Novel Adjunct to Laparoscopic Inguinal Hernia Repair in Pediatric Patients

Abstract

Purpose/Objective:

Pediatric laparoscopic inguinal hernia repair is safe and effective, but the learning curve can be steep. Preperitoneal hydrodissection with saline or local anesthetic is a well-described adjunct to facilitate safe and accurate placement of the deep ring-closing suture. ¹ One issue encountered frequently is that the area of hydrodissection can rapidly dissipate while passing the closing suture and prevent smooth needle dissection through the preperitoneal space and away from the cord structures. ² We aim to adapt this technique to combine hydrodissection with the suture passage to improve the safety profile and flatten the learning curve of these repairs.

Methods/Design:

A novel adjunct to this technique was developed utilizing materials already available in the operating room. We conducted proof of concept testing with this novel configuration on an animal model to assess ease of use and refine the technique. Through iterative testing, we determined that a connector device used in vascular surgery applications to accommodate both guidewire passage and catheter lumen flushing easily facilitates simultaneous hydro dissection during introduction of the suture. We observed that the instillation of saline during needle advancement made the dissection very smooth and that the addition of the connector and syringe did not significantly alter the maneuverability of the needle through the tissue. An assistant provided the manual installation of the saline at the direction of the operative surgeon to free the primary operator to manipulate the placement of the suture passing needle.

Results:

We utilized this configuration on five pediatric patients with inguinal hernias. Using the same set up as shown in the animal model, the spinal needle attached to the Tuohy–Borst was used to hydro dissect from 12 o'clock to 6 o'clock, and the suture loop was then introduced into the peritoneal cavity. The spinal needle was withdrawn and then reintroduced in a similar fashion on the opposite side of the deep ring to complete the encirclement of the ring in the preperitoneal space taking care to avoid the vas deferens and the vessels. This simultaneous hydrodissection anecdotally reduced operative time and ensured a greater margin of safety by lifting the peritoneum off the cord structures in real time.

Conclusion:

In summary, this modification is a successful adaptation to a classic technique that we hope will allow for increased safety and efficiency in the operating room. This novel configuration can also accommodate variations in the actual technique of deep ring encirclement and addresses the problem of rapid dissipation of fluid in the peritoneal space, increasing the safety profile for a procedure that has a steep learning curve. Additional studies to capture quantifiable metrics of efficiency and efficacy for trainees in the advanced pediatric surgery learning environment are planned.

No competing financial interests exist.

Runtime of video: 2 mins 42 secs

Patient Consent:

Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure.