Laparoscopic Hernia Repair in Pediatrics Population, Evaluation of the IDES technique, A French Multi-Centers Study
Ghazwani
Salman1, Scalabre Aurelien2, Jean-Luc Deluca1,
Fakhro Ahmad1, John Yao1, Gallinet Claire2,
Vermersch Sophie2, Varlet Francois1, Fievet Lucile1*
1Division
of Pediatric Surgery, Avignon Regional Hospital.
2Division
of Pediatric Surgery Saint Etienne Regional University Hospital, France.
3Division
of Pediatric Surgery, Jazan University Hospital,Faculty of Medicine, Department
of pediatric Surgery,Saudi Arabia
*Corresponding author: Fievet Lucile, Division of Pediatric Surgery, Avignon Regional Hospital,
France. Email: Fievet.Lucile@ch-avignon.fr
Received Date: 29
June, 2018; Accepted Date: 10 July,
2018; Published Date: 16 July, 2018
Citation: Salman G, Aurelien S, Deluca JL, Ahmad F, Yao J, et al. (2018) Laparoscopic Hernia Repair in Pediatrics Population, Evaluation of the IDES technique, A French Multi-Centers Study. J Surg 2018: 1151. DOI: 10.29011/2575-9760.001151
1. Abstract
1.1. Aim of the Study: Recently several laparoscopic techniques have emerged for repair of inguinal hernia in children, the gold standard still being the open herniotomy. This study Evaluates the Inguinal Dissect, Excise and Suture (IDES) technique which includes incision of the peritoneum at the internal ring, dissection of the vas and vessels, excision of the hernia sac and closure of the peritoneal defect.
1.2. Methods: This retrospective study includes all consecutive children operated on for inguinal hernia using the laparoscopic IDES technique in 2 centers from December 2015 to December 2017. Clinical data were collected from medical charts.
1.3. Main Results: One hundred and fifty-seven (157) patients comprising of 77 females (49.04%) and 80 males (50.96%) were involved in the study. The mean age at surgery was 55 months +/- 43. Asymptomatic contralateral hernias were found in 20 % of cases during laparoscopy and were systematically treated. The mean operating time was 46 min [21;106] for unilateral cases, and 55 min [27;103] for bilateral cases. No intraoperative complications were reported. Clavinet grade 1 complications occurred in 8 cases, mainly postoperative vomiting. 112 patients under 3 months old were discharged on the same day, and younger patients were usually discharged the next morning. All patients had a follow-up within a 6 weeks period after surgery. No recurrence was observed. In only one case recurrence was suspected but not confirmed during re-do procedure.
1.4. Conclusions: Laparoscopic inguinal hernia repair using the IDES technique appeared safe and effective in children, suited to ambulatory surgery.
2. Keywords: IDES; Laparoscopic Hernia Repair; Paediatric Inguinal Hernia
3.
Introduction
The commonness of congenital indirect inguinal hernia requiring
operative treatment among the paediatric population is at a clinically
significant statistical rate of about 1 - 5 % with between 88 - 91% possible
occurrences in boys than it occurs in girls [1]. Because of its clinical significance, the treatment of
paediatric inguinal hernia has attracted various operative interventions with
pain coming out as an important indicator outcome of such procedures. The
hernia sac high ligation open herniotomy has been the conventional gold
standard operative treatment for paediatric inguinal hernia [2]. However, with advancement in clinical interventions various
other approaches in the treatment of inguinal hernia have been developed
including the now common laparoscopic treatments are being employed.
4.
Objective
The aim of this paper is to analyse and present the outcome of
paediatric inguinal hernia laparoscopic repair in French Multiple
centres using The Dissect, Excise, and Suture (IDES)
laparoscopic hernia repair.
5.
Material and Methodology
Carrying
out a retrospective analysis of 2-French medical centres in paediatric
laparoscopic hernia repair, the dissect, excise, and
suture (IDES) laparoscopic hernia repair technique proposed by was
adopted Shah, et al. [3]. One hundred and
fifty-seven (157) patients comprising of 77 females (49.04%) and 80 males
(50.96%) were involved in the study. The average age in terms of months for the
participants was 55 months. The surgical technique employed on each of the
participants involved a general anaesthesia with endotracheal intubation with
the subjects held securely and supine while the operation was on course in a
manner that while the side containing the hernia was in a higher position, the
head was in a lower position. Employing the open technique for 5 mm 30° telescope, a 5 mm supra-umbilical port was
inserted. Pneumo-peritoneum was established
by CO2 insufflations at pressure of 8
cm of water and at the rate of 10 per minute. Examination of the affected side
and then opposite side was performed to check for the patency of the processes
vaginalis. Two more 3 mm trocars were inserted under laparoscopic guidance at
the level of umbilicus in mid-clavicular line on either side as working ports
for bilateral hernia. For unilateral hernia, the working port on the side of
hernia can be little higher and opposite side little lower, for better
triangularisation. In infants and small babies, the working ports were placed
little higher than the level of umbilicus. The symptomatic side on the
peritoneum at the internal ring was the initial point of incision and involved
the proper and careful vas and vessels dissections. Keeping in a mind a
targeted dissection length of about 2 cm in the inguinal canal, the hernial sac
was then dissected using scissors. At the internal ring, it was possible to
approximate the distance between the inguinal ligament and the conjoint muscle.
The closing of the noted peritoneal defect was achieved using a V-Lock 3-0 or Vicryl
4.0 thread introduced the umbilical trocar. Using the body needle and the
dissector, the peritoneal bites were removed and later the removal of the
hernia sac together with the needle were accomplished after suturing and
closing of the peritoneal defect (Figure 1).
6.
Results
The
research involved 157 subjects aged between 0 to 172 months with the average
being 55 months. With an average operating time of 43.18 minutes, the highest
was 106 minutes with the lowest being 14 minutes. There were few incidences of
postoperative complications that included asthmatic crises, gastroenteritis,
abdominal pain, vomiting, and wound infection. In addition, there were no
recurrences. (Tables
1-3) (Figure 2) indicates the descriptive statistics of the
different variables observed in the research process of the study.
7.
Clinical Data Analysis
The
average for hospital stays for each of the subjects in terms of days was 1.36
with the maximum number of days being 7 and the minimum being 1 day. In
reference to the operative time, the average for all the subjects was 43.18
with the longest being 106 minutes and the shortest being 14 minutes with a
standard deviation of 15.12. Graphically, the analysis of operative time
progress can be presented as shown in (Figure 3) below. In the
postoperative course 1 case of asthmatic crises, 1 case of gastroenteritis, 1
case of known pt of diabetes, 1 case of abdominal pain, 2 cases of vomiting and 2
cases of wound infection were reported. However, there
were no recurrences for all of the subjects. In addition, 142 patients did not
experience any postoperative course. In the percentage of concurrent pathology
found intra-operative, the details were as observed in table 4 shown above.
8.
Discussions
An
inguinal hernia is a common paediatric occurrence that has been for long been
treated using the more clinically invasive hernia sac
high ligation open herniotomy technique [4]. The open herniotomy technique has been linked to
observable recurrences of hernia in patients [5,6]. Furthermore, there is a close association of the open
herniotomy method with increase postoperative complications [7-9]. However, in the
recent years, there has been a course to adopt less invasive approaches and
such efforts have included the discovery of surgical techniques such as laparoscopy.
In fact, the popularity of the laparoscopic repair of paediatric inguinal
hernia is quite high resulting from its consideration not only as a technically
easier method due to its ability to improve visualisation of all anatomical
structures, prevention of recurrent hernias as well as the possibility of
employing a low-cost simulator [10,11]. Other
benefits credited to the laparoscopic repair of hernia include minimal
dissection and diminished complication rates, significant cosmetic results as
well as the repairmen of “contralateral Patent Process Vaginalis (PPV) hernias”
[12]. Because of the perceived advantages of the
laparoscopic techniques in paediatric hernia repair, its adoption is becoming
widespread in many medical facilities. In the treatment of paediatric inguinal
hernia, various laparoscopic hernia repair methods have been employed.
For
example, in one method an intracorporal knot tying preceded by a purse-string
sutured around the patent deep inguinal ring is often prepared for surgical
incision 11. In this study, The Dissect,
Excise, and Suture (IDES) laparoscopic hernia repair technique proposed by Shah
et al. was adopted. The method involves making an incision, followed by a
dissection, removal of the peritoneal bites and the hernia sac after suturing
followed by a closing of the peritoneal defect had been done with the incision
closed using polyglycolic acid 3-0 [3]. The
method does not lead to the impairment of testis [13,14].
The use of an absorbable suture is a common practice in laparoscopic hernia
repair as was the case in this study. The use of the absorbable suture has also
been employed in other studies such Schier [15-18]. However, the adoption of non-absorbable
suture can be observed in [16,19,20]. From
our study, the shortest operative time was 14 minutes. Such duration is also
supported by McCormack,
et al. who delineate a surgery time of between 14 to 16 minutes [21]. it
was apparent that there were no incidences of recurrence. Such findings have
also been established by Alzahem who in
his adoption of the laparoscopic inguinal hernia repair described a near-zero
recurrence rate for paediatric patients of all ages [22].
Incidental finding of hernia in contra-lateral side was observed in 20 % which
is significant and repaired at same operation. Concisely, our study supports
that the laparoscopic inguinal hernia repair technique is a very efficient
method with less complications and rapid recovery.
9.
Conclusion
From
our findings, and discussions, it was apparently clear that laparoscopic
inguinal hernia repair is a more cosmetic hernia repair and less painful technique
resulting in minimal complication compared to open inguinal hernia repair. Our
study also showed that with the adoption of the technique there was no
recurrence in our patients.
\
Figure 1: Intra-operative
aspect of IDES technique.
Figure 2: Participants' Gender
distribution.
Figure 3: Operative time progress analysis chart.
Value Label |
Value |
Frequency |
Percent |
Valid Percent |
Cum Percent |
F |
77 |
49.04 |
49.04 |
49.04 |
|
M |
80 |
50.96 |
50.96 |
100 |
|
Total |
157 |
100 |
100 |
Table 1: Sex distribution.
Value Label |
Pathology |
Frequency |
Percent |
Valid Percent |
Cum Percent |
|
Bilateral |
45 |
28.67 |
28.67 |
28.67 |
|
Bilateral with encysted hydrocele |
1 |
0.64 |
0.64 |
28.66 |
|
Incidental finding of contralateral hernia |
32 |
20.38 |
20.38 |
20.38 |
|
Circumcision and Left Hydrocele and varicocele |
1 |
0.64 |
0.64 |
0.64 |
|
Circumcision |
2 |
1.27 |
1.27 |
2.55 |
|
Intussusceptions |
1 |
0.64 |
0.64 |
3.18 |
|
Left Stephen fowler |
1 |
0.64 |
0.64 |
3.82 |
|
Non |
143 |
91.09 |
91.09 |
94.27 |
|
Right Stephen Fowler |
1 |
0.64 |
0.64 |
94.9 |
|
appendectomy and ovarian cyst excision |
1 |
0.64 |
0.64 |
95.54 |
|
circumcision |
4 |
2.55 |
2.55 |
98.09 |
|
foreskin stretching |
1 |
0.64 |
0.64 |
98.73 |
|
huge |
1 |
0.64 |
0.64 |
99.36 |
|
umbilical hernia |
1 |
0.64 |
0.64 |
100 |
Total |
|
157 |
100 |
100 |
|
Table 2: Concomitant Hernial side and other intraoperative pathologies.
Frequency |
Percent |
Valid Percent |
Cum Percent |
||
asthmatic crises |
1 |
0.64 |
0.64 |
0.64 |
|
gastroenteritis |
1 |
0.64 |
0.64 |
1.27 |
|
known patient of diabetes |
1 |
0.64 |
0.64 |
1.91 |
|
no recurrence on reoperation for recurrence suspicion |
1 |
0.64 |
0.64 |
2.55 |
|
non |
148 |
94.27 |
94.27 |
96.82 |
|
post op abdominal pain |
1 |
0.64 |
0.64 |
97.45 |
|
post op vomiting |
2 |
1.28 |
1.28 |
98.73 |
|
wound infection |
2 |
1.27 |
1.27 |
100 |
|
Total |
157 |
100 |
100 |
Table 3: Postoperative course.