Laparoscopic management of recurrent inguinal hernia in childhood

    Laparoscopic Management of Recurrent Inguinal Hernia in Childhood Rafik Shalaby, Maged Ismail, Abdel Aziz Yehya, Samir Gouda, Sayed Hassan, Ahmad Alazab PII: DOI: Reference:

S0022-3468(15)00439-X doi: 10.1016/j.jpedsurg.2015.07.015 YJPSU 57290

To appear in:

Journal of Pediatric Surgery

Received date: Revised date: Accepted date:

12 December 2014 9 July 2015 13 July 2015

Please cite this article as: Shalaby Rafik, Ismail Maged, Yehya Abdel Aziz, Gouda Samir, Hassan Sayed, Alazab Ahmad, Laparoscopic Management of Recurrent Inguinal Hernia in Childhood, Journal of Pediatric Surgery (2015), doi: 10.1016/j.jpedsurg.2015.07.015

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Introduction: Recurrences of congenital inguinal hernia [CIH] are rare complications, typically seen in less than 1 % of elective hernia operations in our clinic which is similar to that reported in

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the literature [1-4]. In cases of strangulated hernia, ascites, and ventriculoperitoneal shunts,

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the recurrence rate may increase up to 24 %.

The delicate structures in the field, namely the vas deferens and testicular vessels are liable

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to injury with recurrent inguinal hernias and it needs an expert surgeon and careful dissection. [5]

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Careful dissection to rule out this risk always increases the operative time. The laparoscopic approach offers a great advantage of approaching the defect from a

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previously untouched field, optical magnification and attacking the exact origin of the defect. [5, 6]. The great advantage of laparoscopy is that it can detect the associated rare types of hernia like femoral and direct hernias which can be treated simultaneously. [7]

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In the majority of cases, the cause of hernia recurrence is excessive tension on the repair, missed tear of the hernia sac, the use of absorbable sutures, weak posterior wall of the

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inguinal canal, or missed concomitant femoral or direct hernias.

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With improvement in laparoscopic techniques and understanding of the mechanisms of inguinal hernia and its prevention, we are heading towards the ultimate goal of preventing

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recurrences completely. [5, 8] The aim of this study is to present our experience in laparoscopic repair of RIH either after open or laparoscopic hernia repair with stress on value of laparoscopic technical refinements to prevent recurrence. Patients and Methods: This is a retrospective study of laparoscopic repair of RIH. It was conducted at the Department of Pediatric Surgery, Al-Azhar University Hospitals, Cairo, Egypt from April 2012 to September 2013. The study protocol was approved by Faculty of Medicine, Al-Azhar University ethics committee. Records of 38 children with 42 recurrent hernial defects that have been subjected to laparoscopic inguinal hernia repair for RIH were reviewed and evaluated regarding demographic data, surgeon in charge [general or pediatric surgeon (senior or junior)], type of repair (open or laparoscopic) and date of

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recurrence. The primary outcome measurements of this study include; operative time and recurrence rate. The secondary outcomes include; intra and postoperative complications, hydrocele formation, and testicular atrophy. All patients were subjected to thorough history clinical

examination,

routine

laboratory

investigations,

abdominal

and

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inguinoscrotal ultrasound, and laparoscopic hernia repair.

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taking,

Operative procedure:

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After induction of general endotracheal tube anesthesia, the patient was placed supine in Trendelenburg's position. Prophylactic intravenous antibiotic in the form of 3rd generation

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cephalosporin in a dose of 50 mg/kg body weight was given at time of induction. Insertion of the main umbilical port was accomplished by the open method.

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Pneumoperitoneum was established to a pressure of 8 to 12 mm Hg. Laparoscopy was used for initial visualization of the pelvis and internal inguinal rings (IIRs) on both sides. The

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laparoscopic hernia repair was done by trans-peritoneal approach as described earlier by Chan et al [9]. Two 3-mm accessory ports were inserted at the lateral borders of the rectus

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muscles at the level of the umbilicus (Fig.1-2 A, B). For boys, normal saline was injected at the extraperitoneal space around IIR to separate the vas deferens and testicular vessels

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from the peritoneum. A shortened (8-cm long) non-absorbable 3-0 Prolene suture was used in all patients. The needle and thread were passed into the abdomen directly through the

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abdominal wall. Two 3-mm needle holders were used for insertion of purse-string suture starting at 3 O`clock and passing under the peritoneum along the inferior margin of IIR with picking up of the peritoneum over the spermatic vessels and vas by the left handed instrument. Then the suture was continued along the upper margin of IIR, but in a deeper plane to include the peritoneum and the deeper fascia transversalis. On placing the needle for the purse-string stitch; “needle sign” was emphasized. “Needle sign” is the sign in which the needle could be seen clearly underneath the peritoneum without the vas and the testicular vessel in between. The sign further protected these important structures to be included in the stitch. A complete ring of peritoneum without any skip area was emphasized [complete encirclement of the peritoneum around IIR without any skip area is called complete ring sign]. The stitch ends were pulled before tightening the knot, the scrotum was squeezed and the intraperitoneal pressure was released to expel the gas in the

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hernial sac and tightened slightly before they were tied together. In some cases the hernia sac was disconnected at the neck of IIR with a purse-string suture of the proximal peritoneum at the level of the IIR. Narrowing of the wide IIR by interrupted stitches was

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done in some cases [The stitches included the peritoneum and the underlying muscular

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tissue lateral to the testicular vessels]. Covering the IIR region by the lateral umbilicus ligament after the purse-string knot were done, especially for the patients with wide hernia

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defect (diameter >2 cm) and the age over 5 years (Fig. 6). The purse-string airtightness was stress-tested by raising the intraperitoneal pressure by 50%. The increase in pressure was

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sustained for about 30 seconds. The patient was monitored carefully during the whole procedure for arrhythmia, change in blood pressure or decreased oxygen saturation. The

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airtightness was confirmed by the absence of hernia sac enlargement with the intraperitoneal pressure increase. A second purse-string stitch would be added at the low intraperitoneal pressure proximal to the first one if the sac enlarged after the pressure

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increased. After the pneumoperitoneum was released, the ports were removed. The umbilical wound was closed with absorbable sutures and the lateral ones with steri-strips.

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All patients were followed up in the out-patient clinic after 7 days, 2 weeks, 6 months, and 1 year. Parents were advised to contact the Department of Pediatric Surgery, if there were

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any concerns in the immediate postoperative period. Recurrences of the hernia, hydrocele formation and testicular atrophy were evaluated by clinical and U/S examinations during

Results:

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follow up period along with the cosmetic results and parent's satisfaction.

In this study 38 children with 42 recurrent hernial defects [4 patients had bilateral recurrent hernia] after either open or laparoscopic repair were operated upon laparoscopically at Department of Pediatric Surgery, Al-Azhar University Hospitals during the period from April 2012 to September 2013. They were 34 males and 4 females with a mean age of 2.54± 1.98 years (range = 0.58 – 10.00 years). One boy had a twice recurrence. The median time interval between surgery and recurrence was 6 months (range 1 day to 2.5 years).The demographic data, operative data and outcome of all patients are showed in [Table. 1- 3]

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A total of 5 recurrences occurred medially to the previous prolene suture [skip area over testicular vessels and vas]. Loosening of prolene suture around IIR was the cause of recurrence in 2 cases. The majority of recurrence [25 hernia defects] occurred after general

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surgeon repair while the recurrence rate after pediatric surgeon was less [17 hernia

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defects]. [Table. 2]

Preperitoneal hydrodissection with normal saline were done in all males hernia defects

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(34/42) 90, 48 %. Complete purse-string suture around IIR without any skip area was achieved in all defects. Disconnection and partial excision of the hernial sac and ligation of

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proximal peritoneum were done in 7/42 defects (16.67%). Narrowing of IIR by two interrupted stitches lateral to the spermatic vessels was done in 7/42 defects (16.67%).

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[Fig. 6]. Covering the internal inguinal ring by the lateral umbilicus ligament after the purse-string knot was done in 14/42 defects (33.33%). The mean duration of surgery was 20±2.24 minutes (rang from 13-30 minutes) for

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unilateral cases and 27±2.24 minutes (rang from 18 -40 minutes) for bilateral cases. None of the patients experienced any arrhythmia, change in blood pressure or decreased

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oxygen saturation during conducting the air-tightness stress tests and the air-tightness stress tests were negative in 36 repairs [no escape of gas into the hernia sac on raising the

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intra-abdominal pressure]. In 2 repairs, the air-tightness stress tests were positive and a second purse-string suture was inserted again proximal to the previous one and the test

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became negative. All patients achieved full recovery without intra or postoperative complications and were discharged on the same day of admission. Follow-up occurred after 7 days, 2 weeks, 6 months, and 1 year later. No postoperative wound infection during the early follow-up period but there were only 2 cases (5.20%) of postoperative hydrocele that disappeared on conservative management. At a mean follow-up of 12.7±2 months (range= 8–38.4 months), 80 % of patients were available for checkup and there were practically no visible scars, no recurrence, no hydrocele, no testicular atrophy with excellent cosmetic results and complete parent's satisfaction Discussion: Open herniotomy is an excellent method of repair in the pediatric population. However, it has the potential risk of injury of the spermatic vessels or vas deferens [especially in recurrent cases], hematoma formation, wound infection, testicular atrophy,

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and recurrence of hernia. It also carries the potential risk of tubal or ovarian damage which may cause female infertility [6, 10 -12]. Technical modifications and new techniques of LIHR have repeatedly been presented,

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implying that they may obviate recurrences eventually [5, 8]. However, recurrences

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still occur. The overall recurrence rate after open hernia repair ranges from 1.76 - 2.5% [6, 13, 14]. Many factors may contribute to recurrence in open inguinal hernia repair in

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children such as; failure to ligate the sac high enough, failure to close an excessively wide internal ring, injury to the floor of the canal with subsequent development of a direct hernia, the presence of comorbid conditions (e.g. collagen disorders,

malnutrition, or

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inguinal

pulmonary disease) [15]. In the majority of cases, the cause of hernia

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recurrence is excessive tension on the repair, missed tear of the hernia sac, the use of absorbable sutures, weak posterior wall of the inguinal canal, or missed concomitant

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femoral or direct hernias hernia. [7]

The recurrence rates after LIHR has ranged from 0.7- 4.5% [6, 13, 14, 8]. The high

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recurrence rate in LIHR could possibly be due to tension at the closure of the IIR, especially in large hernias, and presence of skip area especially over the cord structure. It

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has been claimed that incising the peritoneum can help to prevent recurrence, but this claim has not been substantiated with data [6]. Many technical factors, such as inadequate

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dissection of the hernia sac, rupture of the sac, slippage of the knot, a weak posterior inguinal wall due to massive dissection in previous operations. [7]. Schier stated that all recurrences occurred between the suture and the epigastric vessels. The main reason may be due to the presence of testicular vessels and vas deferens in close proximity to the peritoneum at the expected site of closure near the internal ring [16]. Out of fear to injure the vas and the epigastric vessels, the suture was placed too far laterally. Surgical techniques are continuously refined and will further reduce the recurrence rate [13, 17] Advantages of LIHR include excellent visual exposure, the ability to evaluate the contralateral side, minimal dissection and avoidance of access trauma to the vas deferens and spermatic vessels, iatrogenic ascent of the testis and bladder injuries. [18]. In addition, it is also helpful in detecting other associated pathology and other hernias with excellent cosmetic results and a comparable operative time and recurrence rates. Laparoscopy has

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minimal adhesions as; we did not find any adhesions during the second laparoscopic repair of hernia [7, 13]

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One of the most important advantages of using the laparoscopic approach in cases with

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RIH is that it avoids the previous operative site and provids a high level of safety in carring out the procedures without injuring the vas and trsticular vessels and detection of rare causes of

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recurrence. [19]

Yildiz et al designed a study to compare laparoscopic hernia repairs with classical open

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repairs for pediatric RIH following the first open repair. They stated that avoiding the dense fibrous tissue in the former operation area with the laparoscopic approach facilitates

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the procedure and decreases both the operative time and complication rate, they added that the time taken to repair recurrent hernia laparoscopically is similar to the time taken for open fresh hernia repair without added complications [5, 20]. The laparoscopic approach

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avoids the scarred distorted field with liability to injury and difficult dissection and approaches the problem from a virgin bloodless field with excellent magnification, clear

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anatomy and precise surgery. [6, 7]

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In our series we found that laparoscopic repair of the internal ring in a recurrent case was simple as primary hernia repair. The time of the laparoscopic repair of the recurrent hernias

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was almost the same as with primary laparoscopic hernia repair. Laparoscopy revealed the underlying cause of recurrence in all cases in the form of; missed hernia sac in 15 cases (35.71%) that were associated with very wide IIR in 6 cases (19.35%). Low ligations of hernia sac in 14 cases (33.33%), missed direct inguinal hernias in 4 cases (9.58%). In 2 cases with RIH after previous LIHR, the cause of recurrence was due to loosening of the previous suture (4.76%) (Fig. 5). In our study the majority of previous operations were done by general surgeons and pediatric surgeon with limited laparoscopic experience. In 2 cases of recurrence after laparoscopy, the causes of recurrence were missed femoral hernia in 2 cases (4.76 %) (Fig. 3, 4) and loosening of the suture around the IIR which may be due to insertion of the suture too deep to include much muscular tissues around the IIR during the primary laparoscopic repair. Another cause may be lack of the skills of intracorporeal suturing and knot tying techniques of the primary surgeon in charge.

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Different laparoscopic techniques for repair of inguinal hernia in children were described in the literature with varied results [13]. Lee et al performed micro laparoscopic high ligation in 450 patients with good results. They reported no complications of the surgery

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and a remarkably low recurrence rate (0.88%) [18]. Marte et al stated that the incision of

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the peritoneum lateral to the IIR and the W-shaped suture, compared to the sole W-shaped suture, is safe and effective in preventing hernia recurrence [21]. Tsai et al. and others

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dissected and transected the neck of the sac at IIR with suture closure of the peritoneum and they claimed that this may reduce recurrence as leaving the hernia sac in continuity

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without disconnection at IIR may be the cause of subsequent recurrence and hydrocele formation. [22]

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Esposito and Montupet reported their experience with the laparoscopic treatment of RIH in 10 children after open herniotomy. They claimed that they did not have intra or

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postsurgical complications or recurrence at follow-up of 3 years. They concluded that their early results suggest that laparoscopic surgery is a feasible and safe technique for the

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treatment of RIH in children. [20]. Becmeur et al. recorded no recurrence with their technical modification in the form of complete division of the hernial sac and stitching up

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of the peritoneum by non-absorbable suture at the level of the IIR. [23] Treef et al have so far the largest series of recurrences after laparoscopic inguinal hernia

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repair. Recurrence was reported in 32 out of 1071 cases of LIHR (3%). The recurrences where due to loose suture in 3 cases, medial to the purse string suture in 25 cases, and lateral in 7 cases. The highest recurrences was reported to occur in males up to 2 years, and they reported that the expert surgeon has around half the recurrence rate of a less experienced surgeon. [7] With refinements in the technique in laparoscopic repair, recurrence can be prevented even in this group of patients with recurrent hernia either after open or laparoscopic repair. Eighty percent of our patients were available at mean follow-up period of 12.7±2 months (range= 8–38.4 months). It was difficult for the patients of remote areas to come for follow-up in regular interval. They showed total recovery from the hernia without recurrence.

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Many operative refinements and technical modifications have been mentioned in the literature to eliminate the recurrence rate during LIHR. These include, saline injection around the IIR, needle sign`s during placement of purse-string suture around IIR, the

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placement of purse-string suture without skip area and complete encirclement of the hernia

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sac [complete ring signs], lateral umbilical ligament enforcement of IIR after insertion of purse-string suture, the use of non-absorbable suture and disconnection of the hernia sac at

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the IIR [8, 9, 11]. However, the results of Takehara et al. also support the idea that the hernia sac does not necessarily have to be transacted or removed during hernia repair and

recurrences

[24].

Moreover,

some

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that using nonabsorbable sutures can be sufficient to prevent the development of researchers

have

speculated

that

complete

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circumferential incising of the peritoneum, more or less imitating the open procedure, may lead to a reduction in the recurrence rate due to the scarring involved [22]. Montupet, and Esposito used the laparoscopic herniorrhaphy by sectioning the sac distally to the inguinal

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ring and performing a purse-string suture of the peritoneum around IIR using a 4/0 nonabsorbable suture. At a follow-up between 1 and 15 years, they have only 1.5%

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recurrences. [14]

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We followed operative refinements and technical modifications as described by Chan. [9]. Extraperitoneal injection of saline to separate vas and spermatic vessels from the

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peritoneum and adopting to the use of the "needle" sign avoided damage to the testicular vessel and vas. Placement of purse-string suture without skip area and complete encirclement of the hernial sac around IIR and the use of non-absorbable suture prevent recurrence. For recurrent hernias after either open or laparoscopic repair, the laparoscopic method was as simple as fresh hernia repair. In the present study, we did not have any recurrence at mean follow-up of 12.7±2 months (range= 8–38.4 months); that is because we started laparoscopic hernia repair in our unit after gaining good experiences in different laparoscopic procedures and, in addition, we adapted to technical refinements and steps descried before. In the present study, laparoscopic approach was conducted for all RIH after either previous open or laparoscopic repair as recommended by others [5, 25] and during laparoscopy, we could reach to the under laying causes of recurrence in all cases [Table 3].

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Conclusion: laparoscopic repair is the preferred operation for recurrent childhood inguinal hernia after open operation. With refinements in the technique of laparoscopic hernia repair, recurrence can be prevented even in this group of patients. Our early results suggest

open repair in childhood hernia recurrence developed after open or laparoscopic

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to

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that laparoscopic surgery is a feasible, safe technique and might be a promising alternative

surgery. The retrospective design and the relatively short period of follow up represent limitations of this study. It is necessary to confirm results with bigger cohort

and longer

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some

follow-up. However, the results of our study can give some ideas for

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further studies.

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Figure 1

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Figure 2

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Figure 3

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Figure 4

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Figure 5

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Figure 6

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Table 1: Demographic data of the studied group: No. of patients

%

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Demographic data

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Sex 34 4

89.5 % 10.5 %

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34.21 %

12

31.58%

7

18.42 %

6

15.79%

18

47.36 %

3

7.89%

Rec. Left Inguinal Hernia [after open herniotomy]

10

26.31%

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Male Female

Rec. Left Inguinal Hernia [after laparoscopic repair]

3

7.89%

Rec. Bilateral Inguinal Hernia [after open herniotomy]

4

10.52%

Age per months 1-12

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13-24 25-36

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>36

Presentations

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Rec. Right Inguinal Hernia [after open herniotomy]

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Rec. Right Inguinal Hernia [after laparoscopic repair]

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No.

Percentage

open laparoscopic

25

59.52 %

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2

Pediatric Surgeon 2

4.76 %

-



Junior

15

35.71 %

12

2

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Senior

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

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General Surgeon

Type hernia repair

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Surgeon in charge No. of hernial defects

3

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Cause of recurrence

No of hernial defects

Previous hernia technique

No.

Open

Percentage

Laparoscopic

15

35.71 %

15

-

Low ligations of hernia sac

14

33.33 %

14

-

Missed direct inguinal hernias

4

9.52%

Loosening of the previous suture at IIR

2

4.76%

-

2

Missed femoral hernia

2

4.76%

2

-

Skip area medial to the previous suture at IIR

5

11.90 %

-

5

4

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Table 3: Shows the underlying causes of hernia recurrence:

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Missed hernia sac