Is two-port laparoendoscopic single-site surgery (T-LESS) feasible for pediatric hydroceles? Single-center experience with the initial 59 cases

Accepted Manuscript Is two-port laparoendoscopic single-site surgery (T-LESS) feasible for pediatric hydroceles? Single-center experience with the initial 59 cases Furan Wang, Tiejun Shou, Hongji Zhong PII:

S1477-5131(17)30406-0

DOI:

10.1016/j.jpurol.2017.09.016

Reference:

JPUROL 2664

To appear in:

Journal of Pediatric Urology

Received Date: 1 March 2017 Accepted Date: 12 September 2017

Please cite this article as: Wang F, Shou T, Zhong H, Is two-port laparoendoscopic single-site surgery (T-LESS) feasible for pediatric hydroceles? Single-center experience with the initial 59 cases, Journal of Pediatric Urology (2017), doi: 10.1016/j.jpurol.2017.09.016. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Is two-port laparoendoscopic single-site surgery (T-LESS) feasible for pediatric hydroceles? Single-center experience with the initial 59 cases Furan Wanga,*, Tiejun Shoub, and Hongji Zhonga a

Department of Pediatric Urology, Ningbo Women & Children’s Hospital, Ningbo,

b

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Zhejiang, China Department of Pediatric Surgery, Ningbo Women & Children’s Hospital, Ningbo,

Zhejiang, China

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* Corresponding author. Department of Pediatric Urology, Ningbo Women & Children’s Hospital, No. 266 Cishuixi street, Cicheng New Town, Jiangbei District,

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Ningbo, Zhejiang, China, 315031. E-mail address: [email protected]

Summary Introduction: Although T-LESS is increasingly being used to treat pediatric inguinal hernia, there is no study regarding T-LESS for pediatric hydrocele.

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Objective: To further evaluate the feasibility of T-LESS and present our single-center experience for repair of pediatric hydroceles. Study design: From January 2016 to July 2016, all boys undergoing T-LESS for

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hydrocele in our institute were retrospectively reviewed. A laparoscope and a needle-holding forceps were introduced at umbilicus. A round needle with silk suture was stabbed through the abdominal wall. The peritoneum around the internal ring was

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sutured continuously in a clockwise direction. After a complete purse-string suture, a triple knot was performed by using a single-instrument tie technique. The contralateral patent processus vaginalis (PPV) was repaired simultaneously if present. Results: Overall, 59 boys with hydrocele were included (22 on the left side, 32 on the right side, and 5 bilaterally) (Table). During the procedure, all hydroceles were observed with a PPV but the fluid needed to be aspired in 39 boys. A contralateral PPV was present in 24 boys with unilateral hydrocele, and finally 88 repairs were performed. Mean operative time was 18.3 minutes for unilateral repair and 27.5 minutes for bilateral repair, respectively. All procedures were uneventful besides a 1

ACCEPTED MANUSCRIPT minor injury to the inferior epigastric vessels. After a mean follow-up of 10.7 months, neither recurrence nor other postoperative complication was observed. There were no visible scars on the abdominal wall. Discussion: Compared with open repair of pediatric inguinal hernia and hydrocele,

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laparoscopic surgery had several advantages, such as exploration of contralateral PPV, identification of rare hernias, diminished postoperative pain, improved cosmesis, faster recovery, and fewer complications. Differing from the laparoscopic retroperitoneal approach, T-LESS included no subcutaneous tissue in the ligature, and

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its knot was completely in the peritoneal cavity which could radically prevent the severe pain and suture granuloma in the ligated region. Furthermore, the skin

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incisions after T-LESS were hidden in umbilicus, which could achieve an excellent cosmetic result. By performing T-LESS for pediatric hydroceles, the current study showed very satisfactory results, such as high success rate, minor complication, and excellent cosmesis. However, because of the difficult learning curve of T-LESS, some technical details (e.g. avoiding injury to the spermatic cord, completely suturing the

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peritoneal folds and reducing disturbance between the instruments) still need to be improved in the future.

Conclusion: T-LESS appears to be a safe and effective method for repair of pediatric

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hydroceles. KEYWORDS Children;

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Hydrocele;

Laparoscopy; T-LESS

Table General characteristics and surgical outcomes of the patients who underwent T-LESS for pediatric hydrocele Patients undergoing T-LESS for pediatric hydrocele 3.5 years (2–8 years) 32/22/5 24 (44.4)

Age, mean (range) Laterality of hydroceles, right/left/bilateral Number of CPPVs (%) 2

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Severe pain Subcutaneous granuloma Recurrence Testicular atrophy Visible skin scar

39 (66.1) 18.3 (12–25) minutes /27.5 (20–35) minutes 0 1 (1.1) 0 0 0 0 0

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Introduction

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Number of cases with aspiration Unilateral/bilateral operative time, mean (range) Number of complications (%) Conversion Adjacent injury

Pediatric inguinal hernia and hydrocele are common diseases worldwide, of which a

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patent processus vaginalis (PPV) is the main cause [1]. If the PPV is large enough to pass the bowel, omentum, and other intraperitoneal contents (fallopian tube, ovaries, etc.), the condition is referred to as a hernia; if the PPV is small to only allow the transfer of intraperitoneal fluid, the condition is referred to as a hydrocele [2]. Repair of inguinal hernia and hydrocele is preferred to be performed after a certain age,

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because some PPVs can spontaneously occlude and hydrocele can resolve during the first few months of life [3].

For many decades, open surgery has been widely used in inguinal hernia and

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hydrocele repair in children, which typically consists of the ligation of PPV via an inguinal incision [1,4]. Compared with open procedure, laparoscopic repair has clear

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advantages, such as better cosmesis, minimal invasiveness, and simultaneous evaluation and closure of possible contralateral PPVs (CPPVs) [5,6]. Although laparoscopic herniorrhaphy has been increasingly used to manage pediatric inguinal hernia [7–9], there are very limited studies regarding laparoscopic repair of pediatric hydrocele [10–13]. Two-port laparoendoscopic single-site surgery (T-LESS) is a recently developed minimally invasive surgery for repair of inguinal hernia in children, which leaves no obvious skin scars on the abdominal wall [14]. Although T-LESS has gained excellent cosmetic and minimally invasive results, it is still uncertain whether it can be safely

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ACCEPTED MANUSCRIPT and effectively performed for pediatric hydrocele. To further evaluate the feasibility of T-LESS, we present our single-center experience for treatment of pediatric hydroceles. Materials and methods

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A retrospective review of the boys who underwent T-LESS was conducted at our hospital from January 2016 to July 2016. Patients were included if they met all of the following criteria: (1) communicating hydrocele; (2) age >2 years; (3) duration of disease >1 month; (4) hydrocele with a high tension, volume >5 mL, or ipsilateral

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dysplasia testis; (5) no coexisting with ipsilateral abdomino-scrotal hydrocele, undescended testis, or acute scrotum. Data were collected from medical records and

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personal interviews, including age of patients, laterality of hydrocele, operative time, presence of CPPVs, length of hospital stay, and postoperative complications. Operative time was defined as the time from first incision to wound dressings applied. A CPPV was considered if one of the following conditions was observed [15]: (1) an open tunnel into the contralateral inguinal canal; (2) swelling or palpable crepitus

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in the contralateral groin or scrotum; (3) bubbles or fluid expressed by palpation over the contralateral inguinal region or scrotum. Given that approximately 10.5% of CPPVs develop an inguinal hernia later [16], we informed the patient guardians about

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the conditions, and the pros and cons of surgical operation. We consulted conventionally with the guardians about the treatment decision, and all chose simultaneous repair of the CPPV.

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Surgical procedure

All the procedures were performed by a single surgeon. After general anesthesia, the patient was placed in the Trendelenburg position. The laparoscopic monitor was placed at the patient’s feet. The surgeon stood on the patient’s left side and the assistant on the right. One or two incisions were made at umbilicus and a pneumoperitoneum of CO2 was established (10–12 mmHg). If one incision was applied, it was 1-cm long and placed with two corresponding trocars; if two incisions, they were 5-mm long and placed with a trocar each. Because of no access to the 3-mm instruments, we had to use the 5 mm for all the procedures. A 30° laparoscope 4

ACCEPTED MANUSCRIPT was then introduced via the right port and a needle-holding forceps via the left one, despite the laterality of hydrocele. Because of the setting of the two ports, it is likely that any disturbance between the instruments and exposure of the surgical field was limited. However, to overcome any such limitations, observational direction of the

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laparoscopic lens should be adjusted constantly during such operations. For example, when looking at the back of the internal ring, the lens should be adjusted to look from top to bottom; when looking at the left, the lens should be from right to left, and so on.

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Under direct vision, a medical suture needle (○1/2, 7×17, Fig. 1) with a 2-0 silk suture was stabbed into the peritoneal cavity through the abdominal wall, leaving the

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suture end (Suture A) outside the peritoneal cavity (Fig. 2). Subsequently, the needle was used to suture the peritoneum around the internal ring continuously in a clockwise direction (Fig. 3). Great care should be exercised to avoid injury to the vas deferens and vessels around the ring, and leave no peritoneal gaps. After a complete purse-string suture, the needle was retrieved through the abdominal wall. After the

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needle was cut externally, the suture end (Suture B) was re-pulled into the abdomen. Before closing the internal ring, the scrotum and groin was squeezed to expel the fluid into the peritoneal cavity. The residual fluid could be eliminated by aspiration using a

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syringe. Finally, the purse-string suture was tied intracorporeally with a triple knot using a single-instrument tie technique. The technique was described as follows: first, using a grasping forceps to loop Suture A in the peritoneal cavity and then pull Suture

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B out of the suture loop; next, holding Suture A externally by hand to keep tension and pulling Suture B intraperitoneally by forceps to make a tight knot (Fig. 4) [14]. The CPPV was simultaneously repaired by the same technique if present at exploration. The umbilical incisions were sutured subcutaneously (Fig. 5) and covered with a sterilized dressing. Postoperative management In general, children were allowed to drink a little water at the 3rd hour after surgery and eat a liquid diet at the 6th hour postoperatively. If children felt obvious dizziness, nausea or vomiting, the time to drink and eat would be delayed accordingly. Patients 5

ACCEPTED MANUSCRIPT were discharged when they did not complain of obvious discomfort. All received two regular follow-up visits at the 7th day and 6th month after discharge. Thereafter, patients no longer had regular follow-ups, but they could return to our clinics for any associated discomfort or abnormity. Descriptive statistics were reported in terms of

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mean (range) for all continuous variables using Stata 12.0 (Stata Corporation, USA). Ethical approval

This study was approved by the institutional review board (IRB) of our hospital. All the families of identified patients provided a written consent to participate in this

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study and the content was recorded in the medical chart. The IRB also approved the consent procedures presented in this study.

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Results

During the past 7 months, 59 boys with communicating hydrocele were treated with T-LESS in our department. The mean age was 3.5 years (range 2-12 years). The hydrocele was right-sided in 54.2% (32/59), left-sided in 37.3% (22/59), and bilateral in 8.5% (5/59) of the patients, respectively.

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During the procedure, all hydroceles were observed with a PPV. However, 39 (66.1%) boys needed an aspiration because the fluid in the scrotum and groin could not be completely squeezed into the peritoneal cavity. A CPPV was present in 24

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(44.4%) boys with unilateral hydrocele, and finally 88 repairs were performed with T-LESS. All operations were uneventful without conversion to other procedures. One accident injury occurred to the inferior epigastric vessels. In this case, a

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retroperitoneal hematoma developed immediately while the hemorrhage stopped after the purse-string suture was tied. The learning curve was described as a graph of operative time versus the number

of cases (Fig. 6). The mean operative time was 18.3 minutes (range 12-25 minutes) for unilateral repair and 27.5 minutes (range 20-35 minutes) for bilateral repair, respectively. Overall, the operative time declined with the increasing case numbers, and trended to be stable after approximately 31 cases (including 18 unilateral repairs and 13 bilateral repairs) were done. All patients were discharged at the postoperative 1st or 2nd day. After a mean 6

ACCEPTED MANUSCRIPT follow-up of 10.7 months (range 7-14 months), neither recurrence nor other postoperative complication was observed. There were no visible scars on the abdominal wall except for those hidden in the umbilicus, and all parents were very satisfied with the cosmetic results.

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Discussion Pediatric hydrocele and inguinal hernia usually have similar causes, being associated with PPVs [1,4]. Therefore, the principle for their surgical correction is also similar, consisting of high ligation of the processus vaginalis and hernia sac [1]. Inguinal

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hernia and hydrocele in children can be treated through either an open or laparoscopic technique [1,4]. Open inguinal repair has been regarded as the standard approach for

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many years [17], while laparoscopic repair was introduced as an alternative to open surgery. Compared with the traditional open technique, laparoscopic inguinal hernia repair has the advantages of exploration of CPPV, identification of rare hernias, diminished postoperative pain, improved cosmesis, faster recovery, and fewer complications [5,6]. Although the hospitalization cost of laparoscopic repair is higher

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than that of open surgery, the decreased cost of treatment of complications and contralateral metachronous hernia/hydrocele, derived from a CPPV, should not be disregarded. Unfortunately, this cost cannot be qualified accurately at present.

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Therefore, controversy remains on the cost-effectiveness of laparoscopic repair versus open technique.

Laparoscopic repair of pediatric inguinal hernia and hydrocele can be performed

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either transperitoneally or via a retroperitoneal approach (using hernia needles) with transperitoneal visualization. Recently, the retroperitoneal route has been widely described by many authors [10–13]. Among various retroperitoneal procedures, single-site laparoscopic percutaneous extraperitoneal closure (SLPEC) is one of the most representative techniques [8]. During SLPEC, a hernia needle with a suture is inserted percutaneously into the preperitoneal space under the direct vision of laparoscope; then, the suture is introduced extraperitoneally at one side of the ring and extracted through the other side via the same skin incision; finally, the suture is tied externally to obliterate the ring [18]. The SLPEC technique can be performed easily, 7

ACCEPTED MANUSCRIPT and has gained a comparable success rate to the open technique. However, some unnecessary tissues (e.g. nerves and muscles) between the skin and the internal ring may be included in the ligature during the operation, which may cause postoperative pain and suture granuloma in the ligated region, and even recurrence from loosening

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of the knot [19,20]. T-LESS was recently developed to manage inguinal hernia in pediatrics, which represents a completely transperitoneal approach [14,21]. Different from SLPEC, T-LESS does not include subcutaneous tissues in the ligature and its knot is in the

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peritoneal cavity, which could help to radically prevent the severe pain and suture granuloma. Furthermore, the cosmesis is excellent for T-LESS because the incisions

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are completely hidden in the umbilicus, although the learning curve is difficult. However, whether T-LESS can be used safely and effectively to repair pediatric hydrocele is still uncertain. In this report, we performed T-LESS for 59 boys with communicating hydrocele. Our operative outcomes were very satisfactory except for a minor vascular injury, without conversions, postoperative complications, and visible

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scars on the abdominal wall. Certainly, it should be noted that the present study had the limitations such as short study period and limited follow-up, which might cause limited case numbers and underestimation of postoperative complications.

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The present study reported excellent surgical results, which were probably associated with the following surgical aspects. First, the peri-orificial peritoneum at the level of the internal ring was ligated with an intact purse-string suture. Differing

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from other abdominal contents, the fluid could go through a tiny passage and cause hydrocele recurrence. Bearing this in mind, the needle-in point of the next suturing must be close to the needle-out point of previous suturing so as to leave no significant peritoneal gaps. Next, the ligature of the purse-string suture included as few unnecessary tissues other than peritoneum as possible. The excessive tissues in the ligature might lead to a loose knot during the operation or later loosening of the knot after that [19,20]. Finally, it was ensured that the procedure was performed under direct vision. The vessels around the internal ring (e.g. inferior epigastric vessels, spermatic vessels, and external iliac vessels) might be unexpectedly injured by the 8

ACCEPTED MANUSCRIPT sharp needlepoint if the surgical field cannot be seen clearly. The learning curve of T-LESS is difficult and awkward, but several surgical skills can facilitate the operation to some extent and greatly save operative time. First, the direction of the needle can be quickly adjusted by pushing against the peritoneum [22].

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Second, the peritoneum around the internal ring can be separated from the spermatic cord and vessels without injury by hydrodissection [23]. Third, the peritoneal folds can be flattened by pulling the suture end outside. However, it is still a challenge for those with large wrinkles without the aid of additional forceps. Fourth, an

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intraperitoneal triple knot can be performed efficiently using a single-instrument tie technique [14], although there is another effective method [24]. Fifth, a 30°

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laparoscopic lens or a flexible forceps can be used to increase the angle of the instruments and reduce the instrumental disturbance.

In conclusion, T-LESS appears to be a safe and effective method for the treatment of pediatric hydroceles, with excellent cosmesis and minimal invasiveness. Conflict of interest

Funding

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None.

This work was supported by Ningbo Municipal Bureau of Science and Technology

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Figure 1. The medical suture needle (○1/2, 7×17) used to suture the peri-orificial peritoneum

of the internal

inguinal

ring

in

T-LESS.

T-LESS,

two-port

laparoendoscopic single-site surgery. Figure 2. The exterior of the abdominal wall during T-LESS. Two 5-mm trocars were placed at the umbilicus. A 5-mm, 30° laparoscope was introduced through the right trocar and a 5-mm needle-holding forceps through the left one. A round needle with 11

ACCEPTED MANUSCRIPT 2-0 silk suture was stabbed into the peritoneal cavity through the anterior abdominal wall, leaving the suture end (Suture A) externally. T-LESS, two-port laparoendoscopic single-site surgery. Figure 3. The peri-orificial peritoneum around the internal ring was sutured

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continuously in a clockwise direction using a medical suture needle. Figure 4. A triple knot was performed intracorporeally using a single-instrument tie technique. (a) Using a grasping forceps to loop Suture A in the peritoneal cavity; (b) pulling Suture B out of the circle by forceps; (c) holding Suture A externally to keep

A and B were the two ends of the silk suture.

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tension and pulling Suture B intraperitoneally by forceps to make a tight knot. Sutures

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Figure 5. Appearance of the abdominal incisions after the operation.

Figure 6. The learning curve of T-LESS demonstrated a declining trend of operative time versus number of cases. Unilateral operation was done for the unilateral hydrocele without a CPPV. Bilateral operation included the operation for bilateral hydrocele and the unilateral hydrocele coexisting with a CPPV. T-LESS, two-port

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laparoendoscopic single-site surgery; CPPV, contralateral patent processus vaginalis.

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