Needlescopic Inversion and Snaring Versus Ligation of Hernia Sac in Girls

Overview

Failure of closure of the processus vaginalis during intrauterine life will result in congenital inguinal hernia \[CIH\]. Exact incidence of CIH in children is not known but it has been reported between 1-5 %. In premature babies, the incidence may reach up to 15-30%. Congenital inguinal hernia is more common in boys than girls, ranging from 4:1 to 10:1 \[1\]. Although the open inguinal herniotomy and high ligation of the sac is the gold standard line of the treatment, Laparoscopic inguinal hernia repair become a good option. The laparoscopy has many advantages that it is simple, feasible, and safe with detection of the contralateral hernia and other hernias. In addition to laparoscopy results in excellent cosmetic results low wound infection, less pain, and short hospital stay. The non-division of the hernia sac in during laparoscopic hernia repair may be the cause of recurrence and postoperative hydrocele \[5\]. Division of hernia sac and suturing of proximal part at IIR; is modification of the laparoscopic technique which mimic what happen during open herniotomy. Some authors resected the processus vaginalis and closed the inguinal ring for the repair of CIH. They claimed that they have excellent results with low recurrence.One author described a technique based on the theory that CIH is due to a patent processus vaginalis, and therefore, the procedure should be to entirely resect it, with or without closure of the internal ring. This allows the peritoneal scar tissue to close the area of the ring. Also, this scarring occurs in the extent of the inguinal canal where the dissection took place, therefore causing the same peritoneal scarring and sealing of the inguinal floor with complete resolution of the problem. However, a few studies address the superiority of technique over the other and to date there is no controlled randomized study to compare needlescopic disconnection of the hernia sac and closure of the peritoneum at IIR versus disconnection without closure of the peritoneum.

Description of the Procedure: Instruments: 5-mm trocar and 5-mm 30° telescope, single 2-mm reusable port, two 14-G (1.6-mm) suture grasper devices \[SGD\] \[Mediflex Company, Islandia, New York, USA\], Home made isolated diathermy probe and an endoscopic polypectomy snare \[SN\]. SN is modified by shortening from 2-m to 70-cm. It fits directly in 2-mm port. Operative details: Patient lies in supine position at upper part of OR table towards right edge. OR table tilted to opposite side of hernia with 30- degree Trendelenburg position. Operator stands on patient's right side during either uni-or bi-lateral hernia. Camera man stands at table head and monitor facing patient's feet. Povidone Iodine solution was applied from nipple to mid-thigh and child is then draped. Vertical trans umbilical 5-mm incision is made and 5mm trocar passed under vision using open technique. Pneumoperitoneum is then established with CO2 flow of 1.5-2.5 L/min keeping intraabdominal pressure between 8-12 mmHg according to age and weight. Two-mm incision at point (A) located at junction of upper 1/3 and lower 2/3 of line extending between umbilicus and symphysis pubis for 2mm port passed under direct vision. A 1.6-mm 11-blade scalpel puncture 2- cm. above the corresponding Mc-Burney's Point (B) for SGD. Abdomen is explored to confirm the diagnosis and detect bilateral hernia if present. One SGD was introduced through point A (SGD-A) and another\] one through point B (SGD-B). Both SGDs were used to invert the hernia sac by gradual sustained alternating traction on the round ligament. Each SGD hands to the other one till complete inversion occurs, this is known by the sac hanging from internal ring without retracting-back inside the inguinal canal. At this point, snare (SN) is passed from the trocar at point A in the place of SGD-A and opened inside the abdomen. SGD-B passes inside the loop of SN and re-catches the hernia sac, which is then twisted around its neck several time. SN is closed tightly and diathermy current is applied to it leading to separation of hernia sac at the proper neck. \[2-4\]Detached sac (grasped by SGD-B) is then pushed antigradely out through the umbilical port. Deflation of the abdomen is done and umbilical fascial incision was closed using 2/0 or 3/0 Vicryl and umbilical skin layers were closed using 4/0 Vicryl. Group B; The above operative details will be applied but the inverted twisted sac will be ligated by a home made 3/0 Vicry suture endoloop befor excision and extraction \[5\].