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Inguinal hernia repair is one of the most commonly performed operations in children. The open inguinal approach is an excellent method for repair but has the potential risk of injury to the spermatic cord and vas deferens, development of hematomas, wound infections, iatrogenic cryptorchidism, testicular atrophy, and recurrence. For many surgeons, laparoscopy has become the favored approach for treatment of inguinal hernias. Laparoscopy provides excellent visualization, minimal dissection of the vas deferens and spermatic vessels, comparable recurrence rates, and improved cosmesis when compared to the traditional open inguinal crease approach. The diagnosis and repair of a contralateral patent processus vaginalis (CPPV); femoral, direct, or combined hernias; and recurrent or complicated hernias can also be achieved safely and successfully via laparoscopy.
There have been several techniques described for laparoscopic inguinal hernia repairs in infants and children. These techniques can be categorized as either intracorporeal or percutaneous. This chapter describes an intracorporeal and two percutaneous techniques used to repair inguinal hernias. A recent review of the literature concluded that there is insufficient evidence to support one technique over another one. The decision between a percutaneous or an intracorporeal approach for these repairs depends on surgeon preference and experience.
Indications for Workup and Operation
The indications for a laparoscopic inguinal hernia repair are the same as for the open inguinal approach. Older children are encouraged to empty their bladder preoperatively. A full bladder does not typically hinder a laparoscopic hernia repair, but in situations where the bladder needs to be emptied, a Credé maneuver (i.e., exerting manual pressure on the bladder) can be utilized. This maneuver is especially useful in cases where a direct or femoral hernia is suspected. A urinary catheter is usually not inserted. Bowel preparation has been described in certain patient populations but is not mandatory or necessary for safe completion of this procedure.
The patient is positioned on the operating table in a supine position with his or her arms tucked at his or her sides, and general anesthesia is induced. The patient is appropriately secured and padded. The patient is prepped and draped from the xiphoid to the perineum. The surgeon is usually positioned opposite to the side being repaired. The camera operator usually stands on the side opposite the surgeon, and the screen is positioned at the patient’s feet. A 5-mm port is introduced in the umbilicus using an open technique, and pneumoperitoneum is established. An average intra-abdominal pressure of 10 to 12 mm Hg is used in patients younger than 1 year of age and 12 to 15 mm Hg in older children. A 15- to 20-degree Trendelenburg inclination with or without lateral rotation of the operating table may help displace the bowel cephalad to improve exposure of the inguinal rings. The decision between a percutaneous or intracorporeal approach depends on surgeon preference and experience as there is not enough evidence to support one approach over another.
Percutaneous Repair: Awl Technique (DJ)
Surgeon preference and ergonomics will ultimately dictate on which side the operating surgeon stands. The pneumoperitoneum is established via the 5-mm umbilical cannula. A 3-mm instrument is then introduced via a stab incision at the midaxillary line and lateral to the umbilicus on either the patient’s right or left side, depending on surgeon preference. We have been able to successfully use 3-mm instruments in adolescent patients without difficulty, which negates the need for other ports. An optional second instrument may be inserted on the contralateral side of the abdomen to allow the camera operator to provide exposure or assistance with the operation. Prior to ligation of the hernia sac, we cauterize and mechanically disrupt the peritoneum around the internal opening that is not adjacent to the vessels and vas deferens. Then, at the level of the internal inguinal ring (IIR), a 25-gauge needle is passed through the abdominal wall for hydrodissection of the peritoneum off the vas and vessels in the preperitoneal plane ( Fig. 26-1 ). The fluid utilized depends on the patient’s weight. As we are limited on the volume of 0.25% bupivacaine in patients under 10 kg, we will usually dissect with isotonic injectable saline in these smaller patients. In patients over 10 kg, we often use 0.25% bupivacaine, which is also used for postoperative anesthesia at the inguinal, umbilical, and instrument sites. Typically, no more than 3 to 5 mL of fluid is needed to elevate the peritoneum away from the vas and vessels.
We then close the IIR percutaneously. A 1- to 2-mm stab incision through the skin and fascia overlying the IIR is made to place a circumferential suture around the IIR. A nonabsorbable braided suture is threaded through the eyelet of a zygomatic arch awl ( Fig. 26-2 ). The awl is used to pass the nonabsorbable suture through the stab incision into the hydrodissected preperitoneal space around the medial portion of the IIR, traversing over the vas and vessels (or round ligament), and finally piercing the peritoneum. The awl is then removed after one end of the nonabsorbable suture is pulled into the abdominal cavity with the 3-mm instrument. The awl is next introduced on the contralateral side of the IIR and pierces the peritoneum just past the first suture. This overlap in sutures ensures that the entire circumference of the peritoneum at the internal opening is incorporated in the closure. The operating surgeon then threads the tail end of the intra-abdominal portion of the initial suture through the eye of the awl ( Fig. 26-3 ). The awl and suture are withdrawn, and a single suture thereby circumferentially encircles the IIR.
The assistant then compresses the scrotum (or labia in a girl) to try to evacuate any fluid or air. In a boy, the assistant should also grasp the testis to ensure its proper location within the scrotum as the operating surgeon then ties the suture around the internal opening of the hernia sac, thereby ligating the hernia sac ( Fig. 26-4 ). The process is then repeated on the contralateral side, if indicated.
The instruments are removed and the small incisions and umbilical port site are injected with bupivacaine (if not already done). The pneumoperitoneum is released completely and the umbilical port is withdrawn. The stab incisions are then closed with tissue adhesive or Steri-Strips (3M Co., Minneapolis, MN). The umbilicus is closed with absorbable sutures and a sterile dressing is applied. If a hydrocele was present prior to the operation and has not been evacuated, it is aspirated with a large-gauge needle and syringe prior to the patient being awakened from anesthesia.
Percutaneous Repair: Spinal Needle Technique (TP)
Prior to beginning the operation, an 18-gauge spinal needle is intentionally bent into a gentle curve using two needle drivers and threaded with a looped 3-0 monofilament suture with the loop coming out of the tip of the needle. The loop is then pulled back just inside the tip of the needle ( Fig. 26-5 ). Marcaine 0.25% is injected into the inferior portion of the umbilicus and a 3-mm incision is created. A Veress needle is inserted and the abdomen is insufflated to 15 mm Hg. A 3-mm port is then inserted through the umbilicus and a 3-mm, 70-degree telescope is introduced to identify the inguinal hernia and evaluate the opposite side for the presence of a CPPV. Local anesthetic is then injected in the ipsilateral lower abdominal wall and a 3-mm stab incision is made in the anterior abdominal wall just lateral to the umbilicus through which a Maryland dissector is inserted. Cautery is connected to the Maryland dissector, and the anterior surface of the IIR, staying away from the vas deferens and vessels in a boy, is cauterized. Next, hydrodissection with injectable saline is performed to elevate the peritoneum off the cord structures and vessels (and round ligament in a girl) as previously described. The threaded curved spinal needle with the looped monofilament is inserted through a 1-mm skin incision in the inguinal region overlying the IIR and passed between the peritoneum and the cord structures. We usually proceed from the 12 o’clock position laterally around the IIR. The needle is passed beneath the peritoneum over the vessels and the vas (or round ligament). Ideally, the needle and ultimately the ligatures will remain in the preperitoneal layer created during the previous hydrodissection. The 3-mm instrument can be used to assist with lifting the peritoneum away from the cord structures at this point, if necessary. Once the space overlying the vas/vessels/round ligament has been traversed, the needle is pushed through the peritoneum into the peritoneal cavity, and the loop of monofilament suture is pushed out of the needle ( Fig. 26-6 ). The needle is removed from the peritoneal cavity, leaving a looped suture in the peritoneum with the tails exiting through the 1-mm skin incision ( Fig. 26-7 ).