Transumbilical Single-Site Laparoscopic Inguinal Hernia Inversion and Ligation in Girls

Introduction

Inguinal herniorrhaphy is one of the most common operations for surgeons in pediatrics. ¹ The conventional operation is a small incision on the affected groin and high ligation of the hernia sac. It has been proved to be an effective method over a century. With the development of minimal invasive surgery, laparoscopic herniorrhaphy has been an alternate for pediatric inguinal hernia. The technique of laparoscopy became widely used in the past two decades. El-Gohary ² first performed the laparoscopic inguinal hernia inversion and ligation as a new treatment for female pediatric hernia repair in 1997. Later, larger numbers of cases were consecutively performed with this technique.^3–5 In these reports, the scope was placed via an infraumbilical incision, and working instruments were passed through two stab incisions in the lower quadrant. In 2013, we performed transumbilical single-site laparoscopic inguinal hernia inversion and ligation in girls who presented with inguinal hernia.

Materials and Methods

Since May 2013, 13 girls, from 6 months to 10 years of age, with inguinal hernia have been treated with transumbilical single-site laparoscopic inguinal hernia inversion. All cases were admitted the day before the operation and discharged the day after the operation.

The patient is placed in the Trendelenburg position and given general anesthesia. A 5-mm incision is made on the right rim of the umbilicus, and a laparoscope (0°or 30°) (Storz, Tuttlingen, Germany) is inserted through the incision after pneumoperitoneum (pressure of 9–12 mm Hg) is established. Depending on the size of the patient, a 3-mm or 5-mm trocar is inserted into the abdomen via the left edge of the umbilicus for working instruments (Fig. 1). The pelvis is carefully examined. The uterus and ovary are identified in the case of incarceration. Both sides of the internal ring would be evaluated for contralateral patent processus vaginalis (Fig. 2A). If the patent processus vaginalis is confirmed, it would be repaired at the same time. Then the grasper is introduced into the abdomen through the trocar on the left edge of the umbilicus. It is the very distal bottom of the hernia sac that is twisted and inverted into the peritoneal cavity (Fig. 2B) and hung by the suture from the skin projection of the internal ring (Fig. 2C). The final portion of the operation is the ligation and resection of the hernia sac. A figure of 8 stitch is applied to all hernia sacs at the base of it with nonabsorbable 2-0 suture (Fig. 2D). The excessive sac is resected (Fig. 2E) and removed from the trocar on the left side of the umbilicus. Then the pneumoperitoneum is released. The incisions are closed with a 5-0 absorbable stitch.

OPEN IN VIEWER

FIG. 1.

A 5-mm incision is made on the right rim of the umbilicus for scope (0°or 30°), and a 3-mm or 5-mm trocar is inserted into the abdomen via the left edge of the umbilicus for working instruments.

OPEN IN VIEWER

FIG. 2.

(A) The hernia is evaluated. (B) The hernia is twisted and inverted into the abdomen. (C) The inverted sac is hung by the suture from the skin projection of the internal ring. (D) An 8-type stitch is applied to the hernia sac at its base. (E) The excessive sac is resected.

Results

All of the 13 cases were performed the same procedure by a single surgeon in our institution. None of the patients underwent conversion from single-site laparoscopy to the open approach or conventional laparoscopic surgery.

The average operation time was 35.15±6.68 minutes. The operation time for unilateral hernia was 30.14±3.8 minutes, versus 41.00±3.69 minutes for bilateral hernias. The difference in operation time for unilateral and bilateral procedures was statistically significant (P<.001). Four cases were found to have contralateral inguinal hernia (Table 1). The patients were discharged the day after the operation.

In follow-up of 7 months to a year, all cases showed no recurrence and no incision complication.

We also compared the natural appearance and postoperative exterior of the umbilicus. After the operation, the scar would be hidden in the navel fold, especially for those with a longer postoperative time. There is no manifest distinction between the natural umbilicus and the postoperative one with long-term follow-up (Fig. 3).

OPEN IN VIEWER

FIG. 3.

(A) The natural appearance of the umbilicus. (B) The exterior of the umbilicus at 1 month postoperatively. (C) The exterior of the umbilicus at 6 months postoperatively.

Discussion

For girls, there is no vas, and vessels pass through the internal inguinal ring. ² So, this unique anatomy makes laparoscopic inguinal hernia inversion and ligation possible. Laparoscopic single-site surgery has rapidly progressed from laboratory to clinical use since 2007. ⁶ In this research, we combined together laparoscopic single-site surgery with the inversion herniotomy to meet the trend of minimally invasive surgery.

In 1997, El-Gohary ² first performed the laparoscopic inguinal hernia inversion and ligation as a new treatment for female pediatric hernia repair on a small scale, with the hernia sac inversion and endoscopic loop ligation at the base of the sac. There was no complication in 28 patients, with just one recurrence in the 4-year follow-up. In 2007, Zallen and Glick ³ reported on 37 cases without any significant complication. In 2010, Lipskar et al. ⁴ reviewed 173 cases with laparoscopic inguinal hernia inversion and ligation performed at a single institution, in which there were two recurrences and 3 cases of conversion to the open approach for an incarcerated ovary. In the same year, Guner et al. ⁵ gave a description of 79 cases with laparoscopic inversion herniotomy, in which there were two recurrences and two conversions to the open technique because of sliding hernias. According to these reports, the combination of laparoscopic hernia inversion and ligation is a safe and effective method for female hernia. We performed transumbilical single-site laparoscopic inguinal hernia inversion and ligation on 13 girls without incision complication or recurrence. Although we have a small number of cases, we provided a new technique for female hernia repair.

The technique of laparoscopic invertion and ligation, which uses three ports and an endoloop, was first introduced in 1997. ² Then modifications (excision of the hernia sac^3–5 and laparoscopic inversion herniotomy without ligation ⁷ ) were proposed to lower the rate of recurrence. Nontheless, these cases require three incisions in different sites and use an endoloop in almost all cases. In our report, by hanging the hernia sac, we make it free of the endoloop and lessen the number of ports used. What is more, the modification makes a single-site laparoscopy possible. It meets the trend of minimally invasive surgery and may help to reduce the cost due to the port and endoloop. Compared with conventional laparoscopic techniques, it also has better cosmesis for single-site laparoscopy and fits the preference of parents. ⁸ So we developed this new technique.

Because of visualization of the abdomen, the pelvis is carefully examined. The uterus and ovary are identified in the case of an incarcerated inguinal hernia. Otherwise, it makes the diagnosis of contralateral patent processus vaginalis easier. If the contralateral patent processus vaginalis is confirmed, it takes less time to repair it at the same time. This reduces the incidence rate of metachronous contralateral inguinal hernia.

High ligation of the hernia sac has been the gold standard for hernia repair for over 100 years. Different laparoscopy should reach high ligation similar to that of open access. There has been a greater incidence of hernia recurrence compared with conventional open repair. ⁹ There is a controversy about this problem. Not completely achieving high ligation of the sac and not performing herniotomy are the main explanations for it.^9,10 Laparoscopic hernia inversion and herniotomy had excellent results, with 0%–3.57% recurrence.^2–4 The higher rate of recurrence occurred at the early stage.^4,5 After dissection of the hernia sac and its complete resection, scarring and reperitonization of the inguinal, inguinal ring, and adjacent area will not increase the risk of recurrence, at least for those patients whose inguinal ring is no wider than 10 mm. ⁷ Excising the hernia sac may help limit recurrences.^4,9 Yang et al. ¹¹ believed that the recurrence rate between laparoscopic herniorrhaphy and open surgery is not significantly different. Lack of experience and no excision of the hernia sac may account for the higher recurrence rate.

In this technique, we only use one working instrument. So it is too difficult to tie a knot, and it is impossible to make a tie endoloop. We hang the hernia sac by the suture from the skin projection of the internal ring. A figure of 8 stitch at the base of the hernia sac is more easier and reliable. If a round ligament or Fallopian tube is attached to the sac, it would be separated by blunt and sharp dissection.

Natural orifice translumenal endoscopic surgery (NOTES^®; American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) or single-port or single-site laparoscopy is part of the natural development of minimally invasive surgery, even in pediatrics. ¹² Laparoscopy had constantly evolved with the intent to make surgery “scarless.” ¹³ For girls, beauty is of more importance. In the surgery, we replace three incisions in different places with two incisions in a single site. It has better cosmetic results than that of the open technique and traditional laparoscopic herniorrhaphy. ¹⁴

Conclusions

The approach of transumbilical single-site laparoscopic inguinal hernia inversion and ligation is a new method for inguinal hernia in girls. It is a reliable, safe, and cosmetic herniorrhaphy for girls with inguinal hernia. Long-term follow-up is needed to evaluate the validity of the operation.