Laparoscopic Inguinal Hernia Repair in Infancy and Childhood
Condition: Congenital Inguinal Hernia
MeSH terms: Hernia; Hernia, Inguinal
Study type: Interventional

Summary: 
      Aim of the study The aim of this study is to test the hypothesis that during laparoscopic
      hernia repair, disconnection of the hernial sac along with suture ligation of the neck is
      better than transperitoneal purse string suture around the hernial sac at the neck leaving
      the sac in continuity. Also to compare the two different laparoscopic techniques as regards
      operative time, recurrence rate, hydrocele formation, and other possible complications as
      bleeding, hematoma, injury of the vas and testicular atrophy and post-operative cosmetic
      results.

      ..
    

Detailed description: 
      Ethical Consideration:

      The protocol will be discussed and approved for clinical study by the Ethical Research
      Committee of our University. The procedures and the aim of the study are clearly explained to
      the patient and the family. A written informed consent is obtained before enrollment of the
      patients into the study. The family refusal to give consent for laparoscopic hernia repair by
      either technique does not deprive the patient from getting surgical care by open herniotomy

      • In the 2 groups, after induction of general endotracheal tube anesthesia, the patient is
      positioned supine in Trendelenburg's position. Insertion of the main umbilical port [5-mm] by
      open technique will be done for 5-mm 30° telescope, then pneumoperitoneum will be created to
      a pressure of 8-12 mmHg.

      Laparoscopy will be used for initial visualization of the pelvis and internal inguinal rings
      on both sides. In group I, the laparoscopic hernia repair will be done according to a
      technique described by Scheir Two 3-mm trocars are inserted under laparoscopic guidance at
      the level of umbilicus in mid-clavicular line on either side as working ports unilateral
      hernia, on the side of hernia can be little higher and opposite side little lower, for better
      triangulation. In infants and small babies, the working ports are placed little higher than
      the level of umbilicus.

      Non absorbable 3-0 Prolene suture is used in all patients after its shortening to 8cm.length.

      Group I, laparoscopic closure of hernia sac at internal inguinal ring in continuity using 3 -
      0 non-absorbable purse-string suture. The spermatic vessels and vas deferens are well
      visualized and protected during the suture. In all cases, hydro dissection can be done by
      injection of saline to separate the peritoneum from cord structures. Two 3-mm.needle holders
      are used for intracorporeal insertion of purse string suture around the opened IIR with
      intracorporeal knot tying. The stitches included the peritoneum and the underlying muscular
      tissue lateral to the spermatic cord. The procedure is modified in children with a dilated
      internal ring. Ligature of the hernia sac at internal inguinal ring (IIR) is inadequate in
      such cases. Here, laparoscopic narrowing of IIR by few interrupted sutures will be done.

      Group II, circumferential incision on the peritoneum at IIR will be started to separate
      hernia sac from the peritoneum. Initial disconnection of the vas and vessels will be done and
      then the peritoneum posterior to the internal ring will be divided and then the anterior
      disconnection will be carried out. Saline can be injected to separate the peritoneum from
      cord structures (hydro dissection). Care is taken not to damage the vas and vessels by
      handling them. Then the proximal part of the sac will be sutured using non-absorbable 3-0
      prolene on round body needle. Closure: In both groups, supra-umbilical incision will be
      closed with polyglycolic acid 3-0 suture. Three mm trocar sites will be approximated with the
      steri-strips.
    

Intervention name(s): Hernial sac ligation in continuity; Hernial sac disconnection
Intervention type(s): Procedure; Procedure
Intervention description(s): Laparoscopic closure of hernia sac at internal inguinal ring in continuity using 3 - 0 non-absorbable purse-string suture. The spermatic vessels and vas deferens are well visualized and protected during the suture. In all cases, hydro dissection can be done by injection of saline to separate the peritoneum from cord structures. Two 3-mm.needle holders are used for intracorporeal insertion of purse string suture around the opened IIR with intracorporeal knot tying. The stitches included the peritoneum and the underlying muscular tissue lateral to the spermatic cord. The procedure is modified in children with a dilated internal ring.; Circumferential incision on the peritoneum at IIR will be started to separate hernia sac from the peritoneum. Initial disconnection of the vas and vessels will be done and then the peritoneum posterior to the internal ring will be divided and then the anterior disconnection will be carried out. Saline can be injected to separate the peritoneum from cord structures (hydro dissection). Care is taken not to damage the vas and vessels by handling them. Then the proximal part of the sac will be sutured using non-absorbable 3-0 prolene on round body needle.
Other intervention name(s): Purse string suture around IIR leaving the sac in continuity; Laparoscopic disconnection of the hernial sac at IIR
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Laparoscopy; purse string; hernial sac