Single-puncture Method of Laparoscopic Herniorrhaphy in Children.

To the Editor: Pediatric inguinal hernia repair is a common surgical procedure performed in pediatric patients. Laparoscopic herniorrhaphy has several advantages over conventional open herniotomy; most of them related to the evaluation of possible contralateral patent processus vaginalis (PPV) and avoidance of trauma to the vas deferens and spermatic vessels.

However, percutaneous closure of inguinal hernia cannot prevent simultaneous ligation of subcutaneous tissues (sometimes nerves) of the inguinal canal between the skin and hernia sac; as such, this technique might increase the postoperative morbidity in the long run. The knot is palpable in the subcutaneous space, which might lead to varying degrees of suture reactions.

The procedure for pediatric inguinal hernia was modified to preserve the advantages and overcome the limitations of existing laparoscopic-assisted percutaneous extraperitoneal closure (LPEC). Two 3.5-mm stab incisions were made on both lateral sides of umbilicus, and two trocars of the corresponding size were inserted into the peritoneal cavity. The location of the puncture point through the surface projection of the inner ring was confirmed, and a 1.5-mm stab incision was made. A homemade needle with 2-0 nonabsorbable suture material [Figure 1] was inserted in the loose fat tissues [Figure 2a]. The first half of the circle was begun extraperitoneally from the anterior edge to the posterior edge around the internal inguinal ring. When half of the circle was accomplished, the peritoneal cavity [Figure 2b] was punctured and the end of the 2# thread into the peritoneal cavity was pulled using a grasper [Figure 2c]. The needle was pulled back slowly to the puncture point where it penetrated. In this point, the direction of the needle was adjusted [Figure 2d] and the opposite half of the internal ring was completed. The spermatic duct and gonadal vessels were crossed over carefully to avoid injury (if the patient was boy). When the previous puncture point was reached, the needle was stabbed into the peritoneal with a double thread (named 3# thread) [Figure 2e]. The 3# thread was pulled on one side of the needle to form a new loop, and the end of the 2# thread was grasped to pass through the new loop [Figure 2f]. The needle was drawn out of the abdominal cavity [Figure 2g]. Extracorporeally, the 3# thread and 1# thread were pulled simultaneously [Figure 2h] to remove the 2# thread [Figure 2i]; in this step, the 2# thread was placed around the inguinal ring under the peritoneum and both ends exit the skin through the same puncture point and tunnel. Gas collected in the distal sac was squeezed out, the thread was tied tightly extracorporeally, and the internal inguinal ring was completely closed. The knot was placed underneath peritoneally, rather than subcutaneously. When asymptomatic contralateral PPV was observed, bilateral closure was performed. During the follow-up period, no recurrence, hydroceles, metachronous hernia, or testicular atrophy were detected.

Figure 1

Homemade needle for pediatric inguinal hernia.

Figure 2

Surgical procedure for pediatric inguinal hernia. (a) A homemade needle with 2-0 nonabsorbable suture material (with a long end and a short end: named 1# thread and 2# thread) was inserted at the loose fat tissue (5 mm apart from the outside of inferior epigastric artery). (b) When half of the circle accomplished, punctured the peritoneal and (c) pull the end of the 2# thread into the peritoneal cavity with the aid of the grasper. (d) The needle was then pulled back slowly to the puncture point where it penetrated in (clung to peritoneal). (e) Finished the opposite half of the internal ring, when the previous puncture point was reached, the needle was stabbed into the peritoneal with a double thread (named 3# thread), (f) grasped the end of the 2# thread pass through the new loop. (g) Drew the needle (with the 3# thread) out of the abdominal cavity. (h) Extracorporeally, pulled the 3# thread and (i) the 1# thread simultaneously, so the 2# thread could be brought out. Then, the thread was tied tightly extracorporeally and the internal inguinal ring was completely closed.

Laparoscopic inguinal hernia repair for childhood inguinal hernia was first reported in the 1990s.[1] With the development of medical technology, laparoscopic herniorrhaphy has transitioned from intra-abdominal ligation to total extraperitoneal procedure.[2]

To prevent ligation of celiac wall tissues, both ends of the ligature thread should be in the same channel. In 2014, Liu et al.[3] improved the single-hole sled needle-ring method, in which the needle was punctured twice in the same channel of the abdominal wall fixed through casing. To an extent, this method reduces related complications.

In this proposed procedure, the needle is held underneath the peritoneum during the entire process through a similar method with a homemade hernia needle for LPEC; this procedure ensures that there will be only a single tunnel for two rounds of needle-insertion to prevent the risk of ligating subcutaneous tissues. The proposed method has another advantage over the existing LPEC in terms of reducing suture reactions (ranging from simple granuloma to stitch abscesses), which has been reported in approximately 3% of repairs.[4] In the current procedure, no suture reactions occurred because the knot had been placed deep underneath the peritoneum rather than in the subcutaneous tissue.

In conclusion, the proposed procedure is safe, feasible, reliable, and presents a low recurrence rate; hence, the modified technique should be considered an alternative treatment for pediatric indirect inguinal hernia. However, the technology described here still does not solve the problem of how to prevent the vas deferens and spermatic cord from twisting. This will be gradually improved in the subsequent studies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.