Single-Incision Laparoscopic Percutaneous Extraperitoneal Surgery for the Treatment of Incarcerated Indirect Inguinal Hernia in Children

Introduction

Incarcerated indirect inguinal hernia is one of the most common emergencies in children, ¹ if the hernia cannot be reduced manually, or has incarcerated for >12 hours, the groin exploration surgery will be performed. With the development of laparoscopic technology, the application of laparoscopic surgery in the treatment of incarcerated indirect inguinal hernia in children is becoming increasingly common nowadays ² ; it has the advantages of small trauma and fast recovery for the patient. In this study, we performed a retrospective analysis to show our experiences in single-incision laparoscopic extraperitoneal procedure for the patients presenting with incarcerated indirect inguinal hernia.

Materials and Methods

Surgical procedures

Placing the patient in a supine position, general anesthesia was performed with tracheal intubation, and a 5 mm Trocar was inserted through the umbilical incision that serves as a port for the 30° laparoscope. After that the operating table was adjusted to the low head and high feet posture, and the fascial closure device carrying 2/0 unabsorbable suture was used to ligate the inner ring (Fig. 1A, B).

OPEN IN VIEWER

FIG. 1.

(A) The fascial closure device (hernia needle) for surgery. (B) The fascial closure device carrying a double strand of 2/0 nonabsorbable suture.

Manual reduction of the incarcerated hernia contents under laparoscopic monitoring was performed (Fig. 2A). After successful reduction (Fig. 2B), the projection point on the body surface of the midpoint of the inner ring as the operation point (Fig. 2C) is taken, inserting the fascial closure device until the preperitoneal space, wrapping deep ring around half a circle, piercing the peritoneum, and leaving the end of the suture within the peritoneum cavity (Fig. 2D). Then the fascial closure device was slowly withdrawn until its tip reached the preperitoneal space of the deep ring and again encircled another half circle of the deep ring in the preperitoneal space until the previous breach point was reached (Fig. 2E) (for the male patients, when encircling the deep ring, we needed to separate the testicular vessels and vas). If the inner ring was particularly large and was difficult to be encircled, an additional fascial closure device can be used to assist the operation. Then the suture end was retrieved out of the body, making a knot to ligate the deep ring (Fig. 2F).

OPEN IN VIEWER

FIG. 2.

(A) The intestine was incarcerated in the deep ring and manual reduction was performed under laparoscopic direct vision. (B) The intestine was pushed back, after observation, and there was no intestinal necrosis. (C) Taking the projection point on the body surface of the midpoint of the inner ring as the operation point. (D) Wrapping deep ring around half a circle. (E) Encircled another half circle of the deep ring in the preperitoneal space until the previous breach point was reached. (F) Making a knot to ligate the deep ring.

Then we could assess the vitality of the reduced content and the situation of the contralateral deep ring. If the contralateral deep ring was also unclosed, we would use the same method to close it. For the reduced content, if it were necrotic, we would expand the navel incision and drag it out of the abdominal cavity and treat with resection and anastomosis.

Results

A total of 75 patients (37 females and 38 males) were enrolled in the present study (Table 1). The median age of these patients was 21 months (range: 1–114 M) with a median weight of 9 kg.

Among these patients, the incarcerated hernia contents of 73 patients were successfully pushed back with external manual pressure under the monitoring of laparoscope; then we did the laparoscopic percutaneous extraperitoneal hernia sac high ligation by using the fascial closure device for these patients. After successful reduction, the incarcerated intestine was necrotic in three cases, after which we performed intestinal resection and anastomosis through the enlarged umbilical incision. For two patients, pushing back the incarcerated hernia contents was difficult because of the serious swelling of the deep ring and incarcerated intestine; we then decided to do the open surgery for these patients. The median surgical time for laparoscopic percutaneous extraperitoneal hernia sac high ligation was 15 minutes. For intestinal resection and anastomosis, the median surgical time was 70 minutes, and the average length of postoperative hospital stay for the patients who didn't get incarcerated organ necrosis was 2 days. All of the patients recovered well without any complications.

Discussion

For incarcerated indirect inguinal hernia in children, it is difficult for parents to provide accurate incarcerated time. Sometimes the incarcerated part of the patient is obviously red and swollen; therefore, there is a high risk of manual reduction because we are not sure whether the incarcerated contents are necrotic. Therefore, in such cases laparoscopic surgery has obvious advantages. ³ We can perform manipulative reduction under laparoscopic monitoring, ligate the deep ring, and evaluate the viability of incarcerated contents, thereby avoiding the trauma caused to the patient by traditional open surgery. In addition, for the patients with failed manual reduction, after general anesthesia, their abdominal muscles are relaxed. The success probability of manual reduction will be much higher. If the incarcerated content is necrotic, we can perform further surgery by slightly expanding the umbilical incision.

Owing to the advantages of the laparoscopic surgery, there have been multiple studies on laparoscopic surgery for the treatment of incarcerated inguinal hernia.^4–6 But these surgeries are all performed using multiple trocar holes. In this case, we attempted to use a fascial closure device (hernia needle) to complete the surgery and only required one trocar hole. First, in our experience, it is not advisable to use grasping forceps to pull the incarcerated hernia content back to the abdominal cavity to complete the reduction, as this can crush the incarcerated tissues. Second, if the inner ring is very large and is difficult to be encircled, we can insert another hernia needle to assist in the operation. Without the need for additional trocar holes, the position of the hernia needle can be selected at any point of the lower abdomen according to the surgeon's habits, and the wound is almost invisible after healing.

The occurrence of postoperative complications of traditional open surgery for incarcerated indirect inguinal hernia, such as edema of scrotum, hematoma, indirect hernia recurrence, is high. ⁷ Laparoscopic surgery has several advantages and include small operation incision, fast procedure, and efficient, quick recovery after surgey. ⁸ So the occurrence of postoperative complications is relatively low. In this study, all of the patients recovered very well after surgery, and there was no recurrence of the hernia and any other postoperative complications.

However, the limitations of this study are its retrospective nature and small sample quantity; so a larger multicenter prospective clinical trial and long-term follow-up is deemed necessary to validate the advantages of this technique.

Conclusion

Single-incision laparoscopic percutaneous extraperitoneal surgery for the treatment of incarcerated indirect inguinal hernia in children appears to be safe and feasible. Our experience shows that it is recommended to perform such surgery in children.