Journal of Pediatric Surgery 49 (2014) 1536–1537

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Correspondence

The role of bowel preparation to optimize working space in laparoscopic inguinal hernia repair in infants To the Editor,

Adequate working space is a prerequisite for safe and efficient minimal access surgery [1]. Analyzing the international literature of the last few years, we noted that there are no objective data about the effect of bowel preparation on working space in pediatric laparoscopic surgery, in particular in regard to pediatric laparoscopic inguinal hernia repair. In adult laparoscopic surgery, pre-operative bowel preparation is used to obtain two main goals: first the removal of bulky intraluminal contents to improve handling of the bowel, and, then, the decrease of peritoneal and wound contamination by the intraluminal content in case of bowel opening [2,3]. In adults there is a large abdominal cavity and in general there are no problems of space to move working instruments [2]. Instead, in pediatric patients the abdominal cavity is very small and if the colon or intestinal loops are dilated, it is virtually impossible to perform some laparoscopic procedures without increasing intra-abdominal pressure (IAP). We found this problem particularly evident in neonates and infants affected by an inguinal hernia. In fact in these patients the correct view of the internal inguinal orifice is impossible if intestinal loops are dilated and it is too risky to introduce other trocars avoiding to cause intestinal lesions [4–6]. In infants with an inguinal hernia, as for technical point of view, laparoscopy is technically demanding for the surgeon because he/she has to be able to knot in a very small space. In particular, in infants less than 5 kg, there is a higher risk of bowel distension, leading to visual restriction owing to a smaller operative field in which to handle needle-drivers; hence it is useful to perform enemas before surgery to empty intestinal loops and to have a larger space into the abdominal cavity to move safely instruments [4]. For these reasons, in infants less than 5 kg of weight with inguinal hernia, candidate for elective laparoscopic herniorrhaphy, we adopt a pre-operative bowel preparation protocol that we have already standardized for pediatric patients undergoing renal surgery via laparoscopy. This protocol includes: simethicone for 1 week before surgery; enemas with probe for 2 days before surgery; minimal-residue diet (low fibre intake) at least 3 days before surgery; fasting at least 5 hours prior to surgery. All these measures can be performed easily by parents at home, without increasing the length of hospital stay. To verify objectively the benefits of preoperative bowel preparation, we decided to compare two groups of infants undergoing laparoscopic herniorrhaphy in our department during the last 3 years: group 1 (G1) composed of 15 patients operated without bowel preparation and group 2 (G2) composed of 15 patients who underwent bowel preparation before surgery using our standardized protocol. There were 21 boys and 9 girls with a median weight of 3.5 kg (range 1.9–5.1 kg). We analyzed three aspects to evaluate the role of bowel preparation before laparoscopic herniorrhaphy in infants: the operative time, the 0022-3468/© 2014 Elsevier Inc. All rights reserved.

feasibility of the procedure according to the working space available and the necessity of increasing IAP to have a good visibility. As for the results, the mean length of surgery was 47.5 minutes in G1 and 29 minutes in G2. No intra or post-operative complications were reported. In G1 in 5/15 cases (33.3 %) after the introduction of the optic a conversion to open surgery was necessary because of a too small working space owing to the intestinal loops distension. In these five patients an inguinal approach was performed with a standard closure of peritoneovaginal duct (pvd). In G2, all the procedures were completed in laparoscopy. In 23 cases with a clinically unilateral hernia we discovered during surgery a contralateral patency of pvd in 17/23 cases (73.9%). As for the intra-abdominal pressure (IAP), in G1 IAP varied between 8 and 12 mm of Hg (median 10 mmHg) while in G2, IAP varied between 5 and 9 mm of Hg (median 7 mmHg). We analyzed the results with χ2 test with Yates' correction and there was a statistically significant higher rate of conversion in G1 compared to G2 (p = 0.12). As for IAP, it was statistically significantly lower in G2 compared to G1 (p = 0.01). Also, the length of surgery was statistically significantly lower in G2 compared to G1 (p = 0.11). On the basis of these results, in infants with inguinal hernia who underwent pre-operative bowel preparation, a conversion to open surgery was never necessary and we always were able to complete the procedure in laparoscopy. In addition, the surgery was faster when preoperative bowel preparation is performed. We think that interesting considerations can be done also in regards to the intra-abdominal pressure (IAP). In our experience, in patients with bowel preparation before surgery, it is sufficient that IAP varies between 5 and 9 mm of Hg (median 7 mmHg) to obtain an adequate working space. This aspect is particularly important for the anesthesiologists, in fact in infants a too high IAP can cause hemodynamic problems during and after the procedure [7,8]. However, in our patients who underwent pre-operative bowel preparation, maintaining a mean IAP of 7 mmHg during surgery, pneumoperitoneum caused no significant changes in mean arterial pressure or in end-tidal CO2 pressure. In our experience, the use of bowel preparation, reduction of the operative time and the need of increasing the IAP to complete the procedure, permit that postoperative immune function is preserved or restored faster, and specific physiological responses to laparoscopy are well tolerated by otherwise healthy infants. In conclusion, we believe that pre-operative bowel preparation represents an important additional benefit for infants underwent laparoscopic inguinal herniorrhaphy in elective conditions as it increases working space by reducing bowel content and it permits a faster and safer surgery with a significant lower intra-abdominal working pressure. It is important to underline that preoperative bowel preparation is a useful and safe method, it is well tolerated and can be performed easily by parents at home, without increasing the length of hospital stay.

Correspondence / Journal of Pediatric Surgery 49 (2014) 1536–1537

Conflict of interest statement No competing financial interests exist. C. Esposito⁎ M. Escolino A. Farina M. Cerulo G. Cortese M.G. Caprio T. De Pascale A. Settimi Department of Traslational Medical Sciences, Pediatric Surgery Unit Federico II University, Naples, Italy Via Pansini 5 80131 Naples Italy ⁎Corresponding author at: “Federico II” University of Naples Via Pansini 5, 80131 Naples, Italy E-mail address: [email protected] http://dx.doi.org/10.1016/j.jpedsurg.2014.05.013

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References [1] Vlot J, Slieker JC, Wijnen R, et al. Optimizing working-space in laparoscopy: measuring the effect of mechanical bowel preparation in a porcine model. Surg Endosc 2013;27:1980–5. [2] Slim K, Vicaut E, Panis Y, et al. Meta-analysis of randomized clinical trials of colorectal surgery with or without mechanical bowel preparation. Br J Surg 2004;91:1125–30. [3] Lijoi D, Ferrero S, Mistrangelo E, et al. Bowel preparation before laparoscopic gynaecological surgery in benign conditions using a 1-week low fibre diet: a surgeon blind, randomized and controlled trial. Arch Gynecol Obstet 2009;280:713–8. [4] Esposito C, Turial S, Escolino M, et al. Laparoscopic inguinal hernia repair in premature babies weighing 3 kg or less. Pediatr Surg Int 2012;28:989–92. [5] Nagraj S, Sinha S, Grant H, et al. The incidence of complications following primary inguinal herniotomy in babies weighing 5 kg or less. Pediatr Surg Int 2006;22:500–2. [6] Choi W, Hall NJ, Garriboli M, et al. Outcomes following laparoscopic inguinal hernia repair in infants compared with older children. Pediatr Surg Int 2012;28 (12):1165–9. [7] Ure BM, Suempelmann R, Metzelder MM, et al. Physiological responses to endoscopic surgery in children. Semin Pediatr Surg 2007;16(4):217–23. [8] Gueugniaud PY, Abisseror M, Moussa M, et al. The hemodynamic effects of pneumoperitoneum during laparoscopic surgery in healthy infants: assessment by continuous esophageal aortic blood flow echo-Doppler. Anesth Analg 1998;86 (2):290–3.

The role of bowel preparation to optimize working space in laparoscopic inguinal hernia repair in infants.

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