LAPAROSCOPIC INGUINAL HERNIA INVERSION AND LIGATION IN PEDIATRIC FEMALE PATIENTS, THE EGYPTIAN EXPERIENCE

LAPAROSCOPIC INGUINAL HERNIA INVERSION AND LIGATION IN PEDIATRIC FEMALE PATIENTS, THE EGYPTIAN EXPERIENCE Rifaat Ibrahem Pediatric Surgery Unit, Faculty of Medicine- Al-Azhar University ABSTRACT PURPOSE: Laparoscopic inguinal hernia inversion and ligation is a new, simple, and easy method of pediatric female hernia repair. Simply the surgical procedure includes inversion of the hernial sac towards the peritoneal cavity followed by twisting, transfixation ligation of the neck and excision of the sac. METHODS: A prospective study of laparoscopic inguinal hernia repair in 77 pediatric female patients from March 2010 to June 2012 were done in the pediatric surgery units of Al-Azhar University Hospitals, Cairo, Egypt. RESULTS: One hundred nineteen laparoscopic inguinal hernia inversion and ligation procedures were performed on 77 pediatric female patients. Patients age ranged from 10 months to 12 years. Of the clinically right inguinal hernias 35.5% were found to have bilateral hernias intraoperatively, and of the clinically left inguinal hernias 40% were found to have bilateral hernias intraoperatively. There were no intraoperative complications, there have been postoperative wound complications in 4 hernia repairs (2.4%) and one recurrences (0.8%).CONCLUSIONS: Laparoscopic inguinal hernia inversion and ligation in female children is safe and effective. This approach is used at the pediatric surgery department of Al-Azhar University hospitals for most girls with inguinal hernias and found to be a simple procedure with minimal complications, a very low recurrence rate, and excellent cosmoses. It is still up to the parent to decide what risks are preferred: a metachronous hernia, or the 170

RIFAAT IBRAHEM increased rate of recurrence. Therefore, it seems wise at this time that a pediatric surgical team be well versed in all approaches in order to combine the advantages to the benefit of the patient. INTRODUCTION Inguinal hernia is a common condition in children. The treatment for this condition is high ligation of patent processus vaginalis at the level of the internal inguinal ring. This can be achieved either by conventional open method or by laparoscopic technique. [1] The advent of laparoscopy has changed many dogmas in all fields of surgery, pediatric hernia repair included. Many operations that were considered as gold standard are being challenged by the laparoscopic approach and the new technologies it has brought with it. [2] Therefore, two major applications of laparoscopy were introduced to hernia repair in children. The first, performing an intra-operative diagnostic laparoscopy for diagnosing a non-symptomatic contralateral hernia during open hernia surgery. The second, performing a laparoscopic repair. [3] There have been conflicting reports regarding the place of laparoscopy in the treatment of inguinal hernia in children. [4] At the moment, laparoscopic inguinal hernia repair is not only possible in children, but also is gaining ground as a safe, feasible, and popular method. [5] There are, however, several reports comparing the conventional open method and laparoscopic inguinal hernia repair in children, but the current trend is toward laparoscopic method. [6] With increasing interest in laparoscopic inguinal hernia repair, several treatment techniques have developed over the past two decades, aimed at improving the outcome. [7] The various techniques differ in their approach to the inguinal internal ring, suturing and knotting techniques, number of ports used in the 171

procedure, endoscopic instruments used, mode of dissection of the hernia sac, and gender of the patient as well. The emerging techniques show a tendency for simple extracorporeal suturing and knotting technique, and diminished use of endoscopic ports and instruments. [8] Laparoscopic inguinal hernia inversion and ligation described as a safe and effective operation in girls for the first time in the literature in 1997 by El- Gohary. [9] Zallen and Glick in 2007 reported it again in a small series. [10] Hong et al. described their initial experience with this procedure in 14 girls in 2004. [11] Aaron et al. published a retrospective review of inguinal hernia repair in 173 consecutive girls from 2003 to 2009 at a single institution. They concluded that laparoscopic inguinal hernia inversion and ligation is a safe and effective operation in girls with a low recurrence rate. Benefits of this procedure include diagnosis and repair of the contralateral side using the same incisions, diagnosis of androgen insensitivity and other dysgenic situations, excellent cosmesis and this procedure is a straightforward technique that can be performed by most pediatric surgeons with basic laparoscopic skills. [12] The aim of this article is to review the role of laparoscopy in inguinal hernia repair in female children, the emerging laparoscopic inguinal hernia inversion and ligation surgical technique, and its current trend in pediatric surgical practice. PATIENTS AND METHODS This prospective randomized clinical study was conducted on 77 female pediatric patients presented with inguinal hernia from March 2010 to June 2012 in the pediatric surgery units of Al-Azhar University Hospitals, Cairo, Egypt. The study protocol was approved by the hospital ethical committee. Criteria for enrollment included unilateral inguinal hernia, bilateral inguinal hernia, and ipsilateral hernia with a questionable hernia on the contralateral side. Exclusion 172

RIFAAT IBRAHEM criteria included recurrent hernia, hernia in morbid obese children, complicated hernia, patients who could not tolerate pneumoperitoneum (e.g., congenital heart disease). The main outcome measurements were operative time, hospital stay, complications, recurrence rate, and cosmetic results. The procedure was adopted from Aaron et al. 2010. [12] Under general anesthesia the patient was placed in the supine position on the operating room table, with the abdomen and groin sterility prepped. The stomach is emptied with a suction catheter and the urinary bladder using Crede's maneuver (appling manual suprapubic gentle pressure), where older children are asked to urinate prior to entering the operating room. Five-mm, 30 laparoscope inserted through a trocar that is placed directly through the base of the umbilicus (open-hasson technique), so that incision was completely hidden. Pneumoperitoneum was established with carbon dioxide according to appropriate age (8 10mmHg). Initially the abdomen was visualized using a 5-mm, 30 scope with the operating table positioned in moderate reverse Trendelenburg's position. The pelvis was inspected for anatomical variations of the uterus, ovaries and adnexa, and the inguinal rings are evaluated (Fig. 1A). Preferably two 2.7-mm working instruments are introduced through two lower abdominal stab incisions with (or without) the use of ports following detailed anatomic investigation. By the help of two grasping dissectors, the tip of the hernia sac was grasped by the ipsilateral grasper (Fig. 1B) and gently inverted into the abdominal cavity through the inguinal canal (Fig. 1C). One must be gentle with this blunt traction maneuver since brutal disruption of the distal attachments of the round ligament to the labia may lead to edema formation or extraperitoneal hemorrhage, which may render suturing of the neck of the inverted sac. 173

In cases in which the fallopian tube was near or in the hernia sac (sliding hernia), it can be freed up using a combination of blunt and sharp dissection. The ipsilateral ovary was exposed to confirm that both were not involved in the hernia and to rule out androgen insensitivity and other dysgenic syndromes. In the case of an incarcerated ovary, it can usually be reduced laparoscopically during the inversion by applying external pressure on the groin. The final portion of the operation was ligation and resection of the hernia sac. After confirming that the sac was free of its surrounding attachments, it was twisted on itself (Fig. 1D) and the needle and thread are passed into the abdomen through one port. By the help of a needle holder and grasping dissector, a 2/0 polypropylene transfixing suture was passed through the twisted sac just above the internal ring (Fig. 1E). The first knot locked extracorporeal and the needle pushed away to bring the locked suture (loop) downwards towards the neck of the twisted sac (Fig. 1F). The suture was then secured from the opposite side at the base of the inverted hernia sac. The twisted sac was resected about 1 cm above the knot after completion of suturing (Fig. 1G), since most published studies agree upon the fact that local peritoneal healing aids in preventing recurrences. A similar repair was applied to the contralateral side when indicated using the same incisions. Operation was terminated by removing all instruments under direct vision (Fig. 1H). The fascia and skin are closed with single Vicryl stitch. Stab incisions may be closed and dressed with Steristrips. Caudal block may additionally be used regarding parental consent. Otherwise, it was preferable to infiltrate all instrument or port sites prior to skin closure using local anesthetics. (All incisions are infiltrated with 0.25% bupivacaine solution). A prospective chart of all laparoscopic inguinal hernia repairs in pediatric girls (with this simple technique) including demographic, preoperative, 174

RIFAAT IBRAHEM intraoperative, and postoperative data were collected and analyzed. Statistical analysis was performed using the unpaired Student s t test. Fig. 1 Different steps of laparoscopic inguinal hernia inversion and ligation in a female pediatric patient 175

RESULTS Seventy seven female pediatric patients with inguinal hernia were operated upon laparoscopically. Their age ranged from 10 months to 12 years (Table 1). Clinically, 45 of the patients had right sided inguinal hernia, 10 had left sided inguinal hernia and 22 had bilateral inguinal hernia (Table 2). Table 1: Age distribution of the patients Age No. % Up to 2 years 7 9% 2-6 years 55 71.5% 7-12 years 15 19.5% Total 77 100% Table 2 : Clinical distribution of the side of the hernia Site of the hernia No. % Right sided 45 58.5% Left sided 10 13% Bilateral 22 28.5% Total 77 100% Intraoperatively, 20 of the clinical unilateral inguinal hernias were found to have a contralateral patent processus vaginalis or contralateral inguinal hernia, and all of these were repaired during the same operation using the same incisions (Tables 3 and 4). 176

RIFAAT IBRAHEM Table 3 : Intraoperative incidence of bilateral inguinal hernia Clinical site of the hernia Operative site of the hernia No. % Right sided (R) 16L/45R 61 hernias in 45 patients (100%+35.5%) Left sided (L) 4R/10L 14 hernias in 10 patients (100%+40%) Bilateral (R+L) 22R+22L 44 hernias in 22 patients (100%+100%) Total 71R/48L 119 hernias in 77 patients (100%+54.5%) Table 4 : Final distribution of the side of the hernia Site of the hernia No. Clinical Operative Total Right sided 45 45+4=49 49+22=71 Left sided 10 10+16=26 26+22=48 Bilateral 22 22+22=44 ---- Total 77 patients 119 hernias 119 hernias The mean operative time for unilateral hernia was 35 minutes (±9 minutes). The mean difference in time between unilateral and bilateral inguinal hernia repairs was approximately 10 minutes (Table 5). The difference in time for unilateral and bilateral repairs was statistically significant (p<0.001). Table 5 : Operative time in relation to the site of the hernia Site of the hernia Single side Right sided 26-41 min. Time (min.) Mean (min.) 33.5 min. Left sided 28-44 min. 34.5 min. Total 27-43 min. 35 min. Bilateral 38-50 min. 43.5 min. Total 35-48 min. 42 min. 177

There were no intraoperative significant complications, and there were no measurable blood loss in most cases. Ten patients had sliding hernias. Dissection of the fallopian tube was performed from the hernia sac in these patients. There were three girls with adherent ovaries to the interior of the sac. All ovaries were dissected and were freed from the sac (Table 6). Ovarian dissection resulted in significant increase in the time of the procedure (p<0.001). Table 6: Relations between side of the hernia (intraoperative) and operative difficulty Site of the hernia Sliding hernia Ovarian incarceration No. % Right sided 6 2 9/29 31% Left sided 1 1 2/6 33.3% Bilateral 3 0 3/42 7.1% Total 10 3 13/77 16.9% Postoperatively, 65 of the girls were discharged the same day of the operation. Twelve patients were discharged on the second postoperative day (Table 7). One patient for delayed recovery, six patients for postoperative different complaints, and five patients were residing far away from the hospital. Table 7 : Postoperative discharge Site of the hernia Postoperative discharge The same day The second day Total Right sided 27 (93%) 2 (7%) 29 (100%) Left sided 6 (100%) 0 (0) 6 (100%) Bilateral 32 (76%) 10 (24%) 42 (100%) Total 65 (84.5%) 12 (15.5%) 77 (100%) 178

RIFAAT IBRAHEM Postoperative follow up revealed that 4 patients developed wound complications (three cases of superficial infection and one case of deep infection). There were one recurrence (in the bilateral hernia group) due to slipped ligature of the twisted sac and repaired using an open technique (Tables 8 and 9). Table 8: Post-operative complications according to number of the patients Post operative complications No. % Non complicated cases 72 93.5% Complicated cases Superficial infection 3 3.9% Deep infection 1 5 1.3% Recurrence 1 1.3% 6.5% Total 77 100% Table 9 Post-operative complications according to number of the hernias Post operative complications No. % Non complicated hernias 114 95.8% Superficial infection 3 2.6% Complicated Deep infection 1 5 0.8% 4.2% hernias Recurrence 1 0.8% Total 119 100% 179

DISCUSSION Inguinal hernia is a very common condition in children and adults and is the most common operation performed on children (other than ritual circumcision). Since the classic open surgery in female pediatric patient was introduced (the standard repair in females involves a small groin incision on the affected side, with or without incision of the external oblique muscle and opening of the external ring, dissection of the hernia sac, and high ligation and excision of the sac), it has become the standard operation for hernias, with very few controversies: whether the surgeon should perform only a herniotomy, whether a contralateral groin exploration be performed, and so forth. The operation is quick, safe, and can be done in an outpatient setting with anesthesia via a laryngeal mask. The recurrence rate is acceptable, 1-3%, depending on the expertise of the surgeon, the female child age and concomitant diseases. [13] The advent of laparoscopy has changed many dogmas in all fields of surgery, pediatric hernia repair included. Many operations that were considered as gold standard are being challenged by the laparoscopic approach and the new technologies it has brought with it. Therefore, two major applications of laparoscopy were introduced to hernia repair in female pediatric inguinal hernia. The first, performing an intra-operative diagnostic laparoscopy for diagnosing a non-symptomatic contralateral hernia during open hernia surgery. The second, performing a laparoscopic repair. [14] The incidence of a contralateral, asymptomatic groin hernia in children is not well defined. Reports vary from 10% to 60%, [15] depending on prematurity of the child, gender and side, which is comparable to the results of the present study [20/55 (36.4%)]. Also, there is no consensus on whether a patent processus vaginalis is considered a hernia for practical purposes, i.e. whether it should be repaired or not. It is established that the premature have a higher 180

RIFAAT IBRAHEM incidence of bilateral hernias, and that bilateral hernias are commoner in females with a left sided hernia, [15] which is also comparable to the results of the present study [16/45 (35.5%) on the right sided hernia, and 4/10 (40%) on the left sided hernia]. Until laparoscopy developed, there was controversy regarding whether a contralateral groin exploration should be performed and to whom. On the one hand, an exploration ensured a diagnosis during one operation and anesthesia, an option that carries many advantages to the patient and the parents. On the other hand, most of these explorations performed on children above the age of 1 year were negative, and doubling the operating and anesthetic time. Therefore, most surgeons had loosely based criteria on whom the exploration was performed. Since a hernia can be very easily and accurately diagnosed from within the peritoneum, introduction of a laparoscope during the operation seemed like a natural answer for the question. [16] Many minimally invasive procedures have been proposed for pediatric inguinal hernia repair, including high ligation with or without dissection of the internal ring (using intracorporeal/extracorporeal suturing and/or endolooping), [17] subcutaneous endoscopically assisted ligation, [18] and percutaneous internal ring suturing. [19] A minimally invasive surgical approach for the repair of pediatric inguinal hernias has yet to become the procedure of choice in most institutions. Diagnostic trans-inguinal laparoscopy provides definite advantages in the accurate diagnosis of a contralateral synchronous hernia during a single anesthesia. It is easy to learn and is very comfortable for a surgeon that is proficient in the open hernia repair technique. Usually, the pneumoperitoneum required does not preclude anesthesia via a laryngeal mask and does not require paralytic agents. [20] 181

Female pediatric inguinal hernias are inherently simpler to repair because there is no need to dissect and protect the structures in the spermatic cord. There are definite advantages to the laparoscopic hernia repair in female children. This approach offers excellent diagnosis of a synchronous hernia or patent processus vaginalis and the herniotomy is performed with minimal handling and potential damage to the adenexa. It is very useful for treating incarcerated or recurrent hernias, bypassing the anatomical challenges in these cases. After a necessary learning curve, most technical pitfalls can be avoided and operating times shortened to those of the open hernia repair. [21, 22] In 1997, El-Gohary described a technique of laparoscopic inguinal hernia repair in girls involving inversion of the hernia sac into the abdominal cavity and endoscopic loop tie placement at the base of the inverted sac. His original description of the procedure used three 5-mm ports. He reported no complications in 28 patients, 11% contralateral patency, and 1 recurrence. [9] Zallen and Glick in 2007 reported 37 cases of laparoscopic inguinal hernia inversion and ligation in girls using one 5-mm port and two 3-mm stab incisions. There were no complications or recurrences in this series. [10]Aaron and his colleagues in 2010 used this approach in all female pediatric hernias from 2003 to 2009 with the exception of children who have contraindications to pneumoperitoneum. They performed 241 laparoscopic inguinal hernia inversion and ligations in 173 girls. They had no intraoperative complications, with recurrence rate of (0.83%). In addition, laparoscopic inguinal hernia inversion and ligation has not added time to the operation, especially in cases of bilateral hernias. [12] In the present series, 77 female pediatric patients underwent the same procedure on 119 hernias, with good operative time, minimal complications (6.5% as regard patients number, or 4.2% as regard hernias number), and 182

RIFAAT IBRAHEM recurrence (1.3% as regard patients number, or 0.8% as regard hernias number), which is comparable to the complication, and recurrence rate reported in similar series [9, 10, 12], and most large series of open inguinal hernia repairs. [23] Major advantages of this procedure as compared to the open approach are, first, the ability to easily diagnose and treat contralateral patent processus vaginalis is obvious. These defects were easily repaired at the same operation without additional incisions and with minimal additional time. [24, 25] A second benefit is the ability to diagnose androgen insensitivity and other dysgenic syndromes. There is a slightly higher incidence of these conditions in girls with inguinal hernias, and Laparoscopic inguinal hernia inversion and ligation allows for careful inspection of the uterus, ovaries, and fallopian tubes. [26, 27] One of the major setbacks of laparoscopic inguinal hernia repairs in children has been the troubling rate of recurrences. [28, 29] This is unacceptable as open inguinal hernia repairs have a very low recurrence rate (<1%). [3] The present study had only one recurrence which occurred very early. It may be due to loose ligature on peritoneal sac augmented with dense extraperitoneal fat. The laparoscopic approach does require a learning curve. Most surgeons feel very comfortable with the open technique and would rather face the challenges of a difficult case such as the incarcerated, recurrent or complicated hernia than learn a completely new technique. [30] Laparoscopy in infants requires a more complex anesthetic setting with facilities and personnel that may be not available in outpatient clinics. Undoubtedly, for the time being, laparoscopic repairs carry a higher recurrence rate. Although recurrence after laparoscopy is not as challenging as after open repair, this should be weighed against the potential benefits of the approach. [31, 32] 183

CONCLUSION The advent of laparoscopy has widely changed the scope of pediatric hernia repairs. Whether as a diagnostic or operative tool, the use of laparoscopy is widely gaining popularity as it provides an answer to many dilemmas. Since there are advantages and disadvantages to all approaches, a consensus as to the best approach has not been reached. It seems logical that there is no dogmatic best approach for all cases, each case requiring a specific tailoring of the care required. Laparoscopic inguinal hernia inversion and ligation in female children is safe and effective. This approach is used at the pediatric surgery department of Al-Azhar University hospitals for most girls with inguinal hernias and found to be a simple procedure with minimal complications, a very low recurrence rate, and excellent cosmoses. It is still up to the parent to decide what risks are preferred: a metachronous hernia, or the increased rate of recurrence. Therefore, it seems wise at this time that a pediatric surgical team be well versed in all approaches in order to combine the advantages to the benefit of the patient. 184

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