Laparoscopic Needle Assisted Repair for Pediatric

Inguinal Hernia: Don’t Wait More to Start

Abstract:
Laparoscopic Needle Assisted Repair (LNAR) has recently emerged as an
alternative, safe and effective procedure to manage pediatric inguinal hernia.
however, presented studies did not show the ability of procedure when
trainees or surgeons with no previous experience in laparoscopy would
perform LNAR. Therefore, this study will show the results of this technique in
hands which do not have any laparoscopic experiences.

Introduction:
Congenital Inguinal hernia is one of the most frequently performed operations
in infant and children. Open herniotomy is the standard method of treatment
based on which other modalities of repair are evaluated [1,2]. However, in the
recent years laparoscopic hernia repair is routinely performed in many centers
and its efficacy and safety are well documented [3-6] both intracorporeally or
extracorporeally suturing of internal inguinal ring (IIR) was defined with
various techniques. Laparoscopic needle assisted repair (LNAR) for pediatric
inguinal hernia has been confirmed as feasible, effective and safe procedure
but most of the studies was performed in hands of experts [5,7]. However,
laparoscopic surgery in children remained limited due to the need for
experience before it was applied, while most pediatric surgeons around the
world had not previously received training in laparoscopic surgery, especially
outside Europe and America [8]. One interesting report suggested
conservatism among surgeons. An analysis of the EUPSA-BAPS 2012
questionnaire among 187 participants across 46 countries revealed that 79%
of respondents practiced laparoscopic surgery for pediatric surgical
conditions; however, only 22% routinely performed laparoscopic inguinal
hernia repair [9]. The aim of the study is to evaluate the feasibility, efficacy,
and safety of the (LNAR) procedure when it performs in hands of surgeons
with no previous experiences in laparoscopy and how simple LNAR is.

Methods:
This prospective study was conducted in Tishreen university hospital- from
march 2018 to April 2019. 15 children with 18 hernia (3 bilateral) underwent
Laparoscopic Surgery LNAR by one surgeon and this was the first time of
pediatric laparoscopy in the institution and in Syria generally. Operative time,
intra and postoperative complications, postoperative pain and cosmetics
aspects were recorded. Patients were followed for an average of 12 months to
evaluate the outcomes. Procedures were done under general anesthesia.
5mm supra umbilical camera port is made. Using 0 o scope, Internal ring
identified to confirm the patent process vaginalis and look for contralateral
occult hernia. A small 3mm stab incision made in the inguinal region through
which a 18G needle with folded 2-0 prolene is inserted lateral to internal ring
forming a loop medial to the ring, another 18G needle with 2-0 prolene is
inserted the needle along with the prolene is inserted inside the loop. The loop
is drawn out along the medially inserted prolene.
The ring is encircled in an extraperitoneal plane for the placement of purse
sting suture. The knot is tied
extracorporeally and buried
beneath the skin (fig 1). No
graspers or other intraperitoneal
instruments were used.

Results:
There were 15 patients (10
male and 5 female) patients
underwent laparoscopic
surgery. Patient’s median age at
operation was 4.4 years (20
days — 12 years). 9 hernia was
right side,3 lift and 3 bilateral (2
of them diagnosed
intraoperative). Mean time of
surgery was 22.6 (14-35) min
for unilateral hernias 27.3 (12- Fig. 1: Principle adopted in LNAR
55) min for bilateral hernias. All
Patients were followed for an average of 12 months(7-17months) post-
operative. All procedures were completed laparoscopically without need to be
converted to open approach. [table 1]

Table 1: Results

Parameters Observations
No. of cases 15
No. of repairs 18
Mean age 4.4 years (20 days – 12 years)
Sex M = 10, F = 5
Side of hernia RT = 9 (60%), LT = 3 (20%), B/L = 3 (20%)
Mean follow-up 12 months (7 – 17 months)
Occult PPV 2/14 (14.2%)
Mean operative time 22.6 min (14 – 35 min), B/L – 27.3 min (12 - 55 min)
Recurrent hernias 0
No. of cases converted to open surgery 0

No significant intra-operative complications occurred. Post-operative

complications were grouped into major complications and minor
complications. Overall rate of recurrence was 0% for the total number of
repairs. No other major complications were identified. There were no
instances of testicular atrophy or edema. There were no injuries to the vas
deferens and no episodes of bleeding and no mortalities.
No minor complications included post-operative hydrocele, suture granuloma,
and wound infection were noted. Just in one case there was discomfort of the
palpable note under the skin which disappeared spontaneously after 2
months. All scars were invisible. 6 patients need additional dose to manage
pain after discharge, all of them were under age of 2 years. Two patients had
umbilical hernia repaired Simultaneously.
 Discussion:
In our institution there is one operative room for laparoscopy in department of
general surgery. cholecystectomy, colectomy and gastric paypas are
traditionally performed in. instruments are not suitable for pediatric
laparoscopy, however, we use this room to find our chance in this study. With
5mm camera trocar and pediatric surgeon in first laparoscopic experience to
show how simple is LNAR to perform by trainees. Several large prospective
series have been published documenting the safety and efficacy of the LNAR
technique in children. A review from a single pediatric surgeon involving 495
patients underwent 710 laparoscopic inguinal hernia repairs during the 50-
months study period. Operative time [mean (range)] was 20.5 (8–57) min for
single-sided repair and 26.4 (12–51) min for bilateral repair [10] these results
are same in our study; Mean time of surgery was 22.6 (14-35) min for
unilateral hernias 27.3 (12-55) min for bilateral hernias. Recurrence rate was
(0.56 %) also close to recurrence rate in this study (0%). Wound infection,
recurrence and testicular atrophy and Cosmetic results were similar. Also,
laparoscopic inspection of the contra lateral internal ring has been proven an
effective technique to avoid unnecessary open exploration in patients with
elevated risk of contra lateral patent processus unidentified on clinical exam,
two contralateral was detected and repaired. In comparative with one of other
extracorporeal method Laparoscopic Percutaneous Extracorporeal Closure
(LPEC) [11] same results were founded with best outcome to operative time
(25 min for unilateral,49 min for bilateral). [table 2]

table 2: compare with other studies

Author Yea published pts/ Type Median grasper Follow-up Recurrence rate
r Type of repairs of Operative
study repair time
(uni/bilat)
Yukihiro 201 Prospective 13/18 LPEC 25/49 1 6,07 months 0 % (0/18)
Tatekaw 1 (2-12 months)
a
McClain 201 Prospective 495/710 LNAR 20/26 1 10.7 months 0.56 % (4/710)
et al. 4 (0.3–38.4 months)
This 201 Prospective 15/18 LNAR 22/27 0 12,07 months 0 % (0/18)
study 8 (7 – 17 months)
Results were close to other studies without significant differences and best operative time in compare with other
extracorporeal method LPEC

Conclusion:
LNAR is simple, effective and safe procedure even when perform by trainees
or surgeons without previous experience in laparoscopy and may be
considered as first training operation in laparoscopy or an alternative standard
intervention to manage pediatric indirect hernias.

References:
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