Needlescopic sutureless repair of congenital inguinal hernia: A randomized controlled study.

Congenital inguinal hernia [CIH] can be treated laparoscopically using various methods documented in the literature. Many authors have recommended dividing the sac and stitching peritoneal defects. Other studies claimed that peritoneal disconnection alone is sufficient. In this study, the feasibility, operative time, recurrence rate, and other postoperative complications of needlescopic disconnection of the CIH sac with or without peritoneal defect suturing were compared. A prospective controlled randomized trial was conducted between January 2020 and December 2022. Two hundred and thirty patients who met the study requirements were included. Patients were assigned at random to either Group A or Group B. A group of 116 patients (Group A) had needlescopic separation of the neck of the sac and peritoneal defect closure. The remaining 114 patients (Group B) underwent needlescopic separation without peritoneal defect closure (Sutureless group). A total of 260 hernial defects in 230 patients were repaired using needlescopic disconnection with or without suturing of the defect. There were 89 females (38.7%) and 141 males (61.3%), with a mean age of 5.14 ± 2.79 years. In Group A, the mean operation time was 27.98 ± 2.89 for a unilateral hernia and 37.29 ± 4.68 for a bilateral one, whereas, in Group B, the mean operation time was 20.37 ± 2.37 and 23.38 ± 2.22 for a unilateral and bilateral hernia, respectively. In terms of the operating time, whether unilateral or bilateral, there was a significant difference between the groups. There was no significant difference between groups A and B in the mean Internal Ring Diameter [IRD], which was 1.21 ± 0.18 cm in group A and 1.19 ± 0.11 cm in group B. Throughout the follow-up period, there was no postoperative hydrocele formation, recurrence, iatrogenic ascending of the testes, or testicular atrophy. All patients had nearly invisible scars with no keloid development at 3 months follow-up. Needlescopically separating the hernia sac without stitching the peritoneal defect is feasible, safe, and less invasive. It provides outstanding cosmetic results with a short operative time and no recurrence.

Needlescopic Disconnection and Peritoneal Closure for Pediatric Inguinal Hernia Repair: A Novel Technique.

BACKGROUND: There are many laparoscopic techniques for pediatric congenital inguinal hernia repair. Needlescopic surgery was introduced recently in pediatric patients aiming at getting excellent cosmetic outcomes. PURPOSE: The aim of this study was to describe a novel technique for needlescopic inguinal hernia repair in children. PATIENTS AND METHODS: Needlescopic division of the hernial sac was carried out on 369 children in 6 pediatric tertiary centers during the period from August 2016 to May 2019. All hernias were repaired by a novel needlescopic procedure that replicates all the steps of the open herniotomy. RESULTS: A total of 369 patients with 410 hernias were included in this study. They were 232 (62.9%) males and 137 (37.1%) females, with a mean age of 3.58±1.26 (range=2 to 8 y) and mean internal inguinal ring diameter was 13.65±3.85 mm (range=8 to 20 mm). The mean operative time was 23.36±4.67 minutes for bilateral and 14.28±2.98 minutes for unilateral cases. All cases were completed without conversion to conventional laparoscopy. All cases were followed up for a mean of 19.6±3.2 months. None of our patients developed recurrence or testicular atrophy and the scars were nearly invisible 3 months postoperatively. CONCLUSIONS: Needlescopic pediatric inguinal hernia repair using disconnection of the hernia sac at internal inguinal ring with purse-string suture closure of peritoneum is feasible and safe with no recurrence and with outstanding cosmetic results.

Congenital webbed penis: Surgical outcomes of a simplified technique.

BACKGROUND: Webbed penis is a cause of concealed penis. It reflects abnormal attachment of the scrotal skin to different ventral penile shaft levels, possibly due to abnormal scrotal dartos insertion. Different techniques are available for correction of congenital webbed penis. However, there is no single one versatile for correction of different grades. OBJECTIVE: To evaluate the surgical outcome of penile degloving, excision of abnormal dartos fascia with penoscrotal fixation sutures to correct different grades of congenital webbed penis. STUDY DESIGN: This prospective study was conducted on boys with congenital webbed penis. Thorough clinical examination to determine the degree of webbed penis and associated anomalies were done. A technical modification of previously described technique by Frenkl et al. 2004 (22) was used. The principles include; complete penile degloving with excision of all abnormal scrotal dartos attached to the penile shaft, creation of a well-defined penoscrotal angle by penoscrotal fixation sutures and the short ventral skin was compensated from the prepuce with circumcision. Assessments of surgical outcomes and parents' satisfaction were done during follow up visits. RESULTS: This study included 107 boys. The median age was 9 (range, 6-40) months, and the median operative time was 55 (range, 50-65) min. Five patients (4.7%) developed self-limited postoperative penile edema, two (1.9%) developed wound infections, and two (1.9%) had a self-limited scrotal hematoma. The median follow-up period was 19 months. At the 6 months follow-up, we had two patients with persistent mild grade I webs, with a success rate of 98.13%. Parental satisfaction was obtained for all patients. DISCUSSION: Currently, there is no current single technique suitable for the correction of all grades of webbed penis. In this study, we presented a technical modification of previously described technique by Frenkl et al. 2004 (9), this modified technique is versatile for correction of different grades of congenital webbed penis without leaving a scar at the penoscrotal angle. But, absence of a comparative group is considered a limitation; however, the versatility of this technique overcomes this limitation. CONCLUSIONS: This described technique is simple and feasible. It could correct all types of congenital webbed penis. Short term outcome showed good cosmetic and functional results with parental satisfaction.

Needlescopic Appendectomy in Children and Adolescents Using 14-Gauge Needles: A New Era.

Purpose: We are presenting a very minimally invasive technique for laparoscopic appendectomy (needlescopic appendectomy [NAP]) in children and adolescents using suture grasper device, epidural needle, and homemade isolated long diathermy probe without any conventional laparoscopic instruments. Patients and Methods: NAP was attempted in 48 patients with uncomplicated acute appendicitis at Al-Azhar, Tanta University Hospitals and other allied hospitals during the period from May 2017 to November 2018. The study included patients with acute appendicitis and patients scheduled for interval appendectomy. Exclusion criteria were patients with concealed appendix, patients with appendicular abscess or appendicular mass, patients with acute appendicitis complicated with generalized peritonitis, and patients unfit for laparoscopy. The appendix was brought outside through the umbilical port and the operation was completed extracorporeally. In cases of appendicitis with tethered cecum, the whole procedure was completed intracorporeally. Results: Forty-eight patients with acute uncomplicated appendicitis were treated by NAP. They were 36 males and 12 females with a mean age of 9 ± 3.7 years (range = 4-15 years). Two cases with concealed appendix and one case with appendicular mass were diagnosed during initial laparoscopy and excluded from the study. Thirty-two cases (71.11%) were completed intracorporeally and 13 cases (28.89%) were completed by extracorporeal NAP. The mean operative time was 33.29 ± 3.95 minutes (range = 27-40 minutes) for intracorporeal NAP and 20.9 ± 7.01 minutes (range = 14-40 minutes) for extracorporeal NAP. Degrees of cosmetic satisfaction of the patients and parents were excellent in 93.33% (N = 42/45 patients), and very good in 6.67% (N = 3/45 patients) of patients. Conclusion: NAP using needles only is a new technique that is very minimally invasive, very cheap, safe, reproducible, and easy to be done with outstanding cosmetic results.

Needlescopic Appendectomy in Children and Adolescents Using 14G Needles: A New Era.

Purpose: We are presenting a new very minimally invasive technique for laparoscopic appendectomy (needlescopic appendectomy [NAP]) in children and adolescents using suture grasper device, epidural needle, and homemade isolated long diathermy probe without any conventional laparoscopic instruments. Patients and Methods: NAP was attempted in 48 patients with uncomplicated acute appendicitis at Al-Azhar, Tanta University Hospitals and other allied hospitals during the period from May 2017 to November 2018. The study included patients with acute appendicitis and patients scheduled for interval appendectomy. Exclusion criteria were patients with concealed appendix, patients with appendicular abscess or appendicular mass, patients with acute appendicitis complicated with generalized peritonitis, and patients unfit for laparoscopy. The appendix was brought outside through the umbilical port and the operation was completed extracorporeally. In cases of appendicitis with tethered cecum, the whole procedure was completed intracorporeally. Results: Forty-eight patients with acute uncomplicated appendicitis were treated by NAP. They were 36 males and 12 females with a mean age 9 ± 3.7 years (range = 4-15 years). Two cases with concealed appendix and one case with appendicular mass were diagnosed during initial laparoscopy and excluded from the study. Thirty-two cases (71.11%) were completed intracorporeally and 13 cases (28.89%) were completed by extracorporeal NAP. Mean operative time was 33.29 ± 3.95 minutes (range = 27-40 minutes) for intracorporeal NAP and 20.9 ± 7.01 minutes (range = 14-40 minutes) for extracorporeal NAP. Degrees of cosmetic satisfaction of the patients and parents were excellent in 93.33% (N = 42/45 patients), and very good in 6.67% (N = 3/45 patients) of patients. Conclusion: NAP using needles only is a new technique that is very minimally invasive, very cheap, safe, reproducible, and easy to be done with outstanding cosmetic results.

Novel application of the sewing machine principle; a new simplified intracorporeal suturing technique for pediatric inguinal hernia.

BACKGROUND: The desire of pediatric surgeon to reduce incision related morbidity and pain while achieving good cosmetic results has recently led to the introduction of single incision pediatric endosurgery [SIPES] and needlescopic surgery. Intracorporeal suturing and knot tying during SIPES remain challenging. The aim of this study is to introduce a novel and simple technique for intracorporeal suturing of the pediatric inguinal hernia after needlescopic disconnection of hernia sac using just needles rather than laparoscopic instruments. It is an imitation of the principles of sewing machine. METHODS: The first author discussed the idea of the technique with the coauthors and a demonstration was done on a Silicon Pad before application of the technique on children with congenital inguinal hernia [CIH] for peritoneum closure after needlescopic disconnection of the hernia sac. The main outcome measures were feasibility of the technique, suturing and knotting time and recurrence rate. RESULTS: The sutures were snugly applied to the ridges of Silicon Pad with good approximation and the knot was firmly tightened in all experiments. After applying and mastering the technique on a Silicon Pad, we shifted to use it on 373 children with 491 hernia defects. All operations were completed by the needlescopic technique without the need for insertion of any laparoscopic instruments. The time required for suturing of the peritoneum around internal inguinal ring [IIR] and knot tying, decreased considerably from 6 min 27 s in the first operation to less than 4 min after the fifth operation and stabilized at approximately 4 min 30 s. No major intraoperative complication. There was no recurrence during a mean follow-up period of 19.6 ±â€¯1.2 months. CONCLUSION: The closure of the peritoneum around the IIR using needles mimicking what is happening in sewing machine suturing is a feasible, safe and effective line of treatment of children with CIH. The cosmetic results are 42 outstanding without any recurrence.

Fifteen Years Experience with Laparoscopic Inguinal Hernia Repair in Infants and Children.

BACKGROUND: Laparoscopic inguinal hernia repair (LIHR) is gaining popularity with more studies validating its feasibility, safety, and efficacy. The aim of this work is to review our experience with LIHR in infants and children during the past 15 years, and present and evaluate our innovations of laparoscopic techniques. PATIENTS AND METHODS: A retrospective study of 1284 patients with congenital inguinal hernia (CIH) subjected to different techniques of LIHR from October 2000 to October 2015. The main outcome measurements included the following: operative time, hospital stay, hernia recurrence, hydrocele formation, testicular atrophy, iatrogenic ascent of the testis, and cosmetic results. INCLUSION CRITERIA: All patients with CIH who were managed by LIHR during the period of study. They were bilateral cases, recurrent hernias, unilateral hernia in obese child, unilateral hernia with associated infantile umbilical hernia, and unilateral hernia with questionable contralateral side. RESULTS: A total of 1284 patients with CIH were corrected with different laparoscopic procedures. They were 918 males and 366 females. The age range was variable from 6 to 78 months (mean 28.32 ± 24.46 months). All cases were completed laparoscopically without major intraoperative complications. Contralateral hernial defects were found in 294 patients (22.90%), a direct inguinal hernia (IH) was discovered in 15 patients (1.17%), and a femoral hernia was discovered in 3 patients (0.23%). Recurrence occurred in 9 boys (0.98%) who were among the early cases; however, in later group, no recurrence had been detected. Hydrocele occurred in 19 cases (males) (2.07%), without detection of testicular atrophy or iatrogenic ascent of the testis. CONCLUSION: Our results lead us to believe that LIHR by expert hands is safe and effective. It enables the surgeon to discover and repair contralateral hernia and all forms of IHs. One should be able to tailor a suitable technique for each case according to the resources and expertise.

One trocar needlescopic assisted inguinal hernia repair in children: a novel technique.

BACKGROUND: Inguinal hernia repair using a percutaneous internal ring suturing technique is an effective alternative technique to conventional laparoscopic hernia repair. It is one of the most commonly used approaches for laparoscopic hernia repair in children. However, most percutaneous techniques have utilized extracorporeal knotting of the suture and burying the knot subcutaneously. This approach has several drawbacks. The aim of this study is to present a modified technique for single cannula needlescopic assisted hernia repair in children. PATIENTS AND METHODS: Three-hundred and fifty-seven patients with 397 indirect inguinal hernias underwent a one port needlescopic assisted inguinal hernia repair. The open internal inguinal ring [IIR] was closed using an 18-gauge epidural needle [EN], a 14-gauge venous access cannula [VAC], and a homemade suture device. Saline was injected extraperitoneally around the IIR for hydrodissection. The main outcome measurements were: feasibility, safety of the technique, operative time, recurrence rate, and cosmetic results. RESULTS: This prospective study was conducted on 357 patients at Al-Azhar, Alexandria, and Mansoura University Hospitals during the period from June 2012 to October 2015. There were 286 males and 71 females. The mean age was 2.6±1.3years (range=4months to 6years). One-hundred and ninety-eight patients presented with a right-sided inguinal hernia, 119 patients with a left-sided hernia, and 40 patients with bilateral inguinal hernia. The mean operative time was 12.6±1.7min (range=8-15min) for unilateral cases and 18.6±1.7min (range=14-20min) for the bilateral repairs. No wound complications or umbilical hernias developed. The mean follow-up period was 18.6±1.2months (range=11-36months). During the follow-up period, no recurrence was detected, and the scars were nearly invisible. CONCLUSION: This preliminary study shows that a single port needlescopic assisted hernia repair in infants and children is a very promising technique to achieve nearly scarless surgery. The procedure is very safe, rapid, easy to learn, and reproducible.

Laparoscopic pediatric inguinal hernia repair: a controlled randomized study.

BACKGROUND: Inguinal hernia repair is one of the most frequently performed surgical procedure in infants and young children. Laparoscopic hernia repair in infancy and childhood is still debatable. There are many techniques available for laparoscopic hernia repair in pediatrics. The aim of the study is to compare laparoscopic intracorporeal purse-string suture ligation of the hernia defect leaving the sac intact versus disconnection of the hernia sac with intracorporeal suturing of proximal part. PATIENTS AND METHODS: A prospective controlled randomized study of laparoscopic repair of congenital inguinal hernia (CIH) was conducted over a period of 2years and 8months from April 2014 to December 2016. All patients were randomized into two equal groups: Group I (n=66) received intracorporeal purse string suture ligation of the hernia sac at internal inguinal ring [IIR] leaving the sac intact; and Group II (n=66) received disconnection of the hernia sac with intracorporeal suture of proximal part at IIR. INCLUSION CRITERIA: Male patient with bilateral CIH, questionable other side, cases of CIH associated with umbilical hernia and parental request. EXCLUSION CRITERIA: Recurrent cases, complicated cases, hernia of canal of Nuck in females, inguinal hernia with undescended testis, parental refusal. The main outcome measurements were operative time, postoperative hydrocele formation, recurrence rate. RESULTS: This study included 132 patients with 157 hernia defects. Their age ranged from 6months to 3years. Statistically significant differences regarding the demographic data of the groups. All cases were completed successfully without conversion. There was no statistically significant difference between groups regarding intraoperative complications and hospital stay. There was statistically significant difference in the operative time and post-operative complications between the studied groups. CONCLUSIONS: Laparoscopic inguinal hernia repair by disconnection of the hernia sac at the IIR with peritoneal closure is safe and feasible method. It has a lower recurrence rate than the purse string suturing leaving the sac intact.

Staged laparoscopic traction-orchiopexy for intraabdominal testis (Shehata technique): Stretching the limits for preservation of testicular vasculature.

BACKGROUND: We present the midterm results of the novel technique of two-stage laparoscopic traction orchiopexy (SLTO) for the high intraabdominal testis (IAT) for elongation of the testicular vessels without division. PATIENTS AND METHODS: Boys with IAT proven by laparoscopy were selected for the technique between September 2009 and April 2013 in 2 Egyptian pediatric surgery units. Boys <6months or >9years were excluded. The technique entails fixation of the testis to a point one inch above and medial to the contralateral anterior superior iliac spine for 12weeks. Subdartos orchiopexy is then done at the second stage. Both stages are laparoscopically assisted. RESULTS: SLTO was used in 124 boys (140 testis units) with IAT. Mean follow-up period was 16 (range 6-36) months. Scrotal testes were achieved in 105 (84%) of 125 followed cases. Success was correlated with patient age at operation and with distance of IAT from the internal inguinal ring with higher success in younger patients and in testes nearer to internal inguinal ring. CONCLUSION: The novel technique of two-stage laparoscopic traction-orchiopexy is useful in IAT not amenable to one-stage laparoscopic-assisted orchiopexy; it resulted in significant elongation of testicular vessels without atrophy. It is a safe and valid alternative to two-stage laparoscopic Fowler-Stephens technique, which entails division of the main testicular vessels.

Laparoscopic management of recurrent inguinal hernia in childhood.

BACKGROUND: Open repair of recurrent inguinal hernias [RIH] in infancy and childhood is difficult and there is definite risk of damaging the vas deferens and testicular vessels. Laparoscopic repair of RIH has the benefit of avoiding the previous operative site. The aim of this study is to present our experience with laparoscopic repair of RIH either after open or laparoscopic hernia repair with stress on technical refinements to prevent recurrence. PATIENTS AND METHODS: This is a retrospective study of laparoscopic repair of RIH. Records of 38 patients with 42 recurrent hernial defects that have been subjected to laparoscopic inguinal hernia repair [LIHR] for RIH were reviewed and evaluated. The primary outcome measurements of this study include; operative time and recurrence rate. The secondary outcomes include intraoperative and postoperative complications, hydrocele formation and testicular atrophy. RESULTS: In this study 38 children with 42 recurrent hernial defects [4 patients had bilateral recurrent hernia] were operated upon laparoscopically. They were 34 males and 4 females with a mean age of 2.54±1.989years (range=0.58-10.00years). In 35 hernial defects the recurrence developed after open herniotomy, while in 7 hernial defects it occurred after laparoscopic repair. All procedures were completed laparoscopically without any conversion and there were no intraoperative or postoperative complications during this study. Mean operating time was 15±2.3minutes for unilateral and 20±1.7minutes for bilateral inguinal hernia. All patients achieved full recovery and were discharged on the same day of admission. Two patients developed hydroceles that responded well to conservative management. At mean follow-up of 12.7±2months (range=8-38.4months), there was no recurrence, no testicular atrophy. CONCLUSION: Laparoscopic repair of RIH in infancy and childhood is an attractive option that avoids the difficulties of redo surgery in scarred operative field with delicate structures liable to injury even with expert operator.

Shalaby technique for efficient single incision laparoscopic pediatric inguinal hernia repair.

BACKGROUND: The desire to reduce incision related morbidity and pain while achieving improve cosmetic results has recently led to the introduction of single incision pediatric endosurgery [SIPES]. Over the last few years, SIPES has been increasingly used for a variety of procedures; single incision laparoscopic hernia repair [SILHR] is perhaps its common application. Intracorporeal suturing and knot tying during SIPES remain one of the most challenging tasks. The aim of this study is to present a novel technique to avoid excessive purposeless movements during SILHR in children. PATIENTS AND METHODS: One-hundred and fifty patients with 170 hernial defects were subjected to SILHR during the period from June 2009 to October 2011. Extraperitoneal saline was injected around internal inguinal ring [IIR] in males. The opened IIR was closed by percutaneous insertion of purse string suture using Reverdin Needle (RN) with intracorporeal suture tie. The main outcome measurements were; feasibility of the technique, tightness of the suture tie, operative time, postoperative hydrocele formation, recurrence rate, and cosmetic results. RESULTS: Ages ranged between 6 months and 7 years (mean 2±24.2years). There were 101 males and 49 females. Eighty-four patients presented with right sided inguinal hernia, 46 patients with left sided hernia, and 20 patients with bilateral hernia. The mean operative time was 12.4±1.7min for unilateral cases and 18.6±1.7min for the bilateral cases. On follow-up, there were only 1 case of recurrence and 3 cases of hydrocele and the scar is nearly invisible. CONCLUSION: The preliminary results of this study showed that our technique is very promising to achieve secure closure of IIR and reduced operative time with excellent cosmetic results.

Single instrument intracorporeal knot tying during single port laparoscopic hernia repair in children: a new simplified technique.

BACKGROUND: With the increasing number of open surgical procedures shifting to laparoscopy, laparoscopic suturing and knot tying are becoming integral parts of the skills that any laparoscopist must acquire. It is the most difficult step in laparoscopic surgery, especially in single incision pediatric endosurgery (SIPES). It needs special laparoscopic skills and very long learning curve. The aim of this study is to introduce a new simplified technique for single instrument intracorporeal suture tying during single incision laparoscopic hernia repair (SILHR). PATIENTS AND METHODS: This study was conducted at Al-Azhar University Hospitals between June 2008 and June 2010. Three-hundred and eighty three patients with 402 congenital inguinal hernias were subjected to SILHR using percutaneous insertion of purse string suture by Reverdin Needle (RN) with single instrument intracorporeal suture knot tie. DESCRIPTION OF THE TECHNIQUE: Under general endotracheal tube anesthesia, a 0.8-1.2-cm. longitudinal transumilical skin incision was done for insertion of the umbilical port and a 3-mm Maryland forceps. RN was used for insertion of a purse string suture with single instrument intracorporeal suture tie around internal inguinal ring (IIR). The purse-string knot airtightness was stress-tested by raising the intraperitoneal CO2 pressure to 16-24mm Hg for about 30seconds. RESULTS: A total of 383 patients with 402 congenital inguinal hernias were subjected to SILHR. They were 304 males and 79 females with a mean age of 2.2±2.25years. A single instrument technique was used for intracorporeal suture knot tie and all cases were completed laparoscopically without conversion. The mean operative time was 12.5±3.3minutes for unilateral hernia repair and 17±4.37 for bilateral cases. All patients achieved full recovery without intraoperative or postoperative complications. CONCLUSION: Single instrument intracorporeal suture tie is feasible, simple, and rapid as it resulted in marked decrease of operative time. It is of low cost, secure and gives great help during SIPES surgery without struggling. It is a good alternative option to extra corporeal knot tying.

Laparoscopic inguinal hernia repair; experience with 874 children.

BACKGROUND: Laparoscopic inguinal hernia repair (LIHR) in children has become an alternative to the open procedure. It is gaining popularity with more and more studies supporting its feasibility, safety, and efficacy. This is a retrospective study to present our experience with children who underwent LIHR. PATIENTS AND METHODS: A total of 1184 inguinal hernias were repaired laparoscopically in 874 children. They were 703 boys and 171 girls. Their mean age was 2.9 ± 2.1 years (range, 6-108 months). Six-hundred and twenty four opened internal inguinal rings (IIRs) were closed by transperitoneal purse string suture technique (TPP) and 560 opened IIRs were closed by percutaneous purse string suture with lateral umbilical ligament enforcement using Reverdin Needle (RN) technique. RESULTS: All cases were completed laparoscopically without conversion. There were no serious intraoperative complications. Mean operating time, in TPP technique, was 15 ± 2.3 minutes for unilateral and 20 ± 1.7 minutes for bilateral inguinal hernia, while the mean operating time, in RN technique, was 8.7 ± 1.18 minutes for unilateral and 12.35 ± 2 minutes for bilateral hernia repair. The contralateral patent processus vaginalis (PPV) was present in 176 (20% of cases). Follow-up to date is 10-140 months (mean 80 ± 2.1 months). In the early stage of this study, the recurrence rate was 1.13%. In the last 450 cases, no recurrence occurred. Hydroceles occurred in 0.58% and no testicular atrophy or iatrogenic ascent of the testis. CONCLUSIONS: LIHR can be a routine procedure with results comparable to those of open procedures. Both recurrence and operative time are nearly equal or even less than that for the open procedure after gaining a learning curve and modifications of the techniques.

Laparoscopic Hernia Repair versus Open Herniotomy in Children: A Controlled Randomized Study.

Background. Laparoscopic hernia repair in infancy and childhood is still debatable. The objective of this study is to compare laparoscopic assisted hernia repair versus open herniotomy as regards operative time, hospital stay, postoperative hydrocele formation, recurrence rate, iatrogenic ascent of the testis, testicular atrophy, and cosmetic results. Patients and Methods. Two hundred and fifty patients with inguinal hernia were randomized into two equal groups. Group A was subjected to laparoscopic inguinal hernia repair. Group B was subjected to open herniotomy. The demographic data were matched between both groups. Assessment of the testicular volume and duplex assessment in preoperative, early, and late postoperative periods were done. Results. All cases were completed successfully without conversion. The mean operative time for group A was 7.6 ± 3.5 minutes, 9.2 ± 4.6 minutes and 11.4 ± 2.7 minutes, for unilateral hernia, unilateral hernia in obese child, and bilateral hernia, respectively. The recurrence rate was 0.8% in group A, whereas in group B the recurrence rate was 2.4%. Conclusion. Laparoscopic hernia repair by RN is an effective line of hernia repair. It resulted in marked reduction of operative time, low rate of recurrence, no testicular atrophy, no iatrogenic ascent of the testis, and excellent cosmetic results.

Laparoscopic hernia repair in infancy and childhood: evaluation of 2 different techniques.

PURPOSE: Laparoscopic hernia repair in infancy and childhood is still debatable. There are many techniques available for laparoscopic hernia repair in children. The objective of this study was to compare intracorporeal suturing and knotting with extracorporeal knotting for repair of congenital inguinal hernia in infants and children about operative time, recurrence rate, hydrocele formation, and postoperative cosmetic results. A randomized controlled study was carried out in the Pediatric Surgery Unit of Al-Azhar University Hospitals (Cairo, Egypt) over a 3-year period. PATIENTS AND METHODS: One hundred fifty patients with congenital inguinal hernia were randomized into 2 equal groups (n = 75). Group A was subjected to intracorporeal purse string suture around the internal inguinal ring (IIR) using 2 needle holders. Group B was subjected to insertion of purse string suture around IIR using a Reverdin needle (RN) and extracorporeal knotting. Inclusion criteria included bilateral inguinal hernia, recurrent hernia, hernia in obese children, incarcerated hernia, and ipsilateral hernia with questionable hernia on the contralateral side. Exclusion criteria included unilateral inguinal hernia and hernia with undescended testicles. The main outcome measurements were operative time, length of hospital stay, postoperative hydrocele formation, recurrence rate, and cosmetic results. RESULTS: There were no significant differences about age, sex, and mode of presentation between both groups. All cases were completed successfully without conversion. There were significant statistical differences in the operative time, recurrence rate, and cosmetic results between the studied groups, whereas there were no significant statistical differences in the hospital stay and postoperative hydrocele formation. CONCLUSION: Laparoscopic hernia repair by RN is an effective method of hernia repair in infants and children. It resulted in a marked reduction of operative time and excellent cosmetic results with low recurrence.

Laparoscopic mesh rectopexy for complete rectal prolapse in children: a new simplified technique.

PURPOSE: Rectal prolapse in children without underlying conditions is usually a self-limiting problem and requires no surgical treatment. For children with persistent rectal prolapse, a variety of surgical procedures have been described with success. Recently, there are many reports addressing the successful use of different laparoscopic approaches for complete rectal prolapse. We present a novel simplified laparoscopic technique for management of those patients. The aim of this study is to evaluate the results that can be achieved by using this technique in management of persistent complete rectal prolapse in children. METHODS: We reviewed the reports of 680 patients with primary complete and partial rectal prolapse over the period from August 2000 to August 2008. Fifty-two patients with complete primary rectal prolapse refractory to medical treatment for 2 years underwent a novel simplified technique for laparoscopic mesh rectopexy. RESULTS: Conservative management was successful with no recurrences in 628 patients (92.4%) while 52 (7.6%) patients did not respond to conservative management at a median follow-up period of 2 years. They were 35 males and 17 females. Their ages ranged from 2 to 14 years (mean 6). All patients were subjected to laparoscopic mesh rectopexy successfully without any conversion. The mean duration of surgery was 40 min. No intraoperative complications were reported, but one patient developed postoperative constipation that responded well to conservative treatment. The mean postoperative hospitalization was 2 days. Two cases were lost to follow-up, while the others were available for 36 months. There was no recurrence. CONCLUSION: Laparoscopy mesh rectopexy is safe, rapid, effective technique. It improved functional outcome without recurrence. It is associated with minimal postoperative pain and short hospital stay with excellent cosmoses.

Laparoscopic management of persistent complete rectal prolapse in children.

BACKGROUND: Rectal prolapse is a relatively common condition in children. The multiplicity of surgical approaches used for rectal prolapse indicates that there is no single approach universally accepted and applicable to all cases. The laparoscopic approach promises to become the criterion standard for the management of full-thickness rectal prolapse in children. The aim of this study was to review our experience over the last 5 years and to evaluate the results that can be achieved by using laparoscopy in management of complete rectal prolapse in children. PATIENTS AND METHODS: Forty patients presented with complete rectal prolapse and fecal incontinence grades (3-4) according to Rintala scale (37 secondary to prolapse and 3 neuropathic) had been operated upon laparoscopically from August 2003 to August 2008. They were subjected to clinical examination, investigations, pre- and postoperative electromyogram activities for external sphincter, puborectalis, and pelvic floor muscles. The pathophysiologic changes for each case was identified and dealt with laparoscopically (laparoscopic suture rectopexy, laparoscopic mesh rectopexy, laparoscopic resection rectopexy, and laparoscopic levatorplasty). RESULTS: Among the 40 children with complete rectal prolapse, 22 were males and 18 females. Their median age was 9 years (range, 4-14 years). All cases (n = 40) showed a redundant rectosigmoid junction. Additional laxity of the pelvic floor was present in 32, rectoanal intussusception in 27, anterior wall rectoanal intussusception in 3, and rectosacral hernia in 5 cases. All procedures were completed laparoscopically. The median duration of surgery was 60 minutes (range, 50-70 minutes) for suture rectopexy, 90 minutes (range, 60-110 minutes) for mesh rectopexy, 110 minutes (range, 95-160 minutes) for resection rectopexy, and 120 minutes (range, 100-150 minutes) for laparoscopic levatorplasty. No intraoperative complications occurred in this study. Median postoperative hospitalization was 3 days (range, 2-5 days). Electromyogram studies showed statistically significant improvement during rest, minimal volition, and squeezing in all cases except those children with spina bifida and meningomyelocele. The only complications were postoperative constipation and external colonic fistula. Significant improvement of the continence score was achieved in all cases. The average follow-up time was 36 months. There were no recurrences. CONCLUSION: The use of laparoscopy in the management of complete rectal prolapse is safe, effective, and associated with improved functional outcome. It saved the patients multiple operations and is associated with minimal postoperative pain and short hospital stay.

Thoracoscopic repair of diaphragmatic hernia in neonates and children: a new simplified technique.

Needlescopic techniques have been used recently in different pediatric procedures, which made this type of surgery more feasible and less invasive with decreased hospital stay and improved cosmetic results. The technique is being developed further. New techniques with minor modifications are evolving every day. The objective of this study was to describe and assess the results that can be achieved by using a new simplified technique [Reverdin needle (RN)] in thoracoscopic repair of diaphragmatic hernia in neonates and children. Eighteen patients with symptomatic congenital diaphragmatic hernia (CDH), from Al-Azhar University Hospitals, Cairo, Egypt were assigned to elective thoracoscopic repair using RN to insert mattress sutures between the edges of diaphragmatic defects. The technique will be described in detail. A total of 18 diaphragmatic defects were repaired successfully; there were 12 males and 6 females with a mean age of 1.58 +/- 21 months (range, 5 days-9 months). Left-sided CDH was present in 12 cases (67%) and right-sided CDH in 6 cases (33%). The mean operative time was 30.7 +/- 1.18 min (range, 25-60 min) for each CDH repair. There were no intra or postoperative complications. There was one case of conversion and minimal blood loss. The mean postoperative hospital stay was 5.6 days (range, 2-10 days). There was only one case of mortality on the 10th postoperative day. There was no single case of recurrence. The new technique had all the advantages of thoracoscopy in children (less invasive, less pain, shorter hospital stay) combined with the advantages of reduced operating time, simplicity and feasibility. It may be preferable to intracorporeal suturing and knot tying.

Two-trocar needlescopic approach to incarcerated inguinal hernia in children.

BACKGROUND: Many studies described the safety and effectiveness of laparoscopy in the treatment of inguinal hernia in children. Needlescopic techniques have been recently used in repairing inguinal hernias, which made this type of surgery more cosmetic and less invasive. However, few reports have described its role in the treatment of incarcerated inguinal hernia. The aim of this study was to assess the feasibility and outcome of needlescopy in the treatment of incarcerated inguinal hernia in children. METHODS: A total of 250 children, comprising 190 boys and 60 girls, who presented with incarcerated inguinal hernia were analyzed. Their ages ranged from 6 months to 6 years (mean age, 2 years). In 170 (68%) cases, manual reduction was successful. One hundred of these patients were subjected to definitive surgery in the same day, whereas the remaining 70 patients were subjected to needlescopy 1 to 3 days later. In 80 (32%) cases, external manual reduction was unsuccessful. These children were subjected to urgent needlescopic reduction and herniorrhaphy. The incarcerated herniae were easily reduced and the contents thoroughly inspected under direct vision. Then the hernia was repaired in the same setting. RESULTS: In all patients, there was no need to convert the procedure to an open approach. Immediate needlescopic herniorrhaphy in the same session was added without significant increase in operative time. The mean operative time is 10 minutes. There were no intraoperative complications. CONCLUSIONS: The study showed that needlescopic approach to incarcerated inguinal hernia in children is feasible, safe, easy, and preferable to the open surgery. In addition to reduction of incarcerated hernial contents under direct vision, it allows definitive treatment of hernial defect at the same time without significant increase in operative time and hospital stay.