What is the role of laparoscopic needle-assisted repair in the treatment of inguinal hernia?

Updated: Oct 31, 2018
  • Author: Andre Hebra, MD; Chief Editor: Carmen Cuffari, MD  more...
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Answer

Laparoscopic needle-assisted repair of inguinal hernia

  • A new and innovative technique for repair of inguinal hernia in young children using a total laparoscopic approach has been described. [11] The technique is described as laparoscopic needle-assisted repair.

  • Standard laparoscopy is performed via a small 5-mm umbilical port with a 5-mm, 30 º- angled laparoscope. Once the indirect inguinal hernia is identified, the laparoscopic repair is performed.

  • The first step is to clearly define the inguinal hernia and the lateral and medial border of the open internal inguinal ring. This is accomplished by probing the groin region with a small 22-gauge needle.

  • Under careful laparoscopic-guided visualization, a 22-gauge Tuhoi spinal needle with a 2-0 Prolene suture thread inside the barrel of the needle is inserted and passed underneath the peritoneum and the inguinal ligament, lateral to the internal inguinal ring, away from the spermatic vessels and vas. All needle movements are performed by the operating surgeon from outside the body cavity under direct laparoscopic control so that the position of the tip of the needle can be precisely placed at the desired location inside the peritoneal cavity. The Prolene thread is than pushed through the barrel of the needle into the abdominal cavity, creating an internal “loop." The needle is pulled out, leaving the Prolene loop of the thread inside the abdomen.

  • From the outside the patient’s body, one of the threaded ends is introduced again into the barrel of the spinal needle, and the needle is passed through the same skin puncture point, through the medial aspect of the internal inguinal ring, under the peritoneum. Again, the vas and vessels are mobilized to stay away from the needle, in order to prevent any injury. Once the tip of the needle is in the desired position next to the loop of Prolene, the thread is pushed in so that it passes through the loop. At this point, the thread-loop is pulled out of the abdomen, with the thread end caught by the loop. In this way, the suture thread of Prolene is placed around the internal inguinal ring under the peritoneum, creating a complete purse-string suture with the ends of the suture coming out of the same skin needle hole in the groin region. The knot is tied to close the internal inguinal ring and hernia opening. With this technique the knot is buried in the subcutaneous tissue.

  • The images below illustrate the laparoscopic needle assisted repair of a left indirect inguinal hernia.

  • Laparoscopic view of a left indirect inguinal hern Laparoscopic view of a left indirect inguinal hernia at the time of surgery for laparoscopic needle-assisted repair.
  • Laparoscopic needle-assisted repair of a left indi Laparoscopic needle-assisted repair of a left indirect inguinal hernia. Note the passage of a Prolene suture through a small 22G spinal needle; this is used for creation of the purse-string suture that closes the open inguinal ring.
  • Laparoscopic view of the repaired left indirect in Laparoscopic view of the repaired left indirect inguinal hernia with the closed Prolene purse-string suture around the internal inguinal ring.
  • If an open internal inguinal ring is identified in the contra lateral side, it is closed using the same technique through a small needle hole in the opposite groin.

  • This fairly new technique has had great acceptance among many pediatric surgeons. Because of the very small skin incisions, it is associated with minimal pain and has great cosmetic appeal. Preliminary results suggest a similar recurrence rate as reported for the open technique. [12] However, long-term outcomes have not yet been reported. The author's group at the Medical University of South Carolina conducted a prospective outcome analysis comparing the laparoscopic with the open technique. The author group reported that post-operative data showed that the laparoscopic needle-assisted repair of inguinal hernia (LNAR) technique is safe with a 4% rate of minor complication. The study further reported that the recurrence rate is comparable and in many cases less than open technique. The author group also added that laparoscopy objectively identifies asymptomatic or occult contralateral defect, uses a smaller incision, and eliminates dissection of the cord structures potentially reducing the risk of cord injury. [13]

    Another study that utilized a single port laparoscopic percutaneous repair (LPHR) technique for selected children requiring operative intervention for inguinal hernia, compared operative times and surgical outcomes in patients undergoing LPHR versus traditional open repair. The study concluded that in select patients, LPHR is an efficient, safe, and effective minimally invasive alternative to open repair, with reduced operative times but without increased rates of complications or recurrences. [14]  


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