Pediatric Laparoscopic Inguinal Hernia Repair: A Review of Techniques

First submitted by:
Karen Elizabeth Speck
(see History tab for revisions)
Category
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Compiled by Anne K. Smith, BS# and K. Elizabeth Speck, MD*
#Medical student, Vanderbilt, *Assistant Professor, Department of Pediatric Surgery, Vanderbilt, Nashville, TN.
All illustrations are original artistic renditions of photographs, pictures or descriptions from the literature or videos 
by Ishan Asokan, M.Sc, BA#

Overview

Minimally invasive surgery has been shown to be feasible and safe in pediatric patients since 1975 when laparoscopic surgery was first used to treat a small bowel obstruction.1  Laparoscopy is  an option for surgical repair of inguinal hernias in addition to the traditional open approach.  Since its advent, there has been considerable evolution with the introduction of a number of innovations.  Each iteration has maintained the basic premise of surgical repair in pediatric inguinal hernias – high ligation of the sac.  These techniques can broadly be grouped into those that are performed fully intracorporeally and those that have extraperitoneal components, namely the suturing.

Laparoscopic repair is typically performed under general anesthesia.  The patient is positioned supine, often in the Trendelenberg position.  Most descriptions position the surgeon on the side contralateral to the hernia with the monitor on the ipsilateral side.  The abdomen is insufflated, typically through the umbilicus, to a pressure of 8-15mmHg depending on the size of the child.  A variety of sizes of trocars, cameras, and instruments can be used, with the goal of smaller incisions.  Any hernia contents are reduced before beginning repair of the hernia.  With laparoscopy, the contralateral side can be evaluated and bilateral repair performed when necessary. 

During intracorporeal techniques, all suturing and knot tying is done within the abdominal cavity with laparoscopic instruments.  In extracorporeal techniques, laparoscopic localization with external compression is used to make an incision once the desired spot near the ring is identified.  Some surround the sac entirely in the preperitoneal space and others enter the peritoneum adjacent to the vas or vessels for exchange of the suture.  With extracorporeal techniques, the suture is tied extracorporeally, with the knot buried in the subcutaneous tissue.  For both intracorporeal and extracorporeal techniques, great care is taken in boys to exclude the vas deferens and spermatic vessels, while in girls the round ligament may be included in the closure.  The abdomen can be desufflated and before tying the suture, any air or fluid in the sac is manually expressed with external compression.  The umbilical port site fascia is typically sutured closed, while the other incision sites are often closed solely with steri-strips or skin glue.

Laparoscopic repair of inguinal hernias in pediatric patients was first described in 1997 by El-Gohary.2  Initially this operation was performed only in female patients because the safety of the vas and vessels are of concern in males.  Monteput and Esposito5 were the first to use laparoscopy in the repair of inguinal hernias in male children using an intracorporeal purse-string suture to close the inguinal ring, while Schier described intracorporeal Z-suture closure first in girls only (1998)6 and then in boys (2000).7  New adaptations of fully intracorporeal techniques in girls only4 and in both sexes8-11 have continued to evolve over the years.  In 2003, Chan and Tam8 added intracorporeal hydrodissection as a strategy to more easily avoid the vas and vessels in boys.  Other adaptations of intracorporeal techniques involve incising the peritoneum,9 using peritoneum to cover the patent processus vaginalis,10 and laparoscopically excising the sac.11

In 2003, the use of extracorporeal suturing was described by Prasad et al.12  Since then, a variety of devices have been fashioned and modifications made to make the extracorporeal technique less technically challenging and/or to ensure improved ligation of the hernia sac.13-24,26,29  Hydrodissection has been used not only intracorporeally, but also in extracorporeal techniques.19,24,26,29  The most recent advances involve decreasing the number of incisions necessary for the repair.26,29  One technique has used diagnostic laparoscopy for hernia confirmation to create a smaller incision for an otherwise relatively standard open repair.25 

Below are descriptions of the unique techniques for pediatric laparoscopic inguinal hernia repair, using text, pictorial representations, and video.  Listed colloquial terms used in the papers and videos were maintained.  These techniques were discovered through an exhaustive PubMed search and videos through YouTube.  Published techniques with only minor variations from a previously published protocol were included in the reference section but not described.  These data are compiled for summary purposes to demonstrate the evolution of laparoscopic pediatric hernia repair.  No formal recommendations regarding the choice of technique are made.  

To access referenced content, click on the links at the end of the description (for videos) or click on the citation in the References section.

Girls only (intracorporeal):

Laparoscopic Inguinal Hernia Inversion and Ligation (LIHIL)

El-Gohary (1997),2 Lipskar et. al (2010)3*

  • EQUIPMENT/SUTURE:
    • 5-mm infraumbilical trocar and 30° laparoscope
    • Two 5-mm trocars2 or two 2.7-mm stab incisions3 in upper flanks
    • Maryland grasper
    • 0-PDS Endoloop
  • STEPS:

1.Introduce a grasper through the ipsilateral incision/trocar

2.Place grasper into the hernia sac and grasp the distal end

3.Invert the sac into the abdominal cavity

  • If the fallopian tube or ovary are involved in the hernia, they can be freed using a combination of blunt and sharp dissection, and external pressure

4.Insert an Endoloop through the contralateral incision

5.Pass the Maryland through the loop and regrasp the hernia sac

6.Twist the hernia sac forming a neck at the base

7.Secure the Endoloop at the neck

8.Repeat with 2nd Endoloop for double ligation

9.Excise the remainder of the sac

*Above is a description from Lipskar,2 which utilizes the original El-Gohary3 technique with 2.7-mm rather than 5-mm accessory trocars

ped inguinal hernia 1

Burnia
Godoy Lenz (2013)4§

  • EQUIPMENT/SUTURE:
    • Veress needle and small-caliber tubing for insufflation
    • No trocars used
    • Laparoscopic grasper
  • STEPS:

1.Make an umbilical incision (single incision procedure)

2.Insert Veress needle for insufflation

3.Exchange Veress for small caliber intra-abdominal insufflation tubing

4.Introduce laparoscope and grasper adjacent to the tubing

5.Place grasper into the hernia sac and grasp the distal end

6.Invert the sac into the abdominal cavity

7.Use grasper to cauterize the end of the hernia sac

§ Above is a description of a youTube video, no written description was available:

Both boys and girls:

      Intracorporeal:

Intracorporeal purse-string
Montupet & Esposito (1999)5

  • EQUIPMENT/SUTURE:
    • 5-mm, 0° laparoscope
    • Two 3-mm trocars inserted 3-4cm below the umbilicus on each side
    • 3-0 absorbable suture
  • STEPS:

1.Incise the periorificial peritoneum lateral to the internal ring

2.Create an intracorporeal purse-string stitch around the internal ring

3.In larger hernias (>4-5mm), add one or more interrupted stitches between the conjoined tendon and crural arch

ped inguinal hernia 2

Intracorporeal “Z-suture
Schier (1998)6 in girls only, (2000)7 in both

  • EQUIPMENT/SUTURE:
    • Veress needle
    • 2- or 5-mm laparoscope
    • Two #12 venous cannulae (or 2-mm trocars)
    • 1.7-mm forceps – contralateral side
    • 2-mm needle holder – ipsilateral side
    • 8-cm 4-0 PDS
  • STEPS:

1.Insert two venous cannulae or 2-mm trocars through the anterior abdominal wall superiomedially to the anterior superior iliac spines on each side

2.Pass suture directly through the abdominal wall

3.Close the inguinal ring with 2 or 3 Z-sutures lateral to the vas and vessels

4.Tie sutures intracorporeally

ped inguinal hernia 3

Intracorporeal purse-string with intracorporeal hydrodissection
Chan & Tam (2003)8

  • EQUIPMENT/SUTURE:
    • 5-mm umbilical trocar
    • Two 5-mm trocars lateral to the rectus on each side
    • Irrigation and suction metal cannula
    • Endoscopic injector (6F, 155mm, NM-3K injector; Olympus)
    • Laparoscopic forceps
    • 4-0 prolene suture
  • STEPS:

1.Insert metal cannula into the peritoneal cavity

2.Pass endoscopic injector through the lumen of the cannula (which will be used to stiffen and guide the injector) and cover the opening of the cannula with a plastic cap to prevent gas leakage

3.Pass forceps through the 3rd trocar to pick up the peritoneum near the site where the vas deferens and testicular vessels join

4.Inject 2mL normal saline into the extraperitoneal space to lift the peritoneum away from the vas and vessels

5.Withdraw the cannula and the injector

6.Pass suture directly through the abdominal wall into the peritoneal cavity

7.Complete a purse-string suture around the internal ring with the first bite into the peritoneum taken over the site of hydrodissection

8.Probe the closure for potential residual peritoneal defects. Add interrupted stitches as necessary

ped inguinal hernia 4

Laparoscopic sac resection and peritoneal closure
Becmeur et al. (2004)9

  • EQUIPMENT/SUTURE:
    • 5-mm umbilical trocar
    • Two 3-mm trocars placed laterally, just below the level of the umbilicus on each side
    • 3-0 Vicryl
  • STEPS:

1.Intracorporeally, circumferentially incise the peritoneum at the internal inguinal ring

2.Completely divide the processus vaginalis by separating the sac and the peritoneum at the level of the internal inguinal ring

3.Free the entirety of the processus vaginalis from the vas and vessels to excise the entirety of the hernia sac intact

4.In females, sever the round ligament

5.Introduce suture directly through the abdominal wall

6.Laparoscopically close the ring, avoiding the vas and vessels

ped inguinal hernia 5

Flip-flap
Yip et al. (2004)10

  • POSITIONING:
    • operating surgeon standing at cephalad end of the bed
    • assistant standing on side contralateral to hernia
  • EQUIPMENT/SUTURE:
    • 5-mm infraumbilical trocar and 30° laparoscope
    • Two working trocars inserted in both flanks
    • 4-0 polypropylene suture
  • STEPS:

1.Intracorporeally incise the peritoneum near the anterior and lateral edge of the hernia defect

2.Raise a peritoneal flap laterally that is large enough to cover the hernia defect with blunt dissection beneath the flap

3.With the anterior and lateral half circumference of the sac detached from the surrounding soft tissue the sac spontaneously collapses

4.Introduce suture directly through the abdominal wall

5.Flip the peritoneal flap medially and anchor it with the stitch, tying intracorporeally

ped ing hernia 6

Intraperitoneal hernia sac division and purse-string closure
Wheeler et al. (2011)11

  • EQUIPMENT/SUTURE:
    • 3-mm umbilical trocar and 2.7-mm 30° laparoscope
    • Atraumatic graspers
    • Laparoscopic scissors connected to diathermy or hook cautery
    • 3-0 or 4-0 Vicryl
  • STEPS:

1.Two stab incisions 6-cm lateral to umbilicus on each side

2.Circumferentially incise the peritoneum around the internal ring using scissors or hook cautery, freeing the peritoneum from the vas and vessels beneath

3.Close the proximal defect with a purse string suture

ped inguinal hernia 8

Extracorporeal:

Extracorporeal with steel awl
Prasad et al. (2003)12

  • EQUIPMENT/SUTURE:
    • 2-mm umbilical trocar and 1.7-mm laparoscope
    • 2-mm trocar in lateral abdomen
    • 1.7-mm grasper
    • curved steel awl
    • 2-0 nonabsorbable, braided suture
  • STEPS:

1.Make a stab incision anterolateral to the internal ring and pass a curved awl threaded with suture until the level of the peritoneum is reached

2.Pass the awl and suture around the lateral half of the internal ring

3.When half of the sac is surrounded, pierce the peritoneum with the awl

4.Secure the end of the suture with the grasper and withdraw the awl

5.Reinsert the empty awl into the stab wound and pass it around the medial half of the ring

6.Reenter the peritoneum at the same spot the suture enters the peritoneal cavity

7.Visualize the vas and vessels to ensure they were excluded from the repair

8.Pass the end of the suture through the hole in the awl

9.Withdraw the awl

10.Tie suture extracorporeally

ped inguinal hernia 9

Subcutaneous Endoscopically Assisted Ligation (SEAL)
Harrison et al. (2005)13

  • POSITIONING:

Infant:

ped inguinal hernia 10

Larger child:

ped inguinal hernia 11

  • EQUIPMENT/SUTURE:
    • 3-mm umbilical trocar and 2.7-mm 30° laparoscope
    • 2-0 Tevdek suture on a large swaged-on needle (T12 or T20)
    • Tuohy needle bent into identical curve to the swaged needle with syringe as a handle
  • STEPS:

1.Using the swaged-on needle, enter the skin on the lateral side of the internal ring

2.Guide the needle in the extraperitoneal space from lateral to medial around the half of the ring, excluding the vas and vessels

3.Advance the Tuohy needle on the medial aspect of the internal ring and guide it around in the extraperitoneal space towards the swaged-on needle

4.Push the swaged-on needle into the hollow of the Tuohy needle; with matched curves they should lock together

5.Back the Touhy needle out toward the skin

6.When the swaged-on needle tip is visible beyond the skin, release it from the Touhy needle and grasp the tip with needle-holder

7.Without entirely removing the swaged-on needle from the skin, back it through the subcutaneous tissue anterior to the internal ring

8.Bring the end of the needle out of stab incision it originally entered through

9.Tie suture extracorporeally

ped inguinal hernia 12

Laparoscopic Percutaneous Extraperitoneal Closure (LPEC)
Takehara et al. (2000,14 200615), Oue et al. 200516

  • EQUIPMENT/SUTURE:
    • 4.7-mm to 5-mm umbilical trocar and 4.5-mm to 5-mm laparoscope 2-mm grasping forceps or 3-mm grasping forceps with 3-mm trocar
    • 19-gauge LPEC needle (special needle with wire loop at tip, such as Lapaherclosure™ needle – Hakko Medical Co., Tokyo, Japan16)
    • 2-0 nonabsorbable suture
  • STEPS:

1.Insert grasping forceps with or without trocar on the ipsilateral side to the hernia

2.Insert LPEC needle threaded with suture at the midpoint of the inguinal line on the affected side

3.Guide the needle around the lateral half of the circumference of the internal inguinal ring and advance through the peritoneum

4.Remove the suture material from the needle, leaving it intraabdominally

5.Pass the needle around the medial half of the rim of the internal ring entering the skin and peritoneum at the same locations

6.Grasp the suture material by the wire loop inside the needle

7.Remove needle with suture from the abdomen

8.Tie suture extracorporeally

ped inguinal hernia 13

Percutaneous Internal Ring Suturing (PIRS) with 18-gauge needle
Patkowski et al. (2006)17

  • EQUIPMENT/SUTURE:
    • 2.5-mm trocar and 2.5-mm 5° laparoscope, or 5-mm trocar and 5-mm 5° or 25° laparoscope
    • 18-gauge hollow-bore needle
    • Nonabsorbable 2-0 monofilament suture
  • STEPS:

1.Introduce the suture through the barrel of the hollow-bore needle

2.Maintaining both ends of the preloaded suture extraperitoneally, advance the needle under the peritoneum around lateral half of the internal ring

3.Enter the peritoneum and advance the suture into the abdominal cavity, creating a loop

4.Remove the needle, leaving the loop in place

5.Advance the needle 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 prevent injury

6.Introduce one end of the suture into the hollow of the needle again and advance the suture into the loop

7.Withdraw the needle

8.Catch the suture end in the loop and withdraw them together

9.Tie suture extracorporeally

ped inguinal hernia 14

Extracorporeal with Reverdin needle
Shalaby et al. (2006)18

  • EQUIPMENT/SUTURE:
    • Veress needle
    • 2.7-mm infraumbilical trocar and laparoscope
    • 3-mm trocar-lateral to rectus at the level of the umbilicus
    • Reverdin needle
    • 3-0 PDS
  • STEPS:

1.Mount Reverdin needle with suture

2.Incision for Reverdin needle:

  • Right: 2-cm above and lateral to the right internal inguinal ring
  • Left: 2-cm above and medial to the left internal inguinal ring

3.Advance the Reverdin needle around half of the ring, using the grasper to exclude the vas and vessels in a relatively loose fold

4.Open the hollow of the needle and use the grasper to remove the suture

5.Withdraw the needle

6.Reenter through the same skin site and advance the needle along the other half of the ring, again using the grasper to exclude the vas and vessels

7.Enter the peritoneum

8.Open the hollow of the needle and mount the intraabdominal end of the suture

9.Close the hollow of the needle and withdraw it with the suture

10.Tie suture extraperitoneally

ped inguinal hernia 15

SEAL with hydrodissection and dual encirclage
Saranga Bharathi et al. (2006)19

  • EQUIPMENT/SUTURE:
    • Veress needle
    • 5-mm trocar and 0° or 30° laparoscope
    • 1-0 or 2-0 Vicryl swaged on a 30- to 40-mm curved, round bodied needle
    • Hypodermic or a longer spinal or intracath needle with saline
  • STEPS:

1.Incise at a point that lies lateral to the ring on the right or medial to the ring on the left (for a right-handed surgeon)

2.Advance suture needle through the incision traversing from lateral to medial around the first half of the inguinal ring

3.Introduce hypodermic needle immediately beside suture needle, entering through the same incision

4.Inject a small amount of saline in the retroperitoneal space to lift the peritoneum off the vas and vessels

5.Advance the suture needle superficial to the vas and vessels along the medial aspect of the ring

6.Advance the needle tip through the skin without removing the needle in its entirety*

7.Back the swaged end of the needle through the subcutaneous tissue anterior to the ring to exit through the original stab incision

8.Tie suture extracorporeally

*If unable to safely surround the ring completely on the first pass, skip over the vas and vessels, reducing the ring size. A second suture pass in similar fashion is made, now with traction to lift the peritoneum off the vas and vessels, creating a “dual encirclage”

ped inguinal hernia 16

Extracorporeal hook method
Lee & Yeung, (2003),20 Yeung & Lee (2008)21

  • EQUIPMENT/SUTURE:
    • Veress needle18
    • 3-mm or 5-mm infraumbilical trocar and laparoscope
    • 3-mm laparoscopic grasper
    • Herniotomy hook19
    • 3-0 nonabsorbable suture
  • STEPS:

1.Suprapubic stab incision for grasper

2.Make a 2-mm stab incision at the 12 o’clock position over the internal inguinal orifice so that the tip of the blade is visible, but does not penetrate the peritoneum

3.Pass the herniotomy hook with suture through the stab incision to this same level

4.Manipulate the hook to dissect peritoneum off surrounding structures along the circumference of the internal ring until the vas and vessels have been passed over

5.Pierce peritoneum with the tip of the hook

6.Using the grasper, take the loop of suture out from the hook

7.Withdraw the hook, leaving the suture intraperitoneal

8.In similar fashion, pass the hook along the other half of the internal ring

9.Enter the peritoneum through the same hole

10.Using the grasper, thread the end of the suture through the eye of the hook

11.Withdraw the hook and suture together through the initial stab incision

12.Tie suture extracorporeally

ped inguinal hernia 17

Extracorporeal with Endoneedle
Endo & Ukiyama (2001)22 in girls only, Endo et al. (2009)23 in both

  • EQUIPMENT/SUTURE:
    • 15-gauge grasper
    • 14-gauge sheath needle (port for 15-gauge grasper with electrocautery)
    • 16-gauge sheath needle
    • 19-gauge Endoneedle
    • Metal filament for setting a 2-0 nylon suture into the Endoneedle
  • STEPS:

1.Medially placed stab incision for grasper with medial traction on peritoneum adjacent to vas

2.14-gauge sheath needle enters the skin and peritoneum lateral to the hernia

3.15-gauge grasper through angiocath to cauterize the peritoneum between the vas and vessels

4.Use grasper to separate the vas from its peritoneal covering

5.Advance 16-gauge needle extraperitoneally around the lateral and inferior half of the internal inguinal ring, crossing over the vessels and vas then puncture the peritoneum

6.Remove the 16-gauge needle and place an Endoneedle with 2-0 suture in the same path, exiting the peritoneum where the needle punctured

7.Remove the Endoneedle, leaving the suture intraperitoneally

8.Pass the Endoneedle around the medial half of the ring, entering the peritoneum at the same level

9.Grasp the end of suture and pull out the Endoneedle and the suture together*

10.Tie suture extracorporeally

*In infants younger than 18months old, place an intracorporeal purse-string suture proximally to the previously placed suture, skipping the vas and vessels 

ped inguinal hernia 18

Hydrodissection-lasso technique
Muensterer & Georgeson (2011)24*

  • EQUIPMENT/SUTURE:
    • 5-mm umbilical trocar and laparoscope
    • 3-mm Maryland grasper
    • 22-gauge needle with saline
    • 17-gauge spinal Tuohy needle
    • Polypropelene suture
    • Braided suture
  • STEPS:

1.Make an 8-mm skin incision in the umbilicus

2.Place trocar in the inferior aspect for the laparoscope

3.Place Maryland directly into the upper part of the incision

4.Insert 22-gauge needle percutaneously over the internal inguinal ring and inject saline into the preperitoneal space circumferentially, freeing the vas and vessels

5.Make a 2-mm stab incision directly over the ring and insert Tuohy needle

6.Pass the needle medially around half of the internal inguinal ring in the space created by hydrodissection

7.Once it has passed over the vas and vessels, pierce the peritoneum

8.Pass a loop of polypropelene through the needle, into the abdominal cavity and grasp it with the Maryland

9.Remove the needle, leaving suture intraperitoneally

10.Reintroduce the needle through the same skin incision and pass it along the lateral aspect of the internal ring

11.Enter the peritoneum through the same hole

12.Pass the needle through the loop of suture

13.Introduce a second loop of polypropelene through the needle into the abdomen

14.Remove the needle

15.Use the first loop to pull the second loop completely around the internal ring

16.Extraperitoneally, pass a braided suture through the second loop

17.Pull on the opposite side of suture to pass the braided suture completely around the internal ring, thus exchanging the suture

18.Tie suture extracorporeally

*A video of this technique is provided in the supplemental material to the main article: http://link.springer.com/article/10.1007%2Fs00464-011-1713-2

ped inguinal hernia 19

Lap-assisted micro-incision extra-peritoneal division and ligation
Kim & Hui (2013)25

  • EQUIPMENT/SUTURE:
    • 5-mm umbilical trocar and 30° or 45° laparoscope
    • 25-gauge needle
    • Mosquito clamp
    • Debakey forceps
    • 3-mm Maryland dissector or mosquito clamp
    • Vicryl suture
  • STEPS:

1.Use 25-gauge needle and laparoscopic visualization to find the point on the hernia sac about 5-10 mm distal to the internal ring

2.Make a 5-mm skin incision at the insertion point of the needle

3.Place Maryland or mosquito through this incision

4.Bluntly push the dissector through Scarpa’s fascia and the external oblique fascia

5.Observe the tip of the dissector indenting the hernia sac laparoscopically

6.Spread the dissector to completely clear the tissues overlying the sac

7.Grasp and pull the sac toward the skin until it is externally visible

8.Clamp the sac with mosquito clamp and pull outward, delivering sufficient tissue for surgical manipulation

9.Remove the laparoscope from the abdominal cavity to avoid thermal injury and release the pneumoperitoneum

10.Dissect adherent tissue off the sac with Debakey forceps

11.Incise the sac to confirm the hernia opening

12.Divide the sac and ligate with suture twice at the proximal end, standard high ligation of the sac

13.The distal hernia sac can be removed if desired

14.Reinsert the laparoscope and confirm that the internal ring has been ligated

ped inguinal hernia 20

PIRS-hydrodissection-lasso technique with modification
Ponsky (2013)26*

  • POSITION:
    • Surgeon stands on left side of pt (rt-handed surgeon)
    • Starts laterally on hernia on either side
  • EQUIPMENT/SUTURE:
    • Veress needle
    • 3-mm umbilical trocar and laparoscope
    • 3-mm Maryland dissector
    • 18 gauge spinal needle (create gentle curve of the tip) or Tuohy needle
    • Prolene suture
    • Ethibond suture
  • STEPS:

1.Stab incision for Maryland contralateral to hernia

2.Use the Maryland dissector to burn the peritoneum on the superior half of the ring without completely burning a hole through the peritoneum27

3.Make a 1-mm incision at the 12 o’clock position of the internal ring

4.Use 0.25% bupivicaine to hydrodissect the peritoneum from vas and vessels

5.Preload Tuhoy needle with a loop of Prolene in the hollow with the end near the tip of the needle

6.Introduce needle into 1-mm incision

7.Advance the needle laterally around the ring above the vessels to a point medial to the the vas deferens then advance the tip into the peritoneum

8.Advance the suture so that the loop is intraperitoneal

9.Remove the needle, leaving the suture and secure extracorporeally

10.Thread another suture into the needle as before

11.Introduce needle and suture into the same 1-mm incision

12.Advance the needle medially around the ring, entering the peritoneum through the same hole

13.Put the needle through the first loop, tightening the loop around the needle and then advance the second suture

14.Pull out the needle, leaving second loop within the first loop

15.Pull the first loop up snaring the 2nd and pull out until the 2nd loop completely encircles the ring

16.Pass one end of Ethibond suture through the loop of Prolene to exchange the two27

17.Pull the other loop of the Prolene entirely through until Ethibond comes out the other side and encircles the entire ring

18.Cut the loop of Ethibond which releases the Prolene

19.Tie both Ethibond sutures extracorporeally for double ligation

*Above is a description of a youTube video, no written description was available:

ped inguinal hernia 21

Laparoscopically Assisted Simple Suturing Obliteration (LASSO) of the internal ring using an epidural catheter

Li et al. (2014)29

  • EQUIPMENT/SUTURE:
    • 5-mm laparoscope inserted through umbilicus
    • 18-guage Tuohy needle bent into a slight curve; thread with
    • 2-0 and 4-0 silk suture
    • “Suture-catcher”
  • STEPS:

1.Create slight curve in Tuohy needle and thread 2-0 silk through the tip of the needle then secure it by connecting a saline-filled syringe

2.Create “suture-catcher” by tying 4-0 silk to the tip of an epidural catheter

3.Puncture the skin above the internal ring with a 1-mm stab incision

4.Introduce the Tuohy needle and advance medially in the preperitoneal space around the ring while performing hydrodissection by injecting normal saline to separate the vas from the peritoneum

5.Enter the peritoneum between the vas and vessels after the needle has passed over the vas

6.Detach the syringe from the needle hub releasing the suture intrabdominally then gently withdraw the needle until the tip returns to the preperitoneal space anterior to the internal ring

7.Perform hydrodissection in the preperitoneal space on the opposite side of the ring

8.Thread the ‘suture catcher” through the Tuohy needle

9.Introduce the end of the “suture catcher” that has suture tied to it, keeping the suture taut to form a shape similar to a bow

10.Use the suture catcher to capture the end of the suture that is intraperitoneal

11.Remove the Tuohy needle with the suture

12.Tie suture extracorporeally

ped inguinal hernia 22

REFERENCES:

1.        Becmeur F (2011) Videosurgery–the second generation. J Pediatr Surg 46:275-279

2.        El-Gohary MA (1997) Laparoscopic Ligation of Inguinal Hernia in Girls. Pediatr Endosurgery Innov Techn 1:185-188

3.        Lipskar AM, Soffer SZ, Glick RD, Rosen NG, Levitt MA, Hong AR (2010) Laparoscopic inguinal hernia inversion and ligation in female children: a review of 173 consecutive cases at a single institution. J Pediatr Surg 45:1370-1374

4.        Godoy Lenz J (2013) Laparoscopic Pediatric Inguinal Hernia Repair: BURNIA Technique – J Godoy Chile.

5.        Montupet P, Esposito C (1999) Laparoscopic treatment of congenital inguinal hernia in children. J Pediatr Surg 34:420-423

6.        Schier F (1998) Laparoscopic herniorrhaphy in girls. J Pediatr Surg. 33:1495-1497

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