Inguinal hernia is the most common surgical condition in pediatric patients, caused by congenital failure of the sphincter, and is almost always an inguinal hernia. Although the recurrence rate is low (1%), the open surgery requires dissection of the groin to separate the hernia sac from the spermatic vessels and vas deferens, which inevitably causes injury resulting in scrotal hematoma or edema and even medically induced cryptorchidism.
In the past 20 years, as the feasibility and safety of laparoscopic techniques have been proven in pediatric surgical practice, they have been rapidly developed and improved around the world because of their advantages of not dissecting the spermatic cord structure, identifying contralateral cryptorchid hernia, and being able to deal with both sides of the unclosed sphincter at the same time.
I. Diagnostic value of laparoscopy (Laparoscopic diagnosis)
In 1992, Lobe and Schropp first applied a 2 mm laparoscope through the umbilicus into the abdominal cavity to explore the asymptomatic contralateral internal inguinal ring as a diagnostic tool. This was followed by a series of reports on the use of cystoscopy or laparoscopy via the umbilical route to identify contralateral sphincter incompetence via an open inguinal hernia ring or through the umbilical route. Of these, insertion of a 120° rigid scope via the inguinal route is the most commonly used diagnostic tool.
The effectiveness of laparoscopic diagnosis of suspected unclosed sphincters is further enhanced by the use of probes, endoscopic pullers, or other ancillary instruments. Thus, laparoscopy has a sensitivity of 99.4% and a specificity of 99.5% for the diagnosis of unclosed sphincter and can be used as the gold standard for the diagnosis of inguinal hernia.
Differences in the morphology of the internal ring and the ability of the sphincter to form a hernia can be assessed laparoscopically, which can also be a guide for those sphincters that should be treated surgically.
Thus, the study not only demonstrates the timely effectiveness of laparoscopic surgery, but also puts an end to the debate on the need to explore the contralateral groin for suspected sphincter incompetence. In addition, laparoscopic techniques can clarify the lesion characteristics of suspected recurrent and strangulated hernias, rare straight and femoral hernias in pediatric patients, and other concomitant anomalies.
Laparoscopic inguinal herniorrhaphy (Laparoscopic inguinal hernia repair)
The feasibility of this procedure was first demonstrated laparoscopically by Ger et al. in 1990 using a metal clip to close the internal ring in beagles, thus beginning the era of laparoscopic techniques for the treatment of pediatric inguinal hernias.
Based on the method of closing the internal ring of the hernia, it can be divided into two categories: intraperitoneal and extraperitoneal ligation, the former requiring intraperitoneal ligation or suturing (transection or no incision of the internal ring), and the latter requiring extracorporeal ligation or suturing to complete the procedure. In addition, they can also be divided into three-hole, two-hole and single-hole techniques based on the number of trocars.
1. Three-port laparoscopic techniques
Laparoscopic inguinal hernia repair was initially limited to girls due to concerns about damage to the spermatic structures, and was first reported by El-Gohary in 1997 for girls with inguinal hernia internal ring ligation.
(1) Inverted sac with the internal ring endolooping The inguinal hernia sac is inverted by placing a grasping forceps in the affected trocar from the base of the sac and the neck of the sac is ligated by placing an endoloop in the contralateral trocar without microscopic suturing and knotting. This method is only indicated for female children who do not require dissection of the inguinal structures.
(2) Pure suturing of the internal ring The most common method for early laparoscopic hernia repair is to close the internal ring with interrupted “Z” or continuous purse-string sutures in the abdominal cavity without separating the hernia sac. Generally, only the peritoneum is sutured, and this method requires a specialized technique of in vivo suturing.
At first, the fear of damaging the vas deferens or genital vessels led to a high recurrence rate (3-5%) due to the omission of the peritoneal space during suturing. To make the procedure safer and reduce recurrence of hernias, Chan et al. used an extraperitoneal gap injection technique to separate the peritoneum of the posterior wall of the internal ring from the spermatic vessels and vas deferens to allow complete closure of the hernia defect without tension, thus significantly reducing the recurrence rate.
(3) Hernia sac transection and intracorporeal ligation Because of the high recurrence rate of simple intracorporeal ligation, in 2004 Becmeur et al. followed the principles of open hernia surgery to transect the hernia sac and repair the internal ring, and in 2012 Boo et al. reported no postoperative recurrence in 202 children.
The procedure is essentially the same as traditional open surgery, except that the groin does not have to be opened. Because of the need for internal annulus dissection, this procedure requires greater microscopic skills on the part of the surgeon.
(4) Flip-flap herniorrhaphy, in which the anterior and lateral half of the peritoneum of the hernia sac is dissected and separated to medially cover the hernia defect and sutured for repair, creates a unidirectional living peritoneal flap that prevents intra-abdominal organs from entering the hernia sac and allows fluid to flow into the peritoneal cavity, thus preventing postoperative syringomyelia.
Although this method is technically and physiologically well conceived, there are reports questioning its safety and success rate because of the tendency to cause vascular damage and flap fracture during the suturing process.
2. Two-port laparoscopic techniques (Two-port laparoscopic techniques)
With the deepening of the understanding of minimally invasive concept and the progress of laparoscopic techniques, pediatric laparoscopic hernia repair has been improved to reduce the trauma of multiple incisions in traditional laparoscopic surgery and to improve the aesthetics, which not only can reduce one surgical poke hole to complete the intra-abdominal ring suture by one-handed operation, but also can be performed extraperitoneal ligation of the internal ring by using various improved hernia surgical instruments by percutaneous extracorporeal operation, which is simpler than transabdominal suture and easier for beginners to master. It is easier to master and more widely used in clinical practice.
(1) Two-port techniques with intracorporeal suturing In 2001, Li Long et al. adopted the two-port technique and used a single-handed operation to introduce sutures through the anterior abdominal wall and closed the hernia defect with intra-abdominal purse-string suturing. Good results were achieved in 76 cases of inguinal hernia, but because the operating instruments and laparoscope were both crowded at the umbilicus, intraperitoneal suturing and knotting with a single hand-held needle was difficult and time-consuming, and to avoid puncturing the spermatic vessels or vas deferens would leave a peritoneal gap that might lead to recurrence, so the application of this technique was less reported.
(2) Laparoscopic percutaneous extraperitoneal closure (LPEC) To overcome the technical difficulties of intraperitoneal suturing and knotting, people began to explore percutaneous perforation of the abdominal wall with extraperitoneal loop ligation, and in 1995 Takehara et al. started percutaneous extraperitoneal loop ligation.
Various homemade hernia needles, Endoclose needles, GraNee needles, Reverdin bone penetrating suture needles, and epidural needles have been reported as hernia suturing instruments, and these hernia suturing instruments are used to enter the operative field through the skin of the inguinal region under laparoscopic surveillance, and a second grasping forceps is used to assist in completing the purse-string suturing outside the peritoneum around each half of the medial and lateral sides of the inner ring in turn, and the ligature is placed in and out of the ring. The ligature is placed and removed to encircle the inner ring, then the ends of the thread are pulled from the surgical site and the knot is tied outside the body and buried subcutaneously; this technique eliminates the need for a second auxiliary operation to poke holes.
This technique is still the most commonly used pediatric inguinal hernia repair and tends to develop into a single-incision or single-port laparoscopic technique, which is more convenient for the management of giant, recurrent, and incarcerated hernias.
3.Single-port laparoscopic techniques
(1) Subcutaneous Endo-scopically Assisted Ligation (SEAL) In the early days of pediatric laparoscopic hernia surgery, attempts to treat pediatric inguinal hernias with single-port laparoscopy were initiated.
However, the complication rate (15.7%) and recurrence rate (4.3%) were high because the sutures had to cross the spermatic vessels and vas deferens to avoid damage to the spermatic cord and vas deferens during the percutaneous ligation of the internal ring, which inevitably left a peritoneal gap and could lead to recurrence. This may lead to recurrence.
In 2008, Bharathi et al. used a lumbar needle to separate the extraperitoneal space with water to lift the spermatic structures to cover the peritoneum, and then sutured it twice to completely encircle the internal loop defect to avoid injury and reduce the recurrence rate.
In 2012, Li et al. improved this technique by using plain sutures combined with endoscopic crochet to complete 1107 pediatric inguinal hernias with good results.
(2) Percutaneous Internal Ring Suturing (PIRS) In 2006, Patkowski et al. reported that one end of a non-absorbable ligature wire was placed in the sheath of an 18-gauge injection needle and punctured through the abdominal wall under single-port laparoscopic surveillance, and the ligature wire loop was prepositioned intraperitoneally from the extraperitoneal side of the internal ring, and the injection needle was withdrawn with the wire and then The second ligature wire was placed subcutaneously in the sheath of the 18-gauge injection needle, and the second ligature wire was tightened and knotted outside the body.
Because of the fear of accidental injury to the spermatic cord structures and inevitably missing the peritoneal space, there were 3 cases of accidental injury to blood vessels, 3 cases of recurrent hernias and 5 cases of syringomyelia among the 106 completed cases.
In 2008, Chang et al. improved this technique by first using an 18-gauge vascular retention trocar to puncture extraperitoneally through the inner ring on one side, during which 5-8 ml of isotonic saline could be injected to separate the extraperitoneal space to avoid injury to the vas deferens and spermatic cord vessels, a nonabsorbable ligature wire was sent into the abdomen through the outer sheath for prepositioning, and then a hook needle made from a bone piercing needle was used to hook the ligature wire around the other side of the inner ring into the abdomen to achieve complete closure of the The hernia defect is completely closed without leaving a peritoneal gap.
However, since two punctures of the abdominal wall are required to introduce and withdraw the ligature wire, the abdominal wall tissue in front of the hernia sac may be ligated at the same time, and as with the SEAL technique described above, the ligature of some of the subcutaneous tissue containing nerves and muscles can cause damage that can lead to abdominal wall discomfort and even loosening of the wire knot leading to hernia recurrence.
(3) Single-port LPEC To achieve a tension-free simple extraperitoneal ligation of the internal ring, Chang et al. 2009 created a hook in the proximal sheath of a 16-gauge puncture trocar needle, entered the abdomen with the ligature prepositioned, withdrew the needle to the anterior wall of the hernia ring extraperitoneally (without exiting the abdominal wall), and then entered the abdomen around the opposite side of the internal ring to hook out the prepositioned wire.
During the procedure, the hooked injection needle is kept in the same channel of the abdominal wall for both the introduction and hooking out of the ligature, so that the ligature can closely wrap around the hernia defect without the abdominal wall tissue on it, thus further reducing the damage to the abdominal wall.
In 2012, Li Meng et al. reported that a homemade double-hook hernia needle was used to complete percutaneous intraperitoneal loop ligation by puncturing the abdominal wall in a single pass, and the head end of the hernia needle was similar to a 16-gauge epidural puncture needle with two grooves on the front outer arc of the needle core. The double-hook hernia needle groove is designed in the needle core, and after hanging the thread, it can be returned to the needle sheath to overcome the defect that the groove hooks other tissues during the needle puncture on the outer sheath and hinders the operation.
In addition, for children with huge hernias or recurrent hernias with large defects in the inguinal region, after ligation of the internal ring, the double-hook hernia needle with thread can again enter through the original puncture point of the skin of the abdominal wall, penetrate the peritoneum into the abdominal cavity through the anterolateral aspect of the internal ring, then puncture the ipsilateral umbilical bladder fold and push out the needle core to set the thread preset, then retreat the hernia needle to the extraperitoneal space, continue to penetrate the peritoneum near the spermatic cord vessels posteriorly and laterally, push out the needle core to hook the umbilical bladder fold and enter the abdomen. The bladder fold prepositioning thread is drawn out of the body, and the ipsilateral umbilical bladder fold is ligated with the posterior lateral peritoneum of the hernia ring to strengthen the hernia repair.
III. Evaluation of different techniques
Although the three-hole laparoscopic technique for the diagnosis and treatment of inguinal hernia is conducive to fine manipulation and diagnosis of contralateral inguinal occult hernia, the surgical operation is relatively complicated and requires high microscopic manipulation techniques due to the influence of the traditional thinking that laparoscopic surgery is performed in the abdominal cavity and the suture ligation of the internal ring is performed in the abdominal cavity through two operating holes.
In the early stage, interrupted sutures or jumping purse-string sutures were used to close the internal ring for fear of damaging the genital vessels and vas deferens, which resulted in a high recurrence rate after surgery due to missing part of the peritoneal fissure and incomplete closure of the internal ring. also increased operative time and postoperative pain, and had no aesthetic advantage over the inconspicuous lower transverse abdominal incision of open surgery.
Therefore, the three-hole technique can only be called laparoscopic surgery because of the multiple incisions and the need for pneumoperitoneum, which is not truly minimally invasive surgery; however, technically, the three-hole technique has better controllability by using grasping forceps to assist in lifting and smoothing the peritoneal folds located on the spermatic structures, and the microscopic suture ligation is more operative and can be handled in a timely manner in the event of surgical danger, which is more suitable for young physicians and beginners Exercise and growth.
The significance of the improved two-hole laparoscopic technique is not simply the reduction of one operative hole, but the introduction of the concept of extraperitoneal ligation technique into laparoscopic surgery, bringing the laparoscopic technique for inguinal hernia back to the surgical principle of complete ligation of the internal ring of peritoneum.
Complete closure of the hernia defect without leaving a peritoneal gap and promoting the formation of adhesions should be the key to reduce the postoperative recurrence rate in the era of minimally invasive surgery. Therefore, the auxiliary operating forceps can be used not only to pull the peritoneum to provide for complete ligation of the internal extraperitoneal ring, but also to facilitate the repair of more complex hernias such as giant hernia, incarcerated hernia and recurrent hernia, which simplifies the tedious technique of intra-abdominal three-hole suture ligation and is more conducive to the development of this technique in This can simplify the complicated technique of intra-abdominal triple suture ligation, which is more conducive to the development of this technique at all levels of hospitals.
The single-port laparoscopic technique inherits the surgical principle of extraperitoneal ligation, but the absence of intraperitoneal manipulation forceps makes it difficult to pass the sharp suture needle over the spermatic structures.
In case of huge hernias or recurrent hernias where single-port laparoscopy is difficult, a grasping forceps can be implanted again along the umbilicus to assist in completing the internal ring repair.
The double hook hernia needle can keep the ligature line in and out of the same abdominal wall path, avoiding ligating the abdominal wall tissue between the skin and the hernia defect, and unlike the three-hole technique which requires rich experience in laparoscopic operation, it is similar to interventional treatment operation. Minimally invasive surgery.
In conclusion, laparoscopic techniques for the treatment of pediatric inguinal hernia are diverse and improving, with a trend toward extracorporeal ligation and reduction of operating trocars and endoscopic instruments, and a shift from three-hole to single-hole techniques.
Through continuous development, complete tension-free extraperitoneal ligation of the internal ring without damaging the vas deferens or genital vessels, while avoiding ligation of excessive abdominal wall tissue, has become an important principle in the treatment of pediatric inguinal hernias with laparoscopic techniques today and in reducing recurrence rates.
The choice of technique should be based on the nature of the hernia, the surgeon’s experience, and individual technical conditions; with the accumulation of experience, wider acceptance, elimination of complications, and the advantages of minimally invasive techniques, laparoscopic techniques will become one of the best options for the treatment of pediatric inguinal hernias.