Needlescopic Versus Traditional Laparoscopic Inguinal Hernia Repair in Pediatrics

Patients and methods:

• Place of the study: The study will be held in Department of Pediatric surgery in Sohag University Hospital.
• Type of the study: Prospective comparative Cohort study.
• Duration of the study: The study will last for 6 to 9 months starting from the date of acceptance of the protocol.
• Ethical considerations: The study will be carried out after approval by scientific and ethical committees of Sohag faculty of medicine.
• Method of the study:

Preoperative assessment:

• Demographic data: e.g. name, age, sex …. etc.
• History: e.g. complaint, present history and past surgical and medical history…etc.
• General and local examination: e.g. laterality, associated anomalies …. etc.
• Investigations:

Routine labs. Imaging: to confirm diagnosis in the affected side, to evaluate contralateral side, bilateral testicular volume as volumetric stander to evaluate testicular atrophy postoperative and other anomalies.

Operative technique:

Operative steps:

A. Traditional laparoscopic repair.

• STEPS:

• A 5mm port for the camera is introduced at umbilicus by open technique.
• Using triangulation rule to introduce two working ports.
• The abdomen is insufflated with carbon dioxide to 6-8 mmHg pressure in patients under 1 year of age and to 8-10 mmHg in older children.
• Diathermize the neck of the hernia sac with a diathermy hook.
• A 10-15 cm absorbable suture is passed into the peritoneal cavity through the abdominal wall next to the lateral port under vision.
• The purse-string stitch commences at the 2 o'clock position of the internal hernia opening.
• ensure that a "complete ring" of peritoneum has been included in the purse-string stitch without significant gaps.
• The purse-string suture is tied tightly using intracorporeally knot tying.

B. Needlescopic Internal Ring Suturing.

• EQUIPMENT/SUTURE:

• One 5-mm trocar and 5-mm lens 30° or 0° telescope.
• Epidural needle.
• Non absorbable suture.
• Fascial closure instrument.
• STEPS:

• A 5mm port for the camera is introduced at umbilicus by open technique.
• The abdomen is insufflated with carbon dioxide to 6-8 mmHg pressure in patients under 1 year of age and to 8-10 mmHg in older children.
• The suture is introduced through the barrel of the epidural needle.
• Maintaining both ends of the preloaded suture extra peritoneal, the needle is advanced under the peritoneum around lateral half of the internal ring.
• The peritoneum is entered and the suture advanced into the abdominal cavity, creating a loop.
• Fascial closure instrument is introduced directly through anterior abdominal wall to help to maintain suture loop.
• The needle is removed, leaving the loop in place.
• The needle is entered again through the same skin puncture site around the medial half of the ring and enter the peritoneum, leaving a small space above the vas deferens and testicular vessels to avoid injury.
• The loop of suture is introduced into the hollow of the needle again and advance the suture into the first loop by the help of fascial closure.
• Withdraw the needle.
• Catch the suture end in the loop and withdraw them together then the suture is tied extra corporeally.

Patient outcomes:

Patients assessment and follow up:

• Primary outcome measures:

Operative time. Intraoperative complication. Rate of conversion to open surgery.

• Secondary outcome measures:

1 and 3 months after the surgery to asses:

• Cosmetic appearance: according to (The Scar Cosmesis Assessment and Rating "SCAR" Scale) [7].
• Recurrence.
• Hydrocele.
• Testicular atrophy (postoperative imaging: > 50% loss of testicular volume or < 25% of volume of contralateral testis) [8].

Inclusion criteria

• Include patients presented with inguinal hernia with age < 18 years.

Exclusion criteria

• Age above 18 years.
• Complicated inguinal hernia (e.g. irreducibility, obstruction and strangulation).
• Pervious lower abdominal surgeries.