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Helal Helal simplified technique

INTRODUCTION (e.g. those with congenital heart disease). All children
were subjected to full history taking, thorough clinical
Over recent years, a variety of techniques have been examination, and routine preoperative investigations
used for laparoscopic inguinal hernia repair in children, (complete blood count, bleeding time, clotting time,
involving both extra- and intracorporeal suturing and and liver and renal profiles). All cases were performed
knotting. [1,2] Single-incision laparoscopic hernia repair by the author and his team. The primary outcome
(SILHR) is an excellent and increasingly popular measurements included feasibility of the procedure,
technique for children, and is supported by a number operative time, complications and cosmetic outcome.
of publications describing its feasibility, efficacy, and The secondary outcome measurements included
outstanding cosmetic results. [3-6] parent satisfaction with the cosmetic results.

However, intracorporeal suture tying and knotting Operative steps
remains one of the most difficult and complicated
step for most pediatric surgeons during SILHR, and 1. The patient was placed in a supine Trendelenburg’s
remains the main causative factor for increased position with tilting to the opposite side of the hernia.
operative time. It is possible that the apparent cause
for this obvious problem is that the instruments used 2. A longitudinal trans-umbilical incision (0.5-0.9 mm)
for SILHR lie almost parallel to each other without was made with elevation of the skin flaps.
triangulation (this triangulation creates an environment
in which instruments can be moved comfortably 3. A camera port was inserted for the telescope (5 mm,
during conventional laparoscopic surgery), thus 30 degree) and a 3-mm laparoscopic needle holder was
making intracorporeal suture tying and knotting a very inserted through a separate facial incision within the
challenging task. [7-10] same umbilical skin incision.

During SILHR, many pediatric surgeons prefer 4. A pneumo-peritoneum was created and pressure was
extracorporeal suture ligation with subcutaneous adjusted according to age (from 8 to 10 mmHg).
knotting, under laparoscopic guidance. However,
some authors have reported that this approach may 5. The pelvis, adnexa and both IIRs were carefully
be associated with some drawbacks, such as stitch inspected. If a contralateral patent processus vaginalisis
sinus, infection, granuloma, puckering or dimpling of was identified, it was repaired.
the skin and entrapment of the abdominal wall muscles
with the suture, which may result in later loosening of 6. An EN (gauge-18) was threaded with a 3/0 prolene
the suture with an increased recurrence rate. [11-15] suture and introduced percutaneous at the level of the
IIR [Figure 1A].
Here, we introduce a simplified technique for SILHR
in female children. This technique entails the use of 7. The EN was manipulated extraperitonealy around
gauge-18 epidural needles (EN) to fashion a complete the margin of the IIR starting at 3 o’clock meridian
purse string suture around the internal inguinal ring (on both sides). It was then advanced along the lower
(IIR), accompanied by intracorporeal knotting using margin of the IIR beneath the peritoneum to breach the
extracorporeal self-sliding clinch knot. We have named peritoneum at 9 o’clock meridian on the margin of the
this as the “Helal technique”. Our purpose here, is to IIR [Figure 1B].
demonstrate the feasibility, safety and efficacy of this
new surgical technique. A B

METHODS

This prospective study was conducted and followed-
up at the Pediatric Surgery Department, Al-Azhar
University Hospitals, Cairo, Egypt, between May 2014
and December 2016. A total of 120 inguinal hernias
were repaired with SILHR in 100 female children.
Inclusion criteria included female gender and unilateral
or bilateral inguinal hernia. Exclusion criteria included Figure 1: (A) An epidural needle (EN) threaded with a 3/0 prolene
recurrent hernia, hernia in morbid obese female child, suture was percutaneously introduced into the extra-peritoneal
complicated hernia (e.g. incarcerated ovary), and cavity by direct puncture of the anterior abdominal wall; (B) the EN
was then advanced in an extraperitoneal direction to complete a
children who could not tolerate pneumoperitoneum purse string around the internal inguinal rings
90 Mini-invasive Surgery ¦ Volume 1 ¦ June 30, 2017