Fig. 38.1.
Inguinal anatomy of a left-sided hernia as seen laparoscopically. Note the vas deferens medial to the internal ring, the spermatic vessels lateral to the internal ring, and the inferior epigastric artery superior.
Patient Positioning and Operating Room Setup
The patient is positioned supine with his or her legs spread slightly apart. The operating room table is typically kept flat, but Trendelenburg position may be used if the bowel is obscuring the view. The scrotum is prepped to allow for manual pressure to be applied to expel any air after the procedure. The patient should void before the procedure to eliminate the need for a urinary catheter. In younger patients, a Credé maneuver may be performed to empty the bladder.
The authors prefer to stand on the patient’s left side, regardless of the side of the hernia, but some may find it easier to stand on the ipsilateral side of the hernia. The assistant stands on the same ipsilateral side, closer to the head of the patient. The laparoscopic monitor should be placed at the foot of the bed.
Trocar Position and Instrumentation
A 70-degree, 3-mm laparoscope is inserted infraumbilically. This may be substituted for a 5-mm, 30-degree laparoscope in larger children. A 3-mm Maryland dissector is placed through a stab incision. The location of this instrument is surgeon dependent; some place this on the left side, others prefer to place the instrument on the same side as the hernia, and still others place it in the umbilicus next to the camera. This instrument should have the capability to apply electrocautery to it (Fig. 38.2).
Fig. 38.2.
Port placement for a left inguinal hernia.
An 18-gauge spinal needle is used. The tip of the needle is bent slightly using a hemostat. This is loaded with a loop of 3-0 polypropylene suture such that the ends of suture are at the back of the needle and at the tip of the needle, a 1-mm loop of suture is exposed. The curve of the needle must be gentle or the suture will not pass through (Fig. 38.3).
Fig. 38.3.
Curved spinal needle with looped monofilament suture.
Technique
- 1.
After port placement and preparation of the spinal needle, the hernia is assessed and any contents are reduced laparoscopically with gentle tension.
- 2.
The peritoneum is then thermally injured with electrocautery to stimulate scarring. This should be done on the medial, anterior, and lateral edges with caution to avoid the vas deferens and spermatic vessels. Aim to cauterize just inside the internal ring so the cautery line is not in the exact same location as the final resting spot of the suture. However, this may not be critical. This technique has been shown to significantly improve the durability of repair in rabbits [4]. In fact, Godoy has described treating small inguinal hernias in girls by inversion of the hernia sac and cauterization alone [5] (Fig. 38.4).
Fig. 38.4.
(a, b) Cautery is applied to the anteromedial and anterolateral edges of the internal ring to stimulate scarring of the repair. Care should be used to avoid the spermatic vessels and vas deferens.
- 3.
A 25-gauge finder needle is used to identify the 12 o’clock position of the internal ring (from the view of the laparoscope). The needle is inserted perpendicular to the abdominal wall. External palpation is used to determine the point of entry. An 11-blade scalpel is then used to make a 1-mm nick in the skin at this location. Insert the needle very far laterally on the patient, almost in the flank, so the needle traverses in a straight line, making it easy to advance the needle over the vas deferens and vessels. Next, hydrodissection is performed with 0.25 % bupivacaine or an alternative long-acting local anesthetic to separate the peritoneum off of the cord structures. In smaller patients, the local anesthetic may be diluted to remain beneath the maximum dosage. If a caudal block was performed by anesthesia, 5 mL of normal saline may be used. This is done on the lateral edge of the internal ring followed by the medial edge. It is critical to stay just under the peritoneum (between the peritoneum and the vessels), or the vessels may be lifted up with the peritoneum rather than separated away.
- 4.
The previously prepared 18-gauge spinal needle is then directed through the 1-mm skin incision that was made at the 12 o’clock location overlying the internal ring and is directed along the lateral edge of the internal ring in the plane created by hydrodissection. From this lateral approach, pass the needle over the vessels and, if possible, over the vas deferens before piercing out of the peritoneum. However, sometimes it may be necessary to pass over the vas deferens from the medial side. The tip of the needle should pierce through the peritoneum at the 6 o’clock position. The loop of polypropylene is the then advanced out of the needle and the needle is removed. The ends of the suture are then secured to the operating room drapes with a hemostat. A second curved needle is loaded with an additional polypropylene suture in similar fashion. The needle is inserted and directed medially around the internal ring such that it exits just lateral to the vas deferens at the location of the first suture. If it is difficult to pass over the vas deferens, a millimeter of tissue can be left between the needle and the first suture over the vas deferens. A Maryland dissector can aid in this process by providing counter-tension on the peritoneum. The needle is then directed through the first loop. The first loop is pulled snug, and then the second loop is pushed out of the needle. The needle is removed and then the first loop is pulled up, acting as a snare to bring the second loop around the defect (Fig. 38.5).
Fig. 38.5.
Laparoscopic-assisted ligation of the left internal ring. The needle is passed lateral to the internal ring (a) and the suture is advanced (b). The needle is removed (c) and is then passed medially exiting the peritoneum through the loop of the existing suture (d). The first suture is pulled to snare the second suture (e) and bring it around the defect (f). A permanent braided suture is looped through the polypropylene and is pulled around the defect (g, h). The looped end is then cut and the ends are double ligated (i).
- 5.
A 2-0 permanent braided suture is then exchanged through the loop of polypropylene and pulled around the defect. This is supported by animal research that showed improved durability of the repair when using braided suture, likely by increasing inflammation and scarring [6]. An animal study is currently underway comparing absorbable braided suture to permanent braided suture, but until the study completed, the authors recommend the use of permanent braided suture.
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