ORIGINAL PAPERS

ORIGINAL PAPERS
Adv Clin Exp Med 2006, 15, 5, 851–856
ISSN 1230−025X
© Copyright by Silesian Piasts
University of Medicine in Wrocław
DARIUSZ PATKOWSKI1, RAFAŁ CHRZAN2, WOJCIECH JAWORSKI1, WOJCIECH APOZNAŃSKI1,
JERZY CZERNIK1
Percutaneous Internal Ring Suturing for Inguinal
Hernia Repair in Children Under Three Months of Age
Przezskórne zamknięcie pierścienia pachwinowego wewnętrznego
w leczeniu przepukliny pachwinowej u dzieci poniżej 3. miesiąca życia
1
2
Department of Pediatric Surgery and Urology, Silesian Piasts University of Medicine in Wrocław, Poland
Department of Pediatric Urology, University Hospital for Children, UMC Utrecht, The Netherlands
Abstract
Background. Laparoscopic herniorrhaphy is an alternative method to the open technique of inguinal hernia repa−
ir in children. The technique used here, percutaneous internal ring suturing (PIRS), requires only one umbilical po−
rt and needle puncture point.
Objectives. Evaluating the efficacy of PIRS for inguinal hernia repair in children under three months of age.
Material and Methods. Two hundred four children with 270 hernias were operated on using PIRS at the Pedia−
tric Surgery and Urology Department of the Silesian Piasts University of Medicine in Wrocław, Poland. Twenty−
five were under 3 months of age (22 boys and 3 girls, average age: 59 days, minimum: 20 days) with 38 inguinal
hernias. Bilateral hernia was diagnosed in 8 cases before the operation and an open contralateral inguinal canal was
found during the operative procedure in 5 cases. Nine patients were admitted to the hospital with incarcerated her−
nias that were reduced manually. The procedures were performed under general endotracheal anesthesia. The pneu−
moperitoneum was created with an open technique. Under laparoscopic−guided vision, an 18G injection needle
with nonabsorbable thread inside the canal of the needle was placed through the abdominal wall into the peritone−
al cavity. The thread was passed under the peritoneum, around the entrance into the hernia sac by moving the in−
jection needle. The knot was tightened from outside and placed in the subcutaneous space. The contralateral open
inguinal ring was closed at the same session.
Results. It was necessary to use an accessory port in two cases because of difficult visualization of the inguinal re−
gion. The average operative time was 23 minutes for unilateral and 26 minutes for bilateral hernias. The only in−
traoperative complication was an incidental puncture of the iliac vein in one case which required gentle pressing
from the outside. The follow−up was between 2 and 25 months (average: 13 months) and there was no hernia re−
currence. The cosmetic results were excellent, with almost invisible scars. In three cases a transient hydrocele was
observed.
Conclusions. The PIRS method seems to be a simple and effective, minimally invasive procedure with excellent
cosmetic results. The experience of the authors indicates that infancy is no limitation for the procedure and PIRS
should be taken into consideration as an alternative treatment (Adv Clin Exp Med 2006, 15, 5, 851–856).
Key words: children, inguinal hernia, laparoscopic hernia repair.
Streszczenie
Wprowadzenie. Laparoskopowa herniorafia jest alternatywną dla operacji metodą otwartą w leczeniu przepukli−
ny pachwinowej u dzieci. Nasza własna, oryginalna technika – przezskórne zamknięcie pierścienia pachwinowe−
go wewnętrznego (PIRS – percutaneous internal ring suturing) wymaga jednego portu w pępku oraz punktowego
nakłucia skóry igłą.
Cel pracy. Ocena skuteczności PIRS w leczeniu przepukliny pachwinowej u dzieci poniżej 3. miesiąca życia.
Materiał i metody. W Klinice Chirurgii i Urologii Dziecięcej Akademii Medycznej we Wrocławiu operowano
204 dzieci z 270 przepuklinami za pomocą techniki PIRS. Wśród nich było 25 niemowląt poniżej 3. miesiąca ży−
cia (22 chłopców i 3 dziewczynki, średnia wieku 59 dni, min. 20 dni) z 38 przepuklinami pachwinowymi. Obu−
stronną przepuklinę pachwinową stwierdzono w 8 przypadkach przed operacją, w 5 przypadkach śródoperacyjnie
stwierdzono po stronie przeciwnej otwarty kanał pachwinowy. 9 dzieci zostało przyjętych do Kliniki z powodu
852
D. PATKOWSKI et al.
uwięźniętej przepukliny, którą odprowadzono ręcznie. Zabieg operacyjny wykonano w znieczuleniu ogólnym z in−
tubacją. Odmę otrzewnową wytworzono za pomocą techniki otwartej. Pod kontrolą obrazu laparoskopowego
wprowadzono przez powłoki brzucha do jamy otrzewnej igłę iniekcyjną 18G, z przechodzącym przez jej światło
niewchłanialnym szwem. Za pomocą manipulacji igłą szew umieszczono pod otrzewną, wokół wejścia do worka
przepuklinowego. Od zewnątrz zawiązano węzeł, który umieszczono w tkance podskórnej. Otwarty pierścień pa−
chwinowy po stronie przeciwnej zamykano podczas tego samego zabiegu.
Wyniki. W dwóch przypadkach z powodu trudności w uwidocznieniu okolicy pachwinowej było niezbędne uży−
cie dodatkowego portu. Średni czas zabiegu wyniósł 23 minuty dla jednostronnej i 26 minut dla obustronnej prze−
pukliny. Jedynym śródoperacyjnym powikłaniem było przypadkowe nakłucie żyły biodrowej wymagające delikat−
nego ucisku od zewnątrz. Okres obserwacji wyniósł 2–25 miesięcy (średnio 13 mies.). Nie stwierdzono nawrotu
przepukliny. Wynik kosmetyczny był doskonały z prawie niewidocznymi bliznami pooperacyjnymi. W 3 przypad−
kach obserwowano przemijający wodniak jądra.
Wnioski. Metoda PIRS jest prostą i skuteczną metodą małoinwazyjną z doskonałym wynikiem kosmetycznym.
Według naszego doświadczenia okres niemowlęcy nie jest przeciwwskazaniem dla metody PIRS, którą należy roz−
ważyć jako alternatywny sposób leczenia (Adv Clin Exp Med 2006, 15, 5, 851–856).
Słowa kluczowe: dzieci, przepuklina pachwinowa, laparoskopowa operacja przepukliny pachwinowej.
Inguinal hernia repair is one of the most frequ−
ently performed operative procedures in children.
The operative technique is very well established
including hernia sac dissection from the spermatic
cord and closing the sac at the level of the internal
ring. The procedure is usually performed as a day
surgery. Laparoscopic inguinal hernia repair in
children has become more and more popular in re−
cent years [1–3]. The advantages mentioned inclu−
de minimizing invasiveness, the lack of groin inci−
sion, the diagnosis of contralateral hidden hernia
with the possibility of its repair during the same
procedure, the diagnosis of atypical hernia, mini−
mal risk of cord structure injury, and better cosme−
tic results [3, 4]. Most of the laparoscopic proce−
dures are performed through three, less popularly
two, ports in the abdominal wall and require intra−
peritoneal suturing [3, 5]. The present authors ha−
ve described a special technique which they na−
med “percutaneous internal ring suturing” (PIRS)
[6]. The idea of PIRS is to place the suture through
the puncture−point skin access and tie it around the
hernia sac at the level of the inguinal ring. In con−
trast to other laparoscopic techniques, it requires
only one umbilical port and a puncture of the skin
with an 18G injection needle, which makes this
minimally invasive technique even less invasive,
leaving the skin with only one almost invisible
scar in the umbilicus.
The aim of this study was to evaluate the effi−
cacy and outcome of PIRS for inguinal hernia re−
pair in children under three months of age.
Material and Methods
The study was conducted at the Pediatric Sur−
gery and Urology Department of Silesian Piasts
University of Medicine in Wrocław, Poland. Two
hundred four children aged 20 days to 16 years
(mean: 41 months) with 270 hernias were operated
on using PIRS. There were 25 infants under
3 months of age (22 boys and 3 girls, average age:
59 days, minimum: 20 days). All the patients
except those with incarcerated hernia were opera−
ted on the day of hospital admission. In infants
with incarcerated hernia, the elective operative
procedure was postponed 24 hours after the hernia
was manually reduced. As the hospital policy re−
quired 24 hours of observation after anesthesia in
children under three month of age, the patients we−
re sent home on the next day except for two who
were treated in the Intensive Care Unit for pro−
blems unrelated to the performed procedure.
Description of the Technique
PIRS is performed under general endotracheal
anesthesia with muscle relaxation in the supine po−
sition. The pneumoperitoneum is created by an
open technique by introducing a 2.5−mm or 5−mm
reusable trocar through the transverse incision at
the lower part of the umbilicus. The size of the tro−
car depends on the size of the telescope. Two sizes
of telescopes are used, preferably a 2.5−mm 5o, but
also a 5−mm 5o or 25o. The insufflation pressure is
between 8 and 10 mm Hg. The whole peritoneal
cavity is inspected first. Any hernia is reduced ma−
nually or with the aid of the telescope tip. If there
is any problem with visualization of the inguinal
region, a 2.5−mm laparoscopic instrument is intro−
duced directly through abdominal wall to help. All
the movements of the needle are performed from
outside under camera and direct vision control.
The needle is curved a little in order to improve the
manipulation. To choose the site of puncture of the
needle, the position of the internal inguinal ring is
assessed by pressing the inguinal region from the
outside with the tip of a Pean’s forceps. Under la−
paroscopic−guided vision, an 18G injection needle
with nonabsorbable 2−0 monofilament thread in−
side the needle canal making the loop is introdu−
PIRS for Inguinal Hernia in Children
ced from outside through the abdominal wall into
the abdominal cavity. Recently the present authors
modified the method in such a way that the peri−
toneal surface at the level of the internal ring is cut
with the needle tip to facilitate adhesion after
suturing. The tip of the needle is moved so that the
thread passes under the peritoneum, over the one
half of the internal ring including a part of the
iliopubic band and adjacent tissue (Fig. 1A). The
thread is pushed through the canal of the needle
into the abdominal cavity and eventually makes
a loop. The needle is then taken out, leaving the
loop of the thread inside the abdomen (Fig. 1B).
From outside, one of the thread ends is introduced
again into the canal of the needle and the needle
passes through the same skin puncture point,
including the second half of the internal ring (Fig.
1C, Fig. 2). To prevent the vas deferens and testic−
ular vessels from injury, a small space is left over
these structures. The end of the thread goes
through the canal of the needle into the thread loop
and the needle is taken out. Next the thread loop is
taken out of the abdomen with the thread end
caught by the loop. In this way the thread is placed
around the inguinal ring under the peritoneum,
with both ends leaving the skin through the same
skin puncture point (Fig. 1D). The knot is tied,
closing the internal ring, and placed under the skin
(Fig. 1E). If an open contralateral inguinal ring is
found, it is closed during the same procedure, re−
gardless of its diameter. The umbilical wound is
closed with absorbable stitches and covered with
a pressure dressing to prevent any hematoma for−
mation. The skin puncture point in the inguinal re−
gion is left without any dressing.
Results
Among the 12 (48%) infants with unilateral
hernia were 11 cases (91.7%) on the right side (10
boys, 1 girl) and one boy (8.3%) on the left side.
There were 13 (52%) cases (11 boys, 2 girls) with
bilateral hernias, in 5 of which an open contralate−
ral inguinal canal was found during the operative
procedure. Nine patients (36%) were admitted to
the hospital with incarcerated hernias that were re−
duced manually before the operative procedure.
There was no conversion to the open procedure.
The mean anesthesia time for PIRS was 48 min.
(min: 30 min., max: 75 min.). The mean time of re−
covery from anesthesia was 11 minutes, with
a maximum of 30 minutes in two cases. The mean
operative time was 23 min. for unilateral hernias
and 26 min. for bilateral hernias, overall 24 min.
(min: 15 min., max: 40 min.). The time of the oper−
ative procedure was taken from the beginning of
853
Fig 1. A: The skin is punctured above the right ingui−
nal ring. The injection needle passes through the exter−
nal half of the inguinal ring, taking part of iliopubic
band. Please note the thread loop inside the abdominal
cavity. B: The thread end is pushed into the canal of
the needle and the needle is inserted through the pre−
vious puncture point of the skin. C: The needle passes
through the medial half of the inguinal ring. The thre−
ad end is pushed into the loop. D: After removing the
needle, the thread end caught by the loop is taken out−
side, passing around inguinal ring. E: The knot is tied,
closing the internal inguinal ring
Ryc. 1. A) Nakłucie skóry nad prawym kanałem pach−
winowym. Igła iniekcyjna przechodzi przez zewnętrz−
ną połowę pierścienia pachwinowego wraz z pasmem
biodrowo−łonowym. Widoczna jest pętla szwu we−
wnątrz jamy otrzewnej. B) Koniec nitki jest wsunięty
do światła igły, którą wprowadzono przez poprzednie
miejsce nakłucia skóry. C) Igła przechodzi przez przy−
środkową połowę pierścienia pachwinowego. Koniec
nitki jest wprowadzony do pętli szwu. D) Po usunięciu
igły złapany pętlą koniec nitki jest wyciągnięty na ze−
wnątrz przechodząc wokół pierścienia pachwinowego.
E) Zawiązanie szwu, który zamyka pierścień pachwi−
nowy wewnętrzny
cleaning the operative field to dressing the umbili−
cus and included assembly of the laparoscopic
equipment. In three cases, concomitant umbilical
hernia repair was conducted during the same pro−
854
D. PATKOWSKI et al.
Fig. 2. Intraoperative view: The needle passes through
the medial half of the inguinal ring. The thread end is
pushed into the loop
Ryc. 2. Obraz śródoperacyjny: igła przechodzi przez
przyśrodkową połowę pierścienia pachwinowego.
Koniec nitki jest wprowadzony do pętli szwu
cedure and in one case a Tenckhoff catheter was
placed.
The viscera inspection during laparoscopy re−
vealed no important injury to the bowel wall after
manual reduction of the incarcerated hernia apart
from local delicate congestion. The only intraoper−
ative complication was incidental puncture of the
iliac vein in one case, which required some gentle
pressing from the outside for a short time. There
were no postoperative infections.
The follow−up was between 2 and 25 months
(average: 13 months). The cosmetic results after
PIRS were excellent, with no scars in the inguinal
region and an almost invisible scar in the umbili−
cus. In a few patients the knot was palpable in the
subcutaneous space. There was no hernia recur−
rence in the analyzed group of children, compared
with 8 cases in 270 operated hernias overall. In
three boys, transient hydroceles were observed
that disappeared spontaneously after 2–5 months.
Discussion
Inguinal herniotomy in infancy consists of
a simple ligation of the hernial sac without ope−
ning the external ring [7]. The route of the traditio−
nal approach for inguinal hernia repair is the main
reason for the patient’s pain in the postoperative
course. The advantage of laparoscopic inguinal
hernia repair in children is the direct approach to
the internal inguinal ring. Using PIRS instead of
the inguinal incision, there is a small (0.5 cm) wo−
und in the umbilicus which seems to cause less
pain, although the present authors are still investi−
gating this.
The laparoscopic closure of the internal ring is
Fig. 3. Postoperative view: arrows indicate wounds
after bilateral PIRS
Ryc. 3. Obraz pooperacyjny: strzałki wskazują rany po
obustronnej operacji metodą PIRS
usually accomplished through three access ports
[1, 3]. There are also techniques using only two
access ports [8]. In all these procedures, the inter−
nal ring is closed by intra−abdominal suturing with
laparoscopic needle holders. This is one of the
most difficult technical aspects of laparoscopy. In−
tra−abdominal suturing requires experience and
many hours of training. Even with adequate expe−
rience it is the most time−consuming part of the
operative procedure. Intra−abdominal suturing in−
volves many manipulations with instruments in−
side the abdominal cavity, with the risk of visceral
injury. The PIRS technique leads to the same result
while avoiding this difficult intra−abdominal sutu−
ring. The PIRS technique makes closing the inter−
nal ring easier and shorter, to be performed even
by a person with basic skill in minimally invasive
surgery. PIRS requires only one port in the umbi−
licus. There is no need for additional trocars and
laparoscopic needle holders, which makes the pro−
cedure less expensive than other laparoscopic
techniques of inguinal hernia repair.
The risk of hernia incarceration is as much as
40% in infancy [7]. Reducing the incarcerated bo−
wel carries the risk of injury. The benefit of the la−
paroscopic procedure is direct control of the redu−
ced viscera.
The recurrence rate is still higher for the lapa−
roscopic treatment of inguinal hernia than for the
traditional approach, although the difference is not
significant [9, 10]. The results of this study are si−
milar to others. Hernia recurrences after the PIRS
procedure were noted only in boys older than 1.5
years. There was no recurrence in children youn−
ger than three months, with usually very large her−
nias in premature infants. It is the opinion of the
present authors that narrowing the inguinal ring,
especially in small children, makes the process of
its natural closure easier.
Excellent cosmetic results are claimed to be
855
PIRS for Inguinal Hernia in Children
among the advantages of laparoscopic hernia repa−
ir. PIRS seems to be a specific procedure that has
the advantage over others of leaving the skin with
only a single scar at the umbilicus that becomes al−
most invisible with time, and the cosmetic results
are even more superior (Fig. 3).
To avoid the risk of testicular vessel and vas
deferens injuries, the thread was placed above the−
se structures leaving a very small (1–2 mm) space.
In many cases it was possible to place the suture
just under the peritoneum without disturbing these
structures. It was not difficult to close the entrance
to the hernia precisely in girls.
The position of the inguinal ring is very close
to the iliac vessels and it is possible to puncture
them during the PIRS procedure. The present au−
thors had one case in the analyzed group of infants
of small hemorrhaging after an iliac vein puncture
with no consequence. If it occurs, the hemorrhage
is self−limiting under the peritoneum. It may be ea−
sily stopped by pressing from outside the abdomi−
nal wall at the inguinal region under camera con−
trol. In the experience of the present authors with
older children, the hematoma has never obscured
the operative field, making PIRS impossible to
performed. To avoid accidental puncture of iliac
vein, the authors recently tried to curve the shape
of the injection needle.
The risk of contralateral hernia development is
estimated to be around 10.2% and is much higher
for primary left−sided hernias (19.2%) [11]. There
are many papers reporting that the incidence of
a contralateral hernia is still too low to justify rou−
tine exploration and surgery for a patent processus
vaginalis [12, 13]. However, the laparoscopic tech−
nique offers special advantages over traditional
exploration to repair the contralateral side only in
cases with an open inguinal canal. It is almost im−
possible to predict whether an open inguinal canal
will result in an inguinal hernia. It was the policy of
the present authors to regard it as a hidden contra−
lateral hernia and for this reason it was decided to
repair it during the same procedure in each case.
References
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Address for correspondence:
Dariusz Patkowski
Department of Pediatric Surgery and Urology
Silesian Piasts University of Medicine in Wrocław
M. Skłodowskiej−Curie 50/52
50−369 Wrocław
Poland
tel./fax: +48 71 328 04 85
e−mail: [email protected]
Conflict of interest: None declared
856
Received: 02.06.2006
Revised: 03.08.2006
Accepted: 21.09.2006
Praca wpłynęła do Redakcji: 02.06.2006 r.
Po recenzji: 03.08.2006 r.
Zaakceptowano do druku: 21.09.2006 r.
D. PATKOWSKI et al.