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Comparative Study
. 2009 Aug;23(8):1706-12.
doi: 10.1007/s00464-008-0300-7. Epub 2009 Apr 3.

Laparoscopic completely extraperitoneal repair of inguinal hernia in children: a single-institute experience with 1,257 repairs compared with cut-down herniorrhaphy

Masao Endo  1 , Toshihiko Watanabe, Miwako Nakano, Fumiko Yoshida, Etsuji Ukiyama
Affiliations
Comparative Study

Laparoscopic completely extraperitoneal repair of inguinal hernia in children: a single-institute experience with 1,257 repairs compared with cut-down herniorrhaphy

Masao Endo et al. Surg Endosc. 2009 Aug.

Abstract

Background: Conventional open herniorrhaphy in children has been reported to have 0.3-3.8% recurrence and 5.6-30% postoperative contralateral hernia rates. We developed a unique technique to achieve completely extraperitoneal ligation of PPV without any skip areas under laparoscopic control. This report introduces our technique and results compared with the cut-down herniorrhaphy.

Methods: A consecutive series of 1,585 children with inguinal hernia/hydrocele (1996-2006) was analyzed. In laparoscopic patent processus vaginalis (PPV) closure (LPC), an orifice of PPV was encircled with a 2-0 suture extraperitoneally by a specially devised Endoneedle and tied up from outside of the body achieving completely extraperitoneal ligation of the ring. The round ligament was included in the ligation, whereas the spermatic cord and testicular vessels were excluded by advancing the needle across them behind the peritoneum. Cut-down herniorrhaphy (CD), with or without diagnostic laparoscopy, or LPC was selected according to parental preference under informed consent.

Results: Parents gave more preference to LPC (LPC in 1,257 children, CD in 308, and miscellaneous in 20). Age ranges were equal for both groups. Sex distribution showed female preponderance in the LPC group (44.8% vs. 26.6%, p < 0.001) and umbilical hernia/cysts were predominantly included in the LPC group (11.9% vs. 2.9%, p < 0.001). Mean operation times were equal for both groups for unilateral repair (28.2 +/- 9.2 for LPC vs. 27.8 +/- 13.5 for CD) and were shorter for bilateral repair in the LPC group (35.8 +/- 11.6 vs. 46.7 +/- 17.7). The incidence of postoperative hernia recurrence and contralateral hernia in the LPC group was 0.2% and 0.8%. Two children in the CD group had injuries to their reproductive system during the operation (0.6%).

Conclusions: The advantages of our technique include following: technically simple, short operation time, inspection of bilateral IIRs with simultaneous closure of cPPV, reproductive systems remain intact, routine addition of umbilicoplasty if desired, and essentially indiscernible wounds.

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Figures

Fig. 1
Fig. 1
Instrumentation consisting of 14-gauge sheath needle as a port for 15-gauge grasper with electrocautery, 16-gauge sheath needle for puncture, and 19-gauge Endoneedle for sending and retrieving a suture. A metal filament is used for setting a 2–0 nylon twine as a suture into the Endoneedle
Fig. 2
Fig. 2
Laparoscopic completely extraperitoneal closure of right-sided PPV. (1) Anatomy of male IIR. 1, umbilical plica; 2, inferior epigastric vessels; 3, external iliac vein; 4, transverse abdominal muscle; 5, orifice of PPV; 6, spermatic duct; 7, testicular vessels. (2) A small opening is made on the peritoneum between spermatic duct and testicular vessels using 15-gauge grasper with electrocautery. (3) The spermatic duct is separated from covering peritoneum by the grasper. (4) 16-gauge sheath needle goes along lower half of the IIR extraperitoneally crossing over the testicular vessels and spermatic duct beneath the peritoneum. (5) After the puncture needle penetrates the peritoneum at the opposite side, a 2–0 suture is send by Endoneedle. (6) Free end of the suture is bitten into the Endoneedle that has come along upper half of the orifice and drawn out together with the needle. (7) The orifice of PPV has been encircled without any skip areas. The suture is tied from outside. (8) End of the procedure
Fig. 3
Fig. 3
Double ligation for infant younger than aged 1 year 6 months. An internal pursestring suture is placed, skipping over the spermatic cord and testicular vessels, proximally to the previously placed encircling suture
Fig. 4
Fig. 4
G.K., 2-year-old boy right indirect inguinal hernia. A Preoperative findings; 1 spermatic cord, 2 testicular vessels, 3 inferior epigastric vessels. B Immediately after closure; 4 Umbilical plica. Umbilical plica has been drawn toward the center of ligation. The spermatic cord and testicular vessels run apart from the ligation. C Revisit for contralateral hernia developed after 3 months; 5 suture knot. The primarily closed IIR has been covered by thick cicatricial tissue resulting in super-high ligation. The spermatic cord and testicular vessels have returned to preoperative places
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