| Objective: Inguinal hernia is one of the most common surgical conditions in children, which originates in the presence of a patent processus vaginalis(PPV). In children, the quintessential step of the standard procedure is ligation of the hernial sac at the internal ring through an open inguinal incision. Bleeding owing to trauma to the spermatic vessels is frequent and can cause iatrogenic cryptorchidism, even testicular atrophy. The laparoscopic approach has become an alternative to the conventional open procedure. Advantages of laparoscopic repair include the ability to evaluate the contralateral PPV and complete its repair simultaneously, avoidance of access injury to the vas deferens and gonadal vessels and iatrogenic cryptorchidism, shorter operative time, less postoperative pain, decreased length of hospital stay and better cosmetic results. The surgical principle in laparoscopic repair is also to close the internal inguinal ring. Over the last decade numerous minimally invasive techniques for addressing inguinal hernia have mushroomed and continued to evolve, but there are two basic approaches- laparoscopic-assisted purely intracorporeal ligation and extracorporeal ligation. Nonetheless, the impact of different laparoscopic inguinal herniorrhaphy on the peritoneal healing(hydrocele formation or hernia recurrence) and testicular structure has not been established. The aim of this study is to explore the following different procedures, which include laparoscopic intracorporeal suturing and knot tying(LISKT), laparoscopic hernia sac transection and intracorporeal stitching(LHSTIS), laparoscopic percutaneous extraperitoneal closure via twice puncture on the abdominal wall(LPECT), laparoscopic completely percutaneous extraperitoneal closure via once puncture on the abdominal wall(LPECO), for comparing the advantages and disadvantages regarding to the above different closure techniques. The target experimental animal model was established based on the fact that PPV was confirmed to be congenital in male New Zealand rabbit. Pathologic alterations of peritoneum at internal ring during reparative process were observed in different periods postoperatively. The effects of the structure of testicle were also assessed preliminarily. Based on the data obtained, we provide a better alternative for hernia repair in the clinical application to reduce iatrogenic trauma and complications.Methods:1 Animal experiment. A total of 40 adult male New Zealand rabbits, weighting 2500~3000g, were divided equally into two groups randomly. LISKT and LHSTIS were performed in the same animal using three-port laparoscopic technique in one group, while LPECT and LPECO were performed in the same animal using one-port or two-port laparoscopic technique in another group. Operative time, injury to the vas deferens and spermatic vessels, bleeding, trauma to related visceral organs, cosmetic outcomes were recorded.2 Observation of inner ring closure. Laparoscopic reexploration was used to observe adhesion, the degree of healing of the inguinal region as well as recurrence at 7d, l5 d and 30 d after operation. Then the inguinal canal was dissected to observe whether had cracked or not. In addition, the inner ring tissue was resected and stained by HE for observing the pathological changes under optical microscope.3 Testicular structure evaluation. The changes of the size, colour and position of the testicles were detected every day after operation. The spermatic cord structures were visual inspected when dissecting the inguinal canal. The pathological changes of the testicular tissue were observed under optical microscope. Different levels of spermatogenic cells of the testicular tissue were classified.4 Statistics. The statistical analysis software package SPSS 13.0 was applied for data processing by the benchmark of a=0.05. P<0.05 indicating the difference was statistically significant.Results:1 The breathing and heart rates of all rabbits except one died during the anesthesia and was excluded, were stable after surgery, and recovered within 2 hours. They began to take food within 24 hours, so much as returned normal activity to the preoperative status 72 hours after surgery.2 Operating time. The mean operating time of LISKT, LHSTIS, LPECT and LPECO was 12.05±2.95 min, 14.15±0.93 min, 7.50±1.15 min and 7.15±1.35 min, respectively. The operating time was significantly different among the four groups(P<0.01). The operating time for intracorporeal suturing was significantly longer than extraperitoneal closure(P<0.05).3 Perioperative complications. No testicular retraction, puncture injury, ankylenteron, infection of incision, subcutaneous emphysema and hematoma were observed. In LISKT group, 1 testicular necrosis and 2 subperitoneal hematomas were found in 9 rabbits, which sutured the peritoneum completely; moreover, 3 hernia recurrences and 1 hydrocele were formed among the 10 animals with a peritoneum gap at the location of spermatic vessels and vas deferens intentionally to avoid trauma. In LHSTIS group, 5 injuries to spermatic cord resulting in 4 testicular necroses or atrophies and 1 hydrocele were observed without hernia recurrence. In LPECT group, 3 subcutaneous knot reactions and infections, 5 hernia recurrences were found. In LPECO group, only 1 testicular necrosis was observed. Post-operation recurrence rate was significantly different(P=0.04), further, it was higher in LISKT group and LPECT group than LPECO group(P<0.05). There was also a statistically significant difference among perioperative complications(P=0.015). The complications related to dissecting the spermatic cord were higher in LHSTIS group.4 The degree of adhesion of the inner ring region. The scar formation of the front peritoneum was only found, while the other half was still open and kept smooth in the recurrent rabbits in LISKT group with a peritoneal gap. In LPECT group, the inner ring was narrowed slightly and cut off by the suture, and tying knot could be found in the subcutaneous tissue. The peritoneal adhesion, fibrosis, could be separated on the 7th day postoperatively. However, as time went on, the peritoneum fused together tightness, and could not be separated easily in the period of postoperative 15~30 day, especially in LHSTIS group.5 Morphologic alterations of the inner ring tissue. In the early stage, numerous inflammation cells, with low secretion of collagen fibers(on the postoperative 7th day) were observed; while capillary proliferation, granulomas emerging, reduction of inflammatory cells, collagen secretion increased could be inspected in the middle stage(on the postoperative 15 th day); abundant collagen fibers with mature fusiform fibroblasts, enlarged and thickened vascular wall, tissue scarring and a significant reduction of inflammatory cells could be observed in late stage(on the postoperative 30 th day). The morphologic alterations of the inner ring organization were consistent with reparative process of chronic inflammation.6 Pathologic alterations of testicular tissue. In LHSTIS group, two testicular necroses were found and the histological structure was difficult to distinguish, and only one emerged respectively in both LISKT group and LPECO group. Besides, two testicular atrophies in LHSTIS group were noted, irregular arranged seminiferous tubules, maldevelopment seminiferous epithelium could be found, and spermatogenic cell layers reduced and disordered significantly. The number of sperm and the function of spermatogenesis were decreased, with part of the seminiferous tubules cavity were narrowed and congested by necrotic tissue. The process of spermatogenesis was normal in the rest rabbits. The spermatogenic cell layers arranged regularly, and a large number of sperm cells and normal sperm were observed in the seminiferous tubules.Conclusion:1 With the implementation of LISKT, LHSTIS, LPECT, LPECO on male New Zealand white rabbits, the experimental animal model was established by simple ligation of hernia sac to simulate different inner ring closure techniques. This provides a nice carrier of animal exercise for standardized training of laparoscopic inguinal herniorraphy in children for resident surgeon.2 Using the blunt epidural needle, the spermtic cord and vas deferens can be safely dissected without the assistant of additional grasping forceps to introduce the suture, which makes the procedure easier to perform. Laparoscopic completely percutaneous extraperitoneal closure via once puncture on the abdominal wall(LPECO), performed by the two-hooked needle apparatus, can keep both tails of suture thread goes exactly in the same path, and avoid ligating innocent tissues of the abdominal wall. Moreover, unlike the three-port techniques, which requires excellent intra-abdominal laparoscopic skills, LPECO has the advantages of shorter operative time, quicker recovery, minimized invasiveness, easier to perform, fewer complications, lower recurrence rate and better cosmetic results compared with the other three methods, thus is a safe, effective and worth optimization operative method.3 The adhesion of the inner ring of New Zealand male rabbits increases gradually 7d after operation, and achieves basically stability in the time of 15~30d. All the procedures above-mentioned can effectively resist abdominal pressures as long as whole closing the inner ring without leaving gaps, and reduce the chance of hernia recurrence postoperatively.4 Owing to the thinking limits of the conventional laparoscopic surgery, the three-port laparoscopic herniorraphy intracorporeal sutured repair with endoligation in the abdominal cavity using two working ports. The operation is complex and precision is required. To avoid trauma to the spermatic vessels and vas deferens in the early stage, a small peritoneal gap is intentionally left untouched without preperitoneal dissection, therefore, the hernia sac was not completely ligated at the level of internal ring, which leads to a high recurrence of inguinal hernia or hydrocele.5 Due to the differences of inguinal canal structure between the human and New Zealand rabbits, and the sample numbers of the experiment were not enough, the clinical significance of this experiment remains to be confirmed by further large sample prospective studies. |
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