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Early experience with needleoscopic inguinal herniorrhaphy in children
Early Experience With Needleoscopic Inguinal Herniorrhaphy in Children By Rajeev Prasad, Harold N. Lovvorn III, George M. Wadie, and Thom E Lobe Memphis, Tennessee
Background/Purpose: To validate its safety and efficacy, the authors evaluated their early experience with needleoscopic inguinal herniorrhaphy in children. Methods: Twelve consecutive children, older than 6 months, with unilateral (n ⫽ 8) or bilateral (n ⫽ 4) inguinal hernias underwent a needleoscopic herniorrhaphy. A 1.7-mm needle laparoscope was introduced through the umbilicus, and a grasper placed laterally was used for traction. A curved stainless steel awl introduced percutaneously anterolateral to the internal ring was used to pass a ligature circumferentially to complete an extraperitoneal high ligation of the sac (without handling the vas deferens and spermatic vessels in males). Four of 12 patients underwent their repair combined with other procedures. Children who underwent herniorrhaphy only were allowed immediate return to unrestricted activity. Data recorded with IRB approval included operating
L
APAROSCOPIC HERNIORRHAPHY in children is relatively new. The initial use of laparoscopy in the pediatric hernia patient was to examine the contralateral groin, either through a remotely placed port or the opened processus vaginalis, during open, unilateral hernia surgery.1 However, more recently there have been numerous reports describing various laparoscopic techniques for pediatric inguinal hernia repair. Reported advantages include excellent visual exposure, minimal dissection (and thus less trauma to the inguinal canal and spermatic cord), comparable recurrence rates, and an improved cosmetic result compared with the traditional open approach.2,3 The reported excellent outcome in large series has confirmed that laparoscopic herniorrhaphy in children is an acceptable alternative to the traditional open approach. The purpose of the current study was to evaluate the safety and efficacy of our technique of pediatric needleoscopic inguinal herniorrhaphy. We
time, postoperative discomfort, recurrence, and complications. Results: For herniorrhaphy only the mean operating time was 23 minutes (unilateral, n ⫽ 5) or 46 minutes (bilateral, n ⫽ 3). All were able to return to immediate unrestricted activity. None required any analgesics other than acetaminophen. There were no recurrences or complications. Conclusions: Needleoscopic inguinal herniorrhaphy in children is safe and effective. This technique potentially offers less risk of injury to cord structures with a superior cosmetic result. J Pediatr Surg 38:1055-1058. © 2003 Elsevier Inc. All rights reserved. INDEX WORDS: Inguinal hernia, laparoscopic herniorrhaphy, pediatric hernia.
report the results of our early experience in which unilateral or bilateral indirect inguinal hernia repair was accomplished using a 1.7-mm needle telescope and a ligature passer. MATERIALS AND METHODS
From the University of Tennessee College of Medicine, Le Bonheur Children’s Medical Center, Memphis, TN. Presented at the 33rd annual meeting of the American Pediatric Surgical Association, Phoenix, AZ May 20, 2002. Address reprint requests to Thom E Lobe, MD, University of Tennessee, Memphis, Section of Pediatric Surgery, 777 Washington Ave, Suite P-220, Memphis, TN 38105. © 2003 Elsevier Inc. All rights reserved. 0022-3468/03/3807-0014$30.00/0 doi:10.1016/S0022-3468(03)00191-X
Twelve consecutive children older than 6 months of age, seen by a single surgeon, with either unilateral (n ⫽ 8) or bilateral (n ⫽ 4) inguinal hernias were treated surgically with a modification of the Yeung laparoscopic herniorrhaphy.4 Children younger than 6 months of age were excluded because of the training requirement of open hernia repair in infants for pediatric surgical residents. Notably, 4 of the 12 patients underwent hernia repair in combination with other procedures (contralateral hydrocelectomy, open umblilical hernia repair, laparoscopic gastrostomy tube placement, or excision of a dermoid cyst). A 1.7-mm needle scope is introduced through a 2-mm port in or near the umbilicus, and the abdomen is insufflated with carbon dioxide gas to 12 mm Hg. A 1.7-mm laparoscopic grasper, placed laterally through a second 2-mm port, is used to manipulate the peritoneum near the hernia defect. A curved stainless steel awl (Fig 1), introduced through a stab incision anterolateral to the internal ring (at approximately 30° lateral to the direct anterior approach) (Fig 2), is used to place a single 2-0, braided, nonabsorbable ligature circumferentially at the neck of the hernia sac as follows. The ligature is threaded through a hole in the end of the awl. The awl, with the ligature in place, is passed through the stab incision and the musculature to the level of the peritoneum. Using the grasper for traction, the awl and ligature are passed around the lateral aspect of the hernia sac at the level of the internal ring (remaining extraperitoneal until half of the sac has been surrounded). The peritoneum is pierced with the awl (Fig 3), and while the end of the ligature is secured with the grasper, the awl is withdrawn. The empty awl then is inserted into the stab wound and passed around the medial
Journal of Pediatric Surgery, Vol 38, No 7 (July), 2003: pp 1055-1058
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PRASAD ET AL
Fig 1. Photograph of the curved stainless steel awl used for placement of the ligature.
half of the neck of the hernia defect. The peritoneum is re-entered where the ligature enters the peritoneal cavity. The vas deferens and spermatic vessels are seen easily during ligature placement in boys, and it is relatively straightforward to find the plane between these structures and the hernia sac, ensuring that they are excluded from the repair (Fig 4). The intraperitoneal end of the ligature is passed through the hole in the awl, which is again withdrawn. The ligature is tied extracorporeally, completing an extraperitoneal high ligation of the sac (Fig 5). After cutting the excess ligature, the knot retracts subcutaneously. The instruments are removed, and the abdomen is allowed to desufflate. Steristrips are all that are required for skin closure. With IRB approval the operating time for each procedure was recorded. Those children who underwent only hernia repair were allowed immediate return to normal activities without restrictions. All patients or their parents were queried at the first postoperative visit regarding the extent of postoperative pain, the level of activity, and the need for analgesics. Any recurrence or complication was noted.
RESULTS
Follow-up thus far has been from 8 to 13 months (mean, 10.8 months). The mean operating time in this initial group of patients, excluding the 4 patients who underwent combined procedures, was 23 minutes for
Fig 2. ring.
Position and angle of the awl anterolateral to the internal
Fig 3. The awl, with the ligature looped through the eyelet, pierces the peritoneum after it is passed superficial to the lateral half of the hernia sac.
unilateral hernia repair (n ⫽ 5) and 46 minutes for bilateral repair (n ⫽ 3). These 8 children all were able to return to unrestricted activity immediately. Only minor postoperative discomfort was encountered, and no patient required any analgesic other than acetaminophen. Thus far, there have been no recurrences or complications in any of the 12 patients. DISCUSSION
The application of laparoscopy to the pediatric hernia patient has occurred slowly and in gradual steps. In 1992, Lobe and Schropp1 were the first to report their experience with laparoscopic evaluation of the contralateral groin during open unilateral inguinal herniorrhaphy. This method proved to be a simple and efficient means to detect a contralateral hernia or, conversely, to prove that none existed and thus save the patient an incision. In 1997 El-Gohary5 reported a series of 28 patients, all girls, in which herniorrhaphy was accomplished laparoscopically using one or more endoscopic loops placed at
Fig 4. Photograph shows that the vas deferens and spermatic vessels are excluded from the ligature.
NEEDLESCOPIC INGUINAL HERNIORRHAPHY
Fig 5. sac.
1057
The completed extraperitoneal high ligation of the hernia
the base of the inverted hernia sac. He reported that this was an expeditious, effective, and cosmetically superior operation. However, it was recommended that this operation not be applied in boys because it was not possible to exclude the cord structures from the endoscopic loop ligature. In 1998 Schier6 described his technique of placing 2 to 3 z-sutures laparoscopically using intracorporeal suturing and knot-tying techniques to close the neck of the hernia sac. Again, the procedure was limited to girls to avoid the risk of possible damage to the spermatic cord in boys. Montupet and Esposito7 were the first to report successful laparoscopic herniorrhaphy in boys. They specifically applied the laparoscopic approach to boys to avoid the risks of inadvertent removal of a segment of vas as well as the possible risk of testicular damage (atrophy or high position in the scrotum), that may occur with the traditional open repair. In their series, 45 boys underwent laparoscopic repair in which an intracorporeal pursestring suture was placed around the neck of the hernia sac. There were no intraoperative or postsurgical complications, but 2 patients had a recurrent hernia that required a second laparoscopic repair. Schier8 reported his further experience of laparoscopic hernia repair in 2000 and concluded that the technique was simple for the experienced laparoscopist, that cosmesis was superb, and that the procedure was safe in girls and boys. Other reports have described the utility of the laparoscopic approach for direct inguinal hernias and suspected recurrent hernias.9,10 Innovative techniques have been described recently for use in pediatric laparoscopic inguinal hernia surgery.
Endo and Ukiyama11 introduced the Endoneedle, a 19gauge hollow needle with a notched tip and pre-attached suture, designed specifically for laparoscopic extraperitoneal closure of the patent processus vaginalis. They used this instrument in 61 girls and reported no complications or recurrences. Lee and Liang2 performed microlaparoscopic high ligation in 450 patients with good results. They reported no complications of the surgery and a remarkably low recurrence rate (0.88%). Using Yeung’s technique as a guide, we used an inexpensive instrument (a stainless steel curved awl) and a 1.7-mm telescope to safely perform needleoscopic inguinal herniorrhaphy in boys and girls with good results. The technique adheres to the essential principles of hernia surgery. We reliably identify and ligate the hernia sac at the level of the internal ring, and we “divide” the hernia sac in the sense that the ligature is so tightly tied that the sac obliterates by ischemia. Additionally, there is no disruption of the tissues of the inguinal canal. In boys the spermatic vessels and vas deferens are well visualized during the circumferential passage of the ligature, ensuring that they are excluded from the repair. Thus, there is potentially less risk of injury to the cord structures. Finally, the contralateral inguinal canal is inspected easily for the presence of a hernia. An important issue to consider is the presence of a hydrocele. Others utilize the laparoscopic approach to treat hydroceles. However, we consider a hydrocele, either alone or in conjunction with an ipsilateral hernia, to be a relative contraindication to this laparoscopic approach. In our technique, we do not probe or open the distal sac, but rather we ligate it at its neck circumferentially, effectively obliterating the sac. Thus, we believe that a hydrocele is not adequately treated with this technique. Our patients have had minimal postoperative discomfort (none required a narcotic analgesic), and all resumed normal activities immediately after surgery. There is no longitudinal skin incision in the abdominal wall (only 3 to 4 stab incisions). Thus, the cosmetic result is superior, and the risk for infection is less. Finally, the complication and recurrence rates in our small series as well as in larger series reported in the literature are low. We conclude that needleoscopic inguinal herniorrhaphy in children is a safe and efficacious procedure that should be viewed as an acceptable alternative to the traditional open approach for the experienced laparoscopist.
REFERENCES 1. Lobe TE, Schropp KP: Inguinal hernias in pediatrics: Initial experience with laparoscopic inguinal exploration of the asymptomatic contralateral side. J Laparoendosc Surg 2:135-140, 1992
2. Lee Y, Liang J: Experience with 450 cases of micro-laparoscopic herniotomy in infants and children. Ped Endosurg Innov Techn 6:2528, 2002 3. Schier F, Montupet P, Esposito C: Laparoscopic inguinal herni-
1058
orrhaphy in children: A three-center experience with 933 repairs. J Pediatr Surg 37:395-397, 2002 4. Yeung CK, Tan HL, Lee KH, et al: Extraperitoneal laparoscopicguided inguinal herniotomy in infants and children. Abstracts of the 8th International Congress for Endosurgery in Children. Berlin:118, 1999 5. El-Gohary MA: Laparoscopic ligation of inguinal hernia in girls. Ped Endosurg Innov Techn 1:185-188, 1997 6. Schier F: Laparoscopic herniorrhaphy in girls. J Pediatr Surg 33:1495-1497, 1998 7. Montupet P, Esposito C: Laparoscopic treatment of congenital inguinal hernia in children. J Pediatr Surg 34:420-423, 1999
PRASAD ET AL
8. Schier F: Laparoscopic surgery of inguinal hernias in children— Initial experience. J Pediatr Surg 35:1331-1335, 2000 9. Schier F: Direct inguinal hernias in children: Laparoscopic aspects. Pediatr Surg Int 16:562-564, 2000 10. Perlstein J, Du Bois JJ: The role of laparoscopy in the management of suspected recurrent pediatric hernias. J Pediatr Surg 35:12051208, 2000 11. Endo M, Ukiyama E: Laparoscopic closure of patent processus vaginalis in girl with inguinal hernia using specially devised suture needle. Pediatr Endosurg Innov Tech 5:187-191, 2001
Background/Purpose: To validate its safety and efficacy, the authors evaluated their early experience with needleoscopic inguinal herniorrhaphy in children. Methods: Twelve consecutive children, older than 6 months, with unilateral (n ⫽ 8) or bilateral (n ⫽ 4) inguinal hernias underwent a needleoscopic herniorrhaphy. A 1.7-mm needle laparoscope was introduced through the umbilicus, and a grasper placed laterally was used for traction. A curved stainless steel awl introduced percutaneously anterolateral to the internal ring was used to pass a ligature circumferentially to complete an extraperitoneal high ligation of the sac (without handling the vas deferens and spermatic vessels in males). Four of 12 patients underwent their repair combined with other procedures. Children who underwent herniorrhaphy only were allowed immediate return to unrestricted activity. Data recorded with IRB approval included operating
L
APAROSCOPIC HERNIORRHAPHY in children is relatively new. The initial use of laparoscopy in the pediatric hernia patient was to examine the contralateral groin, either through a remotely placed port or the opened processus vaginalis, during open, unilateral hernia surgery.1 However, more recently there have been numerous reports describing various laparoscopic techniques for pediatric inguinal hernia repair. Reported advantages include excellent visual exposure, minimal dissection (and thus less trauma to the inguinal canal and spermatic cord), comparable recurrence rates, and an improved cosmetic result compared with the traditional open approach.2,3 The reported excellent outcome in large series has confirmed that laparoscopic herniorrhaphy in children is an acceptable alternative to the traditional open approach. The purpose of the current study was to evaluate the safety and efficacy of our technique of pediatric needleoscopic inguinal herniorrhaphy. We
time, postoperative discomfort, recurrence, and complications. Results: For herniorrhaphy only the mean operating time was 23 minutes (unilateral, n ⫽ 5) or 46 minutes (bilateral, n ⫽ 3). All were able to return to immediate unrestricted activity. None required any analgesics other than acetaminophen. There were no recurrences or complications. Conclusions: Needleoscopic inguinal herniorrhaphy in children is safe and effective. This technique potentially offers less risk of injury to cord structures with a superior cosmetic result. J Pediatr Surg 38:1055-1058. © 2003 Elsevier Inc. All rights reserved. INDEX WORDS: Inguinal hernia, laparoscopic herniorrhaphy, pediatric hernia.
report the results of our early experience in which unilateral or bilateral indirect inguinal hernia repair was accomplished using a 1.7-mm needle telescope and a ligature passer. MATERIALS AND METHODS
From the University of Tennessee College of Medicine, Le Bonheur Children’s Medical Center, Memphis, TN. Presented at the 33rd annual meeting of the American Pediatric Surgical Association, Phoenix, AZ May 20, 2002. Address reprint requests to Thom E Lobe, MD, University of Tennessee, Memphis, Section of Pediatric Surgery, 777 Washington Ave, Suite P-220, Memphis, TN 38105. © 2003 Elsevier Inc. All rights reserved. 0022-3468/03/3807-0014$30.00/0 doi:10.1016/S0022-3468(03)00191-X
Twelve consecutive children older than 6 months of age, seen by a single surgeon, with either unilateral (n ⫽ 8) or bilateral (n ⫽ 4) inguinal hernias were treated surgically with a modification of the Yeung laparoscopic herniorrhaphy.4 Children younger than 6 months of age were excluded because of the training requirement of open hernia repair in infants for pediatric surgical residents. Notably, 4 of the 12 patients underwent hernia repair in combination with other procedures (contralateral hydrocelectomy, open umblilical hernia repair, laparoscopic gastrostomy tube placement, or excision of a dermoid cyst). A 1.7-mm needle scope is introduced through a 2-mm port in or near the umbilicus, and the abdomen is insufflated with carbon dioxide gas to 12 mm Hg. A 1.7-mm laparoscopic grasper, placed laterally through a second 2-mm port, is used to manipulate the peritoneum near the hernia defect. A curved stainless steel awl (Fig 1), introduced through a stab incision anterolateral to the internal ring (at approximately 30° lateral to the direct anterior approach) (Fig 2), is used to place a single 2-0, braided, nonabsorbable ligature circumferentially at the neck of the hernia sac as follows. The ligature is threaded through a hole in the end of the awl. The awl, with the ligature in place, is passed through the stab incision and the musculature to the level of the peritoneum. Using the grasper for traction, the awl and ligature are passed around the lateral aspect of the hernia sac at the level of the internal ring (remaining extraperitoneal until half of the sac has been surrounded). The peritoneum is pierced with the awl (Fig 3), and while the end of the ligature is secured with the grasper, the awl is withdrawn. The empty awl then is inserted into the stab wound and passed around the medial
Journal of Pediatric Surgery, Vol 38, No 7 (July), 2003: pp 1055-1058
1055
1056
PRASAD ET AL
Fig 1. Photograph of the curved stainless steel awl used for placement of the ligature.
half of the neck of the hernia defect. The peritoneum is re-entered where the ligature enters the peritoneal cavity. The vas deferens and spermatic vessels are seen easily during ligature placement in boys, and it is relatively straightforward to find the plane between these structures and the hernia sac, ensuring that they are excluded from the repair (Fig 4). The intraperitoneal end of the ligature is passed through the hole in the awl, which is again withdrawn. The ligature is tied extracorporeally, completing an extraperitoneal high ligation of the sac (Fig 5). After cutting the excess ligature, the knot retracts subcutaneously. The instruments are removed, and the abdomen is allowed to desufflate. Steristrips are all that are required for skin closure. With IRB approval the operating time for each procedure was recorded. Those children who underwent only hernia repair were allowed immediate return to normal activities without restrictions. All patients or their parents were queried at the first postoperative visit regarding the extent of postoperative pain, the level of activity, and the need for analgesics. Any recurrence or complication was noted.
RESULTS
Follow-up thus far has been from 8 to 13 months (mean, 10.8 months). The mean operating time in this initial group of patients, excluding the 4 patients who underwent combined procedures, was 23 minutes for
Fig 2. ring.
Position and angle of the awl anterolateral to the internal
Fig 3. The awl, with the ligature looped through the eyelet, pierces the peritoneum after it is passed superficial to the lateral half of the hernia sac.
unilateral hernia repair (n ⫽ 5) and 46 minutes for bilateral repair (n ⫽ 3). These 8 children all were able to return to unrestricted activity immediately. Only minor postoperative discomfort was encountered, and no patient required any analgesic other than acetaminophen. Thus far, there have been no recurrences or complications in any of the 12 patients. DISCUSSION
The application of laparoscopy to the pediatric hernia patient has occurred slowly and in gradual steps. In 1992, Lobe and Schropp1 were the first to report their experience with laparoscopic evaluation of the contralateral groin during open unilateral inguinal herniorrhaphy. This method proved to be a simple and efficient means to detect a contralateral hernia or, conversely, to prove that none existed and thus save the patient an incision. In 1997 El-Gohary5 reported a series of 28 patients, all girls, in which herniorrhaphy was accomplished laparoscopically using one or more endoscopic loops placed at
Fig 4. Photograph shows that the vas deferens and spermatic vessels are excluded from the ligature.
NEEDLESCOPIC INGUINAL HERNIORRHAPHY
Fig 5. sac.
1057
The completed extraperitoneal high ligation of the hernia
the base of the inverted hernia sac. He reported that this was an expeditious, effective, and cosmetically superior operation. However, it was recommended that this operation not be applied in boys because it was not possible to exclude the cord structures from the endoscopic loop ligature. In 1998 Schier6 described his technique of placing 2 to 3 z-sutures laparoscopically using intracorporeal suturing and knot-tying techniques to close the neck of the hernia sac. Again, the procedure was limited to girls to avoid the risk of possible damage to the spermatic cord in boys. Montupet and Esposito7 were the first to report successful laparoscopic herniorrhaphy in boys. They specifically applied the laparoscopic approach to boys to avoid the risks of inadvertent removal of a segment of vas as well as the possible risk of testicular damage (atrophy or high position in the scrotum), that may occur with the traditional open repair. In their series, 45 boys underwent laparoscopic repair in which an intracorporeal pursestring suture was placed around the neck of the hernia sac. There were no intraoperative or postsurgical complications, but 2 patients had a recurrent hernia that required a second laparoscopic repair. Schier8 reported his further experience of laparoscopic hernia repair in 2000 and concluded that the technique was simple for the experienced laparoscopist, that cosmesis was superb, and that the procedure was safe in girls and boys. Other reports have described the utility of the laparoscopic approach for direct inguinal hernias and suspected recurrent hernias.9,10 Innovative techniques have been described recently for use in pediatric laparoscopic inguinal hernia surgery.
Endo and Ukiyama11 introduced the Endoneedle, a 19gauge hollow needle with a notched tip and pre-attached suture, designed specifically for laparoscopic extraperitoneal closure of the patent processus vaginalis. They used this instrument in 61 girls and reported no complications or recurrences. Lee and Liang2 performed microlaparoscopic high ligation in 450 patients with good results. They reported no complications of the surgery and a remarkably low recurrence rate (0.88%). Using Yeung’s technique as a guide, we used an inexpensive instrument (a stainless steel curved awl) and a 1.7-mm telescope to safely perform needleoscopic inguinal herniorrhaphy in boys and girls with good results. The technique adheres to the essential principles of hernia surgery. We reliably identify and ligate the hernia sac at the level of the internal ring, and we “divide” the hernia sac in the sense that the ligature is so tightly tied that the sac obliterates by ischemia. Additionally, there is no disruption of the tissues of the inguinal canal. In boys the spermatic vessels and vas deferens are well visualized during the circumferential passage of the ligature, ensuring that they are excluded from the repair. Thus, there is potentially less risk of injury to the cord structures. Finally, the contralateral inguinal canal is inspected easily for the presence of a hernia. An important issue to consider is the presence of a hydrocele. Others utilize the laparoscopic approach to treat hydroceles. However, we consider a hydrocele, either alone or in conjunction with an ipsilateral hernia, to be a relative contraindication to this laparoscopic approach. In our technique, we do not probe or open the distal sac, but rather we ligate it at its neck circumferentially, effectively obliterating the sac. Thus, we believe that a hydrocele is not adequately treated with this technique. Our patients have had minimal postoperative discomfort (none required a narcotic analgesic), and all resumed normal activities immediately after surgery. There is no longitudinal skin incision in the abdominal wall (only 3 to 4 stab incisions). Thus, the cosmetic result is superior, and the risk for infection is less. Finally, the complication and recurrence rates in our small series as well as in larger series reported in the literature are low. We conclude that needleoscopic inguinal herniorrhaphy in children is a safe and efficacious procedure that should be viewed as an acceptable alternative to the traditional open approach for the experienced laparoscopist.
REFERENCES 1. Lobe TE, Schropp KP: Inguinal hernias in pediatrics: Initial experience with laparoscopic inguinal exploration of the asymptomatic contralateral side. J Laparoendosc Surg 2:135-140, 1992
2. Lee Y, Liang J: Experience with 450 cases of micro-laparoscopic herniotomy in infants and children. Ped Endosurg Innov Techn 6:2528, 2002 3. Schier F, Montupet P, Esposito C: Laparoscopic inguinal herni-
1058
orrhaphy in children: A three-center experience with 933 repairs. J Pediatr Surg 37:395-397, 2002 4. Yeung CK, Tan HL, Lee KH, et al: Extraperitoneal laparoscopicguided inguinal herniotomy in infants and children. Abstracts of the 8th International Congress for Endosurgery in Children. Berlin:118, 1999 5. El-Gohary MA: Laparoscopic ligation of inguinal hernia in girls. Ped Endosurg Innov Techn 1:185-188, 1997 6. Schier F: Laparoscopic herniorrhaphy in girls. J Pediatr Surg 33:1495-1497, 1998 7. Montupet P, Esposito C: Laparoscopic treatment of congenital inguinal hernia in children. J Pediatr Surg 34:420-423, 1999
PRASAD ET AL
8. Schier F: Laparoscopic surgery of inguinal hernias in children— Initial experience. J Pediatr Surg 35:1331-1335, 2000 9. Schier F: Direct inguinal hernias in children: Laparoscopic aspects. Pediatr Surg Int 16:562-564, 2000 10. Perlstein J, Du Bois JJ: The role of laparoscopy in the management of suspected recurrent pediatric hernias. J Pediatr Surg 35:12051208, 2000 11. Endo M, Ukiyama E: Laparoscopic closure of patent processus vaginalis in girl with inguinal hernia using specially devised suture needle. Pediatr Endosurg Innov Tech 5:187-191, 2001