Laparoscopic Inguinal Hernia Repair in Infancy and Childhood
Laparoscopic Inguinal Hernia Repair in Infancy and Childhood
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.

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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.
Inclusion Criteria:

 Bilateral congenital inguinal hernia (CIH), recurrent cases, unilateral cases with
 questionable other side, parental request and cases with CIH associated with umbilical
 hernia.

 Exclusion Criteria:

 Hernia of canal of Nuck in females, Inguinal hernia with undescended testis, Parental
 refusal, Contraindications for laparoscopy as lower major abdominal surgery