Laparoscopically Assisted Percutaneous Inguinal Ring Closure for Resolution of Inguinal/Scrotal Hernias in Rams: Cadaveric Study and Three Cases Report

Abstract

The aim of this study is to evaluate a laparoscopically assisted percutaneous suture (LAPS) procedure to treat inguinal hernia (IH) while preserving testicles in rams. An ex vivo experiment with six ram cadavers and a report of three clinical cases are discussed. In cadavers, both internal inguinal rings (IIR) were partially closed by LAPS. Two LAPS methods were tested: (1) using a laparoscopic portal closure device and (2) using a suture loop inserted through needles in each IIR. After each procedure, the closure was laparoscopically evaluated and the number of U- sutures was recorded. The procedure was also performed on three client-owned rams with unilateral non-strangulated IH and the occurrence of re-herniation was followed up. In cadavers, LAPS of the IIRs could be easily and satisfactorily performed with either of the two systems, requiring one to three U-sutures per IIR. No differences were observed between the two surgical procedures. In two clinical cases, the procedure was successfully performed without reoccurrence of herniation or alterations in reproductive behavior in the following 3 and 6 months. In the third case, the hernia was reduced but a retroperitoneal emphysema during laparoscopy prevented hernioplasty and the animal herniated again. In conclusion, LAPS of IIR can be used as a simple and feasible treatment to preserve testicles in rams with IH.

Keywords: cadaver; case report; hernioplasty; inguinal hernia; laparoscopy; percutaneous suture; ram.

Figure 1

Scheme of laparoscopic portal placement. Red circle: laparoscope portal, placed 5 cm cranial to the prepuce and 5 cm to the right of the midline. Green circles: instrumental portals, placed 10–15 cm cranial to each inguinal ring. Blue dotted lines: inguinal rings.

Figure 2

Needle suture loop technique (NSLT) for laparoscopically assisted percutaneous suture of the right internal inguinal ring in a cadaver. (Top): 12 G 80 mm needle, with a suture loop through it, inserted through the skin incision into the abdominal cavity under laparoscopic control; asterisk: internal inguinal ring; black arrow: spermatic cord. (Bottom): distal end of a 0 USP polyamide suture introduced into the abdomen through the needle and passed into the initial loop with the assistance of laparoscopic forceps.

Figure 3

Case 1: Rasa Aragonesa ram with large left scrotal hernia.

Figure 4

Case 1: Laparoscopically assisted percutaneous suture using the EndoClose device in the first clinical case. (Top left): aspect of the left vaginal ring after hernia reduction. (Top in the middle): a needle was inserted percutaneously into the ventral aspect of the vaginal ring to introduce a 0-USP polyamide suture through it. (Top right): the EndoClose device inserted into the dorsal side of the vaginal ring was used to grasp and exteriorize the suture, completing the U-suture. (Bottom left): with the help of laparoscopic forceps, the suture is positioned to be held by the notched tip of the Endoclose. (Bottom in the middle): externalizing the suture to create the second U-suture; a slight peritoneal tear can be seen due to the manipulations on the cranial side of the vaginal ring. (Bottom right): final laparoscopic appearance of the inguinal ring after placement of three laparoscopically assisted U-sutures.

Figure 5

Pulsed Doppler ultrasonography of right testicle in Case 2, showing perfusion parameters measured in an intratesticular artery. Within the ultrasonographic window, the testicle (asterisk) with herniated omentum and the bowel (arrows) and fluid (arrowhead) can be seen.