Towards a Near-Zero Recurrence Rate in Laparoscopic Inguinal Hernia Repair for Pediatric Patients

Introduction

Congenital inguinal hernia is a common pediatric problem. Herniotomy, the gold standard for its treatment, has been both complimented and challenged by minimal access surgery.^1,2 With the feasibility and safety of laparoscopy firmly established in pediatric surgical practice,^3–7 there is a justified trend toward the use of minimal access surgery to manage congenital inguinal hernia because of the advantages it offers over the conventional procedure.^8–12 Some centers use laparoscopes routinely for inguinal hernia repair in children. ¹³ A randomized single-blinded study has shown that laparoscopic inguinal hernia repair was less painful to the patients and results in earlier recovery and better wound cosmesis. ¹⁴ It also allowed contra-lateral hernias to be defined and repaired in the same operation. Laparoscopic inguinal hernia repair is becoming increasingly popular in pediatric patients. ¹⁵ However, a high recurrence rate is still the main concern. ¹⁶ The aim of this study was to assess whether the median or lateral umbilicus ligament covering the internal hernia opening region after the purse-string knot could eliminate recurrence in laparoscopic inguinal hernia repair in pediatric patients of all ages.

Patients and Methods

Surgical technique

Patients were given general endotracheal anesthesia and then placed in the Trendelenberg position. The monitor was placed at the foot of the operating bed, with the surgeon standing by the patient's shoulder on the opposite side of the hernia. The patient needed to paralyze to allow for insufflation of the median or lateral umbilicus ligament. A 3-mm port was inserted through the umbilicus. A pneumoperitoneal pressure of 8–10 mm Hg was created. The internal opening of the hernia was confirmed, and the contra-lateral side was also inspected. In the opposite side, one 3-mm port was placed medial to the anterior superior iliac spine into the peritoneal cavity under laparoscopic vision. A special endoneedles (Lapaherclosure, a 19-gauge needle) and a 4/0 prolene thread were inserted percutaneously (in the inguinal region) under laparoscopic guidance and weremanipulated around the medial and lateral hemicircumference of the internal ring extraperitoneally, in sequence, to place a purse-string around the internal ring. A grasper, placed through a separate port, was used to manipulate the thread in and out of the hollow of the needles to form a mattress suture. The two ends of the thread then are pulled out of the inguinal region, after which the knot was tied extracorporeally and pushed inside subcutaneouly with. Finally, endoneedles was used percutaneously to suture the median or lateral umbilicus ligament (sometimes patients only have lateral umbilicus ligament) to cover the internal hernia opening region under laparoscopic guidance, and the knot was tied extracorporeally (Figs. 1–3). Generally, three times of suture may get the umbilicus ligament totally covering the internal hernia opening region. After release of the pneumoperitoneum, the ports were removed. The lateral wounds were closed with skin strips, and the umbilical fascia was closed with an absorbable stitch.

OPEN IN VIEWER

FIG. 1.

Suturing the umbilicus ligament.

OPEN IN VIEWER

FIG. 2.

Taking out the suture thread.

OPEN IN VIEWER

FIG. 3.

Umbilicus ligament covering the internal hernia opening region.

Results

Group A included 214 patients, and 239 hernias were repaired; group B included 214 patients, and 243 hernias were repaired (Table 2). The differences of the sex ratio of boys to girls (199:15 versus 197:17) and the mean ages (51.05 ± 49.65 versus 50.59 ± 48.87 months) between the two groups were not statistically significant. The recurrence rate in group B was lower than that in group A and was statistically significant (0.00% versus 4.18%, P < .05) (Tables 2 and 3). Three patients in group A developed transient hydroceles postoperatively, whereas one case occurred in group B, but the difference was not statistically significant (Table 2). There were no cases of postoperative testicular atrophy in either group of patients. There were no patients who had blood pressure, pulse, or oxygen saturation problems during the stress tests.

Discussion

Inguinal hernia is a common problem among children, and herniotomy has been its standard of care. Herniotomy is technically simple and can achieve a good long-term result. However, although the overall recurrence rate was about 1% in the current study, it would be much higher in patients with incarceration or postoperative complications. ⁸ Other postoperative complications, including hydrocele, hematocele, testicular malposition, and atrophy, are commonly encountered. Besides, the vas is very vulnerable to mechanical injury, and the incidence of vas injury may be underestimated because the incidence of unilateral vas deferens obstruction was reported to be 26.7% for a subfertile patient with a history of open inguinal hernia surgery in childhood. ⁹

Laparoscopic inguinal hernia repair is a relatively new procedure in the pediatric surgical practice. Several advantages of laparoscopic inguinal hernia repair in children include improved observation of bilateral inguinal canals and minimal dissection, therefore creating less risk of damaging important anatomic structures, such as the spermatic cord. In addition, laparoscopy allows the surgeon to identify a contralateral patent processus vaginalis and repair the defect before a symptomatic hernia develops. Numerous minimally invasive techniques for addressing pediatric inguinal hernia (PIH) have mushroomed in the past two decades. These techniques vary considerably in their approaches to the internal ring (intraperitoneal or extraperitoneal), use of ports (three, two, or one), endoscopic instruments (two, one, or none), sutures (absorbable or nonabsorbable), and techniques of knotting (intracorporeal or extracorporeal). In addition to the surgeons' experience and the merits/limitations of individual techniques, it is the nature of the defect that should govern the choice of technique. In a large series of 6361 children’ inguinal hernias over a 35-year period treated with open herniotomy, the recurrence rate was found to be 1.2%. ⁹ It should be possible using laparoscopic repair to avoid some of the causes of recurrence in open herniotomy. A major criticism of the laparoscopic repair remains its higher recurrence rate, as compared to the traditional open technique, ranging from 0.83% to 4.1%.^4,5,17 The reasons were versatile. These include failure to ligate the hernia sac high enough at the internal ring, injury to the floor of the inguinal canal from open trauma, and hematoma formation at the open wound. ¹⁰ The high recurrence may be owing to the tension at the closure of the internal opening, large hernia, broken of the purse-string thread, and the suture technical problem. The present study proved that reducing tension on the pursestring knot when closing the internal hernia opening could prevent recurrences. ¹⁸ Followed this conception, we designed a new way that was median or lateral umbilicus ligament covering the internal hernia opening region after the purse-string knot to prevent the recurrence. The method we developed was revolutionary in the principle of pediatric hernia repair. It includes both the security of repair offered by the watertight closure of the hernia opening and the hernia opening region covered with the umbilicus ligament flap. The valve mechanism allows scrotal fluid avoiding scrotal collection. Under the stress of intra-abdominal pressure, the wall of the sac is pressed over by the flap, keeping the sac in a collapsed state. A recurrence will not occur if the purse-string knot and umbilicus ligament covering the internal opening region are confirmed with the stress test by an increase in the intraperitoneal pressure at the end of the operation. The follow-up time for the patients was 69.67 ± 5.19 months in the two groups. However, the recurrence rate in group A and B was 4.18% and 0%, respectively. There was no statistically significant difference between the two groups. This has proved the effectiveness of the valve mechanism. The vas deferens and testicular vessel also are completely untouched throughout the procedure, and injury is avoided. The suture of the ligament to cover the hernia open region might add the operation time, but the total operation time was 20.08 ± 4.52 minutes, and there was no statistically significant difference between groups A and B.

The technique of suturing the ligament is very easy. This procedure needs two Trocars and 3–4 times of suturing to cover the hernia open region completely. No severe complications resulted in the normal sutured ligament in our series of patients. The indication of this technique especially fits for the patients based on the following criteria: (1) large hernia, hernia sac >1.5 cm; (2) recurrence hernia, and (3) the patient's age above 5 years.

Although there was no patient in group B developed recurrence problems during the follow-up, care still needed during the procedure. Further studies are needed to testify this new way for the pediatric patients.