Inguinal hernia is a common pediatric surgical condition with high morbidity, and treatment is usually performed by high ligation of the hernia sac without the need for patch placement
[1]. In recent years, with the development of laparoscopic technology, laparoscopic hernia sac ligation is gradually accepted by doctors and parents of children. In China, several widely used procedures are, laparoscopic sledding needle or homemade epidural needle loading suture to close the inner ring opening, two-hole method of intraperitoneal suture high ligation, single-hole method of intraperitoneal suture high ligation, and single-incision double-channel intraperitoneal suture high ligation through the umbilicus, all of which have achieved better efficacy. However, in the continuous pursuit of curing pediatric inguinal hernia with smaller trauma and more beautiful incision, new improvements in the existing operation are still being applied in clinical practice. 112 cases of pediatric inguinal hernia were treated by double-channel laparoscopic high ligation of the hernia sac via the umbilicus in our department from September 2014 to May 2015, and good results were achieved. They are reported as follows. Hu Yuanjun, Department of Pediatric Surgery, Jinan Children’s Hospital, Jinan, China Data and methods: 1 Data: 112 children were admitted to our department from September 2014 to May 2015. The ages were 1-5 years old, including 98 male and 14 female children. The preoperative diagnosis was right inguinal hernia in 81 cases, left in 23 cases, and bilateral in 8 cases. The criteria for case selection were clinical diagnosis of inguinal hernia, no history of impaction within the last 1 week, no history of intra-abdominal surgery, and no congenital malformation of the umbilicus. 2
Methods: General anesthesia was performed with tracheal intubation, the bladder was emptied by placing a urinary catheter before surgery, and an arc-shaped incision was made along the umbilical margin at the left umbilical folds, with a length of about 20 px. A striated clamp was placed tightly against the navel to separate it into the abdominal cavity, and a 5mm Troca was placed open as an observation hole (Figure 1). Pneumoperitoneum was established with a pressure of 8 mmHg (1 mmHg=0.133 kPa). After satisfactory pneumoperitoneum, a 5-mm curved incision was made from the right umbilical rim, and a 5-mm Troca was punctured and placed as the operation hole; the Troca should not be placed too deeply into the abdominal cavity to avoid interfering with the operation. The operator holds the laparoscope in the left hand and the needle holder in the right hand for the operation (Figure 2). The affected hernia sac and the healthy side of the internal ring are explored, and if necessary, the peritoneum is tugged with the needle holder to detect the occult unclosed sheath. From approximately 75 px above the opening of the internal ring, a 2-0 needle with a silk thread is punctured through the abdominal wall, leaving the end of the thread outside the abdominal wall. The needle should not be inserted too close to the opening of the internal ring, otherwise it will be difficult to complete the knot. The needle holder holds the needle from the lateral side of the internal loop, protects the spermatic vessels, vas deferens and subabdominal vessels, and closes the internal loop with a tightly packed peritoneal suture (Figure 3). Note that the gap between the peritoneum and the vas deferens and spermatic vessels should be separated at the spermatic vessels and vas deferens by the picking and twisting of the needle tip. Larger hernia sacs tend to form folds in the vas deferens area below the inner ring opening, which is a key site for recurrence of missed ligation and requires careful inspection to avoid omission. If necessary, the tail of the thread left outside the abdominal wall can be pulled to tighten the peritoneum. After completing the purse-string suture, the inner and outer parts are combined and knotted to tie the inner ring opening (Figure 4). The needle is removed from the abdominal wall after cutting the thread and puncturing it. During the suturing process, the right inner ring opening is sutured with a forward stitch and the left inner ring opening needs to be sutured with a reverse stitch. In female children, the round ligament should not be stripped and can be sutured together. Results: All 112 children were operated laparoscopically, without any intermediate openings and without serious intraoperative side injuries. 81 children with right-sided disease had 31 cases (38.3%) of contralateral sphincter non-closure. Of the 23 children with left-sided disease, 11 (47.8%) had contralateral sphincter incompetence. The average operating time was 22.7 minutes for the right side, slightly longer than the right side due to the need for backstitching on the left side, averaging 30.4 minutes, and 43.2 minutes for both sides. No recurrence was seen at the 3-month follow-up, no umbilical hernia occurred, no testicular atrophy or medically induced cryptorchidism occurred, and the scar was almost invisible. Discussion: Inguinal hernia is a common disease in children, and it is generally believed that children after 6 months of age have very little possibility of self-healing, and all need surgical treatment. The main treatment modalities are traditional surgery and minimally invasive laparoscopic surgery. Traditional surgery has been used for many years and has the advantages of easy operation, short operation time, no access to the abdominal cavity and no influence on the intra-abdominal environment. Minimally invasive laparoscopic surgery has the following advantages over traditional surgery: 1: No dissection of the inguinal canal is required, reducing the possibility of damage to important tissues in the inguinal canal. The incidence of complications such as vas deferens injury, scrotal hematoma, medically induced cryptorchidism, and testicular atrophy is reduced [2]. Second: laparoscopic surgery allows clear examination of the contralateral internal ring opening for the presence of contralateral unclosed sphincter (contralateral patent processus vaginalis
CPPV), and manage it without increasing the incision and trauma. The contralateral unclosed sheath is the basis for the pathogenesis of postoperative contralateral reherniation (also known as an ochronotic hernia). The probability of becoming a unilateral inguinal hernia with contralateral sphincter unclosure is 31-48% in some reports [3]. In our study, a total of 42 children (40.4%) with unilateral disease had contralateral syringomyelia in 104 children with unilateral disease. Although not all contralateral sphincter incompetence will then develop into an ischial hernia in the future, it has been claimed that approximately 3.6-10% of contralateral sphincter incompetence will develop into a hernia [3]. Therefore, laparoscopic exploration to detect and manage the contralateral unclosed sphincter has great advantages without increasing the number of anesthesia and surgical incisions. Third: Reduction of scarring visible to the naked eye. The direction of modern surgery is minimally invasive and aesthetic, and laparoscopic surgical incisions are obviously more aesthetic and concealed. IV: More precise suture sites and uniform tension around the internal ring opening. In conventional surgery, the height of the ligature site when ligating the hernia sac can be significantly related to the tension of the stretched hernia sac, sometimes varying from the anterior to the posterior wall. Both low and high ligature positions can lead to an increased chance of recurrence. Particularly in girls, excessive tension in pulling the hernia sac can draw the fallopian tube into the hernia sac and cause an artificial sliding hernia. Clinically, it is also common to encounter excessive pursuit of high ligation, resulting in postoperative tension and pulling sensation in the lower abdomen of the child, which manifests itself in a flexed position, unable to stand up straight or lie flat, and requiring a longer recovery time. The laparoscopic ligation can be done in a natural state along the inner ring opening with a ruffle suture, avoiding the above situation. Therefore, laparoscopic high ligation of the hernia sac has obvious advantages over traditional surgery for the treatment of pediatric inguinal hernia. Currently, laparoscopic high ligation of hernia sacs commonly used in China is divided into two-hole and single-hole methods and double-channel method via a single site, with the two-hole method having transumbilical and mid-lower abdomen [4] and transumbilical with the outer edge of the rectus abdominis muscle at the umbilical level [5]. Both of these methods add incisions other than the hidden incision at the umbilicus with unsightly scarring. The main uniportal approaches are laparoscopic hook-and-needle method of high ligation of the hernia sac [6], and the application of various homemade sledding needles and epidural puncture needles and other instruments to complete the high ligation of the hernia sac by laparoscopically monitored extraperitoneal ligation and subcutaneous knotting. All of these surgical approaches not only add a small incision in the inguinal region, but the knots tied subcutaneously are prone to wire knot reaction and foreign body sensation. There is also the application of a multi-instrument introducer trocar device [7], or a special laparoscopic intraperitoneal purse-string suture with an operating orifice in a single site to complete the high ligation [8]. This approach has the advantage of low trauma and hidden scar, but it is difficult to operate and requires custom-made special surgical instruments, which is not suitable for widespread application. In recent years, dual-channel operation via a single site has been reported with a longitudinal split of the navel and a 5mm Troca placed in each of the upper and lower poles [8], and a 5mm Troca placed in each of the left and right poles of the incision through a curved incision at the lower edge of the umbilicus [9]. Not only is the surgical incision concealed, the operation is more convenient, and no special instruments are required, it is easy to learn and master and to promote to primary hospitals. However, the longitudinal splitting of the belly button into the double channel is more damaging to the umbilical ring, and if the sutures are not tight enough or the postoperative healing is poor, there is a potential risk of forming an umbilical hernia. In the present study, we adopted a single-site double-channel laparoscopic high ligation of the hernia sac at the umbilical rim, which is also a single-site double-channel intraperitoneal purse-string ligation of the hernia sac. A small incision is made in the skin folds at the right and left margins of the umbilicus to place the Troca, which is smaller and more aesthetically pleasing than the longitudinal splitting of the navel and the curved incision at the lower umbilical margin (Figure 5). Moreover, placing the two channels at the left and right margins of the umbilicus, which are separated by a certain distance, is also more convenient for surgical operation. However, the dual-channel approach to the umbilical rim is still difficult for beginners and requires a high level of operator skill. First, the operator’s left hand holds the laparoscope and the right hand holds the instruments, which tests the operator’s left and right hand coordination skills. Secondly, the parallel relationship between the laparoscope and the operating instruments makes it more difficult to grasp the angle of the needle holder and the depth of the needle entry, especially when the hernia sac is large and the peritoneum at the vas deferens has more folds, so extra care should be taken not to injure the vas deferens by entering the needle too deeply. When the vas deferens is sewn, the thread tail outside the abdominal cavity can be pulled so that the peritoneum is stretched under certain tension and the vas deferens is fully exposed and then the twisting action of the needle tip is used to separate the gap between the vas deferens and the peritoneum to avoid ligating the vas deferens. In addition, it should be noted that the area of the peritoneal folds is easily missed and leads to recurrence, and the peritoneum should be pulled for inspection after the completion of the purse-string suture. The knotting is done by a combination of internal and external knotting. After the winding is completed in the peritoneal cavity, the operator uses a needle holder to pull the end of the thread inside the peritoneal cavity and the assistant pulls the end of the thread outside the peritoneal cavity. Be sure to apply even force and form a three-point line to ensure a secure ligature. In addition, it is important to control the position of the thread with the needle into the abdominal cavity not to be too close to the opening of the inner ring, otherwise it will be difficult to perform the knotting operation; our experience is that it is easier to tie the knot by inserting the thread with the needle at a position about 75 px above the opening of the inner ring. In conclusion, although laparoscopic high ligation of the hernia sac at the umbilical rim with dual channels requires a longer learning curve compared with traditional surgery and the two-hole and hook-and-needle methods, the technique has the advantages of minimal damage to the umbilical ring, concealed scar, low recurrence rate, simultaneous treatment of the contralateral unclosed sphincter, and high operability when mature, and has high promotion value.