Modified Laparoscopic Percutaneous Extraperitoneal Closure Using a Sledge-Shaped Needle for Inguinal Hernia and Hydrocele in 1199 Pediatric Patients

Abstract

Background:

The objective of the study is to determine the safety and efficiency of the modified laparoscopic percutaneous extraperitoneal closure (LPEC) to treat pediatric patients with inguinal hernia or hydrocele.

Methods:

From January 2014 to July 2018, the patients with inguinal hernia or hydrocele who were operated on using modified LPEC were included. We modified LPEC with a sledge-shaped needle and reinforcement flag. By means of medial umbilical fold, the reinforcement surgery should be performed on the patients with huge internal rings (diameter >1.5 cm). Operative time, complication rate, incidence of reinforcement, and contralateral patent processus vaginalis were described between inguinal hernia and hydrocele.

Results:

In this study, 764 patients with inguinal hernia and 435 patients with hydrocele were successfully performed by the modified LPEC. The 383 (50.1%) patients with inguinal hernia and 266 (61.1%) patients with hydrocele were identified with a contralateral patency of internal ring and underwent simultaneous prophylactic surgery. During surgical procedures, the medial umbilical fold reinforcement (inguinal hernia/hydrocele = 50/1) was performed on 51 patients. Hernia recurrence occurred in 2 cases. All patients had a good cosmetic appearance without additional dissection.

Conclusion:

Modified LPEC using a sledge-shaped needle and applying the medial umbilical fold reinforcement is a safe and effective surgical procedure.

Introduction

Inguinal hernia and hydrocele are relatively common diseases in pediatric surgery. They have a similar etiology, anatomy, pathophysiology, and surgical procedures.¹ With the rapid development of minimally invasive technology, the type of surgery procedure had changed from conventional open surgery to laparoscopic repair.

Now, laparoscopic percutaneous extraperitoneal closure (LPEC) has become a routine operation for repairing the internal rings, with the advantages of cosmetic appearance and simultaneous management of contralateral patent processus vaginalis (CPPV).² Whether closure of CPPV or not is a controversial topic.³ For one point, to close CPPV found in the laparoscopic exploration may block them into symptomatic inguinal hernias or hydroceles.^3,4 For another point, CPPV may never develop into be symptomatic and additional operations may increase the risk of iatrogenic injury.⁴ However, the recurrence rates of the traditional LPEC have varied from 0.48% to 0.73% in large series of surgical procedures.^5,6

In this study, we modified the LPEC with a homemade sledge-shaped needle and selectively applied the medial umbilical fold reinforcement to the patients with huge internal rings (diameter >1.5 cm). Laparoscopic exploration for internal ring among pediatric patients with unilateral hernia or hydrocele is a routine surgical procedure. LPEC using a sledge-shaped needle could perform the exploration and double ligations of the CPPV simultaneously to prevent the development of contralateral metachronous inguinal hernia (CMIH). Additionally, the medial umbilical fold is covered over the huge internal ring as reinforcement to provide a reliable defense against the development of the recurrent inguinal hernias and hydroceles. The study aimed to evaluate the value of the modified LPEC in pediatric patients with inguinal hernia or hydrocele.

Methods

Study design

The study retrospectively enrolled children with inguinal hernia or hydrocele in the Pediatric Surgery Ward of the First Affiliated Hospital of Harbin Medical University from January 2014 to July 2018, and all the patients performed modified LPEC by experienced pediatric surgeons. The baseline data of all the patients were collected routinely. The Institutional Review Board of Harbin Medical University approved this retrospective study.

The preoperative diagnosis was based on clinical presentation, preoperative physical examination, and scrotal ultrasound findings. The postoperative diagnosis was composed of results of laparoscopic exploration and preoperative diagnosis. The CPPV was unclosed internal ring without clinical symptoms, but which can be found by preoperative ultrasonography and laparoscopic exploration.

According to the diameter of internal ring, the morphology of the internal rings is classified as follows: type 1, a huge internal ring (diameter >1.5 cm), type 2, a narrow open internal ring (diameter 0.5–1.5 cm), and type 3, a concealed internal ring (diameter < 0.5 cm).⁷ The diameter of internal ring is measured by the opening size of grasping forceps. The type 1 internal ring is a high-risk relapse type because of the defect of transverse abdominal fascia and greater peritoneal laxity. For the patients with huge internal rings (diameter >1.5 cm), internal rings were covered by the medial umbilical fold as reinforcement.⁸ Highlights in the procedures are the medial umbilical fold flap reinforcement, the double circuit ligations, the sledge-shaped needle, and 2-0 nonabsorbable braided polyester suture used, not silk suture (Fig. 1A).

FIG. 1.

The modified LPEC using a sledge-shaped needle. (A) The sledged-shape needle with double-share 2-0 nonabsorbable suture. (B) Surgical instrument position for internal rings. (C) Laparoscopic view of the left internal ring. (D) The needle is placed around the medial half of the internal ring. (E) The needle advances along the lateral half side and pierces into the peritoneal cavity at the same puncture point. (F) The short head of suture is through the loop on the needle's convex face. (G) The internal ring is encircled. (H) Cosmetic appearance after LPEC. Both of the incision scars are hidden in an umbilical fold. LPEC, laparoscopic percutaneous extraperitoneal closure. Color images are available online.

Follow-up

After 16–24 months of discharge from day care unit, patients were followed up by the telephone call and outpatient clinic for inguinal hernia/hydrocele recurrence, and different kinds of postoperative complications and concerns. The patients' prognosis information was assessed and reported in a standardized questionnaire administered by researchers.

Operative procedures

Under anesthesia with orofacial mask, all patients were positioned supinely, with lower abdominal skin lifted up. The operator stood on the left side of the patient, the assistant stood on the right side, and the viewing monitor on the same side as the assistant, closer to the foot of patients. The abdominal skin was cleansed well and the area was draped. Through two incisions in the umbilicus (5.0 mm incision in the upper border and 3.0 mm incision in the left border), a laparoscope was inserted in the 5.0 mm trocar and a grasping device was inserted in the 3.0 mm trocar (Fig. 1B). Pneumoperitoneum pressure was maintained at 8.0–12.0 mm Hg, a carbon dioxide flow rate was 1.0–3.0 L/minute, depending on the patients' weight and age.

Both internal rings were clearly inspected by a 3.0 mm grasping forceps (Fig. 1C). The location was chosen by pressing the surface marker of internal inguinal rings and made a 1.0-mm incision. A sledged-shape needle with double-share 2-0 nonabsorbable suture (short head of line was on the concave side of the needle) passed through the skin incision and pierced the muscles and peritoneum into the peritoneal space under laparoscopic guidance (Fig. 1A). The needle was placed around the medial half of the internal ring (Fig. 1D). To avoid injuring vas deferens and spermatic vessels, sledged-shape needle crossed over the internal ring carefully. The needle was removed to an extraperitoneal space.

With the aid of a grasping device, the short head of suture was leaved into the peritoneal cavity. The tip of needle advanced along the lateral half side and pierced the into peritoneal cavity at the same puncture point (Fig. 1E). Then, the short head of suture was pulled through the loop on the needle's convex face (Fig. 1F). The needle was pulled out slowly and the short head of suture was also taken out together. The short suture was cut in the middle. The two short sutures were twisted and the two relevant ends of the suture were tied extracorporeally, to make the suture knot deeply buried into the subcutaneous space. The inner ring of the hernia was tightly encircled (Fig. 1G). If the CPPV exists, the ligation was operated by the same procedure. The skin incision was closed with medical glue (Fig. 1H).

In reinforcement cases, the sledge-shaped needle with same suture pierced through the medial umbilical fold and the suture was taken out by the same surgical procedures. As the suture was tightened extracorporeally, the medial umbilical fold was covered as reinforcement over the ipsilateral internal ring (Fig. 2).

FIG. 2.

The medial umbilical fold used as reinforcement is covered over the closed internal ring. (A) The needle pierced into the peritoeal space at the original incision. (B) The medial umbilical fold was fixed to internal ring. Color images are available online.

Results

From February 2014 to July 2018, there were 1199 patients who underwent modified LPEC in the Pediatric Surgery Ward. The baseline demographics and characteristics of patients are listed in Table 1. A total of 764 patients with inguinal hernias and 435 patients with hydroceles were included in the study. The median age of patients with both inguinal hernia/hydrocele were 3 years. There were 1042 males (86.8%) and 157 females (13.2%), with sex ratio (males: females) of 6.6:1 (P < .001). Physical examination, scrotal ultrasound findings, and laparoscopic surgery revealed that the incidence of patients with the bilateral side accounts for more than half of all patients, especially with hydrocele. In the unilateral cases, the incidence of the right side was higher than the left side.

Table 1.

Baseline Characteristics of Patients

Variables	Inguinal hernia (n = 764)	Hydrocele (n = 435)
Age (years)	3 [1–6]	3 [1–4]
Sex (male/female)	612/152	430/5
Laterality (postoperative) (right/left/bilateral)	204/132/428	90/52/293
Laterality (preoperative) (right/left/bilateral)	430/289/45	243/165/27
CPPV (%)	383 (50.1)	266 (61.1)
Right/left	158/225	113/153
Reinforcement (%)	50 (6.5)	1 (0.2)
Incarcerated hernia (%)	52 (6.8)	0 (0)
Operation time	17.2 [13.9–19.9]	16.4 [12.4–18.5]
Unilateral	13.3 [12.5–15.2]	11.2 [10.2–12.6]
Bilateral	19.4 [17.9–21.3]	17.4 [16.2–19.3]

Categorical variables are represented as n (%) and continuous variables as median [25th–75th percentiles].

CPPV, contralateral patent processus vaginalis.

The 383 (50.1%) patients with inguinal hernia and 266 (61.1%) patients with hydrocele were identified with a contralateral patency of internal ring and underwent simultaneous prophylactic surgery, to avoid developing the CMIH. For both inguinal hernia and hydrocele, the prevalence of CPPV was higher on the left side than that on the right side.

Meanwhile, the medial umbilical fold was reinforced over the internal ring in 51 patients characterized with huge internal rings (diameter >1.5 cm). In all, 52 patients (6.8%) presented with incarcerated hernias. The median operation time was 13.2 minutes [11.7–14.4 minutes] and 18.7 minutes [17.1–20.6 minutes] for unilateral and bilateral inguinal hernias/hydroceles.

Finally, 741 patients with inguinal hernia and 426 patients with hydrocele successfully completed the follow-up. The average follow-up time was 19.9 [18.1–21.5] months in the inguinal hernia group and 19.9 [18.3–21.4] months in the hydrocele group. All surgical procedures were successful. No severe intraoperative complications and iatrogenic injury occurred. The prognosis conditions included two recurrences, one wound infection, and two suture knot reactions. During second surgery, the medial umbilical fold was sutured as reinforcement in the 2 patients whose recurrences were due to trauma and early physical activity. They had a good recovery after operation, and only two infants with incarcerated hernia had suture knot reactions 1 month after surgery.

When an inflammatory reaction surrounding the nonabsorbable suture knot occurred, disinfection with alcohol was recommended until the inflammation subsided. If not, the suture had to be removed to promote tissue healing. The only 1 patient with umbilical infection, who was washed with disinfectant and squeezed recovered well now. Most parents and children were satisfied with the cosmetic appearance. The other major postoperative complications were not found in all patients. All results are summarized in Table 2.

Table 2.

Follow-Up Outcomes of Patients

Variables	Inguinal hernia (n = 741)	Hydrocele (n = 426)
Follow-up period (months)	19.9 [18.1–21.5]	19.9 [18.3–21.4]
Recurrence	2	0
Severe pain	0	0
Wound infections	1	0
Suture knot reaction	2	0
Testicular atrophy	0	0
Iatrogenic ascent of the testis	0	0
Scrotal edema	0	0
Umbilical hernia	0	0

Categorical variables are represented as n (%) and continuous variables as median [25th–75th percentiles].

Discussion

Inguinal hernia and hydrocele are very common diseases managed by pediatric surgeons with similar etiology, anatomy, pathophysiology, and surgical procedures.¹ Pediatric inguinal hernias and hydroceles are attributed to the failure of processus vaginalis (or female's canal of Nuck) closure in the anterior abdominal wall.⁹ The overall rate of inguinal hernia ranges from 0.8% to 4.4%, but the risk will increase to ∼25% in infancy.¹⁰ The male patients have an asymmetrical propensity to develop inguinal hernia on the right (2:1 ratio),⁹ which is consistent with our findings.

Owing to the morphology of patent processus vaginalis being cavernous type, the inguinal hernia also has a high risk to develop into incarceration and infarction. Multiple factors have a major impact on the closure of processus inguinal, including decreased strength of the abdominal wall, increased intra-abdominal pressure, and involvement of calcitonin gene-related peptide. Therefore, incarcerated hernia has a high risk especially in the premature and low-birth-weight infants.¹¹

As science and technology develop, laparoscopic repair that was performed by pediatric surgeons is a safe and conventional technique, which is associated with a learning curve. Surgeons need to separate the inguinal canal and dissect the processus vaginalis carefully in the invasive surgery. Compared with open approach, laparoscopic repair with extracorporeal suturing has a low risk to develop iatrogenic cryptorchidism and injury to vas deferens, spermatic vessel, testicular vessels, or other inguinal structures.¹²

The laparoscopic intracorporeal and extracorporeal approaches for inguinal hernia/hydrocele have many advantages, including shorter operation time for bilateral hernias/hydroceles, full bowel inspection, low complications, shorter length of hospital stay, better cosmetic outcome, as well as the inspection of the CPPV.^10,13–15 According to previous studies, the prevalence of CPPV ranged from 42.3% to 50.0%.^16,17 In our study, the incidence of CPPV is about 50.1% in inguinal hernia and 61.1% in hydrocele, slightly higher than previously reported.⁴ CPPV was significantly more common on the left-sided internal ring, which is consistent with the results shown by other studies.^11,16 Another advantage of the laparoscopic approaches is to treat the rare hernias and inguinal ovarian hernias.¹⁰

However, the laparoscopic approaches described also have some potential weak points. For instance, the wound scar in the abdomen caused by three-trocar laparoscopic technique is clearly visible, and during the surgical procedure, the circle needle extracted could cause minor complications.¹⁵ Our laparoscopic technique not only has the above advantages, but also has two major features: the sledge-shaped needle and the medial umbilical fold reinforcement.

In our operation, we use a self-made needle like sledge to dissect the cord structures sharply and cross through the internal rings gently. The Kirschner wire with a diameter of 2 mm is polished into a sledge shape of 1/8 of a circle.^18,19 The top of the needle is blunt and flat, with a threading hole in the middle. The length of the needle is about 15–18 cm. This modification is to ligate the internal ring, similar to what is done with open repairs. The special structure facilitates surgical procedures and shortens operative time. It also indirectly reduces the risk of surgical and anesthesia injuries to which pediatric patients are exposed to. Due to the repeated use after disinfection, the sledge-shaped needle can reduce medical treatment cost greatly.

Circuit suture around the internal ring is fixed with a 2-0 nonabsorbable silk suture. In our study, we use two pieces of 2-0 nonabsorbable braided polyester suture to complete double circuit sutures. The braided polyester suture is better than silk suture because of its better knot-pull tensile strength, better tissue compatibility, and lower wound infectious risk.²⁰ The suture choice and double circuit sutures can improve closure of internal rings during laparoscopic-assisted extraperitoneal ligations, especially among obese children.

Meanwhile, the medial umbilical fold represents the remnant of the fetal umbilical arteries. It is on the deep surface of the anterior abdominal wall and has a certain degree of stretch and toughness.²¹ The medial umbilical ligament is easily dissected off the abdominal wall and spread to cover the ipsilateral internal ring in a tension-free way. The procedure of simple laparoscopic surgery is not sufficient enough for all pediatric patients, and some children need reinforcement of the internal ring. Therefore, we use the medial umbilical fold as reinforcement to complete the surgical treatment of huge internal rings.⁸

In this study, in a total of 51 patients with huge internal rings (diameter >1.5 cm) the reinforcement surgery was successfully performed. Due to the etiology and pathophysiology, most of them who suffered from inguinal hernia needed to have reinforcement. Both simple laparoscopic surgical procedures and reinforcement procedures are suitable for the treatment of inguinal hernia and hydrocele, and the only difference of hydrocele is syringe aspiration after surgery.

In addition, the reported recurrence rates have varied from 0.48% to 0.73% in a large series of traditional LPEC procedures.^5,6 For premature babies weighing 3 kg or less, the rate of hernia recurrence was up to 4.4%.²² In addition, for boys <3 months, there was no hernia recurrence after surgery, and a standard orchidopexy at the time of inguinal herniotomy did not increase the risk of testicular atrophy and hernia recurrence.²³ The recurrence rate of our patients on whom modified LPEC was performed was 0.17%, which was far lower compared with premature babies weighing 3 kg or less. The recurrence rate in premature infants was higher due to the fact that the hernia sac was paper thin and fragile, and tears easily on handling.²⁴ Therefore, we speculate that the key point to minimize recurrences was the integrity of internal ring suture.

The modified LPEC and reinforcement procedure may reduce the recurrence rate. However, due to the limited sample size of this study, this conclusion needs to be further proved by increasing the research population in the future. Advanced laparoscopic equipment and extensive work experience of the surgical team could reduce the complication rate and improve the efficiency of the surgery.

Conclusions

In a word, the modified laparoscopic percutaneous extraperitoneal double closure using a sledge-shaped needle combined with the medial umbilical fold reinforcement is a highly effective and safe procedure to treat pediatric inguinal hernia and hydrocele.

Footnotes

Authors' Contributions

Y.H. conceptualized and designed the study, drafted the initial article, and reviewed and revised the article. Y.H., C.W., S.L., B.Y., X.L., S.K., and Q.A. designed the data collection instruments, collected data, carried out the initial analyses, and reviewed and revised the article. Y.M. and Z.X. conceptualized and designed the study, coordinated and supervised data collection, and critically reviewed the article for important intellectual content. All authors approved the final article as submitted and agree to be accountable for all aspects of the work.

Disclosure Statement

No competing financial interests exist.

Funding Information

This work was supported by the Research Fund of the First Affiliated Hospital of Harbin Medical University (2019L01), Outstanding Youth Training Fund from Academician Yu Weihan of Harbin Medical University (2014), Chen Xiaoping Foundation for the Development of Science and Technology of Hubei Province (CXPJJH11900001-2019349), Natural Science Foundation of Heilongjiang Province of China (QC2013C094, LC2018037), and the National Natural Science Foundation of China (81100305, 81470876, 81502605, and 81270527).

References

Rafailidis

, Varelas

, Apostolopoulou

, Rafailidis

. Nonobliteration of the processus vaginalis: Sonography of related abnormalities in children. J Ultrasound Med, 2016; 35:805–818.

Gollu

, Ates

, Bahadir

, et al. Transinguinal laparoscopic evaluation of contralateral side during unilateral inguinal hernia repair for children. J Pediatr Urol, 2019; 15:561.e561–561.e566.

Chen

, Wang

, Zhong

, Zhao

, Li

, Shi

. A systematic review and meta-analysis concerning single-site laparoscopic percutaneous extraperitoneal closure for pediatric inguinal hernia and hydrocele. Surg Endosc, 2017; 31:4888–4901.

, Wu

, Wang

, et al. Incidence of pediatric metachronous contralateral inguinal hernia and the relationship with contralateral patent processus vaginalis. Surg Endosc, 2019; 33:1087–1090.

Saka

, Okuyama

, Sasaki

, Nose

, Yoneyama

. Safety and efficacy of laparoscopic percutaneous extraperitoneal closure for inguinal hernias and hydroceles in children: A comparison with traditional open repair. J Laparoendosc Adv Surg Tech A, 2014; 24:55–58.

Miyake

, Fukumoto

, Yamoto

, et al. Risk factors for recurrence and contralateral inguinal hernia after laparoscopic percutaneous extraperitoneal closure for pediatric inguinal hernia. J Pediatr Surg, 2017; 52:317–321.

Liu

, Baird

, Tang

, et al. Medial umbilical ligament flap reinforcement of the internal ring in children with indirect inguinal hernia. J Laparoendosc Adv Surg Tech A, 2011; 21:561–565.

Chen

, Xiang

, Wang

, Xiao

. Towards a near-zero recurrence rate in laparoscopic inguinal hernia repair for pediatric patients. J Laparoendosc Adv Surg Tech A, 2011; 21:445–448.

Lee

, Kim

, Pokarowski

, et al. Clinical and economic value of routine pathological examination of hernia sacs and scheduled clinic follow-ups after inguinal hernia and hydrocele repair in a Canadian Tertiary Care Children's Hospital. J Pediatr Surg, 2020; 55:1463–1469.

10.

Esposito

, Escolino

, Cortese

, et al. Twenty-year experience with laparoscopic inguinal hernia repair in infants and children: Considerations and results on 1833 hernia repairs. Surg Endosc, 2017; 31:1461–1468.

11.

Wang

, Zhang

, Chen

, et al. Laparoscopic percutaneous extraperitoneal internal ring closure for pediatric inguinal hernia: 1,142 cases. J Laparoendosc Adv Surg Tech A, 2019; 29:845–851.

12.

Shibuya

, Miyazaki

, Miyano

, et al. Comparison of laparoscopic percutaneous extraperitoneal closure versus conventional herniotomy in extremely low birth weight infants. Pediatr Surg Int, 2019; 35:145–150.

13.

Amano

, Tanaka

, Kawashima

, et al. Comparison of single-incision laparoscopic percutaneous extraperitoneal closure (SILPEC) and open repair for pediatric inguinal hernia: A single-center retrospective cohort study of 2028 cases. Surg Endosc, 2017; 31:4988–4995.

14.

Jessula

, Davies

. Evidence supporting laparoscopic hernia repair in children. Curr Opin Pediatr, 2018; 30:405–410.

15.

Esposito

, Montinaro

, Alicchio

, et al. Technical standardization of laparoscopic herniorraphy in pediatric patients. World J Surg, 2009; 33:1846–1850.

16.

Yang

, Zeng

, Yin

, et al. The advantages of transumbilical single-site laparoscopic percutaneous extraperitoneal closure for inguinal hernia in 1583 children. Surg Endosc, 2018; 32:1923–1928.

17.

Dreuning

KMA

, Ten Broeke

CEM

, Twisk

JWR

, et al. Diagnostic accuracy of preoperative ultrasonography in predicting contralateral inguinal hernia in children: A systematic review and meta-analysis. Eur Radiol, 2019; 29:866–876.

18.

Wang

, Zhong

, Chen

, et al. Single-site laparoscopic percutaneous extraperitoneal closure of the internal ring using an epidural and spinal needle: Excellent results in 1464 children with inguinal hernia/hydrocele. Surg Endosc, 2017; 31:2932–2938.

19.

, Liu

, Wong

KKY

, Liu

, Li

. Single-port laparoscopic herniorrhaphy using a two-hooked cannula device with hydrodissection. J Pediatr Surg, 2018; 53:2507–2510.

20.

Kelly

, Krpata

, Blatnik

, Ponsky

. Suture choice matters in rabbit model of laparoscopic, preperitoneal, inguinal hernia repair. J Laparoendosc Adv Surg Tech A, 2014; 24:428–431.

21.

Konschake

, Brenner

, Moriggl

, et al. New laparoscopic approach to the pudendal nerve for neuromodulation based on an anatomic study. Neurourol Urodyn, 2017; 36:1069–1075.

22.

Esposito

, Turial

, Escolino

, et al. Laparoscopic inguinal hernia repair in premature babies weighing 3 kg or less. Pediatr Surg Int, 2012; 28:989–992.

23.

Wright

, Davidson

, Major

, et al. The management of boys under 3 months of age with an inguinal hernia and ipsilateral palpable undescended testis. J Pediatr Surg, 2017; 52:1108–1112.

24.

Vaos

, Gardikis

, Kambouri

, Sigalas

, Kourakis

, Petoussis

. Optimal timing for repair of an inguinal hernia in premature infants. Pediatr Surg Int, 2010; 26:379–385.