Efficacy Of Laparoscopically Assisted High Ligation Of Patent Processus Vaginalis in Children

BY

Dr.Hisham H. Ahmed, M.D, MRCS.EngAss.Professor of General and Pediatric Surgery

Benha University Hospitals

Overview• Minimally invasive surgery proved to be feasible and safe in pediatric patients

since 1975 when laparoscopic surgery was first used to treat a small bowel obstruction. (Becmeur F ,2011)

• 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. (Becmeur F ,2011)

• 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 Intracorporeal and Extracorporeal suturing. (Becmeur F ,2011)

  

Overview• A patent processus vaginalis (PPV) has been estimated to be present in 80-

95% of all male newborns, declining to 60% at one year of age, 40% at two years, and 15- 37% thereafter. (Watson DS, et al 1994)

• It represents a natural communication between the peritoneum and scrotum through which bowel or peritoneal fluid may descend. (Watson DS, et al 1994)

• A patent processus has been recognized more and more often with evolution of laparoscopic techniques for pediatric hernia repairs and has been theorized to be a potential area for development for hernia. (Miltenburg DM, et al 1998)

Objectives

To evaluate the Efficacy, Safety and Outcome of the Laparoscopically Assisted Piecemeal High Ligation Of a Patent Processus Vaginalis (PPV) in Children.

Patients& Methods

Patients & Methods

• This prospective study was conducted at Benha University Hospitals, department of general surgery, pediatric surgery unit during the period from October 2009 to March 2011, After approval of ethics research committee and parents informed consent.

26 boy

s65%

14 girls35%

40 patients

BoysGirls

8 bi-lateral20%32 uni-

lateral80%

Number of patientsRegarding the laterality

BilateralUnilateral

Children’s characteristics and clinical data

Patients & Methods• Inclusion criteria ; * Children with an indication for hernia repair. * No contraindication for laparoscopic intervention.

• Exclusion criteria; * High body mass index * Coagulopathy * Complicated hernias * Those associated with other inguino-scrotal swellings.

Patients and Methods All children:

• General inhalational endotracheal anesthesia with muscle relaxation

• Trendelenburg position• Insertion of Foley’s catheter• Pneumoperitoneum using the open technique ( pressure adjusted between8-10 mm Hg)

Patients and Methods

Equipment and Suture:1. 3-mm trocar for a 30° telescope2. 3-mm trocar for an endo-clinch grasper3. Regular needle holder4. 2/0 or 3/0 Prolene on a ½ circle needle

Operative Procedure

STEPS

• Insertion of a 3 mm 30° telescope through an infra-umbilical circular incision.

• Inspection of the contralateral side for the possibility of bilateral hernias.

• Insertion of an infra-umbilical 3 mm working trocar.

STEPS

• Reduction of the hernia.• 10 cc lidocaine 0.5% and saline

mixture in 1:1 ratio was injected extraperitoneally.

• A Prolene 2/0 or 3/0 suture on a curved ½ circle round bodied taper ended 25-30 mm needle grabbed on a regular needle holder.

• Passage of the needle through a tiny inguinal skin crease incision.

The working grasper picks up the peritoneum in a piece meal fashion while the needle is advanced behind the peritoneum to encircle the neck of the sac forming a purse string suture.

1 2

The needle is passed out close to the insertion site forming a semicircle around the Internal ring, and then manipulated back to the entrance point where it’s tied and the knot buried subcutaneously.

3 4

Results• All patients passed smooth intraoperative course without intraoperative Complications and no conversion to open surgery.

• Mean operative time was 25±4 (range 13-37) minutes for unilateral cases and 34.6±3.8 (range 23-48) minutes for bilateral cases.

• Nine patients (28.1%) with unilateral hernias (6 right and 3 left) were found to have

synchronous contralateral hernia diagnosed intraoperatively with a total number of hernias operated 57 hernias.

Results

• All patients showed no immediate postoperative complications with mild to moderate pain sensation that responded to non-steroidal anti-inflammatory drugs.

• Mean postoperative hospital stay was 4.3±1.5 (range 2-8) hours.

Operative and hospital stay data

Results• Through a mean follow-up period of 18.5±5.4 (range 12-30)

months, one patient with bilateral hernia developed unilateral left side recurrence 4 months after surgery and was managed conventionally using open approach.

• No contralateral or ipsilateral, direct or indirect inguinal hernias developed in unilateral

cases. • No cases of testicular atrophy have been reported.• Two boys developed a minimal post-operative hydrocele that

have been resorbed spontaneously over a period of 2-3 weeks.

Discussion

Discussion• In the present study, an exploratory laparoscopy was conducted for 32 children who were clinically diagnosed as having a unilateral inguinal hernia. • Nine of them were found to have a contralateral hernia, with a detection rate of 28.1%.

• Chan et al. , Esposito et al. , Toufique et al. and Niyogi et al. reported similar figures for laparoscopic contralateral hernia detection rates of 28%, 39%, 39.7% and 29.2%, respectively.

Discussion

•Parelkar et al, Esposito et al. and Giseke et al., who reported mean operative times of 23, 7-30 and 26.2 min for Unilateral and 29, 12-42 and 34.5 min for bilateral hernia, respectively.

• In the present study, the mean operative time was 25 and 35 min for unilateral and bilateral cases, respectively, which was in line with that reported by.

Discussion• In the present study, the mean postoperative hospital stay was 3.4h (range 2-8 h). • Parelkar et al. and Giseke et al. reported a coincident hospital stay for laparoscopic inguinal hernia repair as a day-case procedure.• In the present study, only one child had a recurrent hernia, giving a frequency of 2.5% for children and 1.75% for repaired hernias. • The reported recurrence rate goes in hand with that previously reported by Niyogi et al. and Parelkar et al.

Discussion • The present technique of ligating the (PPV) at the level

of the internal ring seems to be simpler and does not need any specially designed instruments. Knotting does not require any special skill because it is done externally in the subcutaneous tissue in the conventional manner.

• Tam et al. used the hook method during hernia repair to allow extraperitoneal passage of the suture to close the hernia sac.

• Endo et al. needs a specially designed needle and the stitch around the internal ring is laparoscopically tied, with the possibility that it may loosen.

Discussion

• Bharathi et al. assessed the differences in outcome between the three-port technique and the single port laparoscopically assisted ligation technique, and found that both are safe and efficacious day-case procedures.

• In the present studythe operative time was comparable to that reported in the literature for the three-port technique and was without difficulty in visualization during the procedure.

Discussion

• Rothenberg et al. described their experience using a single port for various operative procedures without focusing on hernia repair.

• The current study found no need for an additional port, as the vision was clear with satisfactory manipulation.

Conclusion

Conclusion

• Laparoscopically assisted piecemeal closure of patent processus vaginalis in Children is safe, effective day- case procedure with satisfactory cosmetic appearance.

• It helps in detection of contralateral hernia without prolongation of operative time.

Conclusion• The current trend is toward extracorporeal suturing and knotting technique and single-port access technique as well.

• The future or recent advancement is the use of tissue adhesives in laparoscopic inguinal hernia repair in children.