|Year : 2013 | Volume
| Issue : 2 | Page : 72-75
Incise, dissect, excise and suture technique of laparoscopic repair of paediatric male inguinal hernia
Rasik Shah, Jamir Arlikar, Nitin Dhende
Department of Pediatric Surgery, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India
|Date of Submission||08-Dec-2011|
|Date of Acceptance||05-Apr-2012|
|Date of Web Publication||22-Apr-2013|
F/5, Pannalal Terraces, Grant Road, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Authors report incise, dissect, excise and suture (IDES) technique of laparoscopic repair of paediatric male inguinal hernia (LRPMIH). This series retrospectively evaluates a consecutive personal series of children undergoing laparoscopic hernia repair by this new technique. Materials and Methods: It is a retrospective review of the LRPMIH done by single surgeon from January 2001 to December 2007. All male patients who were referred to the first author for management of inguinal hernia were given the option of laparoscopic repair. Parents who gave consent for their child to undergo LRPMIH were retrospectively reviewed. Results: A total of 155 patients were operated. Age group was 2 months to 13 years (average-5 years). Follow-up period ranges from 1 to 7 years. Average operating time was 29 min for unilateral and 40 min for bilateral inguinal hernia. Maximum time required was 50 min which was for bilateral inguinal hernia. Bilateral inguinal hernia was present in 10 (6.4%) patients. There were no intraoperative complications. Contralateral processus vaginalis was patent in 25 (16.12%) patients. In the immediate post-operative period 8 patients had port site surgical emphysema which resolved on its own. There are no recurrences so far. One patient developed port site hernia, which was repaired with the standard surgery. There is no incidence of clinical testicular atrophy. Conclusion: LRPMIH can be done as routine procedure and also has fewer complications. It has advantage of diagnosing and repairing contra lateral patent processus vaginalis. However a double-blind controlled study is required to establish the results.
Keywords: Laparoscopic, paediatric male inguinal hernia, recurrence
|How to cite this article:|
Shah R, Arlikar J, Dhende N. Incise, dissect, excise and suture technique of laparoscopic repair of paediatric male inguinal hernia. J Min Access Surg 2013;9:72-5
|How to cite this URL:|
Shah R, Arlikar J, Dhende N. Incise, dissect, excise and suture technique of laparoscopic repair of paediatric male inguinal hernia. J Min Access Surg [serial online] 2013 [cited 2020 Aug 5];9:72-5. Available from: http://www.journalofmas.com/text.asp?2013/9/2/72/110966
| ¤ Introduction|| |
There are many concerns for repairing paediatric male inguinal hernia laparoscopically.  Certain concerns like (1) laparoscopic repair is performed transperitoneally unlike extraperitoneal approach in open surgery leading to peritoneal violation, (2) unnecessary handling of vas and testicular vessels leading to testicular atrophy,  (3) need of controlled general anaesthesia when one can manage it with mask and caudal block, (4) need of personnel with laparoscopic expertise, (5) reported higher rate of recurrence in the literature  and (6) more time consuming compared to open repair. Laparoscopic repair is currently being accepted for female inguinal hernia. The authors devised IDES technique to replicate all the steps of open surgery with the idea to decrease the recurrences seen by other laparoscopic repair of male inguinal hernia published in the literature.
| ¤ Materials and Methods|| |
Authors have operated 155 male patients by incise, dissect, excise and suture (IDES) technique. Age ranged from 2 months to 13 years. Average age was 5 years. Only 6% of the patients had bilateral inguinal hernia at the time of presentation.
Controlled general anaesthesia with endotracheal intubation was given in all cases. Patients were kept supine and properly secured to operating table to avoid sliding of the patient while changing the position. The patient was positioned head low along with elevation of the side of the hernia to be repaired, i.e. if operating for right inguinal hernia left lateral tilt to the operating table was given. Supra-umbilical 5 mm port was inserted using open technique for 5 mm 30° telescope. Pneumo-peritoneum was established by CO 2 insufflations at pressure of 8 cm of water and at the rate of 1 l per minute. Examination of the affected side and then opposite side was performed to check for the patency of the processus vaginalis. Two more 3 mm trocars were inserted under laparoscopic guidance at the level of umbilicus in mid-clavicular line on either side as working ports for bilateral hernia. For unilateral hernia, the working port on the side of hernia can be little higher and opposite side little lower, for better triangularisation. In infants and small babies, the working ports were placed little higher than the level of umbilicus.
The incision on the peritoneum at the internal ring was started on the symptomatic side. For a right-handed person, if operating on right side then incision was started laterally and then continued medially [Figure 1], while on the left side medial to lateral incision was taken. Initial dissection of the vas and vessels was done and then the peritoneum posterior to the internal ring was divided and then the anterior dissection was carried out. Care was taken not to damage the vas and vessels by handling them [Figure 2]. The dissection of the hernial sac was continued in the inguinal canal for approximate length of 2 cm [Figure 3]. The dissected sac was excised, either with cautery hook or scissors. At this point, assessment of the approximation of the conjoint muscle with the inguinal ligament was observed at the internal ring. In case of poor approximation, suturing of the conjoint muscle with inguinal ligament was performed lateral to the inferior epigastric vessels using 3-0 polyglycolic acid suture [Figure 4]. Then the peritoneal defect was closed using absorbable 3-0 polyglycolic acid on round body needle. The needle was inserted trans-abdominally and either a purse string [Figure 5] or 'Z' suture was taken at the deep ring. While closing the peritoneal defect the needle was kept relatively fixed and the peritoneal bites were taken by feeding it on to the needle with the help of the dissector. After suturing was accomplished the needle and the hernial sac was removed along with the trocars. Supra-umbilical incision was closed with polyglycolic acid 3-0. Three mm trocar sites were approximated with the steristrips. The feeds were started after 4 h and patients were discharged on the same day or next day morning.
|Figure 1: Incision taken medially on the peritoneum while operating left inguinal hernia|
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|Figure 3: While dissecting hernial sac care is taken not to handle vas and vessels|
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|Figure 4: Suturing of the conjoint tendon and inguinal ligament with polyglycolic acid|
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| ¤ Results|| |
A total of 155 patients were operated. Age group was 2 months to 13 years (average-5 years). Follow-up period ranges from 1 to 7 years. Average operating time was 29 min for unilateral and 40 min for bilateral inguinal hernia. Maximum time required was 50 min which was for bilateral inguinal hernia. Bilateral inguinal hernia was present in 10 (6.4%) patients. There were no intraoperative complications. Suturing of the conjoint tendon with the inguinal ligament was done in 7 (4.51%) patients. Contralateral processus vaginalis was patent in 25 (16.12%) patients. Most patients were discharged on the same day or next morning. Sixteen patients were discharged next morning mainly because of the parental concern, preferences and distance from the hospital. In the immediate post-operative period eight patients had port site surgical emphysema, which resolved on its own. All patients had a follow-up within 4 week period after surgery. There are no recurrences so far. One patient developed port site hernia, which was repaired with the standard surgery. There is no incidence of clinical testicular atrophy. So far there is no incidence of metachronus hernia in our study.
| ¤ Discussion|| |
Laparoscopic male inguinal hernia repair is an evolving procedure with slow acceptance by paediatric surgical society. There are no reports in the literature of the untoward effect of doing transperitoneal procedure. Even in our series we did not had any complications while intra-operatively or immediate in the post-operative period because of transperitoneal approach. Even chances of damage to vas and vessels are minimized because of the magnification we get during laparoscopy. Laparoscopic inguinal hernia repair using suture closure of internal inguinal ring does not impair testicular perfusion.  Earlier reports of laparoscopic repair show high incidence of testicular damage and recurrence  (0.2% and 4.1%, respectively). But as technical advances in the laparoscopy and also our experience is increasing chances of damage to testicular vessels and also recurrence of hernia have reduced. Chan  from Hong Kong has reported recurrence of only 0.4% in their tensionless repair of inguinal hernia. Sneider et al.  has used selection of age to reduce the recurrence. They have selected the patients between the age group of 3 months to 6 years with zero recurrence.
Incising peritoneum on the right side in right inguinal hernia and on left side in left inguinal hernia is only for ease of doing it for a right-handed person. In the past some surgeons have used either absorbable or non-absorbable suture depending upon their preference. Shier  is using non-absorbable suture for same purpose when his initial experience with absorbable suture had more recurrence. But we believe that recurrence is more related to the technicalities rather than on suture material. Mohta  and colleagues believe that non-ligation of the hernia sac during herniotomy does not lead to recurrence. Oak et al.  have done extracorporeal suturing of the deep ring with an absorbable sutures in their 18 repairs of large infantile inguinal hernias without any recurrence.
At present we are using the 3 mm trocars, but others have used 2 mm also.  Trocar placement remains same for all patients. We are of the view that relative changes in position of trocar should be based on patient's age and length and also on side which we are operating.
If parental concern regarding contralateral hernia or patent processus vaginalis is considered, then according to Holcomb et al.,  90 of the 113 parents considered laparoscopy and contralateral inspection for a unilateral hernia. Their concern was mainly regarding convenience rather than worry about second procedure and about the anaesthesia.
Among children undergoing unilateral hernia repair, there is up to a 30% chance that a hernia will develop on the contralateral side requiring subsequent repair. , When the risk of metachronus hernia is higher, laparoscopy effectively eliminates the possibility of a subsequent hernia and injury that may occur with incarceration in children at high risk for these events.  One can diagnose the contralateral patent processus vaginalis. Bhatia et al.  from Georgia found that positive exploration of contralateral patent processus vaginalis was seen in 38% of children less than 2 years, 20% of between 2 and 8 years and 8% of children greater than 8 years. So children below 8 years are good candidates for laparoscopic repair. Chan  detected five contralateral hernias in their 42 patients of open surgery on follow-up. There are no reports in the literature of the patients who have patent processus vaginalis which were diagnosed during laparoscopy and subsequently followed up for the hernia on that side. In their series of an investigation on the mechanism of contralateral manifestation after unilateral herniorrhaphy in children based on laparoscopic evaluation, Watanabe  et al. have found that predicted incidence of contralateral hernia was 11.2%. Laparoscopy has well-established role in all cases of recurrent inguinal hernia if no cause is found. Laparoscopy accurately identifies the nature of the defect in children with recurrent groin hernias, detecting unsuspected contralateral indirect, direct or femoral hernias in 44% of those undergoing laparoscopy. 
One interesting outcome of Sneider's  study was that recurrence has no relation with the level of expertise; recurrence rate was similar when operated by resident or a faculty. Whereas according to Treef and Schier  an experienced surgeon has only half the recurrence of a less experienced surgeon. Treef and Schier are of view that medial stitch at the inguinal ring is very crucial for the recurrence and also most of the recurrence occurred by 3.8 months post-operatively. The author is also of the opinion that experience does matter while doing the laparoscopic repair not only in terms of recurrence but also in view of damage to vas and vessels. In our series all repairs are done by author who has almost 15 years experience. Also, authors feel that use of purse string and Z stitch for closure of defect is technically easier. Our present study does not have any recurrence; explanation for this may be use of purse string or Z suture, suturing the conjoint tendon to inguinal ligament and author's experience of laparoscopic surgery. If one has mastered the intra-corporeal suturing then it is easy to do this repair.
The incidence of metachronus hernia after unilateral repair of hernia, as reported by Burd,  is up to 30%. We have not seen a single metachronus hernia in last 7 years possibly because open inguinal ring detected during laparoscopic repair has been taken care with closure during same procedure.
Our present study does not report any incidence of hydrocele and testicular atrophy in the post-operative periods. This can be attributed to minimal or no handling of vas and surrounding structures during laparoscopy. It is easier to identify vas and surrounding structures as magnification and anatomical details that we get during the laparoscopy is excellent.
| ¤ Conclusion|| |
Laparoscopic repair of paediatric male inguinal hernia by using IDES technique can be done effectively with minimal complications and without any recurrence. However long-term follow-up and double blind controlled trial will establish its efficacy.
| ¤ References|| |
|1.||Schier F. Laparoscopic inguinal hernia repair-a prospective personal series of 542 children. J Pediatr Surg 2006;41:1081-4. |
|2.||Schier F, Turial S, Hückstädt T, Klein KU, Wannik T. Laparoscopic inguinal hernia repair does not impair testicular perfusion. J Pediatr Surg 2008;43:131-5. |
|3.||Chan KL, Chan HY, Tam PK. Towards a zero recurrence rate in laparoscopic inguinal hernia repair for pediatric patients of all ages. J Pediatr Surg 2007;42:1993-7. |
|4.||Sneider EB, Jones S, Danielson PD. Refinements in selection criteria for pediatric laparoscopic inguinal hernia repair. J Laparoendosc Adv Surg Tech A 2009;19:237-40. |
|5.||Mohta A, Jain N, Irniraya KP, Saluja SS, Sharma S, Gupta A. Non-ligation of hernial sac during herniotomy: A prospective study. Pediatr Surg Int 2003;19:451-2. |
|6.||Oak SN, Parelkar SV, Ravikiran K, Pathak R, Viswanath N, Akhtar T, et al. Large inguinal hernias in infants: Is laparoscopy the answer? J Laparoendosc Adv Surg Tech A 2007;17:114-8. |
|7.||Holcomb GW, Miller KA, Chaignaud BE, Shew SB, Ostlie DJ. The parental perspective regarding the contralateral inguinal region in a child with a known unilateral inguinal hernia. J Pediatr Surg 2004;39:480-2. |
|8.||Miltenburg DM, Nuchtern JG, Jaksic T, Kozinetz CA, Brandt ML. Meta-analysis of the risk of metachronus hernia in infants and children. Am J Surg 1997;174:741-4. |
|9.||Burd RS, Heffington SH, Teague JL. The optimal approach for management of metachronus hernias in children: A decision analysis. J Pediatr Surg 2001;36:1190-5. |
|10.||Bhatia AM, Gow KW, Heiss KF, Barr G, Wulkan ML. Is the use of laparoscopy to determine presence of contralateral patent processus vaginalis justified in children greater than 2 years of age? J Pediatr Surg 2004;39:778-81. |
|11.||Chan KL, Hui WC, Tam PK. Prospective randomized single-center, single-blind comparison of laparoscopic versus open repair of pediatric inguinal hernia. Surg Endosc 2005;19:927-32. |
|12.||Watanabe T, Nakano M, Endo M. An investigation on the mechanism of contralateral manifestation after unilateral herniorrhaphy in children based on laparoscopic evaluation. J Pediatr Surg 2008;43:1543-7. |
|13.||Perlstein J, Du Bois JJ. The role of laparoscopy in the management of suspected recurrent pPediatric hernias. J Pediatr Surg 2000;35:1205-8. |
|14.||Treef W, Schier F. Characteristics of inguinal hernia recurrences. Pediatr Surg Int 2009;25:149-52. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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