Abstract
Abstract
Purpose:
The aim of this study was to evaluate the effect of the percutaneous internal ring suturing (PIRS) technique on testicular vascularization when used for inguinal hernia repair in children.
Subjects and Methods:
In this prospective study, 49 boys older than 1 year who had been diagnosed with unilateral inguinal hernia were evaluated. Hernias were repaired using the laparoscopic PIRS technique. The testes of each patient were examined using Doppler ultrasound at the preoperative, early postoperative, and late postoperative periods. Peak systolic velocity (PSV), end diastolic velocity (EDV), and resistivity index (RI) of the intratesticular centripetal and testicular capsular arteries were determined.
Results:
PSV, EDV, and RI of the centripetal and capsular arteries were similar between preoperative, early postoperative, and late postoperative periods, with no statistically significant differences detected.
Conclusions:
Testicular vascularization was not affected by hernia repair using the PIRS technique in our study. We therefore conclude that PIRS is a safe technique for inguinal hernia repair with respect to testicular vascularization.
Introduction
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In recent years, minimally invasive techniques, including laparoscopic techniques, have become popular for pediatric surgeries, including inguinal hernia repair.3–5 Laparoscopic hernia repairs offer several advantages, including lack of a groin incision, better cosmetic results, ability to diagnose contralateral hidden hernias, and minimal risk of injury to the testicular vessels and ductus deferens.5,6 Although different types of laparoscopic hernia repairs exist,3,4,5,7 the majority are performed using two or three ports. The technique of “percutaneous internal ring suturing” (PIRS) described by Patkowski et al. 8 is performed using only one umbilical port and a needle puncture point, thus leaving only one nearly invisible scar in the umbilicus. In this prospective study, we evaluated the effect of the PIRS technique on testicular vascularization as determined by Doppler ultrasound (DUS).
Subjects and Methods
Subjects
Fifty-five boys older than 1 year of age and diagnosed with unilateral inguinal hernia in our clinic between November 2013 and October 2014 were included in this prospective study. Data from 6 patients were excluded because they did not come back for DUS evaluation in the early or late postoperative period, so 49 patients were included the study. Children younger than 1 year of age were excluded because of their inability to cooperate for the DUS examination. Children with testicular pathologies and hydroceles were also excluded. This study was approved by the Faculty Ethics Committee, and written informed consent was obtained for all participants. Inguinal hernias were diagnosed by a pediatric surgeon, who also performed the subsequent surgeries.
PIRS surgery
Laparoscopic PIRS was performed on all patients as described by Patkowski et al. 8 Specifically, pneumoperitoneum was established with the open technique by introducing a 3.9-mm trocar through the umbilicus. A 3.3-mm, 30° telescope was used under an insufflation pressure of 8–10 mm Hg. Nonabsorbable polypropylene monofilament thread (2-0; Prolene®) was purchased from Ethicon (a Johnson & Johnson Company, Somerville, NJ). The patients were discharged at the same day of the operation. Only 1 patient experienced a recurrence of his hernia, which was discovered 2 months postoperatively. This patient was re-operated on using the conventional open technique.
Calculation of peak systolic velocity, end diastolic velocity, and resistivity index
The testes of all patients were examined by DUS before the surgical procedure (preoperative), 1 week postoperatively (early postoperative), and 1 month postoperatively (late postoperative). The examination was performed using an Aplio™ 500 sonography scanner (Toshiba Medical Systems Corp., Tochigi, Japan) with a 7.5–10-MHz PLT-704 linear phased transducer (Toshiba Medical Systems Corp.). Sedation was not used for the examination. Peak systolic velocity (PSV), end diastolic velocity (EDV), and resistivity index (RI) of the centripetal and capsular arteries on the same side as the hernia were determined using the sonography scanner. The average values were calculated after several spectral samples from different segments of the arteries were determined.
Statistical analyses
Variance analysis was used for repeated measurements, and a paired-sample t test was used for detection of the variant group. The results were evaluated at a confidence interval of 95% and a level of significance of P<.05.
Results
The average age of the patients evaluated in this study was 5.27 years (range, 1–14 years). The PSV, EDV, and RI were similar among the preoperative, early postoperative, and late postoperative periods for both the intratesticular centripetal (Table 1) and testicular capsular (Table 2) arteries, with no statistically significant differences detected. A trend toward increased PSV of the centripetal artery was detected in the early postoperative period, but this value decreased by the late postoperative period (Table 1).
Data are mean±standard deviation values.
EDV, end diastolic velocity; PSV, peak systolic velocity; RI, resistivity index.
Data are mean±standard deviation values.
EDV, end diastolic velocity; PSV, peak systolic velocity; RI, resistivity index.
Discussion
Traditional laparoscopic surgeries have been shown not to affect testicular blood flow. The influence of laparoscopic inguinal hernia repair on the testes of children was first evaluated by Schier et al., 9 who determined that this type of surgery does not impair testicular perfusion. It was later determined that several laparoscopic hernia repair surgeries, including the N-suture closure and purse-string techniques, similarly do not impair testicular vascularization. 10
PIRS is a laparoscopic hernia repair technique, first described by Patkowski et al., 8 that is simpler and quicker than previously described hernia repair techniques and requires only a single port in the umbilicus. This technique can be performed by surgeons at the basic level of laparoscopy and is less expensive than other laparoscopic inguinal hernia procedures. 8 We evaluated the influence of the PIRS technique on testicular vascularization in children.
The testicular artery has an anastomotic arterial network that branches to form capsular and centripetal arteries. 11 The capsular artery is located under the tunica albuginea and enters the testicular parenchyma as centripetal arteries. DUS is a useful tool to visualize testicular blood flow to evaluate postoperative testicular circulation. It is a noninvasive technique often used to evaluate testicular vascularization in pediatric patients, 12 often after hernia repair.10,13
In the current study, DUS was used to determine PSV, EDV, and RI before and after hernia repair surgery, measurements that compare blood flow in the systole and diastole, as well as resistance to blood flow by the peripheral vascular bed, respectively. Elevation of these parameters is often an indication of increased arterial resistance resulting from vasoconstriction in the testicular ischemia. The Doppler RI ([PSV − EDV]/PSV) shows the reflection of arterial impedance 14 and was found to be a useful parameter for evaluating alterations in testicular blood flow. 15
In the current study, PSV, EDV, and RI of both the intratesticular centripetal artery and testicular capsular artery were similar throughout the preoperative, early postoperative, and late postoperative periods, with no statistically significant differences detected. We therefore concluded that hernia repair using the PIRS technique does not impair testicular vascularization.
Conclusions
In conclusion, the PIRS technique is a simple technique that is relatively easy, quick, and inexpensive. It can be performed easily by the majority of surgeons and does not impair testicular vascularization, thus making it an excellent choice for laparoscopic hernia repair surgeries in children.
Footnotes
Disclosure Statement
No competing financial interests exist.