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Transumbilical endoscopic surgery for completely enclosing inguinal hernias in children
Journal of Pediatric Surgery (2011) 46, 2417–2420
www.elsevier.com/locate/jpedsurg
Operative techniques
Transumbilical endoscopic surgery for completely enclosing inguinal hernias in children☆,☆☆ Xuewu Zhoua,⁎, Daiqiang Song a , Qifeng Miao b , Wangyong Shana a
Department of Pediatric Surgery, Taizhou Hospital, Zhejiang Province 317000, China Department of Stomatology, Taizhou Hospital, Zhejiang Province, China
b
Received 28 February 2011; revised 18 August 2011; accepted 19 August 2011
Key words: Inguinal hernia; Laparoscopy; Children; TUES
Abstract Background/Purpose: There has been great interest in natural orifice transluminal endoscopic surgery in recent years. We report another new approach for pediatric inguinal hernia repair: transumbilical endoscopic surgery (TUES). Compared with the natural orifice transluminal endoscopic surgery technique, TUES can obtain similar scarless results on the abdomen. Methods: In our hospital, 2-trocar TUES was the standard procedure used to repair pediatric inguinal hernias. Through 2 intraumbilical incisions, two 5-mm trocars were inserted into the abdomen under laparoscopic guidance. With the use of a needle-holding forceps, a round needle with 2-0 nonabsorbable suture material was introduced into the peritoneal cavity through the anterior abdominal wall near the internal inguinal ring. The orifice of the hernial sac was closed extraperitoneally with a purse-string suture around the internal inguinal ring, and intraperitoneal knot-tying was performed. Results: A total of 76 inguinal repairs were performed in 64 children (age range, 6 months to 9 years; median, 3.8 years; 44 boys, 20 girls). All operations were completed successfully by TUES, with the exception of one case of intraoperative bleeding because the inferior epigastric vein was punctured. The mean operating time was 20 minutes (range, 15-30 minutes). No postoperative bleeding, hydrocele, or scrotal edema in this group of patients was found, and there were no known cases of postoperative testicular atrophy or hypotrophy nor hernia recurrence on the symptomatic side. Conclusions: Our preliminary experience shows satisfactory outcomes with TUES for completely enclosing inguinal hernias in children. This technique appears to be safe, effective, and reliable. The cosmetic result is excellent. Published by Elsevier Inc.
In pediatric surgery, laparoscopy has been used to repair inguinal hernias. Laparoscopic herniorrhaphy has clear advantages, especially those related to the evaluation of ☆
Source of support: Departmental sources. Authors’ contributions: Study design, Zhou; Surgical treatment, Zhou, Song, Shan; Manuscript preparation, Zhou, Song, Miao; Literature search, Miao. ⁎ Corresponding author. Tel.: +86 137576 16987; fax: +86057685199876. E-mail address: [email protected] (X. Zhou). ☆☆
0022-3468/$ – see front matter. Published by Elsevier Inc. doi:10.1016/j.jpedsurg.2011.08.013
possible contralateral opening; excellent cosmesis; and minimal invasiveness in children. Among various laparoscopic techniques, laparoscopic percutaneous extraperitoneal closure (LPEC) of the hernia is a recently welldeveloped technique. The current study evaluated the safety, efficacy, and reliability of LPEC in children. However, because this is a technique of percutaneous closure of inguinal hernias, the inclusion of tissues between the skin and hernial sac, including nerves and muscles, may
2418
X. Zhou et al.
cause injury and increase the postoperative morbidity in the long term [1,2]. To preserve the advantages and overcome the limitations of LPEC, we recently developed transumbilical endoscopic surgery (TUES) to treat pediatric inguinal hernias. We herein evaluate its technical feasibility, safety, and preliminary results.
1. Patients and methods Between June 2009 and June 2010, a total of 64 consecutive children (age range, 6 months to 9 years; median, 3.8 years; 44 boys, 20 girls) with inguinal hernias (18 left sided, 46 right sided, 12 bilateral) were included in this study. The study only included cases of inguinal hernias without a coexisting hydrocele. After general anesthesia, the patients lay supine in the Trendelenburg position with a 15° tilt and legs tucked under. The television screen was placed at the patient's feet. The surgeon operated by standing on the patient's left side, and the camera assistant was on the right side. Two 5-mm curvilinear intraumbilical skin incisions were made (Fig. 1). A Veress needle was inserted into the abdomen, and pneumoperitoneum was established at 8 to 12 mm Hg. Two 5-mm trocars were inserted through the umbilicus, and a 4.5-mm 0° laparoscope and a 4-mm needle-holding forceps
Fig. 2
Two 5-mm trocars were inserted through the umbilicus.
(curved) were placed through the umbilical incision (Fig. 2). The needle-holding forceps were placed in the identical side for the convenience of suturing. Under laparoscopic monitoring, a round needle with 2-0 nonabsorbable suture material was introduced into the peritoneal cavity through the anterior abdominal wall near the internal inguinal ring. The end of the suture outside the peritoneal cavity intraperitoneal suture was 5 to 8 cm long in favor of suturing and ligation. Three to four continuous sutures that just penetrated the peritoneum (Fig. 3) were placed for closure of the internal inguinal ring (purse-string suture), counterclockwise on the left and clockwise on the right. However, great care was taken to cross over the spermatic duct and gonadal vessels to avoid causing injury. When the last suture had been placed, the intraperitoneal tie was ligated by a one-hand tie using grasping forceps to hold the shank of the suture needle and cause the needle tip to circle the other end of the suture (Fig. 4). An operating assistant drew one end of the suture outside the abdominal cavity, and a grasping forceps was used to hold the suture inside the abdominal cavity. A ligation was made when the suture was tensed in the opposite direction. Finally, the suture needle was used to circle the suture again and perform triple ligations. The needle was retrieved through the anterior abdominal wall. The same procedure was performed on the contralateral side if there was patent processus vaginalis. No stitching was required for the needle and trocar puncture wound. The umbilical wound sites were covered with sterile aseptic absorbent gauze.
2. Results
Fig. 1 Two curvilinear paraumbilical 5-mm bilateral incisions were made.
Seventy-six repairs were performed in 64 children with TUES. All patients did well during the procedure with the exception of one inferior epigastric vein that was injured; a retroperitoneal hematoma was noted during the operation, hemostasis by ligation was performed, and there was no need
Transumbilical endoscopic surgery
Fig. 3 The hernial sac orifice was closed extraperitoneally by a purse-string suture around the internal inguinal ring using a round needle.
to add an additional working port or convert the procedure to an open approach. The mean operating time was 20 minutes (range, 15-30 minutes). All patients were discharged on the first postsurgical day. The mean follow-up period was 13 months (range, 6-18 months), with no recurrence or postoperative hydroceles occurring up to the time of this writing. There was no testicular atrophy or ascent in this group.
3. Discussion Laparoscopic inguinal hernia repair in children has become an alternative to conventional open herniotomy. Among various laparoscopic techniques, LPEC of the hernia is a recently well-developed technique. However, because this is a technique of percutaneous closure of inguinal hernias, some subcutaneous tissues, including nerves and
Fig. 4 Using a grasping forceps to hold the shank of the suture needle, the needle tip circled the other end of the suture.
2419 muscles, may become injured by their inclusion in the upper portion of the circuit suturing. The technique may fail to entirely enclose the hernial defect and has the potential to lead to higher incidences of hydrocele and hernia recurrence. In the present series, no special instruments were used. This technique is simple and can be performed quickly. The TUES hernia repair operating time was comparable with the time needed for LPEC repair. It is easier to perform in females than in males; because there is no vas deferens or spermatic cord, the operator has less concern about causing injury. Postoperative hernia recurrence is a complication of inguinal hernias [3]. The main factors affecting recurrence have been recognized as (1) failure to ligate the sac high enough at the internal ring, (2) injury to the floor of the inguinal canal because of operative trauma, (3) failure to close the internal ring in females, and (4) postoperative wound infection and hematoma [4]. The laparoscopic technique has been proven to avoid all of these possible causes of recurrence [5]. The reported recurrence rates of inguinal hernia repair differ [6,7]. We did not observe any recurrence in our patients during our limited follow-up. During recent years, new interest has arisen in scarless endoscopic abdominal surgery with the development of minimally invasive surgery. The new concept known as natural orifice transluminal endoscopic surgery appeared with the publication of the first experimental report by Kalloo et al [8]; however, few clinical reports have appeared to date. The major barriers that limit its clinical application include access, closure, infection, suturing technology, and orientation [9]. Compared with the natural orifice transluminal endoscopic surgery technique, TUES is much simpler and safer. Transumbilical endoscopic surgery results in similar scarless results on the abdomen and theoretically has the same advantages of rapid recovery. Our technical experience shows that TUES can be safely performed in both males and females without injury. This treatment modality preserves the benefits of laparoscopy with avoidance of trauma to the vas deferens and spermatic vessels
Fig. 5 One-day postoperative picture of a female with bilateral inguinal hernias.
2420 and ligation of abdominal wall tissues (nerves and blood vessels) and eliminates the necessity of another assistant instrument port. In addition, our method provides excellent cosmetic results because of the presence of only two 5-mm umbilical wounds for both unilateral and bilateral hernias. The wound scar of the laparoscopic port is hidden in the umbilicus, and the puncture wounds made by the working devices are minimal. Females with bilateral hernias have particularly better cosmetic results (Fig. 5). Undoubtedly, TUES will be an option for scarless abdominal surgery [10]. Compared with the current laparoscopic extraperitoneal closure techniques, the method we have developed is easy to perform, and the instruments are readily available. These results suggest that TUES for pediatric inguinal hernia repair is safe, effective, and reliable and has a low recurrence rate. The cosmetic result is excellent. Further study and longer follow-up will be necessary to determine whether the recurrence rate is similar to that of open surgery.
References [1] Ozgediz D, Roayaie K, Lee H, et al. Subcutaneous endoscopically assisted ligation (SEAL) of the internal ring for repair of inguinal
X. Zhou et al.
[2]
[3]
[4] [5] [6]
[7]
[8]
[9]
[10]
hernias in children: report of a new technique and early results. Surg Endosc 2007;21:1327-31. Patkowski D, Czernik J, Chrzan R, et al. Percutaneous internal ring suturing: a simple minimally invasive technique for inguinal hernia repair in children. J Laparoendosc Adv Surg Tech 2006;16:513-7. Chang YT, Wang JY, Lee JY, et al. A simple single-port laparoscopicassisted technique for completely enclosing inguinal hernia in children. Am J Surg 2009;198:e13-6. Grosfeld JL, Minnick K, Shedd F, et al. Inguinal hernia in children: factors affecting recurrence in 62 cases. J Pediatr Surg 1991;26:283-7. Chan KL, Tam PK. Technical refinements in laparoscopic repair of childhood inguinal hernia. Surg Endosc 2004;18:957-60. Chan KL, Hui WC, Tam PK, et al. Prospective randomized singlecenter, single-blind comparison of laparoscopic vs open repair of pediatric inguinal hernia. Surg Endosc 2005;19:927-32. Takeharaa H, Yakabeb S, Kameoka K. Laparoscopic percutaneous extraperitoneal closure for inguinal hernia in children: clinical outcome of 972 repairs done in 3 pediatric surgical institutions. J Pediatr Surg 2006;41:1999-2003. Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc 2004;60: 114-7. Fuente SG, DeMaria EJ, Reynolds JD, et al. New development in surgery: natural orifice transluminal endoscopic surgery (NOTES). Arch Surg 2007;142:295-7. Zhu JF, Hu H, Ma YZ, et al. Transumbilical endoscopic surgery: a preliminary clinical report. Surg Endosc 2009;23:813-7.
www.elsevier.com/locate/jpedsurg
Operative techniques
Transumbilical endoscopic surgery for completely enclosing inguinal hernias in children☆,☆☆ Xuewu Zhoua,⁎, Daiqiang Song a , Qifeng Miao b , Wangyong Shana a
Department of Pediatric Surgery, Taizhou Hospital, Zhejiang Province 317000, China Department of Stomatology, Taizhou Hospital, Zhejiang Province, China
b
Received 28 February 2011; revised 18 August 2011; accepted 19 August 2011
Key words: Inguinal hernia; Laparoscopy; Children; TUES
Abstract Background/Purpose: There has been great interest in natural orifice transluminal endoscopic surgery in recent years. We report another new approach for pediatric inguinal hernia repair: transumbilical endoscopic surgery (TUES). Compared with the natural orifice transluminal endoscopic surgery technique, TUES can obtain similar scarless results on the abdomen. Methods: In our hospital, 2-trocar TUES was the standard procedure used to repair pediatric inguinal hernias. Through 2 intraumbilical incisions, two 5-mm trocars were inserted into the abdomen under laparoscopic guidance. With the use of a needle-holding forceps, a round needle with 2-0 nonabsorbable suture material was introduced into the peritoneal cavity through the anterior abdominal wall near the internal inguinal ring. The orifice of the hernial sac was closed extraperitoneally with a purse-string suture around the internal inguinal ring, and intraperitoneal knot-tying was performed. Results: A total of 76 inguinal repairs were performed in 64 children (age range, 6 months to 9 years; median, 3.8 years; 44 boys, 20 girls). All operations were completed successfully by TUES, with the exception of one case of intraoperative bleeding because the inferior epigastric vein was punctured. The mean operating time was 20 minutes (range, 15-30 minutes). No postoperative bleeding, hydrocele, or scrotal edema in this group of patients was found, and there were no known cases of postoperative testicular atrophy or hypotrophy nor hernia recurrence on the symptomatic side. Conclusions: Our preliminary experience shows satisfactory outcomes with TUES for completely enclosing inguinal hernias in children. This technique appears to be safe, effective, and reliable. The cosmetic result is excellent. Published by Elsevier Inc.
In pediatric surgery, laparoscopy has been used to repair inguinal hernias. Laparoscopic herniorrhaphy has clear advantages, especially those related to the evaluation of ☆
Source of support: Departmental sources. Authors’ contributions: Study design, Zhou; Surgical treatment, Zhou, Song, Shan; Manuscript preparation, Zhou, Song, Miao; Literature search, Miao. ⁎ Corresponding author. Tel.: +86 137576 16987; fax: +86057685199876. E-mail address: [email protected] (X. Zhou). ☆☆
0022-3468/$ – see front matter. Published by Elsevier Inc. doi:10.1016/j.jpedsurg.2011.08.013
possible contralateral opening; excellent cosmesis; and minimal invasiveness in children. Among various laparoscopic techniques, laparoscopic percutaneous extraperitoneal closure (LPEC) of the hernia is a recently welldeveloped technique. The current study evaluated the safety, efficacy, and reliability of LPEC in children. However, because this is a technique of percutaneous closure of inguinal hernias, the inclusion of tissues between the skin and hernial sac, including nerves and muscles, may
2418
X. Zhou et al.
cause injury and increase the postoperative morbidity in the long term [1,2]. To preserve the advantages and overcome the limitations of LPEC, we recently developed transumbilical endoscopic surgery (TUES) to treat pediatric inguinal hernias. We herein evaluate its technical feasibility, safety, and preliminary results.
1. Patients and methods Between June 2009 and June 2010, a total of 64 consecutive children (age range, 6 months to 9 years; median, 3.8 years; 44 boys, 20 girls) with inguinal hernias (18 left sided, 46 right sided, 12 bilateral) were included in this study. The study only included cases of inguinal hernias without a coexisting hydrocele. After general anesthesia, the patients lay supine in the Trendelenburg position with a 15° tilt and legs tucked under. The television screen was placed at the patient's feet. The surgeon operated by standing on the patient's left side, and the camera assistant was on the right side. Two 5-mm curvilinear intraumbilical skin incisions were made (Fig. 1). A Veress needle was inserted into the abdomen, and pneumoperitoneum was established at 8 to 12 mm Hg. Two 5-mm trocars were inserted through the umbilicus, and a 4.5-mm 0° laparoscope and a 4-mm needle-holding forceps
Fig. 2
Two 5-mm trocars were inserted through the umbilicus.
(curved) were placed through the umbilical incision (Fig. 2). The needle-holding forceps were placed in the identical side for the convenience of suturing. Under laparoscopic monitoring, a round needle with 2-0 nonabsorbable suture material was introduced into the peritoneal cavity through the anterior abdominal wall near the internal inguinal ring. The end of the suture outside the peritoneal cavity intraperitoneal suture was 5 to 8 cm long in favor of suturing and ligation. Three to four continuous sutures that just penetrated the peritoneum (Fig. 3) were placed for closure of the internal inguinal ring (purse-string suture), counterclockwise on the left and clockwise on the right. However, great care was taken to cross over the spermatic duct and gonadal vessels to avoid causing injury. When the last suture had been placed, the intraperitoneal tie was ligated by a one-hand tie using grasping forceps to hold the shank of the suture needle and cause the needle tip to circle the other end of the suture (Fig. 4). An operating assistant drew one end of the suture outside the abdominal cavity, and a grasping forceps was used to hold the suture inside the abdominal cavity. A ligation was made when the suture was tensed in the opposite direction. Finally, the suture needle was used to circle the suture again and perform triple ligations. The needle was retrieved through the anterior abdominal wall. The same procedure was performed on the contralateral side if there was patent processus vaginalis. No stitching was required for the needle and trocar puncture wound. The umbilical wound sites were covered with sterile aseptic absorbent gauze.
2. Results
Fig. 1 Two curvilinear paraumbilical 5-mm bilateral incisions were made.
Seventy-six repairs were performed in 64 children with TUES. All patients did well during the procedure with the exception of one inferior epigastric vein that was injured; a retroperitoneal hematoma was noted during the operation, hemostasis by ligation was performed, and there was no need
Transumbilical endoscopic surgery
Fig. 3 The hernial sac orifice was closed extraperitoneally by a purse-string suture around the internal inguinal ring using a round needle.
to add an additional working port or convert the procedure to an open approach. The mean operating time was 20 minutes (range, 15-30 minutes). All patients were discharged on the first postsurgical day. The mean follow-up period was 13 months (range, 6-18 months), with no recurrence or postoperative hydroceles occurring up to the time of this writing. There was no testicular atrophy or ascent in this group.
3. Discussion Laparoscopic inguinal hernia repair in children has become an alternative to conventional open herniotomy. Among various laparoscopic techniques, LPEC of the hernia is a recently well-developed technique. However, because this is a technique of percutaneous closure of inguinal hernias, some subcutaneous tissues, including nerves and
Fig. 4 Using a grasping forceps to hold the shank of the suture needle, the needle tip circled the other end of the suture.
2419 muscles, may become injured by their inclusion in the upper portion of the circuit suturing. The technique may fail to entirely enclose the hernial defect and has the potential to lead to higher incidences of hydrocele and hernia recurrence. In the present series, no special instruments were used. This technique is simple and can be performed quickly. The TUES hernia repair operating time was comparable with the time needed for LPEC repair. It is easier to perform in females than in males; because there is no vas deferens or spermatic cord, the operator has less concern about causing injury. Postoperative hernia recurrence is a complication of inguinal hernias [3]. The main factors affecting recurrence have been recognized as (1) failure to ligate the sac high enough at the internal ring, (2) injury to the floor of the inguinal canal because of operative trauma, (3) failure to close the internal ring in females, and (4) postoperative wound infection and hematoma [4]. The laparoscopic technique has been proven to avoid all of these possible causes of recurrence [5]. The reported recurrence rates of inguinal hernia repair differ [6,7]. We did not observe any recurrence in our patients during our limited follow-up. During recent years, new interest has arisen in scarless endoscopic abdominal surgery with the development of minimally invasive surgery. The new concept known as natural orifice transluminal endoscopic surgery appeared with the publication of the first experimental report by Kalloo et al [8]; however, few clinical reports have appeared to date. The major barriers that limit its clinical application include access, closure, infection, suturing technology, and orientation [9]. Compared with the natural orifice transluminal endoscopic surgery technique, TUES is much simpler and safer. Transumbilical endoscopic surgery results in similar scarless results on the abdomen and theoretically has the same advantages of rapid recovery. Our technical experience shows that TUES can be safely performed in both males and females without injury. This treatment modality preserves the benefits of laparoscopy with avoidance of trauma to the vas deferens and spermatic vessels
Fig. 5 One-day postoperative picture of a female with bilateral inguinal hernias.
2420 and ligation of abdominal wall tissues (nerves and blood vessels) and eliminates the necessity of another assistant instrument port. In addition, our method provides excellent cosmetic results because of the presence of only two 5-mm umbilical wounds for both unilateral and bilateral hernias. The wound scar of the laparoscopic port is hidden in the umbilicus, and the puncture wounds made by the working devices are minimal. Females with bilateral hernias have particularly better cosmetic results (Fig. 5). Undoubtedly, TUES will be an option for scarless abdominal surgery [10]. Compared with the current laparoscopic extraperitoneal closure techniques, the method we have developed is easy to perform, and the instruments are readily available. These results suggest that TUES for pediatric inguinal hernia repair is safe, effective, and reliable and has a low recurrence rate. The cosmetic result is excellent. Further study and longer follow-up will be necessary to determine whether the recurrence rate is similar to that of open surgery.
References [1] Ozgediz D, Roayaie K, Lee H, et al. Subcutaneous endoscopically assisted ligation (SEAL) of the internal ring for repair of inguinal
X. Zhou et al.
[2]
[3]
[4] [5] [6]
[7]
[8]
[9]
[10]
hernias in children: report of a new technique and early results. Surg Endosc 2007;21:1327-31. Patkowski D, Czernik J, Chrzan R, et al. Percutaneous internal ring suturing: a simple minimally invasive technique for inguinal hernia repair in children. J Laparoendosc Adv Surg Tech 2006;16:513-7. Chang YT, Wang JY, Lee JY, et al. A simple single-port laparoscopicassisted technique for completely enclosing inguinal hernia in children. Am J Surg 2009;198:e13-6. Grosfeld JL, Minnick K, Shedd F, et al. Inguinal hernia in children: factors affecting recurrence in 62 cases. J Pediatr Surg 1991;26:283-7. Chan KL, Tam PK. Technical refinements in laparoscopic repair of childhood inguinal hernia. Surg Endosc 2004;18:957-60. Chan KL, Hui WC, Tam PK, et al. Prospective randomized singlecenter, single-blind comparison of laparoscopic vs open repair of pediatric inguinal hernia. Surg Endosc 2005;19:927-32. Takeharaa H, Yakabeb S, Kameoka K. Laparoscopic percutaneous extraperitoneal closure for inguinal hernia in children: clinical outcome of 972 repairs done in 3 pediatric surgical institutions. J Pediatr Surg 2006;41:1999-2003. Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc 2004;60: 114-7. Fuente SG, DeMaria EJ, Reynolds JD, et al. New development in surgery: natural orifice transluminal endoscopic surgery (NOTES). Arch Surg 2007;142:295-7. Zhu JF, Hu H, Ma YZ, et al. Transumbilical endoscopic surgery: a preliminary clinical report. Surg Endosc 2009;23:813-7.