Multimedia manuscript: inguinal hernia repair by single-incision pediatric endosurgery (SIPES) using the hydrodissection-lasso technique.

Many different techniques for laparoscopic inguinal hernia repair have been introduced recently, using either an intraperitoneal [1-3] or an extraperitoneal [4-6] approach. One of the main challenges is to obtain a complete circumferential closure of the sack at the level of the internal ring without injury to the adjacent vas deferens or spermatic vessels. In an effort to separate these structures from the peritoneum before passing a suture around the base of the sack, we developed the hydrodissection-lasso technique, which is performed using a single-incision endosurgical approach.With the patient in Trendelenburg position, an 8-mm skin incision is made in the umbilicus, and a 5-mm trocar is placed in the inferior aspect for the endoscope. A 3-mm Maryland grasper is placed directly through the fascia in the upper part of the incision. Using a 22-gauge needle inserted percutaneously over the internal inguinal ring, saline is injected into the subperitoneal plane circumferentially, hydrodissecting the peritoneum off the vas deferens and vessels and creating a safe space through which the suture can pass without compromising these structures. A 2-mm stab incision is made directly over the internal inguinal ring, and a lasso technique is used to pass two strands of braided polyester suture around the hernia sack, as demonstrated in the video. Both sutures are tied tightly, leaving the knots under the skin. No direct or indirect manipulation of the vas deferens or vessels takes place during any part of the procedure.In contrast to other described techniques [7], the hydrodissection-lasso technique can be used for all indirect inguinal hernias in both girls and boys, and hydrodissection itself may be a useful adjunct to any of the other aforementioned techniques. Although an age limit for exclusive high ligation of the hernia sack for indirect inguinal hernias has not been established, the recurrence rate may be higher for adults if the procedure is not combined with inguinal floor reconstruction [8]. At this time, we therefore limit the proposed technique to prepubertal patients.We have performed the described procedure for 22 patients without any recurrences during a maximum follow-up period of 12 months (Table 1). The patients had minimal postoperative pain. There were no complications except for a transient genitofemoral nerve paresis experienced by one girl in whom the hydrodissection was performed using 1% lidocaine instead of the usual normal saline solution. Although the sack was not resected, there were no cases of postoperative hydroceles.To evaluate whether this novel technique is an adequate long-term solution, a prospective clinical trial comparing standard open and single-incision endosurgical inguinal hernia repair using hydrodissection should be performed.