| Purpose: Indirect inguinal hernia, which is fundamentally the result offailure of closure of the processus vaginalis, is one of the most commondiseases in pediatric population. High ligation has been the accepted asclassical treatment for indirect inguinal hernias. However, layers of inculpabletissues were involved and both inner rings can not be explored during oneprocedure, patent inguinal defect on the contralateral side may not be awareduntil symptoms began to show up. With the rapid advancing of minimallyinvasive surgery (MIS), laparoscopic management for pediatric indirectinguinal hernia has been one of the hottest topics. However, comparing withtraditional high ligation approach, neither technical profits nor cosmeticadvancements were observed in conventional three port video-guidedtechnique. With further study of laparoscopic management for pediatricinguinal hernia, pediatric surgeons now trend to perform inner ring closureextraperitoneally with aid of injection needles and kinds of hernia apparatus,it’s easier to perform and lower recurrence rate was observed in clinicalpractice. In our department, the one-hooked needle, which was developedbased on the homemade epidural needle, was finally modified to two-hookedneedle. Here we summarize our technical essentials and development of hernianeedles, outcomes of laparoscopic procedures for pediatric indirect inguinalhernia were observed, to evaluate the feasibility and safety of laparoscopicMIS technique for this disease and explore strategy for peri-operativecomplications and provide feasible suggestions for avoiding intra-operativeaccidents, decreasing morbidity rate, improving the post-operative recovery.Methods: With the approval of hospital’s Institutional Review Board. Hernia needles were made under the guidance of medical literatures andconstantly modified in practice. Homemade epidural needles were firstlyapplied in our department. Both the sheath and core of the needles weredesigned to have a hook at the lateral side of the spoon-shaped tips andslightly curved at1/3from the distal end of the hernia needle, to facilite theprocess of passing through along the internal hernia orifice extraperitoneally.However, innocent tissue might be injured by the hook of the sheath duringoperation. To overcome the defects mentioned previously, we upgraded ourneedle into one-hooked hernia needle. The hook at the sheath was abolishedwhile a hub, male screw and spring adaptor were added on the proximal end ofthe sheath for locking the core of the device. The barb-like hook was alsodesigned on the lesser curvature (instead of lateral side) of the core forretrieving the hernia suture line. Unfortunately, one-hooked needle was notguaranteed passing hernia suture thread through the same path when introduceand withdraw the device and extra-abdominal tissues might be ligated with theinner ring. Therefore, we further modified this apparatus by making two slotson the greater curvature of the core instead of the one over lesser curvature.The first shallow slot is0.5cm away from the distal end for sending the loopof hernia suture into the peritoneal cavity and the second deep slot is0.5cmproximal from the first slot for pulling out the indwelling intra-abdominalsuture, with this device, we can safely close inner ring within one puncture.We retrospectively analyzed the clinical data of466boys who had receivedhomemade epidural needle single-port laparoscopic assisted percutaneousextraperitoneal closure (SPLPEC) of inner ring(epidural needle group), one-hooked needle single-port laparoscopic assisted percutaneous extraperitonealclosure of inner ring (one hooked-needle group)and two-hooked needlesingle-port laparoscopic assisted percutaneous extraperinoneal closure of innerring (two-hooked needle group) during2007and2012.412single sideinguinal hernia and54double side hernia were diagnosed before operations.97received epidural needle SPLPEC,103received one-hooked needleSPLPEC and266received two-hooked SPLPEC. All groups were finished by single-port laparoscopic assisted percutaneous extraperitoneal closure of innerring. One5-mm trocar was applied for laparoscope at the site of umbilicus, theprocedure goes once both inner ring were observed:①Epidural needle group:Firstly, an epidural needle without any hook on the sheath was introducedthrough the skin stab, then penetrated the subcutaneous tissue and muscles ofthe abdominal wall, extending into the extra-peritoneal space and the needlefurther advanced along the medial side of the internal orifice of the herniadefect. The blunt tip of the needle separated the vas deferens from peritoneumand passed intraperitoneally between the vas deferens and spermatic vessels,after the suture was introduced by the core, we pulled the needle out. Secondly,another homemade epidural needle, which equipped with a hook at the lateralside of the tip was introduced at the original skin stab site and advanced alongthe inner ring on contralateral side. After the peritoneum dissected fromspermatic vessels, the hook pin was crossed in spermatic vessels anteriorlyand reentered the peritoneum through the original passage. Finally, theprevious silk thread was placed into the hook and the needle was pulled out ofthe abdomen to guide the thread out of the body. After frapping both tips ofsuture thread, a surgical knot was performed and the knots were left undermuscular layer.②One-hooked needle group: the procedure was similar tohomemade epidural needle group we mentioned above, the differencesbetween both techniques were the previous placed silk thread was placed intothe core slot and locked inside the sheath by sequentially pressing andreleasing the proximal end of the core. In that moment, the hook pin waspulled out of the abdomen to guide the thread out of the body. The inner ringof the hernia was closed by knotting the silk thread outside of the body.③Two-hooked needle group: After introducing a laparoscope into theintra-abdominal cavity, the middle of a folding suture (silk2-0) was placed inthe distal slot and then locked inside the sheath by pressing and releasing theproximal end of the core sequentially. The suture loaded apparatus wasintroduced into the peritoneum in the same way as the single hook needledescribed above. With the assistance of the laparoscope and pushing the core slot out of the sheath, the folding suture line was released and kept in theperitoneum. The apparatus was gently pulled back to the anterior wall of theinner ring under the peritoneum, and reentered into the peritoneum in the samepath as the single hook pin. The previously placed folding suture line was thenplaced in the proximal slot by pressing and holding the proximal end of thecore, and then locked inside the sheath by releasing the core. Then the hookneedle was pulled out of the abdomen to guide the thread out of the body. Theinner ring of the hernia was closed by knotting the silk thread outside of thebody and the knots were left under muscular layer and at the extraperitonealspace at the anterior wall of inner ring. Operation time, post-operationhospitalization duration, post-operation recurrence, peri-operation complica-tions, satisfaction rate of operation outcomes were analyzed.Results: All the patients received SPLPEC uneventfully, of the412children who were diagnosed to be unilateral hernia,79cases were found tohave an unclosed inner ring contralaterally and both inner rings were closedduring the same procedure. Of all466patients,97received homemadeepidural needle SPLPEC,103received one-hooked needle SPLPEC and266received SPLPEC. Mean operation time was21.2±9.9min,17.9±4.7min and13.3±3.5min for unilateral hernia respectively, P＜0.01; and for bilateralhernia,35.7±12.9min,27.9±7.9min,17.4±4.7min respectively, P＜0.01;post-operation hospitalization duration was2.9±0.5d,2.8±0.6d,2.1±0.4d，P=0.295; peri-operation complication rate was10.31%,5.83%and0.75%, P＜0.01; In epidural needle group,5extraperitoneal hematoma,3abdominaldiscomfort after ligation and2subcutaneous knots reaction were observed,while in one-hooked group,1extraperitoneal hematoma,4abdominaldiscomfort after ligation and1subcutaneous knots reaction were observed, intwo-hooked group, one patient with hemophilia had hematoma duringoperation and1subcutaneous knots reaction were observed. post-operationrecurrence was2.06%,1.94%and0.38%，P=0.246. satisfaction rate was92.78%,94.17%and98.79%respectively, P＜0.01; No testicular atrophywere found in all three groups. Conclusions:1Laparoscopic surgery for inguinal hernia can be used to detect herniadefects on both sides, and unexpected hernia defect can be closed within oneprocedure;2Although homemade epidural needle can be used to finish single-portlaparoscopic assisted percutaneous extraperitoneal closure of inner ring andrich the benefits of invisible scar, quick recovery and excellent cosmeticoutcomes. There are some disadvantages of homemade epidural needleapproach, the hook on the sheath might cause injury of spermatic vessels andvessels near by, as a result, hematoma was found and the procedure wouldbecome time consuming. Introducing and reintroducing of hernia needle maycause ligation of abdominal wall tissue and finally lead to foreign bodyreaction or infection of abdominal wall;3One-hooked needle may make it easier to perform SPLPEC, however,Introducing and reintroducing of hernia needle may cause ligation ofabdominal wall tissue and lead to abdominal discomfort post-operatively;4In two-hooked needle group, both tails of suture thread goes exactly inthe same path, and almost impossible to ligate additional tissues of theabdominal wall, inner ring is close in a tension-free method and less operationtime is needed. |
PDF Full Text Request