Modifications of surgical techniques in laparoscopic percutaneous extraperitoneal closure of inguinal ring for childhood inguinal hernia to achieve zero recurrence and zero subcutaneous stitch granuloma.

PURPOSE: To present our technical modifications of single incision laparoscopic percutaneous extraperitoneal closure (SILPEC) of the internal inguinal ring (IIR) for pediatric inguinal hernia (PIH). METHODS: The prospectively collected data of all children diagnosed with PIH undergoing SILPEC at our center from 2016 to 2023 were reviewed and divided into two groups for result comparison: Group A: before and Group B: after the implementation of full modifications. Our modifications included using a nonabsorbable monofilament suture, creating a peritoneal thermal injury at the internal inguinal ring (IIR), employing a cannula to ensure the suture at the IIR ligates only the peritoneum, and double ligation of the IIR in selected cases. RESULTS: 1755 patients in group A and in group B (1 month to 14 years old) were enrolled. There were no significant differences regarding baseline patient characteristics between the two groups. At a median follow-up of 40 months, the rate of recurrent CIH and subcutaneous stitch granuloma (SSG) was 2.3% and 1.5% in group A vs. 0% and 0% in group B (p < 0.001). There were no hydroceles, no ascended or atrophic testis. CONCLUSIONS: Our SILPEC technical modifications can achieve zero recurrence and zero SSG for PIH.

Laparoscopic percutaneous closure of patent processus vaginalis without hydrocelectomy for childhood primary hydrocele.

PURPOSE: To present our surgical technique and the outcome of single-incision laparoscopic percutaneous extraperitoneal closure (SILPEC) of patent processus vaginalis (PPV) without hydrocelectomy for childhood primary hydrocele (CPH). METHODS: A prospective study was conducted on all cases of CPH treated with SILPEC at our center between June 2016 and December 2021. In our SILPEC procedure, PPV was closed extraperitoneally using a percutaneous needle with a wire lasso. No hydrocelectomy or fenestration of the hydrocele was performed. Percutaneous aspiration was performed when the hydrocele fluid could not be pushed back to the peritoneal cavity. RESULTS: 553 patients were enrolled, with a median age of 34 months (range from 22 months to 13 years). Ipsilateral PPV was present in all cases. There were no intraoperative complications and no conversion. At follow-up 6-72 months, recurrent hydrocele occurred in 0.36%, and subcutaneous stitch inflammatory reaction was noted in 0.7%. There was no case of testicular atrophy or iatrogenic cryptorchidism. Postoperative cosmesis was excellent as all patients were virtually scarless. CONCLUSIONS: Ipsilateral PPV was present in all cases of CPH in our series. Our technique of SILPEC of PPV without hydrocelectomy is feasible and safe, with excellent postoperative cosmesis in the management of CPH.

Laparoscopic versus open Kasai procedure for biliary atresia: long-term results of a randomized clinical trial.

PURPOSE: The role of the laparoscopic approach for the Kasai procedure in the management of biliary atresia is still controversial. The aim of this study is to compare the long-term results of the laparoscopic Kasai procedure (LKP) to the open Kasai procedure (OKP). METHODS: A randomized clinical trial was carried out from October 2009 to March 2017. Patients diagnosed with biliary atresia type III were randomized into 2 groups: one group underwent LKP and the other group-OKP. All the surgical procedures were performed by the same surgeon with the same technical principles. The long-term outcomes were compared between the two groups. RESULTS: 61 patients underwent LKP and 61 patients-OKP, with a median age at the surgery of 79.7 days. The two groups had no significant differences regarding the patients' baseline characteristics. At follow-up up to 142 months, the jaundice-free rate at the 6th postoperative month for LKP and OKP was 52.5% and 60.7%, respectively (p = 0.23). The 10-year cumulative survival after LKP tended to be inferior to OKP, respectively 44.3% vs. 58.9% (p = 0.09). CONCLUSIONS: In this study, the long-term results of LKP tended to be inferior compared to OKP although the differences were not significant.

Reduction of recurrence by peritoneal thermal injury in laparoscopic percutaneous extraperitoneal closure of internal ring for inguinal hernia in children.

PURPOSE: To evaluate the impact of peritoneal thermal injury (PTI) in the reduction of recurrence incidence in laparoscopic percutaneous extra-peritoneal closure of internal ring (LPEC) for pediatric inguinal hernia (PIH) in children. METHODS: Medical records of patients undergoing LPEC for PIH at our center were reviewed and divided into 2 groups: Group A (period from June 2017 to December 2017)-without PTI and Group B (period from January 2018 to December 2018) with PTI. The surgical technique and the type of suture used for LPEC were the same for both groups. The outcomes of the two groups were analyzed and compared. RESULTS: 277 patients with 283 IHs in group A were compared to 376 patients with 389 IHs in group B. There were no significant differences between the two groups in terms of age, gender, uni- or bilateral hernia. At a median follow-up period of 48 months, there was no hydrocele, suture granuloma, testicular atrophy, or iatrogenic cryptorchidism in both groups. The recurrence rate in group A was 6.4%, significantly higher than 1.8% in group B (p = 0.002). CONCLUSIONS: Our study showed that PTI in LPEC for PIH is safe and associated with a significant reduction of recurrence incidence.

Long-term absorbable versus non-absorbable suture in laparoscopic percutaneous extraperitoneal closure of internal ring for inguinal hernia in children.

AIM: To compare the results of using long-term absorbable (LTAS) versus non-absorbable suture (NAS) in laparoscopic percutaneous extraperitoneal closure of internal ring (LPEC) for indirect inguinal hernia (IH) in children METHODS: Prospectively collected data from children undergoing LPEC for IH at our center were retrospectively reviewed to compare group A repaired with NAS (2.0 monofilament polypropylene or braided polytetrafluoroethilene) to group B repaired with LTAS 2.0 polydioxanone. RESULTS: 481 patients with 499 IHs in group A were compared to 277 patients with 283 IHs in group B. There were no significant differences in terms of age, bodyweight and laterality of IH between the two groups. At a median follow up period of 30 months, the incidence of suture knot reaction (SKR) and hernia recurrence were 3.1% and 1.0% in group A vs. 0% and 6.4% in group B with p = 0.002 and p<0.001, respectively. Monofilament NAS was associated with a low rate of both recurrence and SKR. CONCLUSIONS: LPEC repair for pediatric IH using LTAS is associated with no SKR but a higher recurrence rate compared to NAS. Monofilament NAS such as Prolene could be a good choice in LPEC because of its low rate of both recurrence and SKR.

Early outcomes of laparoscopic surgery for biliary atresia.

AIM: The aim of the study was to present early outcomes of the laparoscopic technique for biliary atresia with some technical modifications. MATERIALS AND METHODS: We reviewed charts of all patients with biliary atresia who underwent laparoscopic portoenterostomy from July to December 2008. There were 11 patients with biliary atresia, including 5 boys and 6 girls. The operation was carried out using 4 trocars. The liver was elevated by 2 transcutaneous stay sutures: one on the round ligament and the other on the gallbladder remnant. The left and right hepatic arteries and portal veins were dissected and retracted laterally by 2 transcutaneous sutures to expose the liver hilum. A stay suture was placed on fibrotic tissue at the liver hilum to facilitate its maximal removal. A jejunal end-to-side anastomosis was constructed extracorporeally. Portoenterostomy was carried out laparoscopically. RESULTS: Mean operative time was 245 +/- 31 minutes. No patient required conversion. There were no operative deaths. Blood loss during operation was minimal. One patient died on day 65 after operation because of intractable hepatic liver. Follow-up after discharge from 10 to 16 months revealed that 6 patients still survived and 4 patients died. One patient died because of milk aspiration at 12 months of age. Three patients died because of repeated cholangitis and liver failure at 10, 10, and 14 months, respectively. CONCLUSION: With a modified laparoscopic technique, good early outcomes of laparoscopic surgery for biliary atresia were achieved.

Laparoscopic repair for choledochal cyst: lessons learned from 190 cases.

OBJECTIVE: The aim of this study is to report the technical details, early outcomes, and lessons learned from laparoscopic repair of 190 cases of choledochal cyst. METHOD: The operation was performed using 4 ports. The cystic duct was identified and divided. The liver was elevated by 2 stay-sutures: one on the round ligament and the other on the distal cystic duct. The choledochal cyst was isolated and removed completely, and then biliary-digestive continuity was reestablished. RESULTS: From January 2007 to April 2009, 190 patients were operated on. There were 144 girls and 46 boys. Ages ranged from 2 months to 16 years (mean, 46.9 +/- 29.3 months). Cyst diameter ranged from 10 to 184 mm. A total of 106 patients were classified as Todani type I cysts, and 84 were type IV. Cystic excision and hepaticoduodenostomy were performed in 133 patients and hepaticojejunostomy in 57 patients. The operating time varied from 70 to 505 minutes (mean, 186 minutes). Conversion to open surgery was required in 2 patients. Intraoperative blood transfusion was required in 4 patients. There were no perioperative deaths. Postoperative anastomotic leakage occurred in 7 patients, resolving spontaneously in 6 and requiring a second operation in 1. Postoperative hospital stay ranged from 5 to 27 days (mean, 7.2 +/- 3.3 days). Follow-up occurred between 1 and 24 months postdischarge (mean, 9 +/- 2.2 months) and was obtained in 161 patients (84.7%). Of these patients, cholangitis occurred in 4 patients (2.4%). CONCLUSION: Laparoscopic repair is a safe and effective procedure for choledochal cyst.

Laparoscopic near-total pancreatectomy for persistent hyperinsulinemic hypoglycemia of infancy: report of two cases.

Near-total pancreatectomy for persistent hyperinsulinemic hypoglycemia (PHH) of infancy has been done, so far, only by open surgery, and the application of laparoscopic techniques for this procedure has not been documented. In this article, we report 2 cases of successful laparoscopic near-total pancreatectomy for PHH. Two infants underwent surgery at the age of 60 and 54 days and at body weights of 7700 and 5700 g, respectively. Four ports were used for the patient 1 and three ports plus fixation sutures of the stomach to the abdominal wall for stomach traction were used for patient 2. The pancreas was dissected free from the spleen and splenic vessels and was mobilized beyond the right side of the superior mesenteric vein. The head of the pancreas was transected by using the Harmonic Scalpel (Tokyo, Japan), leaving only 1 cm of the pancreas along the duodenal C-loop. The operative times were 180 and 160 minutes. There was neither an intra- nor a postoperative abdominal complication. Oral feeding was resumed on the postoperative day 1. The blood glucose level increased immediately after the operation. Follow-up period of 12 months showed normal levels of blood sugar and insulin for both patients. Laparoscopic near-total pancreatectomy can be a safe, effective procedure for small infants with PHH.