Laparoscopic Inguinal Hernia Repair;

experience with 874 children

Angela Tiana
112016287
 Background
• This study was conducted in Al-Mishary Hospital, Riyadh, Saudi Arabia,
Pediatric Surgery Unit, Al-Azhar University Hospitals and some private
hospitals in Cairo, Egypt between June 2000 and June 2012
• A total of 1184 (703 boys and 171 girls) inguinal hernias were repaired
laparoscopically in 874 children
• The main outcome measurements of this study included; operative time,
hospital stay, development of hydrocele, hernia recurrence, testicular atrophy,
iatrogenic ascent of the testis and cosmetics results
 Description of the technique
• Laparoscopic Inguinal Hernia Repair (LIHR) was done by 2 different techniques;
namely transperitoneal purse string suture (TPP) technique and percutaneous insertion
of purse string suture around internal inguinal rings (IIRs)with lateral umbilical
ligament enforcement using Reverdin Needle (RN)
• In both techniques, extraperitoneal saline was injected around IIR to facilitate
complete encirclement of suture around IIR safely without leaving a skip area or
fearing of injury of spermatic vessels and vas deferens
• Patients were placed supine in the Trendelenburg’s position with tilting to the
opposite side of the hernia

TPP Technique – Chan and Tam
• A telescope 5 mm, 30 degree was used
• Two 3mm needle holders were inserted directly
without trocars at the mid clavicular line on both sides
at the level of the umbilicus
• Laparoscopy was started by inspection of both IIRs
• At the marked site, a 21 gauge needle attached to a
10cc syringe filled with saline was introduced at 12
o’clock and advanced along the preperitoneal space on
the medial site of the hernia defect medial to the vas
deferens
• Then 17mm needle with non absorbable monofilament
2-0 suture was used to close IIR by a purse string
suture starting at 3 o’clock and going all around IIR
• The suture mainly included the subperitoneal tissues
except at the inferior border of IIR where only
peritoneum was taken by carefully picking and lifting it
with the tip of left hand needle holder and the needle
was seen all the time beneath the peritoneum to avoid
injury of the spermatic vessels and vas deferens
 RN Technique – Martin Medizin
• A 3mm Maryland forceps, holding the tip of a non absorbable monofilament 2-0 thread, was inserted into the abdomen without
trocar at the right mid clavicular line at the level of the umbilicus for both unilateral and bilateral CIH
• A stab incision of the skin was done (2cm above and lateral to the IIR on the right side and 2cm above and medial to the IIR on
the left side) and RN was inserted into the peritoneal cavity
• The needle was manipulated to pierce the peritoneum at 3 o’clock on IIR and was advanced to pass through the inferior margin
of IIR under the peritoneum and in front of the spermatic vessels and vas deferens to pierce the peritoneum at 9 o’clock on the
IIR
• Then, the side of the hole of RN was opened and the thread was inserted inside it
• Then, the side of the hole was closed and the needle was withdrawn backward in the same path to the starting point at 3 o’clock
• Then, RN mounted by the thread was reinserted again at 3 ‘clock and was advanced along the superior margin of the IIR
beneath the peritoneum and fascia transversalis to come out from the same opening at 9 o’clock
 Results
• A total of 1184 inguinal hernias were repaired laparoscopically in 874 children
• 624 IIR were closed by TPP technique and 560 IIRs were closed by percutaneous RN technique
• All patients achieved full recovery without intraoperative or postoperative complications
• Most children went home at the same day → the mean hospital stay was 7.79 ± 1.28 hours
• Followup to date is 10-140 months → there were 8 recurrences (8/703, 1.13%) in boys and no
recurrence in girls
• In the last 450 cases (350 RN and 100 TPP technique), the recurrence rate was 0%
• On followup, there were 4 hydroceles (0.57%)
• There were no instances of postoperative testicular atrophy or testicular malposition in our series
 Discussion
• Laparoscopic inguinal hernia repair is a relatively new procedure in the pediatric surgical practice
• It is rapidly gaining popularity with more and more studies validating its feasibility, safety, and efficacy
→ become an alternative to the conventional open procedure
• Advantages of LIHR include excellent visual exposure, the ability to evaluate the contralateral side,
minimal dissection and avoidance of access trauma to the vas deferens and spermatic vessels, bladder
injuries and iatrogenic ascent of the testis
• It is also helpful in detecting other associated pathology and other hernias with excellent cosmetic
results
• A major criticism of the laparoscopic repair remains its higher reccurence rate, as compared to the
traditional open technique, ranging from 0.83% to 4.1%
• Generally, the high recurrence rate in LIHR could possibly be owing to tension at the closure of the IIR
and presence of skip area especially over the vas and spermatic vessels without complete encirclement
of IIR
• In fact, it was found that reccurences of less experienced surgeons are high – beginners may not dare to
place sutures as closely as required to the vessels medially
• The present study proved that reducing tension on the purse string knot when closing the IIR and the
addition of the lateral umbilical ligament to enforce purse string knot resulted in elimination of recurrence
• Chan et al used medial or lateral umbilical ligaments to cover the internal hernia opening region after
finishing purse string knot to prevent the recurrence
• The method they developed was revolutionary in the principle of pediatric hernia repair
• It includes both the security of repair offered by the watertight closure of the hernia opening and the hernia
opening region covered with the umbilical ligament flap
• The valve mechanism allows scrotal fluid avoiding scrotal collection
• Under the stress of intra abdominal pressure, the wall of the sac is pressed over by the flap, keeping the sac
in a collapsed state
• They claimed that their technique is very easy and the recurrence will not occur
• They added that their technique has no severe complications and is indicated in the following cases: (1) large
hernia, hernia sac >1.5cm; (2) recurrence hernia; and (3) the patient’s age above 5 years
• In Pediatric surgery unit, Al Azhar University Hospitals, the IIR is closed by purse string suture encircling
its whole circumference without any skip area either by TPP or by RN technique
• Both, the operative time and the recurrence rate in our series are lower than that reported in the literature
because LIHR was started after gaining good experiences in different laparoscopic procedures
• Used an easy, safe, simple, and rapid technique for repair of CIH using percutaneous insertion of purse string suture by
RN and extracorporeal suture ligation which is less time consuming
• Followed many technical refinements such as injecting normal saline into the extraperitoneal space at IIR, including sub
peritoneal tissue all around IIR without any skip area, reducing tension on the knot of purse string suture by deflation of
the abdomen and sequeezing the scrotum to empty the hernia sac, lateral umbilical ligament enforcement and the use of
non absorbable suture → these latest technical refinements and modifications of the techniques resulted in marked
reduction of development of post operative hydrocele, lowering the recurrence of hernia 0% and reduced operative time
→ no recurrence in last 450 LIHR cases as we followed some technical refinements as described before
• LIHR in children is known to take longer operative time than open herniotomy (25 to 74 minutes) →
Schier stated that LIHR is not more time consuming than open techniques, he added that LIHR is quicker
than the open approach especially in male newborns and in bilateral hernias
• There is always a risk of intra abdominal adhesions in open technique as seen by Schier
• However we did not have a single case of adhesive obstruction in our series of LIHR and the laparoscopic
view of recurrent right sided hernia after bilateral laparoscopic hernia repair showed no adhesion on both
sides
 Conclusion
• LIHR is technically easier and safe owing to better visualization of all
anatomical structures, thus minimizing chances of injury of the vas deferens
and spermatic vessels
• Although both recurrences and operative time were slightly higher in the
early stages, now they are nearly equal or even less than with the open
procedure
• The cosmetic results are excellent and there are virtually no scars