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Journal of Pediatric Surgery 49 (2014) 460–464

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Journal of Pediatric Surgery


journal homepage: www.elsevier.com/locate/jpedsurg

Laparoscopic inguinal hernia repair; experience with 874 children


Rafik Shalaby ⁎, Maged Ismail, Abdelhady Samaha, Abdelaziz Yehya, Refaat Ibrahem, Samir Gouda,
Ahmed Helal, Omar Alsamahy
Department of Pediatric Surgery, Al-Azhar University Hospitals, Cairo, Egypt

a r t i c l e i n f o a b s t r a c t

Article history: Background: Laparoscopic inguinal hernia repair (LIHR) in children has become an alternative to the open
Received 1 June 2013 procedure. It is gaining popularity with more and more studies supporting its feasibility, safety, and efficacy.
Received in revised form 23 October 2013 This is a retrospective study to present our experience with children who underwent LIHR.
Accepted 23 October 2013 Patients and methods: A total of 1184 inguinal hernias were repaired laparoscopically in 874 children. They
were 703 boys and 171 girls. Their mean age was 2.9 ± 2.1 years (range, 6–108 months). Six-hundred and
Key words:
twenty four opened internal inguinal rings (IIRs) were closed by transperitoneal purse string suture
Laparoscopy
Reverdin needle
technique (TPP) and 560 opened IIRs were closed by percutaneous purse string suture with lateral umbilical
Congenital inguinal hernia ligament enforcement using Reverdin Needle (RN) technique.
Lateral umbilical ligament Results: All cases were completed laparoscopically without conversion. There were no serious intraoperative
complications. Mean operating time, in TPP technique, was 15 ± 2.3 minutes for unilateral and 20 ± 1.7 minutes
for bilateral inguinal hernia, while the mean operating time, in RN technique, was 8.7 ±1.18 minutes for unilateral
and 12.35 ± 2 minutes for bilateral hernia repair. The contralateral patent processus vaginalis (PPV) was present
in 176 (20% of cases). Follow-up to date is 10–140 months (mean 80 ± 2.1 months). In the early stage of this
study, the recurrence rate was 1.13%. In the last 450 cases, no recurrence occurred. Hydroceles occurred in 0.58%
and no testicular atrophy or iatrogenic ascent of the testis.
Conclusions: LIHR can be a routine procedure with results comparable to those of open procedures. Both
recurrence and operative time are nearly equal or even less than that for the open procedure after gaining a
learning curve and modifications of the techniques.
© 2014 Elsevier Inc. All rights reserved.

Laparoscopic techniques have been applied widely in the man- 2012. A total of 1184 inguinal hernias were repaired laparoscopically
agement of various common pediatric surgical conditions. Laparo- in 874 children. All children were subjected to full history taking,
scopic inguinal hernia repair (LIHR) in children has become an thorough clinical examination, and routine laboratory investigations
alternative to the conventional open procedure [1–8]. However, (CBC, BT, CT, FBS, liver and renal profile). The main outcome
current evidence is insufficient to justify its widespread use in measurements of this study included; operative time, hospital stay,
children and various concerns are raised against the LIHR in children development of hydrocele, hernia recurrence, testicular atrophy,
including: it is more time consuming, it has a higher recurrence rate, it iatrogenic ascent of the testis and cosmetic results. The ethical
violates the peritoneal cavity, and there is no overall advantage committee of our hospital approved the study protocol and a written
compared to the open procedure. It is important to critically evaluate informed parental consent was obtained.
the effectiveness and the potential risks of new techniques before they
can be accepted as the treatment modality of choice [9,10]. The aim of 1.1. Description of the technique
this study was to present our experience with children who under-
went LIHR over a period of 12 years. General endotracheal tube anesthesia was used in all cases. An open
Hasson's technique through supra-umbilical incision was used for
1. Patients and methods creation of pneumoperitoneum to a pressure of 8–12 mmHg. LIHR was
done by 2 different techniques; namely transperitoneal purse string
This study was conducted in Al-Mishary Hospital, Riyadh, Saudi suture (TPP) technique and percutaneous insertion of purse string
Arabia, Pediatric Surgery Unit, Al-Azhar University Hospitals and suture around IIR with lateral umbilical ligament enforcement using
some private hospitals in Cairo, Egypt between June 2000 and June Reverdin Needle (RN). In both techniques, extraperitoneal saline was
injected around IIR to facilitate complete encirclement of suture around
⁎ Corresponding author at: Al-Houssain University Hospital, Darrasa, Cairo, Egypt. IIR safely without leaving a skip area or fearing of injury of spermatic
Tel.: +20 1000722072; fax: +20 1223975160. vessels and vas deferens. Patients were placed supine in the Trendelen-
E-mail address: rafikshalaby@hotmail.com (R. Shalaby). burg’s position with tilting to the opposite side of the hernia.

0022-3468/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jpedsurg.2013.10.019
R. Shalaby et al. / Journal of Pediatric Surgery 49 (2014) 460–464 461

TPP technique was done according to the technique described by vas and spermatic vessels by grasping and lifting the peritoneum
Chan and Tam [11] with some modifications. A telescope 5-mm, 30 away from them and the RN was seen all the time beneath the
degree was used. Two 3-mm needle holders were inserted directly peritoneum (needle sign). Then, the side of the hole of RN was opened
without trocars at the mid-clavicular line on both sides at the level of and the thread was inserted inside it. Then, the side of the hole was
the umbilicus. Laparoscopy was started by inspection of both IIRs. The closed and the needle was withdrawn backward in the same path to
corresponding skin of the hernial defect was first marked by means of the starting point at 3 o’clock. Then, RN mounted by the thread was
transabdominal illumination of the laparoscope and slight fingertip reinserted again at 3 o’clock and was advanced along the superior
external pressure. At the marked site, a 21-gauge needle attached to a margin of the IIR beneath the peritoneum and fascia transversalis to
10-cc syringe filled with saline was introduced at 12 o’clock and come out from the same opening at 9 o’clock. The side of the hole of
advanced along the preperitoneal space on the medial side of the RN was opened and the short end of the thread was withdrawn out.
hernia defect medial to the vas deferens. Then saline was injected RN was withdrawn outside the abdomen and the short end of the
while withdrawing the needle back to the starting point. Then, the thread was pulled outside the abdominal cavity for extracorporeal
same procedure was repeated along the lateral side of the hernia suture tie and pushed by a tie pusher for tightening of the suture
defect lateral to the spermatic vessels (Fig. 1). Then 17-mm needle around the IIR (Fig. 4). In both techniques, the airtight tightening of
with non-absorbable mono-filament 2–0 suture was used to close IIR purse-string knot was stress-tested by raising the intraperitoneal CO2
by a purse string suture starting at 3 o’clock and going all around IIR. pressure by 50%. The increase in pressure was sustained for about
The suture mainly included the subperitoneal tissues except at the 30 seconds during which the patient was carefully monitored for
inferior border of IIR where only peritoneum was taken by carefully blood pressure, pulse, and oxygen saturation. The air tightness was
picking and lifting it with the tip of left hand needle holder and the confirmed by the absence of hernial sac enlargement with the
needle was seen all the time beneath the peritoneum (needle sign) to increased intraperitoneal pressure. In case of escape of gas into the
avoid injury of the spermatic vessels and vas deferens (Fig. 2). hernial sac, a second suture was inserted around IIR
Extracorporeal suture tie was used and before tightening the knot, the
scrotum was squeezed and the intraperitoneal pressure was released 2. Results
to expel the gas in the hernial sac.
RN technique (Martin Medizin-Technik, D-78501 Tuttlingen, A total of 1184 inguinal hernias were repaired laparoscopically in
Germany) was done according to the technique described earlier by 874 children. The reports of these patients were collected and
Shalaby et al with some modifications in the form of retroperitoneal analyzed. The demographic data of all patients are shown in
saline injection around IIR and lateral umbilical ligament enforcement (Table 1). All cases were completed laparoscopically without
[8,12]. A 3-mm Maryland forceps, holding the tip of a non-absorbable conversion. At operation, contralateral PPV was seen and closed in
mono-filament 2–0 thread, was inserted into the abdomen without 176 (20%) of cases. Six-hundred and twenty four IIR were closed by
trocar at the right mid clavicular line at the level of the umbilicus for TPP technique and 560 IIRs were closed by percutaneous RN
both unilateral and bilateral CIH. A stab incision of the skin was done technique. The mean operating time from skin-to-skin for both
(2 cm above and lateral to the IIR on the right side and 2 cm above techniques is shown in (Table 1). All patients achieved full recovery
and medial to the IIR on the left side) and RN was inserted into the without intraoperative or postoperative complications. In 2 cases,
peritoneal cavity (Fig. 3A–C). The needle was manipulated to pierce stress-test resulted in escape of gas into the hernial sac and a second
the peritoneum at 3 o’clock on IIR and was advanced to pass through suture was inserted again around IIR. Most children went home at the
the inferior margin of IIR under the peritoneum and in front of the same day. The mean hospital stay was 7.79 ± 1.28 hours (range, 5–
spermatic vessels and vas deferens to pierce the peritoneum at 9 19 hours). Ten percent of children stayed one night postoperatively
o’clock on the IIR (Fig. 3D–F). Care was taken to avoid damage of the because of parental preference, or geographical far distance. Follow-

Fig. 1. Extraperitoneal saline injection around IIR.


462 R. Shalaby et al. / Journal of Pediatric Surgery 49 (2014) 460–464

Fig. 2. Needle is safely placed at the elevated peritoneum and traverses just under peritoneum, in front of the spermatic vessels and vas with complete encirclement of the IIR.

up to date is 10–140 months (mean 80 ± 2.1 months). There were the IIR, tension at the closure of the internal opening, large hernia,
8 recurrences [8/703] (1.13%) in boys and no recurrence in girls. In the broken purse-string thread, the suture technical problem and
last 450 cases (350 RN and 100 TPP technique), the recurrence rate hematoma formation at the open wound [10]. Generally, the high
was 0%. On follow-up, there were 4 hydroceles [4/703] (0.57%), one recurrence rate in LIHR could possibly be owing to tension at the
required percutaneous aspiration, and the others responded well to closure of the IIR and presence of skip area especially over the vas and
conservative treatment. There were no instances of postoperative spermatic vessels without complete encirclement of IIR. It appears
testicular atrophy or testicular malposition in our series. There was no that surgeons with more practice have fewer recurrences. Beginners
metachronous hernia and the cosmetic results were excellent (Fig. 5). may not dare to place sutures as closely as required to the vessels
medially. In fact, it was found that recurrences of less experienced
3. Discussion surgeons are high [19]. In this study, all operations were done by the
first and second authors who have an extended experience with
Laparoscopic inguinal hernia repair is a relatively new procedure different laparoscopic techniques, specially laparoscopic hernia repair
in the pediatric surgical practice. It is rapidly gaining popularity with and that is why we have a very low recurrence in the beginning of this
more and more studies validating its feasibility, safety, and efficacy. It series and no recurrence in the last 450 cases.
has become an alternative to the conventional open procedure [1– The present study proved that reducing tension on the purse-
8,13,14]. Advantages of LIHR include excellent visual exposure, the string knot when closing the IIR and the addition of the lateral
ability to evaluate the contralateral side, minimal dissection and umbilical ligament to enforce purse-string knot resulted in elimina-
avoidance of access trauma to the vas deferens and spermatic vessels, tion of recurrence. A recurrence will not occur if the purse-string knot
bladder injuries and iatrogenic ascent of the testis [13,15]. In addition, and umbilical ligament covering the IIR are confirmed with the stress
it is also helpful in detecting other associated pathology and other test by an increase in the intraperitoneal CO2 pressure at the end of
hernias with excellent cosmetic results. It has a comparable operative the operation as stated by Chan [20].
time and recurrence rates [7,8,16,17]. The first large series of intracorporeal repair of CIH was reported
Many minimally invasive techniques for addressing pediatric by Schier, with primary closure of the peritoneum lateral to the cord
inguinal hernia have mushroomed in the past two decades. These with interrupted sutures [10]. Then, he modified the technique to use
techniques vary considerably in their approaches to the internal ring 2-mm instruments without a trocar for intra-abdominal suturing of
(intraperitoneal or extraperitoneal), use of ports (three, two, or one), the IIR by the placement of 2 Z-sutures [5]. Other modifications
endoscopic instruments (two, one, or none), sutures (absorbable or include an N-suture instead of a purse-string suture [6]. Subcutaneous
nonabsorbable), and techniques of knotting (intracorporeal or endoscopic assisted ligation (SEAL) of the hernial sac and other
extracorporeal). A major criticism of the laparoscopic repair remains similar techniques resulted in marked reduction of operative time
its higher recurrence rate, as compared to the traditional open when compared to the transperitoneal purse string suture using
technique, ranging from 0.83% to 4.1% [7,8,18]. The reasons were standard 3-port technique [8]. Avoiding the vas deferens and gonadal
versatile. These include failure to ligate the hernial sac high enough at vessels during the SEAL repair in boys may leave a small gap at the

Fig. 3. RN is inserted intraperitoneal at 3 o’clock and advanced through the inferior margin of IIR for picking the thread and withdrawn back (A, B, C). Then RN is passing through the
superior margin of the IIR to leave the suture for encircling the IIR (D, E, F).
R. Shalaby et al. / Journal of Pediatric Surgery 49 (2014) 460–464 463

Table 1
Demographic data of all patients (age, sex, presentations and operative time).

No. of patients 874


No. of opened IIR 1184
Sex
Male 703
Female 171
Age in month Mean, 2.9 ± 2.1 months
6–12 314
12–24 244
24–36 140
N36 176
Presentation
Right sided hernia 460
Left sided hernia 260
Bilateral hernia 134
Fig. 4. The suture is tightened around IIR.
Recurrent hernia 20
Contralateral hernia 176
Operative time RN TPP
internal ring as well as leaving the hernial sac in continuity, which has Unilateral hernia (recurrent or fresh) 8.7 ± 1.18 minutes 15 ± 2.3 minutes
the potential to contribute to a higher incidence of recurrence [21]. Bilateral hernia 12.35 ± 2 minutes 20 ± 1.7 minutes
However, SEAL is associated with a high recurrence rate and
development of granuloma, infection, and skin puckering at the site
of a subcutaneously placed knot [8,22]. These drawbacks of SEAL and recurrence will not occur. They added that their technique has no
other similar techniques were avoided by the use of RN technique. In severe complications and is indicated in the following cases: (1) large
the beginning phase of this study, we had more recurrences (1.13%) in hernia, hernial sac N1.5 cm; (2) recurrent hernia, and (3) the patient’s
boys as of June 2008, excluding the last 450 cases, but this rate is lower age above 5 years [24].
than that reported by others (3.4%–4.1%) performing LIHR [8,10] and In our pediatric surgery unit, Al-Azhar University Hospitals, the IIR
even lower than noted in open herniotomy (1.2%) [18]. Chan and Tam is closed by purse-string suture encircling its whole circumference
stated that injecting normal saline into the extraperitoneal space at IIR without any skip area either by TPP or by RN technique [8]. Both, the
to elevate the peritoneum away from vas and spermatic vessels allows operative time and the recurrence rate in our series are lower than
stitches to be inserted safely without any skip area for a tight purse that reported in the literature because LIHR was started after gaining
string suture. However, care still is needed to make sure the vas good experiences in different laparoscopic procedures. Recently we
deferens and testicular vessels are not included [23]. used an easy, safe, simple and rapid technique for repair of CIH using
Chen et al used medial or lateral umbilical ligaments to cover the percutaneous insertion of purse string suture by RN and extracorpo-
internal hernia opening region after finishing purse-string knot to real suture ligation which is less time consuming. Also, we followed
prevent the recurrence. The method they developed was revolution- many technical refinements such as injecting normal saline into the
ary in the principle of pediatric hernia repair. It includes both the extraperitoneal space at IIR, including sub peritoneal tissue all around
security of repair offered by the watertight closure of the hernia IIR without any skip area, reducing tension on the knot of purse string
opening and the hernia opening region covered with the umbilical suture by deflation of the abdomen and squeezing the scrotum to
ligament flap. The valve mechanism allows scrotal fluid avoiding empty the hernial sac, lateral umbilical ligament enforcement and the
scrotal collection. Under the stress of intra-abdominal pressure, the use of non-absorbable suture. These latest technical refinements and
wall of the sac is pressed over by the flap, keeping the sac in a modifications of the techniques resulted in marked reduction of
collapsed state. They claimed that their technique is very easy and the development of post-operative hydrocele, lowering the recurrence of

Fig. 5. A: Rt. Recurrent huge inguinal hernia. B: Post-operative view.


464 R. Shalaby et al. / Journal of Pediatric Surgery 49 (2014) 460–464

hernia to 0% and reduced operative time. The above mentioned operative time were slightly higher in the early stages, now they are
technical refinements have been described before by Chan and others nearly equal or even less than with the open procedure. The risk of
[20,23,24]. We have no recurrence in our last 450 LIHR cases as we metachronous hernia is reduced. The cosmetic results are excellent
followed some technical refinements as described before. Also we and there are virtually no scars. LIHR can be adopted routinely in
started laparoscopic hernia repair after gaining a good experience in pediatric centers and it can be considered good training for residents
other laparoscopic techniques. Others have no recurrence in their in pediatric surgery because it helps to improve their ability with both
series [24–27]. Marte et al stated that the incision of the peritoneum intracorporeal and extracorporeal suture tying.
lateral to the IIR and the W-shaped suture, compared to the sole W-
shaped suture, prevented hernia recurrence in their series [25]. References
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