathi RS, Arora M, Baskaran V. How we ‘‘SEAL’’ internal ring in pediatric inguinal hernias. Surg Laparosc Endosc Percutan Tech 2008;18:192–194. 6. Chang YT, Wang JY, Lee JY, Chiou CS, Hsieh JS. Onetrocar laparoscopic transperitoneal closure of inguinal hernia in children. World J Surg 2008;32:2459–2463. 7. Saranga Bharathi R, Arora M, Baskaran V. Minimal access surgery of pediatric inguinal hernias: A review. Surg Endosc 2008;22:1751–1762. 8. Chang YT, Wang JY, Lee JY, Chiou CS. A simple singleport laparoscopic-assisted technique for completely enclosing inguinal hernia in children. Am J Surg 2009; 198:e13–e16.
193
9. Chan KL, Tam PK.A safe laparoscopic technique for the repair of inguinal hernias in boys. J Am Coll Surg 2003; 196:987–989. 10. Shalaby R, Shams AM, Mohamed S, el-Leathy M, Ibrahem M, Alsaed G. Two-trocar needlescopic approach to incarcerated inguinal hernia in children. J Pediatr Surg 2007;42: 1259–1262. 11. Bharathi RS, Dabas AK, Arora M, Baskaran V. Laparoscopic ligation of internal ring-three ports versus single-port technique: Are working ports necessary? J Laparoendosc Adv Surg Tech A 2008;18:891–894. 12. Uchida H, Kawashima H, Goto C, Sato K, Yoshida M, Takazawa S, Iwanaka T. Inguinal hernia repair in children using single-incision laparoscopic-assisted percutaneous extraperitoneal closure. J Pediatr Surg 2010;45:2386– 2389. 13. Yamoto M, Morotomi Y, Yamamoto M, Suehiro S. Singleincision laparoscopic percutaneous extraperitoneal closure for inguinal hernia in children: An initial report. Surg Endosc 2011;25:1531–1534. 14. Liu J, Baird M, Tang Y, Bi J, Tian H, Chen Y, Li M. Medial umbilical ligament flap reinforcement of the internal ring in children with indirect inguinal hernia. J Laparoendosc Adv Surg Tech A 2011;21:561–565.
Address correspondence to: Suolin Li, MD Department of Pediatric Surgery The Second Hospital of Hebei Medical University No. 215, Hepingxi Road Xinhua District, Shijiazhuang, Hebei Province, 050000 China E-mail: [email protected]
