A novel technique for the treatment of pediatric congenital inguinal hernia

1. Efficacy Of Laparoscopically Assisted High
Ligation Of Patent Processus Vaginalis in
Children
BY
Dr.Hisham H. Ahmed, M.D, MRCS.Eng
Ass.Professor of General and Pediatric Surgery
Benha University Hospitals

2. Overview
• Minimally invasive surgery proved to be feasible and safe in pediatric patients since
1975 when laparoscopic surgery was first used to treat a small bowel obstruction.
(Becmeur F ,2011)
• Laparoscopy is an option for surgical repair of inguinal hernias in addition to the
traditional open approach. Since its advent, there has been considerable evolution
with the introduction of a number of innovations. (Becmeur F ,2011)
• Each iteration has maintained the basic premise of surgical repair in pediatric inguinal
hernias – high ligation of the sac. These techniques can broadly be grouped into
Intracorporeal and Extracorporeal suturing. (Becmeur F ,2011)

3. Overview
• A patent processus vaginalis (PPV) has been estimated to be present in
80-95% of all male newborns, declining to 60% at one year of age, 40% at
two years, and 15- 37% thereafter. (Watson DS, et al 1994)
• It represents a natural communication between the peritoneum and
scrotum through which bowel or peritoneal fluid may descend. (Watson DS,
et al 1994)
• A patent processus has been recognized more and more often with
evolution of laparoscopic techniques for pediatric hernia repairs and has
been theorized to be a potential area for development for hernia.
(Miltenburg DM, et al 1998)

4. Objectives
To evaluate the Efficacy,
Safety and Outcome of the
Laparoscopically Assisted
Piecemeal High Ligation Of a
Patent Processus Vaginalis
(PPV) in Children.

6. Patients & Methods
• This prospective study was
conducted at Benha University
Hospitals, department of
general surgery, pediatric
surgery unit during the period
from October 2009 to March
2011, After approval of ethics
research committee and
parents informed consent.
26 boys
65%
14 girls
35%
40 patients
Boys
Girls
8
bilateral
20%
32
unilater
al
80%
Number of patients
Regarding the laterality
Bilateral

7. Children’s characteristics and clinical data

8. Patients & Methods
• Inclusion criteria ;
* Children with an indication for hernia repair.
* No contraindication for laparoscopic intervention.
• Exclusion criteria;
* High body mass index
* Coagulopathy
* Complicated hernias
* Those associated with other inguino-scrotal
swellings.

9. Patients and Methods
All children:
• General inhalational endotracheal anesthesia with muscle
relaxation
• Trendelenburg position
• Insertion of Foley’s catheter
• Pneumoperitoneum using the open
technique ( pressure adjusted between8-10 mm Hg)

10. Patients and Methods
Equipment and Suture:
1. 3-mm trocar for a 30° telescope
2. 3-mm trocar for an endo-clinch grasper
3. Regular needle holder
4. 2/0 or 3/0 Prolene on a ½ circle needle

11. Operative Procedure
STEPS
• Insertion of a 3 mm 30° telescope through
an infra-umbilical circular incision.
• Inspection of the contralateral side for the
possibility of bilateral hernias.
• Insertion of an infra-umbilical 3 mm
working trocar.

12. STEPS
• Reduction of the hernia.
• 10 cc lidocaine 0.5% and saline
mixture in 1:1 ratio was injected
extraperitoneally.
• A Prolene 2/0 or 3/0 suture on a
curved ½ circle round bodied
taper ended 25-30 mm needle
grabbed on a regular needle
holder.
• Passage of the needle through a
tiny inguinal skin crease

13. The working grasper picks up the peritoneum in a piece
meal fashion while the needle is advanced behind the
peritoneum to encircle the neck of the sac forming a purse
string suture.1 2

14. The needle is passed out close to the insertion site forming a
semicircle around the Internal ring, and then manipulated back to
the entrance point where it’s tied and the knot buried
subcutaneously.
3 4

17. Results
• All patients passed smooth intraoperative course without intraoperative
Complications and no conversion to open surgery.
• Mean operative time was 25±4 (range 13-37) minutes for unilateral cases
and
34.6±3.8 (range 23-48) minutes for bilateral cases.
• Nine patients (28.1%) with unilateral hernias (6 right and 3 left) were found
to have
synchronous contralateral hernia diagnosed intraoperatively with a total
number
of hernias operated 57 hernias.

18. Results
• All patients showed no immediate postoperative
complications with mild to moderate pain sensation that
responded to non-steroidal anti-inflammatory drugs.
• Mean postoperative hospital stay was 4.3±1.5 (range 2-8)
hours.

19. Operative and hospital stay data

20. Results
• Through a mean follow-up period of 18.5±5.4 (range 12-30) months, one
patient with
bilateral hernia developed unilateral left side recurrence 4 months after
surgery and
was managed conventionally using open approach.
• No contralateral or ipsilateral, direct or indirect inguinal hernias developed
in unilateral
cases.
• No cases of testicular atrophy have been reported.
• Two boys developed a minimal post-operative hydrocele that have been

22. Discussion
• In the present study, an exploratory laparoscopy was
conducted for 32 children who were clinically diagnosed
as having a unilateral inguinal hernia.
• Nine of them were found to have a contralateral hernia,
with a detection rate of 28.1%.
• Chan et al. , Esposito et al. , Toufique et al. and Niyogi et
al. reported similar figures for laparoscopic contralateral
hernia detection rates of 28%, 39%, 39.7% and 29.2%,
respectively.

23. Discussion
• Parelkar et al, Esposito et al. and Giseke et al., who
reported mean operative times of 23, 7-30 and 26.2
min for Unilateral and 29, 12-42 and 34.5 min for
bilateral hernia, respectively.
• In the present study, the mean operative time was 25
and 35 min for unilateral and bilateral cases,
respectively, which was in line with that reported by.

24. Discussion
• In the present study, the mean postoperative hospital stay
was 3.4h (range 2-8 h).
• Parelkar et al. and Giseke et al. reported a coincident
hospital stay for laparoscopic inguinal hernia repair as a
day-case procedure.
• In the present study, only one child had a recurrent hernia,
giving a frequency of 2.5% for children and 1.75% for
repaired hernias.
• The reported recurrence rate goes in hand with that
previously reported by Niyogi et al. and Parelkar et al.

25. Discussion
• The present technique of ligating the (PPV) at the level of the
internal ring seems to be simpler and does not need any specially
designed instruments. Knotting does not require any special skill
because it is done externally in the subcutaneous tissue in the
conventional manner.
• Tam et al. used the hook
method during hernia repair
to allow extraperitoneal
passage of the suture to
close the hernia sac.
• Endo et al. needs a
specially designed needle
and the stitch around the
internal ring is
laparoscopically tied, with
the possibility that it may
loosen.

26. Discussion
• Bharathi et al.
assessed the differences in
outcome between the three-port
technique and the single port
laparoscopically assisted ligation
technique, and found that both
are safe and efficacious day-
case procedures.
• In the present study
the operative time was
comparable to that reported in
the literature for the three-port
technique and was without
difficulty in visualization during
the procedure.

27. Discussion
• Rothenberg et al.
described their experience
using a single port for
various operative
procedures without
focusing on hernia repair.
• The current study
found no need for an
additional port, as the
vision was clear with
satisfactory manipulation.

29. Conclusion
• Laparoscopically assisted piecemeal closure of patent
processus vaginalis in Children is safe, effective day- case
procedure with satisfactory cosmetic appearance.
• It helps in detection of contralateral hernia without
prolongation of operative time.

30. Conclusion
• The current trend is toward extracorporeal suturing and
knotting technique and single-port access technique as
well.
• The future or recent advancement is the use of tissue
adhesives in laparoscopic inguinal hernia repair in
children.