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Helal Helal simplified technique

without intraoperative or postoperative complications. publication entitled “A purse-string suture at the level
There was no recurrence. All children returned home of internal inguinal ring, taking only the peritoneum
on the same day. The mean hospital stay was 7.79 ± leaving the distal sac: is it enough for inguinal hernia
1.28 h (range 5-19 h). All parents were satisfied with in pediatric patients?” These authors concluded that
the cosmetic outcome with an almost invisible scar. The laparoscopic purse-string suture of the hernia sac at
mean postoperative follow-up period was 12 months the IIR, taking only the peritoneum and leaving the
(range 8-24 months). distal sac intact, is a safe, effective, and reliable course
of treatment for pediatric inguinal hernia.
DISCUSSION
At the moment, SILHR appears to be taking the upper
In 2015, we published a paper describing a novel hand as a very important development in minimal access
technique for the repair of inguinal hernia in female surgery, with most pediatric surgeons tending to use the
children using a single laparoscopic instrument (needle simple and rapid percutaneous extraperitoneal closure
holder). [12] However, we observed that the entry for of opened IIR with subcutaneous suture knotting.
this single instrument required a separate port in the However, the major concern of percutaneous closure
abdominal wall, plus the camera port. As a consequence, is the unavoidable inclusion of tissues between the skin
this particular technique was not cosmetically optimal and the hernia sac, including nerves and muscles, which
for a female child. Moreover, closure of opened IIR may result in unnoticed injury and may be reflected by
using a single laparoscopic instrument technique a subsequent increase in postoperative morbidity. [23-26]
requires special laparoscopic skills to manipulate the Moreover, the subcutaneous sutures may cause stitch
needle easily around the IIR, and to develop the back- sinus, infection, granuloma, puckering or dimpling of the
hand movement skills, with protection of the inferior skin; or it may cut through the muscles with subsequent
epigastric vessels. Consequently, this technique loosening of the suture around the IIR, thus resulting
requires a long learning curve. in the recurrence of hernia. [27-29] Therefore, from the
author’s point of view, one of the major advantages of
Therefore,we continued our research in order to identify our new technique, is that the knot was sutured and tied
a single-incision access technique, which was more using an extracorporeal clinch knot with an intracorporeal
feasible for children and required a relatively short knotting. Thus, we avoided subcutaneous placement of
learning curve. This research culminated in the novel the suture and associated complications.
technique described in this paper. From the author’s
point of view, there is no doubt that this new technique Yang et al. [29] reported that the rate of recurrence
represents a simpler procedure with a relatively short following laparoscopic inguinal hernia repair in children
learning curve. Moreover, the new technique achieves was still a matter of controversy. Shalaby et al. [30]
better cosmetic outcomes in female children. published a description of 150 patients treated with
SILHR, and reported one case of recurrence and
Over recent years, laparoscopic inguinal hernia repair for three cases of hydrocele. It appears that the cause of
children has progressively developed from conventional recurrence may have been related to a weak point (the
laparoscopic surgery with 2 working instruments (with superficial purse) in the area above the vas and vessels.
or without ports) and a camera port, to become single Helal [12] published an investigation of a further series of
laparoscopic instrument repair with a camera port. 60 girls with 68 hernias, treated by laparoscopic single
Most recent studies have described and supported the instrument closure of inguinal hernia, and reported only
feasibility and safety of pediatric single-port and single- one case of recurrence (1.47%). Furthermore, Helal [12]
incision pediatric laparoscopic hernia repair. [12,17-19] explained that this recurrence may have occurred due
to skip areas around the IIR during his learning curve.
However, there is still debate over which laparoscopic
technique is the most appropriate and beneficial for In the present study of SILHR, we observed no recurrence
pediatric hernia repair. Becmeur et al. [20] concluded that during the postoperative follow up (up until the time of
pediatric inguinal hernia must be treated in the same writing). We believe that this is because we used an
manner as that carried out for open surgery; this is EN to easily fashion a complete, secure and tight purse
achieved with complete separation of the sac at the IIR, string suture around the IIR with intracorporeal knotting
and suturing of the peritoneum at the IIR. Giseke et al. [21] (i.e. no abdominal wall muscles were included within
further reported that laparoscopic hernia repair in the knot) without any skip areas (no vas or vessels
children should be a reproduction of the open inguinal need to be protected in female children). Furthermore,
approach with dissection of the sac at the IIR. In 2015, we performed SILHR after gaining significant prior
Lee et al. [22] reappraised one critical concern in their experience in performing different laparoscopic
92 Mini-invasive Surgery ¦ Volume 1 ¦ June 30, 2017