Needlescopic Inversion and Snaring for Inguinal Hernia in Girls Using 1.6-mm Instruments

Operative details: Patient lies in supine position at upper part of OR table towards right edge. Operating table is tilted to opposite side of hernia with 30-degree Trendelenburg position. Operator stands on patient's right side during either uni-or bi-lateral hernia. Camera man stands at table head and monitor facing patient's feet. Vertical trans umbilical 5-mm incision [Point A] was made and 5-mm trocar passed under vision using open technique. Pneumoperitoneum is then established with CO2 flow of 1.5-2.5 L/min keeping intraabdominal pressure between 8-12 mmHg according to patients' age and weight. Early in our experience, a two-mm incision is done at a point located midway between umbilicus and symphysis pubis [point B] for 2-mm port passed under direct vision and a tiny 11-blade scalpel puncture was done at the corresponding Mac-Burney's [Point C] for SGD. Abdomen was then explored to confirm the diagnosis and detect contralateral or other hernias if present.

One SGD was introduced through point B (SGD-B) and another one through point C (SGD-C). Both SGDs were used to invert the hernia sac by gradual sustained alternating traction on the round ligament. Each SGD hands to the other one till complete inversion occurs, this is known by the hernial sac hanging from internal ring without retracting-back inside the inguinal canal. Occasionally, investigators had to fix the sac to the anterior abdominal wall by a suture [Prolne 2/0 on a half circle 20-mm needle] placed percutaneously lateral to the corresponding Mac-Berney's point to prevent its retraction. Then, the MPS was introduced via the trocar at point B and opened inside the abdomen and SGD-C passed inside the loop of MPS and re-catches the hernial sac, which is then twisted around its neck several times. MPS was closed tightly at the proper neck and coagulation diathermy current is applied to it leading to separation of the hernia sac. Detached sac (grasped by SGD-C) was then pushed antegradely out through the umbilical port. In some cases, the Fallopian's tube was closely related to the round ligament and investigators had to divide the round ligament with the long microdiathermy needle introduced directly via point B before hernia sac snaring to avoid its injury during the application of MPS. Deflation of the abdomen is done, and umbilical fascial incision is closed using 2/0 or 3/0 Polygalctin suture and umbilical skin layers were closed using 4/0 Polygalctin suture. Later in the study, we were able to innovate a HMS by using the guide wire of central venous catheter looped through VAC and connected to a regular diathermy probe and investigators modified our technique. An11-blade scalpel puncture is done at point-B through which VAC is introduced directly instead of 2-mm trocar. This VAC is used for the insertion of HMS and SGD-B. Then, complete inversion of the sac was done using 2 SGDs as previously described. Followed by introduction of HMS through #14-G VAC at point-B and the procedure completed as before.

Postoperative Management:

Patients received antibiotics and analgesics according to hospital protocols. Oral fluids started 2 hours post operatively and diet was advanced gradually as tolerated. Patients were discharged the same post-operative day. Follow up period ranged from 12 to 24 (Median 16.5) months. with for recurrence and cosmetic results.

Discussion: