Secondary Logo

Journal Logo

Subcutaneous endoscopically assisted ligation using miniport for the treatment of girls with inguinal hernia

Hinoki, Akinari; Rie, Ikeda; Kitagawa, Daiki; Koiwai, Kazuki; Tanimizu, Takemaru; Hase, Kazuo; Takahashi, Shigeki

doi: 10.1097/01.XPS.0000473472.66487.e6
HOW TO DO IT
Free

Background This report describes the first miniport method using subcutaneous endoscopically assisted ligation (SEAL) for the treatment of girls with inguinal hernia. To validate its safety and efficacy, the authors evaluated their early experiences.

Methods Between April 2014 and December 2014, 19 SEALs using miniport were performed on 14 patients at the Fukaya Red-Cross Hospital, Saitama, Japan. Their mean age was 6 years (range, 11–128 months). This technique was performed using two ports (a 5 mm port placed using the open technique and an additional 2 mm miniport). A 5 mm laparoscope was inserted via the umbilicus. The miniport was introduced percutaneously in the inguinal region under laparoscopic guidance and manipulated around the medial or lateral hemicircumference of the internal ring extraperitoneally to place a purse-string around the internal ring. The hernia sac and patent processus vaginalis were closed at the level of the internal inguinal ring extraperitoneally with circuit suturing using the 2 mm miniport. Only the umbilical fascia was closed with an absorbable suture. No skin sutures were applied. We collected data regarding operative time, complications, and recurrence.

Results The mean operative time was 20±6 min (unilateral, n=9) or 42±8 min (bilateral, n=5). The mean follow-up period was 12.8±2.5 (range, 9–19) months. No intraoperative complications associated with the procedure occurred and no hernial recurrences have been identified so far.

Conclusion SEAL using miniport proved to be a successful operative procedure compared with other laparoscopic percutaneous extraperitoneal closure procedures and produced excellent cosmetic results. SEAL using miniport for the treatment of girls with inguinal hernias appears to be safe, effective, and reliable.

Department of Surgery, Division of Pediatric Surgery, National Defense Medical College, Tokorozawa, Japan

Correspondence to Akinari Hinoki, MD, PhD, Department of Surgery, Division of Pediatric Surgery, National Defense Medical College, Tokorozawa, Japan Tel: +81 80 3938 4600; e-mail:hinoki@med.nagoya-u.ac.jp

* Akinari Hinoki and Ikeda Rie contributed equally to the writing of this article.

Received May 28, 2015

Accepted October 18, 2015

Back to Top | Article Outline

Introduction

There are numerous minimally invasive surgery techniques that can be used for pediatric inguinal hernias 1–10. Subcutaneous endoscopically assisted ligation (SEAL) is a novel technique in minimal access surgery for pediatric inguinal hernias 7,8,10. Here, we report our experience with SEAL using miniport, which is a new technique that has been proven to be safe and effective for the treatment of inguinal hernias in girls. However, a high recurrence rate with the previous SEAL technique was the main concern with its use 7. To overcome this recurrence issue, we designed a new technique in which we closed the hernia sac percutaneously, aided by a 5-mm laparoscope and a 2-mm miniport. Our SEAL technique has evolved and now includes the application of an external purse string suture around the hernia sac, without any division of the hernia sac. The aim of this study was to introduce our modified SEAL technique for the treatment of inguinal hernia in girls.

Back to Top | Article Outline

Patients and methods

A total of 19 SEAL procedures were performed on 14 girls at Fukaya Red-Cross Hospital, Saitama, Japan (April 2014–December 2014). The diagnosis of an inguinal hernia was confirmed during a preoperative examination for each patient. The SEAL procedure was selected on the basis of parental preference after informed consent was obtained. We analyzed the short-term outcomes of 14 girls who underwent the SEAL procedure. The main outcome measurements of this study included operative time, intraoperative and postoperative complications, and recurrence.

This study protocol was approved by the ethical committee and informed consent was obtained from the parents; the technique,expected results,and possibilities of surgical exploration were explained to them.

Back to Top | Article Outline

Surgical technique

General endotracheal tube anesthesia was used in all cases. The viewing monitor was placed at the left side of the patient. The operator stood on the right side of the patient, and the camera assistant stood on the other side. Through a 5-mm intraumbilical incision, a 5-mm port for a 5-mm 0° laparoscope was placed using an open technique. The abdomen was insufflated to 8–10 mmHg of pressure. The 2-mm grasping forceps through a 2-mm port was used to send and retrieve a 4-Fr indwelling feeding tube. A 23-G needle attached to a 10-ml syringe filled with saline was introduced at the 12 o’clock position of the internal inguinal ring and saline was injected to create space behind the peritoneum. A 2-mm stab incision was made over the internal inguinal ring, and the tip of the miniport was then introduced into the preperitoneal space. Using the miniport, saline was injected around the internal inguinal ring to make enough retroperitoneal space for the SEAL (Fig. 1). Two 3-0 nylons through the 4-Fr indwelling feeding tube were introduced through the miniport to encircle the posterior hemicircumference of the ring. The tip of the tube was backed off using the 2-mm grasping forceps through the miniport, anterior to the ring to exit from the original stab of entry (Figs 2 and 3). A 4-Fr indwelling feeding tube was pulled out and the two 3-0 nylons remained (Fig. 3). They were tied extracorporeally under laparoscopic visualization. The orifice of the hernia sac and patent processus vaginalis was encircled without any skip areas (Fig. 4). Stab incision at the site of miniport entry permits knot placement in correct deeper plane, preventing skin puckering and knot protrusion. This prevents stitch infections and enhances cosmesis.

Fig. 1

Fig. 1

Fig. 2

Fig. 2

Fig. 3

Fig. 3

Fig. 4

Fig. 4

Back to Top | Article Outline

Results

Fourteen girls (mean age=6.0±3.3 years; range=11–128 months) were identified for the report. A total of 19 procedures were performed, and the mean operative time was 20±6 min (unilateral, n=9) or 42±7 min (bilateral, n=5). With experience, the surgery time gradually decreased. The mean follow-up period was 12.8±2.5 (range=9–19) months. The patients felt little pain after surgery and so most patients did not need painkiller, and no intraoperative complications associated with the procedure occurred. The cosmetic result was very good in all cases. There were no operative complications and there was no evidence of early recurrence.

Back to Top | Article Outline

Discussion

Minimal-access surgery has clear advantages in pediatric inguinal hernia repair. Among the various laparoscopic techniques, laparoscopic-assisted percutaneous extraperitoneal closure (LPEC) of the internal ring has become a well-developed technique.

This procedure utilizes the extracorporeal closure of the hernia sac and eliminates the need for intra-abdominal laparoscopic skills compared with the current laparoscopic extraperitoneal closure techniques 1,4,5. The method that we have developed is simple to perform; therefore, this procedure can be recommended for pediatric inguinal hernia. The present data were limited due to the short duration of the follow-up period. A longer follow-up period would enable evaluation of the longer-term recurrence rates. Our modified SEAL technique for the treatment of inguinal hernia in girls proved to be as successful as LPEC and produced excellent cosmetic results.

However, a major criticism of using the SEAL procedure for the repair of inguinal hernias, especially in boys, remains its higher recurrence rate, as compared with LPEC or single-incision LPEC. The incidence of recurrence has been reported as 0–4.3% 4,5,7. In a recent review of recurrences after laparoscopic hernia repair, the most common site of recurrence was along the medial internal ring at the site of the passage of the cord structures 5,11. We believe that, when using single-port techniques with extracorporeal knotting, including the SEAL technique and the percutaneous internal ring suturing technique, passing anterior to the vas deferens and spermatic vessels was the main method to protect them; this could leave a small gap that could lead to recurrence 4,5,7,8,12,13. The potential for recurrence is the limiting factor in both techniques. The original SEAL technique has not been standardized and there can be a high risk for collateral damage and recurrence in inexperienced hands. Actually, there have been no reports about the long-term outcomes from the SEAL technique 7,8,10. Methods of laparoscopic repair have recently evolved toward applying an external purse string suture around the hernia sac, without any division of the sac and leaving no gap 1,9,14. This is the reason we first performed our modified SEAL procedure only in girls to avoid the risk of recurrence and injury to the vas deferens or the blood supply to the testes. This type of damage may cause atrophy and diminished size of the testis, and iatrogenic cryptorchidism. Since the techniques have been established and the operators have become more skilled, we are now planning to extend the procedure to boys.

Back to Top | Article Outline

Conclusion

Our data suggest that the SEAL using miniport is a safe and effective operative procedure compared with other laparoscopic percutaneous extraperitoneal closure procedures and produced excellent cosmetic results for inguinal hernias in girls. We think the SEAL using miniport renders the technique easier and safer by reducing chances of complications. The long-term follow-up of the SEAL using miniport is awaited.

Back to Top | Article Outline

Acknowledgements

The authors thank Enago (http://www.enago.jp) for the English language review.

Back to Top | Article Outline

Conflicts of interest

There are no conflicts of interest.

Back to Top | Article Outline

References

1. Uchida H, Kawashima H, Goto C, Sato K, Yoshida M, Takazawa S, Iwanaka T. Inguinal hernia repair in children using single-incision laparoscopic-assisted percutaneous extraperitoneal closure. J Pediatr Surg 2010; 45:2386–2389.
2. McClain L, Streck C, Lesher A, Cina R, Hebra A. Laparoscopic needle-assisted inguinal hernia repair in 495 children. Surg Endosc 2015; 29:781–786.
3. Saka R, Okuyama H, Sasaki T, Nose S, Yoneyama C. Safety and efficacy of laparoscopic percutaneous extraperitoneal closure for inguinal hernias and hydroceles in children: a comparison with traditional open repair. J Laparoendosc Adv Surg Tech A 2014; 24:55–58.
4. Shalaby R, Ismail M, Samaha A, Yehya A, Ibrahem R, Gouda S, et al.. Laparoscopic inguinal hernia repair; experience with 874 children. J Pediatr Surg 2014; 49:460–464.
5. Kastenberg Z, Bruzoni M, Dutta S. A modification of the laparoscopic transcutaneous inguinal hernia repair to achieve transfixation ligature of the hernia sac. J Pediatr Surg 2011; 46:1658–1664.
6. Chang YT, Wang JY, Lee JY, Chiou CS. A simple single-port laparoscopic-assisted technique for completely enclosing inguinal hernia in children. Am J Surg 2009; 198:e13–e13e16.
7. Ozgediz D, Roayaie K, Lee H, Nobuhara KK, Farmer DL, Bratton B, Harrison MR. Subcutaneous endoscopically assisted ligation (SEAL) of the internal ring for repair of inguinal hernias in children: report of a new technique and early results. Surg Endosc 2007; 21:1327–1331.
8. Harrison MR, Lee H, Albanese CT, Farmer DL. Subcutaneous endoscopically assisted ligation (SEAL) of the internal ring for repair of inguinal hernias in children: a novel technique. J Pediatr Surg 2005; 40:1177–1180.
9. Takehara H, Yakabe 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.
10. Bharathi RS, Arora M, Baskaran V. How we ‘SEAL’ internal ring in pediatric inguinal hernias. Surg Laparosc Endosc Percutan Tech 2008; 18:192–194.
11. Treef W, Schier F. Characteristics of laparoscopic inguinal hernia recurrences. Pediatr Surg Int 2009; 25:149–152.
12. Patkowski D, Czernik J, Chrzan R, Jaworski W, Apoznański W. Percutaneous internal ring suturing: a simple minimally invasive technique for inguinal hernia repair in children. J Laparoendosc Adv Surg Tech A 2006; 16:513–517.
13. Chan KL, Chan HY, Tam PK. Towards a near-zero recurrence rate in laparoscopic inguinal hernia repair for pediatric patients of all ages. J Pediatr Surg 2007; 42:1993–1997.
14. Endo M, Watanabe T, Nakano M, Yoshida F, Ukiyama E. Laparoscopic completely extraperitoneal repair of inguinal hernia in children: a single-institute experience with 1,257 repairs compared with cut-down herniorrhaphy. Surg Endosc 2009; 23:1706–1712.
© 2016 Annals of Pediatric Surgery