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Single-puncture Method of Laparoscopic Herniorrhaphy in Children.

Byline: Xue-Qiang. Yan, Hou-Fang. Kuang, Nan-Nan. Zheng, Jun. Yang, Xu-Fei. Duan, Zhen-Chuang. Zhu, Hong-Qiang. Bian

To the Editor: Pediatric inguinal hernia repair is a common surgical procedure performed in pediatric patients. Laparoscopic herniorrhaphy has several advantages over conventional open herniotomy; most of them related to the evaluation of possible contralateral patent processus vaginalis (PPV) and avoidance of trauma to the vas deferens and spermatic vessels.

However, percutaneous closure of inguinal hernia cannot prevent simultaneous ligation of subcutaneous tissues (sometimes nerves) of the inguinal canal between the skin and hernia sac; as such, this technique might increase the postoperative morbidity in the long run. The knot is palpable in the subcutaneous space, which might lead to varying degrees of suture reactions.

The procedure for pediatric inguinal hernia was modified to preserve the advantages and overcome the limitations of existing laparoscopic-assisted percutaneous extraperitoneal closure (LPEC). Two 3.5-mm stab incisions were made on both lateral sides of umbilicus, and two trocars of the corresponding size were inserted into the peritoneal cavity. The location of the puncture point through the surface projection of the inner ring was confirmed, and a 1.5-mm stab incision was made. A homemade needle with 2-0 nonabsorbable suture material [Figure 1] was inserted in the loose fat tissues [Figure 2]a. The first half of the circle was begun extraperitoneally from the anterior edge to the posterior edge around the internal inguinal ring. When half of the circle was accomplished, the peritoneal cavity [Figure 2]b was punctured and the end of the 2[sup]# thread into the peritoneal cavity was pulled using a grasper [Figure 2]c. The needle was pulled back slowly to the puncture point where it penetrated. In this point, the direction of the needle was adjusted [Figure 2]d and the opposite half of the internal ring was completed. The spermatic duct and gonadal vessels were crossed over carefully to avoid injury (if the patient was boy). When the previous puncture point was reached, the needle was stabbed into the peritoneal with a double thread (named 3[sup]# thread) [Figure 2]e. The 3[sup]# thread was pulled on one side of the needle to form a new loop, and the end of the 2[sup]# thread was grasped to pass through the new loop [Figure 2]f. The needle was drawn out of the abdominal cavity [Figure 2]g. Extracorporeally, the 3[sup]# thread and 1[sup]# thread were pulled simultaneously [Figure 2]h to remove the 2[sup]# thread [Figure 2]i; in this step, the 2[sup]# thread was placed around the inguinal ring under the peritoneum and both ends exit the skin through the same puncture point and tunnel. Gas collected in the distal sac was squeezed out, the thread was tied tightly extracorporeally, and the internal inguinal ring was completely closed. The knot was placed underneath peritoneally, rather than subcutaneously. When asymptomatic contralateral PPV was observed, bilateral closure was performed. During the follow-up period, no recurrence, hydroceles, metachronous hernia, or testicular atrophy were detected.{Figure 1}{Figure 2}

Laparoscopic inguinal hernia repair for childhood inguinal hernia was first reported in the 1990s.[sup][1] With the development of medical technology, laparoscopic herniorrhaphy has transitioned from intra-abdominal ligation to total extraperitoneal procedure.[sup][2]

To prevent ligation of celiac wall tissues, both ends of the ligature thread should be in the same channel. In 2014, Liu et al. [sup][3] improved the single-hole sled needle-ring method, in which the needle was punctured twice in the same channel of the abdominal wall fixed through casing. To an extent, this method reduces related complications.

In this proposed procedure, the needle is held underneath the peritoneum during the entire process through a similar method with a homemade hernia needle for LPEC; this procedure ensures that there will be only a single tunnel for two rounds of needle-insertion to prevent the risk of ligating subcutaneous tissues. The proposed method has another advantage over the existing LPEC in terms of reducing suture reactions (ranging from simple granuloma to stitch abscesses), which has been reported in approximately 3% of repairs.[sup][4] In the current procedure, no suture reactions occurred because the knot had been placed deep underneath the peritoneum rather than in the subcutaneous tissue.

In conclusion, the proposed procedure is safe, feasible, reliable, and presents a low recurrence rate; hence, the modified technique should be considered an alternative treatment for pediatric indirect inguinal hernia. However, the technology described here still does not solve the problem of how to prevent the vas deferens and spermatic cord from twisting. This will be gradually improved in the subsequent studies.

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Conflicts of interest

There are no conflicts of interest.


1. Montupet P, Esposito C. Laparoscopic treatment of congenital inguinal hernia in children. J Pediatr Surg 1999;34:420-3. doi: 10.1016/S0022-3468(99)90490-6.

2. Lee DY, Baik YH, Kwak BS, Oh MG, Choi WY. A purse-string suture at the level of internal inguinal ring, taking only the peritoneum leaving the distal sac: Is it enough for inguinal hernia in pediatric patients? Hernia 2015;19:1-4. doi: 10.1007/s10029-015-1348-7.

3. Liu W, Wu R, Du G. Single-port laparoscopic extraperitoneal repair of pediatric inguinal hernias and hydroceles by using modified Kirschner pin: A novel technique. Hernia 2014;18:345-9. doi: 10.1007/s10029-013-1181-9.

4. Ozgediz D, Roayaie K, Lee H, Nobuhara KK, Farmer DL, Bratton B, et al. 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;21:1327-31. doi: 10.1007/s00464-007-9202-3.
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Author:Yan, Xue-Qiang; Kuang, Hou-Fang; Zheng, Nan-Nan; Yang, Jun; Duan, Xu-Fei; Zhu, Zhen-Chuang; Bian, Ho
Publication:Chinese Medical Journal
Article Type:Report
Date:Aug 20, 2016
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