A Modified Technique with a New Device of Laparoscopic Percutaneous Extraperitoneal Closure for Pediatric Inguinal Hernia

Abstract

Introduction:

Laparoscopic percutaneous extraperitoneal closure (LPEC) in boys is more complex than in girls, because the vas deferens and testicular vessels must be separated from the peritoneum. We therefore developed a needle-shaped surgical instrument that enables blunt separation. Here, we report the effectiveness of this new device.

Surgical technique:

The new device is a ligature carrier consisting of (1) an inner tube (19-G blunt needle) through which slides a rod with a loop wire at its tip that can catch and release suture materials and (2) an outer tube (17-G needle) with a cutting edge. The blunt-structured inner tube enables blunt separation. All actions (stabbing, separation, and catching) in the LPEC procedure that are required to close the hernia orifice using a thread are facilitated through a simple small incision by switching between the inner and outer tubes.

Subjects and methods:

From January 2013 to September 2015, 73 boys with inguinal hernia or hydrocele underwent LPEC, and the new device was used in 45 of these cases. We compared surgical results between cases wherein the new (group A) and conventional devices (LPEC needle; group B) were used.

Results:

The mean surgery duration was 33.4 and 34.8 min for groups A and B, respectively. Neither group experienced complications during or after surgery.

Conclusion:

Our findings suggest that the newly developed needle device may improve the safety of the LPEC procedure for boys, although further investigation involving more cases and long-term follow-up is needed in the future.

Introduction

Laparoscopic surgery has been increasingly used for pediatric inguinal hernia repair in recent years. This procedure has several advantages. It enables surgeons to assess possible contralateral patent processus vaginalis, which reduces the incidence of metachronous contralateral hernias. In addition, laparoscopic surgery is associated with few complications, has comparable recurrence rate, better cosmetic results, provides an excellent view of cord structures, and prevents trauma to the vas deferens and testicular vessels because minimal tissue dissection is involved.^1–4 However, the small gap that remains when the vas deferens and testicular vessels are passed anteriorly to prevent trauma could lead to recurrence.^5–8 Therefore, laparoscopic repair methods have evolved toward placing external purse string sutures around the hernia sac, leaving no gap, to ensure a low recurrence rate.^9–12 Laparoscopic percutaneous extraperitoneal closure (LPEC), introduced by Takehara et al.,¹³ is one of the most reliable methods. In LPEC, a purse string suture is placed extraperitoneally around the hernia orifice by using a special suture needle (LPEC needle). When encircling the hernia sac while avoiding a peritoneal gap, protection of the vas deferens and testicular vessels is the most important step. This is why LPEC is a more complex procedure for boys than it is for girls. Because of the risk involved in separating the vas deferens and testicular vessels from the peritoneum, some facilities limit this surgery to girls only.

In this study, we developed a special needle-shaped surgical instrument that enables blunt separation, and can be used to safely separate the vas deferens and testicular vessels from the peritoneum. We report the effectiveness of this new device.

Materials and Methods

We developed a special needle-shaped surgical instrument in 2013, and we started to use the new device in patients who are 1 year or older. From January 2013 to September 2015, 73 boys aged 1 year or older with inguinal hernia or hydrocele underwent LPEC. Our novel needle-shaped surgical instrument was used in 45 of these patients, whereas an LPEC needle was used in the remaining 28 patients. Before surgery, the parents of all patients were informed about the risks of the procedure, and they provided parental consent. The diagnosis of inguinal hernia was confirmed during preoperative examination. The new needle device used in this study was approved by the institutional ethics review board. We compared surgical results between cases wherein the new needle device (group A) and conventional LPEC needle (group B) were used. The demographic and clinical features of the children were also reviewed retrospectively. For all patients, age at surgery, operative time, intra- and postoperative complications, and recurrence were analyzed. Lastly, all patients were scheduled for follow-up visits at 1 week and 1 month postoperatively.

New Needle Device

The novel needle-shaped surgical instrument used in this study is a ligature carrier consisting of (1) an inner tube (19-G blunt needle) through which slides a rod with a loop wire at its tip that can catch and release suture materials and (2) an outer tube (17-G needle) with a cutting edge. The blunt-structured inner tube enables blunt separation (Fig. 1). All actions in the LPEC method (stabbing, separation, and catching) that are required for closure of the hernia orifice using a thread are facilitated through a simple small incision by switching between the inner and outer tubes. Figure 2 shows the LPEC needle.

FIG. 1.

New needle device. (a) Outer tube (17-G needle) with a cutting edge. (b) Inner tube (19-G blunt needle) through which slides a rod with a loop wire at the tip that can hold and open sutures. (c) Loop wire at the tip.

FIG. 2.

LPEC needle. (a) A 19-G needle through which slides a rod with a loop wire at the tip that can hold and open sutures. (b) Loop wire at the tip. LPEC, laparoscopic percutaneous extraperitoneal closure.

Surgical Procedure

All procedures were performed with the patients under general anesthesia administered through an endotracheal tube. Patients were placed in a slight Trendelenburg position. A 3.5-mm port for a 3-mm laparoscope was placed through a transumbilical incision. Pneumoperitoneum was established with CO₂ insufflation at 8–10 mm Hg pressure. Subsequently, a 2 mm trocar into which a grasping forceps can be inserted was introduced on the left side of the umbilicus. The following steps were performed using the method developed by Takehara et al.¹³ Under laparoscopic guidance, an LPEC needle or new needle device was inserted along with nonabsorbable suture material at the midpoint of the right or left inguinal line (Fig. 3). For conventional LPEC, the hernia sac was closed extraperitoneally by using the LPEC needle with the aid of forceps, with circuit suturing without any peritoneal gap. Care was taken to cross over the vas deferens and testicular vessels. During the modified LPEC method with the new needle device, blunt dissection of the extraperitoneal space was performed using the blunt-structured inner tube, with the needle instrument crossed over the vas deferens and testicular vessels (Fig. 4). Closure on both sides was performed if an asymptomatic contralateral patent processus vaginalis was observed.

FIG. 3.

Port and needle device placement.

FIG. 4.

LPEC procedure using the new needle device. Circuit suturing was initiated by inserting the needle device with suture material through the medial side of the internal inguinal ring. Subsequently, circuit sutures were placed around the lateral half of the inguinal ring using the outer tube. (a) Insertion of the outer tube through the lateral half of the internal inguinal ring. (b) The outer tube is switched to the inner tube (arrow: testicular vessels). (c) The needle device with the blunt tip crossing over the testicular vessels beneath the peritoneum. (d) The needle device with the blunt tip crossing over the vas deferens (arrow: vas deferens). LPEC, laparoscopic percutaneous extraperitoneal closure.

Results

Of the 73 boys included in this study, 93 internal inguinal rings were closed (53 unilaterally and 20 bilaterally). In the 45 patients in group A, 58 hernias were repaired, whereas 35 hernias were repaired in the 28 patients in group B. No significant differences were found between the groups for age, need for repair on both sides, and operating time (Table 1). No surgical complications or early recurrence was found in either group. Furthermore, no cases of hydrocele or testicular atrophy were found in either group.

Table 1.

Comparison of Demographic and Clinical Characteristics and Surgical Results Between Groups A and B

	Group A	Group B	P
Age (months)	57.1 ± 28.4	52.8 ± 30.9	.47
Operation time (unilateral) (minutes)	33.4 ± 9.0	34.8 ± 9.6	.55
Operation time (bilateral) (minutes)	45.4 ± 6.2	48.8 ± 8.4	.1
Recurrence	0	0	1
Postoperative testicular atrophy	0	0	1

Group A: LPEC performed using new needle device.

Group B: LPEC performed using a conventional LPEC needle.

LPEC, laparoscopic percutaneous extraperitoneal closure.

Discussion

Although many laparoscopic techniques for children have been described, no technique has been widely accepted yet.¹ As one of the most recently developed techniques, LPEC is simple, reliable, and easy to apply.^3,13

LPEC for pediatric inguinal hernia involves placing a purse-string suture of nonabsorbable material extraperitoneally around the hernia orifice using an LPEC needle (Lapa-her-closure™). This method reportedly has a low recurrence rate and is generally adopted by pediatric surgeons worldwide,^1,3,14 particularly in the Far East during the last decade.^1,4,12,15 Since Takehara et al. first reported the LPEC technique, many modifications have been described, with various instruments replacing the LPEC needle, for example, Kirschner pins, angiocatheters, Reverdin needle, hooks, swaged needles, hypodermic needles, normal suture needles, and epidural needles.^{1,3,4,9,10,14,16,17} Meticulous manipulation of the needle-shaped instruments used for percutaneous closure during LPEC is vital. Particular care needs to be taken in the vicinity of the vital cord structure. To ensure this, we developed a needle-shaped surgical instrument that enables blunt separation. For closure of the hernia sac, we modified Takehara's technique¹³ by using our new device. The risk of injury to the vas deferens and testicular vessels is low in this procedure, because it does not involve the use of any sharp instrument under the peritoneum. However, it is slightly more complex than conventional LPEC because of the additional handling required (switching between the inner and outer tubes around the vas deferens and the testicular vessels). Nonetheless, our comparison between groups A and B in this study showed no significant differences in the operation time. Therefore, a modified technique with the new LPEC device seems to be an alternative.

In conclusion, the novel needle device described in this study ensures safe dissection in the subperitoneal space because it does not use a sharp instrument around the vas deferens and the testicular vessels. Our findings suggest that this new device improves the safety of the LPEC procedure for laparoscopic inguinal hernia repair in boys, although further investigation with more cases and long-term follow-up is needed.

Footnotes

Disclosure Statement

No competing financial interests exist.

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