Shalaby technique for efficient single incision laparoscopic pediatric inguinal hernia repair

doi:10.1016/j.jpedsurg.2015.07.019

Journal of Pediatric Surgery

Volume 50, Issue 11, November 2015, Pages 1995-2000

https://doi.org/10.1016/j.jpedsurg.2015.07.019 Get rights and content

Abstract

Background

The desire to reduce incision related morbidity and pain while achieving improve cosmetic results has recently led to the introduction of single incision pediatric endosurgery [SIPES]. Over the last few years, SIPES has been increasingly used for a variety of procedures; single incision laparoscopic hernia repair [SILHR] is perhaps its common application. Intracorporeal suturing and knot tying during SIPES remain one of the most challenging tasks. The aim of this study is to present a novel technique to avoid excessive purposeless movements during SILHR in children.

Patients and methods

One-hundred and fifty patients with 170 hernial defects were subjected to SILHR during the period from June 2009 to October 2011. Extraperitoneal saline was injected around internal inguinal ring [IIR] in males. The opened IIR was closed by percutaneous insertion of purse string suture using Reverdin Needle (RN) with intracorporeal suture tie. The main outcome measurements were; feasibility of the technique, tightness of the suture tie, operative time, postoperative hydrocele formation, recurrence rate, and cosmetic results.

Results

Ages ranged between 6 months and 7 years (mean 2 ± 24.2 years). There were 101 males and 49 females. Eighty-four patients presented with right sided inguinal hernia, 46 patients with left sided hernia, and 20 patients with bilateral hernia. The mean operative time was 12.4 ± 1.7 min for unilateral cases and 18.6 ± 1.7 min for the bilateral cases. On follow-up, there were only 1 case of recurrence and 3 cases of hydrocele and the scar is nearly invisible.

Conclusion

The preliminary results of this study showed that our technique is very promising to achieve secure closure of IIR and reduced operative time with excellent cosmetic results.

Section snippets

Patients and methods

This study was conducted at Pediatric Surgery Units, Al-Azhar and Alexandria University Hospitals, Egypt between June 2009 and October 2011. A total of 150 patients with 170 inguinal hernial defects were subjected to SILHR. All children were subjected to full history taking, thorough clinical examination, and routine laboratory investigations (CBC, BT, CT, FBS, liver and renal profile) and inguino-scrotal U/S. Inclusion criteria: Bilateral CIH, unilateral CIH with questionable other side, cases

Description of the technique

The patient is placed supine in the Trendelenburg’s position with tilting to the contralateral side of the hernia. General endotracheal tube anesthesia is used for all cases. A 0.5–0.8-mm longitudinal trans-umbilical skin incision is done within the umbilical cicatrix with elevation of skin flaps that allows wide skin incision for easy port placement. The abdomen is entered through a 5-mm fascial incision and a 5-mm port is inserted into the abdomen for a telescope 5-mm, 30°. Creation of

Results

A total of 170 inguinal hernia defects were repaired laparoscopically in 150 children. The reports of these patients were collected and analyzed. There were 101 males and 49 females with a mean age of 2 ± 24.2 years. [range = 6 months to 7 years]. The demographic data of all patients are shown in Table 1. RN is used for both insertion of a purse string suture and assistance with Maryland for intracorporeal suture tie around IIR and all cases were completed laparoscopically without conversion The

Discussion

One of the main obstacles of the progress of laparoscopy is the difficulty in some laparoscopic techniques, mainly intra corporeal knotting and manipulations, which leads to prolonged operative time and frustration with tendency to conversion [9].

Any technique or maneuver which helps reduce operative time and manipulation and shorten the learning curve in laparoscopy will greatly improve the acceptance and progress of any new technique in laparoscopy.

Single incision laparoscopic hernia repair

Conclusion

Economy of movement during SILHR avoided excessive purposeless movements, which resulted in decreasing the operative time and rendering the procedure easier, progressive, smooth and reproducible. The results suggest that our technique is safe, effective, and reliable, with a low recurrence rate equal to that obtained with conventional open repair and excellent cosmetic results. We therefore suggest its use for single port laparoscopic repair of inguinal hernias in children.

The following are the

Acknowledgment

The authors are grateful for the support, suggestions and revision offered by Abdel Wahab El-Okby and Amin Abokifa Professors of Pediatric surgery, Pediatric Surgery Unit, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.

References (13)

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There are more references available in the full text version of this article.

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Novel application of the sewing machine principle; a new simplified intracorporeal suturing technique for pediatric inguinal hernia
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Citation Excerpt :
The knot quality was assessed using the scale previously published by Muresan C. et al. 2010 [8]. In this scale the knot quality is based on tightness, ability to hold, and adaptation of the edges of the peritoneum together with negative stress test [8,11]. The protocol was discussed and approved for clinical study by the Ethical Research Committees of Al-Azhar and Mansoura Universities.
The desire of pediatric surgeon to reduce incision related morbidity and pain while achieving good cosmetic results has recently led to the introduction of single incision pediatric endosurgery [SIPES] and needlescopic surgery. Intracorporeal suturing and knot tying during SIPES remain challenging. The aim of this study is to introduce a novel and simple technique for intracorporeal suturing of the pediatric inguinal hernia after needlescopic disconnection of hernia sac using just needles rather than laparoscopic instruments. It is an imitation of the principles of sewing machine.
The first author discussed the idea of the technique with the coauthors and a demonstration was done on a Silicon Pad before application of the technique on children with congenital inguinal hernia [CIH] for peritoneum closure after needlescopic disconnection of the hernia sac. The main outcome measures were feasibility of the technique, suturing and knotting time and recurrence rate.
The sutures were snugly applied to the ridges of Silicon Pad with good approximation and the knot was firmly tightened in all experiments. After applying and mastering the technique on a Silicon Pad, we shifted to use it on 373 children with 491 hernia defects. All operations were completed by the needlescopic technique without the need for insertion of any laparoscopic instruments. The time required for suturing of the peritoneum around internal inguinal ring [IIR] and knot tying, decreased considerably from 6 min 27 s in the first operation to less than 4 min after the fifth operation and stabilized at approximately 4 min 30 s. No major intraoperative complication. There was no recurrence during a mean follow-up period of 19.6 ± 1.2 months.
The closure of the peritoneum around the IIR using needles mimicking what is happening in sewing machine suturing is a feasible, safe and effective line of treatment of children with CIH. The cosmetic results are 42 outstanding without any recurrence.
Laparoscopic inguinal hernia repair by modified peritoneal leaflet closure: Description and initial results in children
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Citation Excerpt :
Since then, several variations or modifications of the procedure have been proposed [9,10]. Although all laparoscopic herniorrhaphy techniques have the same goal – to obliterate the patent processus vaginalis – some use an entirely intracorporeal approach while others take advantage of extracorporeal or percutaneous techniques [6,11–15]. Proponents of the laparoscopic approach for hernia repair cite a similar success rate to that using the open approach, with several additional advantages including decreased post-operative pain, improved cosmetic results, ability to easily visualize and assess the contralateral internal inguinal ring for synchronous hernia, and lower post-operative complication rate [16,17].
Inguinal hernias are common in infants and children. While the gold standard for hernia repair in the pediatric period has been via an open inguinal incision with dissection and high ligation of the hernia sac, over the past two decades laparoscopic herniorrhaphy has increased in popularity. The advantages of laparoscopy include decreased post-operative pain, improved cosmetic results, ability to easily assess the contralateral side for an open internal inguinal ring, and decreased risk of metachronous hernias. Herein, we describe a modified laparoscopic herniorrhaphy using a peritoneal leaflet closure and report our operative experience with intermediate-term results.
We retrospectively reviewed our IRB-approved registry for all children who underwent initial laparoscopic herniorrhaphy at our tertiary care center over a 2.5-year period. All surgeries were performed by a single surgeon using a technique we have termed the peritoneal leaflet closure. This technique involves incising the peritoneum circumferentially around the open internal ring and developing peritoneal leaflets which are then closed together over the ring with a running non-absorbable barbed stitch (Figure). Intraoperative findings and complications, operative times, and post-operative complications were reviewed for all children.
A total of 50 initial laparoscopic hernia repairs (4 bilateral, 42 unilateral) were performed in 46 children (43 boys, 3 girls) at a median age of 5.9 years (range 0.5–16.7). Median operative time was 73 min (range 48–138) for unilateral and 106 min (range 104–135) for bilateral herniorrhaphy. No patient had an intraoperative complication. Two children (4%) had contralateral open rings discovered at time of surgery and underwent unplanned bilateral laparoscopic hernia repair. All patients went home on the same day as the procedure and three children (6%) had minor post-operative complaints (umbilical bulge, thigh pain, and urine holding) that all self-resolved. Thirty-nine children had follow-up data available. Intermediate-term complications occurred in two children (5%): one boy developed a contralateral hydrocele (despite a closed ring at surgery) and one boy had a hernia recurrence that required open repair. Overall, operative success with the modified peritoneal leaflet closure technique was therefore 97% (38 of 39 children with follow-up). All 37 boys who followed up had bilateral descended testes of normal size and consistency.
Laparoscopic herniorrhaphy using a peritoneal leaflet closure technique is safe and effective when used in infants and children to close an indirect hernia (i.e. patent processus vaginalis). No intraoperative complications occurred in this cohort and success rate was 97%.
Natural History and Conservative Treatment Outcomes for Hydroceles: A Retrospective Review of One Center's Experience
2018, Urology
Citation Excerpt :
Christensen et al3 also reported that of the 302 patients, 7 (2.3%) had a viral infection, 5 (1.6%) had a history of trauma, 5 (1.6%) had a history of inguinal surgery, and 3 (1.0%) had epididymitis. Moreover, the ratio of hydroceles after inguinal hernia surgery in other studies was 0.16%-1.2%.14,15 Our high ratio may be due to the detailed questioning of the patients' families in addition to the review of the medical files.
To elucidate epidemiological data and hydrocele progression, we reviewed pediatric patients diagnosed with hydroceles in our institution retrospectively.
We reviewed data from 355 pediatric patients with hydroceles. Questionnaires regarding age at diagnosis, time of delivery, presence of hydroceles in the father and brothers, age at recovery, age at surgery, cause of hydrocele (if present), type of hydrocele, associated pathologies, treatments, and posthydrocelectomy complications were completed by reviewing patients' medical records and interviewing their families.
Patients with congenital hydroceles were more frequently born prematurely (32.5%) than were patients with noncongenital hydroceles (15.9%; P = .001). Fathers of 10 patients (3.7%) and brothers of 21 patients (7.7%) also had hydroceles. Hydroceles were associated with inguinal hernias on the same side (12.2%), cryptorchidism (7.5%), varicoceles (6.0%), and testis torsion (0.5%). Among patients aged >1 year (n = 185), 27 did not undergo operations and healed spontaneously at an average of 5.30 ± 3.36 months. For children aged >1 year who did not undergo surgery, the rate of spontaneous recovery within 6 months was 77.8% and that within 1 year was 96.3%.
Until strong evidence of hydrocele-induced testicular damage in children arises, we recommend following up congenital hydroceles until at least 1 year and preferably 2 years of age. We recommend following up noncongenital hydroceles for at least 6 months and preferably 1 year if there is no associated pathology indicating the need for earlier surgery such as an inguinal hernia, cryptorchidism, tense hydrocele, testis torsion, or testis mass.
One trocar needlescopic assisted inguinal hernia repair in children: a novel technique
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Inguinal hernia repair using a percutaneous internal ring suturing technique is an effective alternative technique to conventional laparoscopic hernia repair. It is one of the most commonly used approaches for laparoscopic hernia repair in children. However, most percutaneous techniques have utilized extracorporeal knotting of the suture and burying the knot subcutaneously. This approach has several drawbacks. The aim of this study is to present a modified technique for single cannula needlescopic assisted hernia repair in children.
Three-hundred and fifty-seven patients with 397 indirect inguinal hernias underwent a one port needlescopic assisted inguinal hernia repair. The open internal inguinal ring [IIR] was closed using an 18-gauge epidural needle [EN], a 14-gauge venous access cannula [VAC], and a homemade suture device. Saline was injected extraperitoneally around the IIR for hydrodissection. The main outcome measurements were: feasibility, safety of the technique, operative time, recurrence rate, and cosmetic results.
This prospective study was conducted on 357 patients at Al-Azhar, Alexandria, and Mansoura University Hospitals during the period from June 2012 to October 2015. There were 286 males and 71 females. The mean age was 2.6 ± 1.3 years (range = 4 months to 6 years). One-hundred and ninety-eight patients presented with a right-sided inguinal hernia, 119 patients with a left-sided hernia, and 40 patients with bilateral inguinal hernia. The mean operative time was 12.6 ± 1.7 min (range = 8–15 min) for unilateral cases and 18.6 ± 1.7 min (range = 14–20 min) for the bilateral repairs. No wound complications or umbilical hernias developed. The mean follow-up period was 18.6 ± 1.2 months (range = 11–36 months). During the follow-up period, no recurrence was detected, and the scars were nearly invisible.
This preliminary study shows that a single port needlescopic assisted hernia repair in infants and children is a very promising technique to achieve nearly scarless surgery. The procedure is very safe, rapid, easy to learn, and reproducible.
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Operative TechniqueShalaby technique for efficient single incision laparoscopic pediatric inguinal hernia repair

Abstract

Background

Patients and methods

Results

Conclusion

Section snippets

Patients and methods

Description of the technique

Results

Discussion

Conclusion

Acknowledgment

J Pediatr Surg

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J Pediatr Surg

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Operative Technique
Shalaby technique for efficient single incision laparoscopic pediatric inguinal hernia repair