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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1281_Библиотеки_им_академика_М_И_Перельмана
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Pediatric Surgical Procedures – An Updated Guide – Volume I
101
Considering the frequency of cases requiring this surgery, the use of laparoscopy,
a relatively less invasive technique, for inguinal hernia repair was begun in the s
[, ]. It has many advantages, such as the examination of the internal genital organs
to exclude testicular feminization syndrome in girls, reduction of incarcerated hernias
under direct vision, as well as simultaneous examination of the intestine for signs of
ischemia, thus enabling immediate repair of the hernia and reducing the risk of bladder
injury [], and better cosmesis. One of the many advantages of laparoscopy is that it
can differentiate recurrent inguinal hernias from femoral hernias by evaluating the
groin area. Less than one percent of all groin masses seen in children are due to femoral
hernias []. In addition, the presence of bilateral patent processus vaginalis and urachal
anomalies, which could not be detected preoperatively in this case, might be observed.
The various procedures described for inguinal hernia repair include placing
sutures on the neck of the hernia sac while performing laparoscopy, performing
subcutaneous endoscopically assisted ligation of the hernia sac (SEAL), and singlesite techniques [, ]. Raveenthiran reviewed the different laparoscopic and open
techniques for inguinal hernia repair [].
The laparoscopic inguinal hernia inversion and ligation (LI-HIL) technique,
originally described by El-Gohary in [], is described for laparoscopic repair
of indirect inguinal hernia in girls and consists of inverting the hernia sac into the
abdominal cavity and ligating the base of the sac with an endoscopic loop [].
Laparoscopic techniques in inguinal hernia repair in children can also be divided
according to the division or ligation of the processus vaginalis. According to the
processus vaginalis, there are those with and without peritoneal closure and many
variations in the processus vaginalis division. There are hook, PIRS (percutaneous
internal ring suturing), SEAL, and many variations in processus vaginalis ligation.
Surgery involving laparoscopic percutaneous extraperitoneal closure of the
internal ring using an epidural needle for inguinal hernia in girls only requires a
-mm laparoscopy, a simple internal ring mouth puncture technique, and a knotting
technique, with no particular indication for the laparoscopic suture technique. The
method is simple and easy to master, and the learning curve is short [–].
Percutaneous internal ring suturing (PIRS) is a method of laparoscopic herniorrhaphy, i.e., percutaneous closure of the internal inguinal ring under the control of a
telescope placed in the umbilicus [].
Laparoscopic techniques for inguinal hernia repair are also broadly divided into
extracorporeal and intracorporeal approaches. Extracorporeal techniques are carried
out as a laparoscopic-assisted procedure as they involve the introduction of a needle,
under visual control, to create a loop of thread that closes the internal inguinal ring.
The intracorporeal techniques, on the other hand, are performed using one or more
trocars as well as the use of intracorporeal sutures [, , ]. The knot is buried in
subcutaneous tissue using extracorporeal techniques [].
In laparoscopic inguinal hernia repair, iliopubic tract repair (LIPTR) has been
recommended in addition to internal inguinal ring closure for dilated inguinal rings.
The iliopubic tract is approximated to the transverse arch by an interrupted suture
to narrow the internal ring []. However, no distinguishing information is given on
whether this repair was performed on girls in that study.
Although the laparoscopic treatment of pediatric inguinal hernia (PIH) offers
more benefits than traditional surgery, it is difficult to avoid the problem of recurrence completely. Wang et al. investigated the causes of recurrence after laparoscopic
percutaneous extraperitoneal repair (LPER) of PIH []. They recommended LPER
Laparoscopic Inguinal Hernia Repair Using the Burnia Technique
DOI: http://dx.doi.org/10.5772/intechopen.115067
102
for PIH as a safe and effective operation and advised that to reduce the recurrence
rate of LPER. Surgeons should improve surgical skills, choose an appropriate ligature,
and avoid using LPER for a huge internal inguinal ostium (especially over mm). It
is appropriate to be converted to open surgery for patients with a very wide internal
inguinal ostium [].
Laparoscopic techniques are constantly advancing toward increasing the application of extraperitoneal repair and decreasing the use of assistant instruments and
trocars. Zhang et al. [] used a simple hernia needle for single-port laparoscopic
percutaneous inguinal hernia repair in children. Their study found that the technique
requires special operating instruments, such as a multi-channel puncture device,
Kirschner wire, epidural puncture needle, and abdominal wall suture straight needle.
O’Brien et al. added monopolar diathermy of the peritoneum at the superior
aspect of the internal ring, which was performed. Following this, the peritoneum
around the open internal ring was closed by purse-string technique using a .
nonabsorbable monofilament suture. The knot was tied in an intracorporeal manner.
The recurrence rate was . [].
In the single-port technique, the ligation of the hernia defect could be achieved
percutaneously without the need for intracorporeal manipulation of the needle and
knot tying. Subcutaneous endoscopically assisted ligation (SEAL) is one of these
reported single-port techniques, first described in [] using only the camera
port inserted via an umbilical incision and extracorporeal subcutaneous knotting,
which decreases the number and size of skin incisions and reduces the operative
time over the traditional three/two ports laparoscopic hernia repair due to the fewer
number of ports and no need for intra-abdominal surgical maneuvers [].
Multiple techniques exist for direct internal ring suture closure without sac dissection and excision. Internal ring suture closure may be achieved by intracorporeal or
extracorporeal suturing. In the laparoscopic intracorporeal purse-string technique,
sac dissection is avoided. An absorbable or nonabsorbable suture is used to make a
purse-string stitch around the internal inguinal ring to approximate the crural arch
and conjoined tendon after incising the peritoneum around the internal ring.
In larger hernias, one or more interrupted stitches are made. In laparoscopic
percutaneous extracorporeal closure, under laparoscopic vision using a suture passer
device transabdominal, a suture is passed through a mm stab incision and guided
around the lateral half of the circumference of the internal inguinal ring [].
Salgaonkar et al. [] explained the stages of laparoscopic inguinal hernia surgery
as follows: marking the peritoneum at the internal ring with diathermy, incising the
peritoneum at the level of the internal ring, dissecting and excising the hernial sac,
purse-string closure of internal inguinal ring.
Sutureless laparoscopic inguinal hernia repair (LIHR) in children is increasingly being reported in the literature, although a specific technique has not yet been
standardized [].
Peritoneal traumas reportedly play essential roles in the obliteration of the internal
inguinal ring [, ]. The Burnia Technique is one of the most recent techniques
for inguinal hernia repair [, ]. In girls, the absence of cords and elements that
must be protected in boys facilitated the applicability of this technique. In the Burnia
technique, the peritoneum at the inner mouth of the inguinal canal is thermally
cauterized, ensuring fibrosis formation [].
Figure generally shows the modifications that can be made in laparoscopic
inguinal hernia.
Pediatric Surgical Procedures – An Updated Guide – Volume I
103
Figure 1.
Modifications of laparoscopic inguinal hernia repair.
. Inguinal hernia repair
. Indications
The detection of inguinal hernia in children is an indication for surgery. Surgery is
planned as soon as possible as the risk of incarceration is higher in infants. In cases of
reducible hernia in premature babies, inguinal hernia repair can be postponed until
the time of discharge.
. Contraindications
The only absolute contraindication to laparoscopic repair is hemodynamic instability. A relative contraindication may be previous abdominal surgery [].
. Anesthesia
Either endotracheal intubation or laryngeal mask is planned for general anesthesia
by the anesthesiologist, considering the child’s age and the presence of any other
diseases.
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. Surgery
. Patient positioning and operating room setup
The patient is placed in the supine position. It may be more appropriate for the
patient to lie slightly obliquely on the table regarding ergonomics. If the patient has
a full bladder, the bladder is first emptied using a Crede Maneuver, and the patient
should be placed in the Trendelenburg position to provide a better viewing angle.
The layout of the surgery room is presented in Figure . If the left side has to be
operated on, the opposite placement is also possible.
. Trocar position and instrumentation
When the laparoscopic instruments are inserted into the patient’s abdomen, the
abdominal wall’s anatomical structure must be considered, particularly regarding a.v.
epigastrica inferior (Figure ).
Figure 2.
Schematic of the surgical setup.
Pediatric Surgical Procedures – An Updated Guide – Volume I
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Figure 3.
Sketch of the anatomical structures and the possible port entry in laparoscopy.
The pneumoperitoneum is created either through direct puncture (Veress Needle
Technique) or using the Open Technique (Hasson) (the technique preferred by the
author) through the umbilicus. A pneumoperitoneum is created with CO at a flow
rate of .L/min and a maximum pressure of mmHg [].
The camera is gradually advanced through the -mm trocar placed through the
umbilicus. After a general abdomen examination, the working instrument, such as
a Maryland Dissector or Ligasure Device, is advanced into the abdomen through
a stab incision or a trocar in the lower right quadrant or the lower left quadrant
(Figure ). The working instrument must have an electrocautery feature, with
low-wattage used. Depending on the patient’s age, a -, -, or -mm instrument
may be used. It must be considered that the peritoneum is quite flexible in children
(Figures and ).
The instrument is entered from the same side in the case of a unilateral inguinal
hernia. If the hernia is bilateral, entering from the side on which the internal inguinal
ring is wide and the sac is larger should be prioritized. Instruments from both sides
are not required to be inserted in bilateral inguinal hernias. Both inguinal sacs could
be intervened by entering from just one side in our clinic. If a single-site has to be
used, the instrument could also be entered from the umbilicus or just an infra umbilical incision. After entering the abdomen with the camera, it is essential to conduct a
general evaluation of the inside of the abdomen. A right ovarian torsion was detected
in the -month-old baby girl. After the detorsion, the inguinal hernia surgery was
performed using the Burnia Technique, and no problems were observed in the followups after the surgery [].
. The Burnia
After the working instrument is inserted, any organs that have entered the internal inguinal canal, such as the omentum, are removed (Figure ). The right or left
internal inguinal ring is then evaluated (Figures and ).
Laparoscopic Inguinal Hernia Repair Using the Burnia Technique
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Figure 4.
Marking of stab incision and telescope entrance.
Figure 5.
The peritoneum remains quite flexible when the abdomen is entered through a stab incision.
The hernia sac is held after entering the inguinal canal, pulled toward the peritoneal cavity, and cauterized using low-wattage monopolar diathermy or ligasure
instrument (Figures –). If the sac is large, it is held several times and then cauter-
ized at the level of the internal inguinal ring.
Pediatric Surgical Procedures – An Updated Guide – Volume I
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Figure 6.
The scalpel visible inside the abdomen during the stab incision.
Figure 7.
Left inguinal hernia and the omentum that had entered the inguinal canal.
It is crucial to cauterize the internal ring level here. If the uterine tube enters
the inguinal canal, the sac must be cauterized without damaging the tubes.
Figure shows the internal inguinal rings after cauterization of bilateral inguinal
hernia with the Burnia technique.
. Closing
The operating instrument is removed, and the entry site is examined using the
camera to detect any bleeding after the procedure is completed. The pneumoperitoneum is evacuated. The area entered through the umbilicus, and the stab incision
Laparoscopic Inguinal Hernia Repair Using the Burnia Technique
DOI: http://dx.doi.org/10.5772/intechopen.115067
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Figure 8.
Right inguinal hernia.
Figure 9.
Left inguinal hernia.
Figure 10.
Maryland grasper being advanced toward the internal ring of the right inguinal hernia.
Pediatric Surgical Procedures – An Updated Guide – Volume I
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Figure 11.
Maryland grasper visible in the right inguinal canal.
Figure 12.
Right inguinal hernia sac being inverted and pulled into the abdomen.
Figure 13.
Cauterization of the right inguinal hernia sac.
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DOI: http://dx.doi.org/10.5772/intechopen.115067
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Figure 14.
Right inguinal hernia after the cauterization.
Figure 15.
Left inguinal hernia sac involvement.
Figure 16.
Left inguinal hernia sac being inverted, pulled into the abdomen, and cauterized.
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