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Pediatric Laparoscopic Inguinal Hernia Repair: A

Review of Techniques
First submitted by: Karen Elizabeth Speck

Category Hernia Surgery, Minimally Invasive Surgery, Pediatric Surgery

Compiled by Anne K. Smith, BS# and K. Elizabeth Speck, MD*


#Medical student, Vanderbilt, *Assistant Professor, Department of Pediatric Surgery,
Vanderbilt, Nashville, TN.
All illustrations are original artistic renditions of photographs, pictures or descriptions from
the literature or videos by Ishan Asokan, M.Sc, BA#

Overview
Minimally invasive surgery has been shown to be feasible and safe in pediatric patients since
1975 when laparoscopic surgery was first used to treat a small bowel obstruction.1
 Laparoscopy is  an option for surgical repair of inguinal hernias in addition to the traditional
open approach.  Since its advent, there has been considerable evolution with the introduction
of a number of innovations.  Each iteration has maintained the basic premise of surgical
repair in pediatric inguinal hernias – high ligation of the sac.  These techniques can broadly
be grouped into those that are performed fully intracorporeally and those that have
extraperitoneal components, namely the suturing.

Laparoscopic repair is typically performed under general anesthesia.  The patient is


positioned supine, often in the Trendelenberg position.  Most descriptions position the
surgeon on the side contralateral to the hernia with the monitor on the ipsilateral side.  The
abdomen is insufflated, typically through the umbilicus, to a pressure of 8-15mmHg
depending on the size of the child.  A variety of sizes of trocars, cameras, and instruments can
be used, with the goal of smaller incisions.  Any hernia contents are reduced before beginning
repair of the hernia.  With laparoscopy, the contralateral side can be evaluated and bilateral
repair performed when necessary. 

During intracorporeal techniques, all suturing and knot tying is done within the abdominal
cavity with laparoscopic instruments.  In extracorporeal techniques, laparoscopic localization
with external compression is used to make an incision once the desired spot near the ring is
identified.  Some surround the sac entirely in the preperitoneal space and others enter the
peritoneum adjacent to the vas or vessels for exchange of the suture.  With extracorporeal
techniques, the suture is tied extracorporeally, with the knot buried in the subcutaneous
tissue.  For both intracorporeal and extracorporeal techniques, great care is taken in boys to
exclude the vas deferens and spermatic vessels, while in girls the round ligament may be
included in the closure.  The abdomen can be desufflated and before tying the suture, any air
or fluid in the sac is manually expressed with external compression.  The umbilical port site
fascia is typically sutured closed, while the other incision sites are often closed solely with
steri-strips or skin glue.

Laparoscopic repair of inguinal hernias in pediatric patients was first described in 1997 by El-
Gohary.2  Initially this operation was performed only in female patients because the safety of
the vas and vessels are of concern in males.  Monteput and Esposito5 were the first to use
laparoscopy in the repair of inguinal hernias in male children using an intracorporeal purse-
string suture to close the inguinal ring, while Schier described intracorporeal Z-suture closure
first in girls only (1998)6 and then in boys (2000).7  New adaptations of fully intracorporeal
techniques in girls only4 and in both sexes8-11 have continued to evolve over the years.  In
2003, Chan and Tam8 added intracorporeal hydrodissection as a strategy to more easily avoid
the vas and vessels in boys.  Other adaptations of intracorporeal techniques involve incising
the peritoneum,9 using peritoneum to cover the patent processus vaginalis,10 and
laparoscopically excising the sac.11

In 2003, the use of extracorporeal suturing was described by Prasad et al.12  Since then, a
variety of devices have been fashioned and modifications made to make the extracorporeal
technique less technically challenging and/or to ensure improved ligation of the hernia sac.13-
24,26,29  Hydrodissection has been used not only intracorporeally, but also in extracorporeal
techniques.19,24,26,29  The most recent advances involve decreasing the number of incisions
necessary for the repair.26,29  One technique has used diagnostic laparoscopy for hernia
confirmation to create a smaller incision for an otherwise relatively standard open repair.25 

Below are descriptions of the unique techniques for pediatric laparoscopic inguinal hernia
repair, using text, pictorial representations, and video.  Listed colloquial terms used in the
papers and videos were maintained.  These techniques were discovered through an
exhaustive PubMed search and videos through YouTube.  Published techniques with only
minor variations from a previously published protocol were included in the reference section
but not described.  These data are compiled for summary purposes to demonstrate the
evolution of laparoscopic pediatric hernia repair.  No formal recommendations regarding the
choice of technique are made.  

To access referenced content, click on the links at the end of the description (for videos) or
click on the citation in the References section.

Girls only (intracorporeal):

Laparoscopic Inguinal Hernia Inversion and Ligation (LIHIL)

El-Gohary (1997),2 Lipskar et. al (2010)3*

EQUIPMENT/SUTURE:
5-mm infraumbilical trocar and 30° laparoscope
Two 5-mm trocars2 or two 2.7-mm stab incisions3 in upper flanks
Maryland grasper
0-PDS Endoloop
STEPS:

1.Introduce a grasper through the ipsilateral incision/trocar

2.Place grasper into the hernia sac and grasp the distal end

3.Invert the sac into the abdominal cavity

If the fallopian tube or ovary are involved in the hernia, they can be freed using a
combination of blunt and sharp dissection, and external pressure

4.Insert an Endoloop through the contralateral incision

5.Pass the Maryland through the loop and regrasp the hernia sac

6.Twist the hernia sac forming a neck at the base

7.Secure the Endoloop at the neck

8.Repeat with 2nd Endoloop for double ligation

9.Excise the remainder of the sac

*Above is a description from Lipskar,2 which utilizes the original El-Gohary3 technique with
2.7-mm rather than 5-mm accessory trocars
Burnia
Godoy Lenz (2013)4§

EQUIPMENT/SUTURE:
Veress needle and small-caliber tubing for insufflation
No trocars used
Laparoscopic grasper
STEPS:

1.Make an umbilical incision (single incision procedure)

2.Insert Veress needle for insufflation

3.Exchange Veress for small caliber intra-abdominal insufflation tubing

4.Introduce laparoscope and grasper adjacent to the tubing

5.Place grasper into the hernia sac and grasp the distal end

6.Invert the sac into the abdominal cavity

7.Use grasper to cauterize the end of the hernia sac


Laparoscopic Pediatric Inguinal Hernia Repair: BURNIA Technique - J Godo…

§ Above is a description of a youTube video, no written description was available:

Both boys and girls:


      Intracorporeal:

Intracorporeal purse-string
Montupet & Esposito (1999)5

EQUIPMENT/SUTURE:
5-mm, 0° laparoscope
Two 3-mm trocars inserted 3-4cm below the umbilicus on each side
3-0 absorbable suture
STEPS:

1.Incise the periorificial peritoneum lateral to the internal ring

2.Create an intracorporeal purse-string stitch around the internal ring

3.In larger hernias (>4-5mm), add one or more interrupted stitches between the conjoined
tendon and crural arch
Intracorporeal “Z-suture”
Schier (1998)6 in girls only, (2000)7 in both

EQUIPMENT/SUTURE:
Veress needle
2- or 5-mm laparoscope
Two #12 venous cannulae (or 2-mm trocars)
1.7-mm forceps – contralateral side
2-mm needle holder – ipsilateral side
8-cm 4-0 PDS
STEPS:

1.Insert two venous cannulae or 2-mm trocars through the anterior abdominal wall
superiomedially to the anterior superior iliac spines on each side

2.Pass suture directly through the abdominal wall

3.Close the inguinal ring with 2 or 3 Z-sutures lateral to the vas and vessels

4.Tie sutures intracorporeally

Intracorporeal purse-string with intracorporeal hydrodissection


Chan & Tam (2003)8

EQUIPMENT/SUTURE:
5-mm umbilical trocar
Two 5-mm trocars lateral to the rectus on each side
Irrigation and suction metal cannula
Endoscopic injector (6F, 155mm, NM-3K injector; Olympus)
Laparoscopic forceps
4-0 prolene suture
STEPS:

1.Insert metal cannula into the peritoneal cavity


2.Pass endoscopic injector through the lumen of the cannula (which will be used to stiffen and
guide the injector) and cover the opening of the cannula with a plastic cap to prevent gas
leakage

3.Pass forceps through the 3rd trocar to pick up the peritoneum near the site where the vas
deferens and testicular vessels join

4.Inject 2mL normal saline into the extraperitoneal space to lift the peritoneum away from the
vas and vessels

5.Withdraw the cannula and the injector

6.Pass suture directly through the abdominal wall into the peritoneal cavity

7.Complete a purse-string suture around the internal ring with the first bite into the
peritoneum taken over the site of hydrodissection

8.Probe the closure for potential residual peritoneal defects. Add interrupted stitches as
necessary

Laparoscopic sac resection and peritoneal closure


Becmeur et al. (2004)9

EQUIPMENT/SUTURE:
5-mm umbilical trocar
Two 3-mm trocars placed laterally, just below the level of the umbilicus on each
side
3-0 Vicryl
STEPS:

1.Intracorporeally, circumferentially incise the peritoneum at the internal inguinal ring

2.Completely divide the processus vaginalis by separating the sac and the peritoneum at the
level of the internal inguinal ring

3.Free the entirety of the processus vaginalis from the vas and vessels to excise the entirety of
the hernia sac intact

4.In females, sever the round ligament


5.Introduce suture directly through the abdominal wall

6.Laparoscopically close the ring, avoiding the vas and vessels

Flip-flap
Yip et al. (2004)10

POSITIONING:
operating surgeon standing at cephalad end of the bed
assistant standing on side contralateral to hernia
EQUIPMENT/SUTURE:
5-mm infraumbilical trocar and 30° laparoscope
Two working trocars inserted in both flanks
4-0 polypropylene suture
STEPS:

1.Intracorporeally incise the peritoneum near the anterior and lateral edge of the hernia
defect

2.Raise a peritoneal flap laterally that is large enough to cover the hernia defect with blunt
dissection beneath the flap

3.With the anterior and lateral half circumference of the sac detached from the surrounding
soft tissue the sac spontaneously collapses

4.Introduce suture directly through the abdominal wall

5.Flip the peritoneal flap medially and anchor it with the stitch, tying intracorporeally

Intraperitoneal hernia sac division and purse-string closure


Wheeler et al. (2011)11

EQUIPMENT/SUTURE:
3-mm umbilical trocar and 2.7-mm 30° laparoscope
Atraumatic graspers
Laparoscopic scissors connected to diathermy or hook cautery
3-0 or 4-0 Vicryl
STEPS:

1.Two stab incisions 6-cm lateral to umbilicus on each side

2.Circumferentially incise the peritoneum around the internal ring using scissors or hook
cautery, freeing the peritoneum from the vas and vessels beneath

3.Close the proximal defect with a purse string suture

Extracorporeal:

Extracorporeal with steel awl


Prasad et al. (2003)12

EQUIPMENT/SUTURE:
2-mm umbilical trocar and 1.7-mm laparoscope
2-mm trocar in lateral abdomen
1.7-mm grasper
curved steel awl
2-0 nonabsorbable, braided suture
STEPS:

1.Make a stab incision anterolateral to the internal ring and pass a curved awl threaded with
suture until the level of the peritoneum is reached

2.Pass the awl and suture around the lateral half of the internal ring

3.When half of the sac is surrounded, pierce the peritoneum with the awl

4.Secure the end of the suture with the grasper and withdraw the awl

5.Reinsert the empty awl into the stab wound and pass it around the medial half of the ring

6.Reenter the peritoneum at the same spot the suture enters the peritoneal cavity

7.Visualize the vas and vessels to ensure they were excluded from the repair

8.Pass the end of the suture through the hole in the awl
9.Withdraw the awl

10.Tie suture extracorporeally

Subcutaneous Endoscopically Assisted Ligation (SEAL)


Harrison et al. (2005)13

POSITIONING:

Infant:

Larger child:

EQUIPMENT/SUTURE:
3-mm umbilical trocar and 2.7-mm 30° laparoscope
2-0 Tevdek suture on a large swaged-on needle (T12 or T20)
Tuohy needle bent into identical curve to the swaged needle with syringe as a
handle
STEPS:

1.Using the swaged-on needle, enter the skin on the lateral side of the internal ring
2.Guide the needle in the extraperitoneal space from lateral to medial around the half of the
ring, excluding the vas and vessels

3.Advance the Tuohy needle on the medial aspect of the internal ring and guide it around in
the extraperitoneal space towards the swaged-on needle

4.Push the swaged-on needle into the hollow of the Tuohy needle; with matched curves they
should lock together

5.Back the Touhy needle out toward the skin

6.When the swaged-on needle tip is visible beyond the skin, release it from the Touhy needle
and grasp the tip with needle-holder

7.Without entirely removing the swaged-on needle from the skin, back it through the
subcutaneous tissue anterior to the internal ring

8.Bring the end of the needle out of stab incision it originally entered through

9.Tie suture extracorporeally

Laparoscopic Percutaneous Extraperitoneal Closure (LPEC)


Takehara et al. (2000,14 200615), Oue et al. 200516

EQUIPMENT/SUTURE:
4.7-mm to 5-mm umbilical trocar and 4.5-mm to 5-mm laparoscope 2-mm grasping
forceps or 3-mm grasping forceps with 3-mm trocar
19-gauge LPEC needle (special needle with wire loop at tip, such as
Lapaherclosure™ needle – Hakko Medical Co., Tokyo, Japan16)
2-0 nonabsorbable suture
STEPS:

1.Insert grasping forceps with or without trocar on the ipsilateral side to the hernia
2.Insert LPEC needle threaded with suture at the midpoint of the inguinal line on the affected
side

3.Guide the needle around the lateral half of the circumference of the internal inguinal ring
and advance through the peritoneum

4.Remove the suture material from the needle, leaving it intraabdominally

5.Pass the needle around the medial half of the rim of the internal ring entering the skin and
peritoneum at the same locations

6.Grasp the suture material by the wire loop inside the needle

7.Remove needle with suture from the abdomen

8.Tie suture extracorporeally

Percutaneous Internal Ring Suturing (PIRS) with 18-gauge needle


Patkowski et al. (2006)17

EQUIPMENT/SUTURE:
2.5-mm trocar and 2.5-mm 5° laparoscope, or 5-mm trocar and 5-mm 5° or 25°
laparoscope
18-gauge hollow-bore needle
Nonabsorbable 2-0 monofilament suture
STEPS:

1.Introduce the suture through the barrel of the hollow-bore needle

2.Maintaining both ends of the preloaded suture extraperitoneally, advance the needle under
the peritoneum around lateral half of the internal ring

3.Enter the peritoneum and advance the suture into the abdominal cavity, creating a loop

4.Remove the needle, leaving the loop in place


5.Advance the needle through the same skin puncture site around the medial half of the ring
and enter the peritoneum, leaving a small space above the vas deferens and testicular vessels
to prevent injury

6.Introduce one end of the suture into the hollow of the needle again and advance the suture
into the loop

7.Withdraw the needle

8.Catch the suture end in the loop and withdraw them together

9.Tie suture extracorporeally

Extracorporeal with Reverdin needle


Shalaby et al. (2006)18

EQUIPMENT/SUTURE:
Veress needle
2.7-mm infraumbilical trocar and laparoscope
3-mm trocar-lateral to rectus at the level of the umbilicus
Reverdin needle
3-0 PDS
STEPS:

1.Mount Reverdin needle with suture

2.Incision for Reverdin needle:

Right: 2-cm above and lateral to the right internal inguinal ring
Left: 2-cm above and medial to the left internal inguinal ring

3.Advance the Reverdin needle around half of the ring, using the grasper to exclude the vas
and vessels in a relatively loose fold

4.Open the hollow of the needle and use the grasper to remove the suture

5.Withdraw the needle

6.Reenter through the same skin site and advance the needle along the other half of the ring,
again using the grasper to exclude the vas and vessels
7.Enter the peritoneum

8.Open the hollow of the needle and mount the intraabdominal end of the suture

9.Close the hollow of the needle and withdraw it with the suture

10.Tie suture extraperitoneally

SEAL with hydrodissection and dual encirclage


Saranga Bharathi et al. (2006)19

EQUIPMENT/SUTURE:
Veress needle
5-mm trocar and 0° or 30° laparoscope
1-0 or 2-0 Vicryl swaged on a 30- to 40-mm curved, round bodied needle
Hypodermic or a longer spinal or intracath needle with saline
STEPS:

1.Incise at a point that lies lateral to the ring on the right or medial to the ring on the left (for a
right-handed surgeon)

2.Advance suture needle through the incision traversing from lateral to medial around the
first half of the inguinal ring

3.Introduce hypodermic needle immediately beside suture needle, entering through the same
incision

4.Inject a small amount of saline in the retroperitoneal space to lift the peritoneum off the vas
and vessels

5.Advance the suture needle superficial to the vas and vessels along the medial aspect of the
ring

6.Advance the needle tip through the skin without removing the needle in its entirety*
7.Back the swaged end of the needle through the subcutaneous tissue anterior to the ring to
exit through the original stab incision

8.Tie suture extracorporeally

*If unable to safely surround the ring completely on the first pass, skip over the vas and
vessels, reducing the ring size. A second suture pass in similar fashion is made, now with
traction to lift the peritoneum off the vas and vessels, creating a “dual encirclage”

Extracorporeal hook method


Lee & Yeung, (2003),20 Yeung & Lee (2008)21

EQUIPMENT/SUTURE:
Veress needle18
3-mm or 5-mm infraumbilical trocar and laparoscope
3-mm laparoscopic grasper
Herniotomy hook19
3-0 nonabsorbable suture
STEPS:

1.Suprapubic stab incision for grasper

2.Make a 2-mm stab incision at the 12 o’clock position over the internal inguinal orifice so that
the tip of the blade is visible, but does not penetrate the peritoneum

3.Pass the herniotomy hook with suture through the stab incision to this same level

4.Manipulate the hook to dissect peritoneum off surrounding structures along the
circumference of the internal ring until the vas and vessels have been passed over

5.Pierce peritoneum with the tip of the hook

6.Using the grasper, take the loop of suture out from the hook

7.Withdraw the hook, leaving the suture intraperitoneal


8.In similar fashion, pass the hook along the other half of the internal ring

9.Enter the peritoneum through the same hole

10.Using the grasper, thread the end of the suture through the eye of the hook

11.Withdraw the hook and suture together through the initial stab incision

12.Tie suture extracorporeally

Extracorporeal with Endoneedle


Endo & Ukiyama (2001)22 in girls only, Endo et al. (2009)23 in both

EQUIPMENT/SUTURE:
15-gauge grasper
14-gauge sheath needle (port for 15-gauge grasper with electrocautery)
16-gauge sheath needle
19-gauge Endoneedle
Metal filament for setting a 2-0 nylon suture into the Endoneedle
STEPS:

1.Medially placed stab incision for grasper with medial traction on peritoneum adjacent to vas

2.14-gauge sheath needle enters the skin and peritoneum lateral to the hernia

3.15-gauge grasper through angiocath to cauterize the peritoneum between the vas and
vessels

4.Use grasper to separate the vas from its peritoneal covering

5.Advance 16-gauge needle extraperitoneally around the lateral and inferior half of the
internal inguinal ring, crossing over the vessels and vas then puncture the peritoneum
6.Remove the 16-gauge needle and place an Endoneedle with 2-0 suture in the same path,
exiting the peritoneum where the needle punctured

7.Remove the Endoneedle, leaving the suture intraperitoneally

8.Pass the Endoneedle around the medial half of the ring, entering the peritoneum at the same
level

9.Grasp the end of suture and pull out the Endoneedle and the suture together*

10.Tie suture extracorporeally

*In infants younger than 18months old, place an intracorporeal purse-string suture
proximally to the previously placed suture, skipping the vas and vessels 

Hydrodissection-lasso technique
Muensterer & Georgeson (2011)24*

EQUIPMENT/SUTURE:
5-mm umbilical trocar and laparoscope
3-mm Maryland grasper
22-gauge needle with saline
17-gauge spinal Tuohy needle
Polypropelene suture
Braided suture
STEPS:

1.Make an 8-mm skin incision in the umbilicus

2.Place trocar in the inferior aspect for the laparoscope

3.Place Maryland directly into the upper part of the incision


4.Insert 22-gauge needle percutaneously over the internal inguinal ring and inject saline into
the preperitoneal space circumferentially, freeing the vas and vessels

5.Make a 2-mm stab incision directly over the ring and insert Tuohy needle

6.Pass the needle medially around half of the internal inguinal ring in the space created by
hydrodissection

7.Once it has passed over the vas and vessels, pierce the peritoneum

8.Pass a loop of polypropelene through the needle, into the abdominal cavity and grasp it with
the Maryland

9.Remove the needle, leaving suture intraperitoneally

10.Reintroduce the needle through the same skin incision and pass it along the lateral aspect
of the internal ring

11.Enter the peritoneum through the same hole

12.Pass the needle through the loop of suture

13.Introduce a second loop of polypropelene through the needle into the abdomen

14.Remove the needle

15.Use the first loop to pull the second loop completely around the internal ring

16.Extraperitoneally, pass a braided suture through the second loop

17.Pull on the opposite side of suture to pass the braided suture completely around the
internal ring, thus exchanging the suture

18.Tie suture extracorporeally

*A video of this technique is provided in the supplemental material to the main article:
http://link.springer.com/article/10.1007%2Fs00464-011-1713-2
(http://link.springer.com/article/10.1007%2Fs00464-011-1713-2)
Lap-assisted micro-incision extra-peritoneal division and ligation
Kim & Hui (2013)25

EQUIPMENT/SUTURE:
5-mm umbilical trocar and 30° or 45° laparoscope
25-gauge needle
Mosquito clamp
Debakey forceps
3-mm Maryland dissector or mosquito clamp
Vicryl suture
STEPS:

1.Use 25-gauge needle and laparoscopic visualization to find the point on the hernia sac about
5-10 mm distal to the internal ring

2.Make a 5-mm skin incision at the insertion point of the needle

3.Place Maryland or mosquito through this incision

4.Bluntly push the dissector through Scarpa’s fascia and the external oblique fascia

5.Observe the tip of the dissector indenting the hernia sac laparoscopically

6.Spread the dissector to completely clear the tissues overlying the sac

7.Grasp and pull the sac toward the skin until it is externally visible

8.Clamp the sac with mosquito clamp and pull outward, delivering sufficient tissue for
surgical manipulation

9.Remove the laparoscope from the abdominal cavity to avoid thermal injury and release the
pneumoperitoneum

10.Dissect adherent tissue off the sac with Debakey forceps


11.Incise the sac to confirm the hernia opening

12.Divide the sac and ligate with suture twice at the proximal end, standard high ligation of
the sac

13.The distal hernia sac can be removed if desired

14.Reinsert the laparoscope and confirm that the internal ring has been ligated

PIRS-hydrodissection-lasso technique with modification


Ponsky (2013)26*

POSITION:
Surgeon stands on left side of pt (rt-handed surgeon)
Starts laterally on hernia on either side
EQUIPMENT/SUTURE:
Veress needle
3-mm umbilical trocar and laparoscope
3-mm Maryland dissector
18 gauge spinal needle (create gentle curve of the tip) or Tuohy needle
Prolene suture
Ethibond suture
STEPS:

1.Stab incision for Maryland contralateral to hernia

2.Use the Maryland dissector to burn the peritoneum on the superior half of the ring without
completely burning a hole through the peritoneum27

3.Make a 1-mm incision at the 12 o’clock position of the internal ring

4.Use 0.25% bupivicaine to hydrodissect the peritoneum from vas and vessels

5.Preload Tuhoy needle with a loop of Prolene in the hollow with the end near the tip of the
needle

6.Introduce needle into 1-mm incision

7.Advance the needle laterally around the ring above the vessels to a point medial to the the
vas deferens then advance the tip into the peritoneum
8.Advance the suture so that the loop is intraperitoneal

9.Remove the needle, leaving the suture and secure extracorporeally

10.Thread another suture into the needle as before

11.Introduce needle and suture into the same 1-mm incision

12.Advance the needle medially around the ring, entering the peritoneum through the same
hole

13.Put the needle through the first loop, tightening the loop around the needle and then
advance the second suture

14.Pull out the needle, leaving second loop within the first loop

15.Pull the first loop up snaring the 2nd and pull out until the 2nd loop completely encircles
the ring

16.Pass one end of Ethibond suture through the loop of Prolene to exchange the two27

17.Pull the other loop of the Prolene entirely through until Ethibond comes out the other side
and encircles the entire ring

18.Cut the loop of Ethibond which releases the Prolene

19.Tie both Ethibond sutures extracorporeally for double ligation

*Above is a description of a youTube video, no written description was available:


Laparoscopic, Non-Mesh, Inguinal Hernia Repair (Todd Ponsky)

Laparoscopically Assisted Simple Suturing Obliteration (LASSO) of the internal ring


using an epidural catheter

Li et al. (2014)29

EQUIPMENT/SUTURE:
5-mm laparoscope inserted through umbilicus
18-guage Tuohy needle bent into a slight curve; thread with
2-0 and 4-0 silk suture
“Suture-catcher”
STEPS:

1.Create slight curve in Tuohy needle and thread 2-0 silk through the tip of the needle then
secure it by connecting a saline-filled syringe

2.Create “suture-catcher” by tying 4-0 silk to the tip of an epidural catheter


3.Puncture the skin above the internal ring with a 1-mm stab incision

4.Introduce the Tuohy needle and advance medially in the preperitoneal space around the
ring while performing hydrodissection by injecting normal saline to separate the vas from the
peritoneum

5.Enter the peritoneum between the vas and vessels after the needle has passed over the vas

6.Detach the syringe from the needle hub releasing the suture intrabdominally then gently
withdraw the needle until the tip returns to the preperitoneal space anterior to the internal
ring

7.Perform hydrodissection in the preperitoneal space on the opposite side of the ring

8.Thread the ‘suture catcher” through the Tuohy needle

9.Introduce the end of the “suture catcher” that has suture tied to it, keeping the suture taut to
form a shape similar to a bow

10.Use the suture catcher to capture the end of the suture that is intraperitoneal

11.Remove the Tuohy needle with the suture

12.Tie suture extracorporeally

REFERENCES:
1.        Becmeur F (2011) Videosurgery–the second generation. J Pediatr Surg 46:275-279
(http://www.ncbi.nlm.nih.gov/pubmed/21292072)

2.        El-Gohary MA (1997) Laparoscopic Ligation of Inguinal Hernia in Girls. Pediatr


Endosurgery Innov Techn 1:185-188
(http://online.liebertpub.com/doi/abs/10.1089/pei.1997.1.185)

3.        Lipskar AM, Soffer SZ, Glick RD, Rosen NG, Levitt MA, Hong AR (2010) Laparoscopic
inguinal hernia inversion and ligation in female children: a review of 173 consecutive cases at
a single institution. J Pediatr Surg 45:1370-1374
(http://www.ncbi.nlm.nih.gov/pubmed/20620347)

4.        Godoy Lenz J (2013) Laparoscopic Pediatric Inguinal Hernia Repair: BURNIA Technique
– J Godoy Chile.

Laparoscopic Pediatric Inguinal Hernia Repair: BURNIA Technique - J Godo…

5.        Montupet P, Esposito C (1999) Laparoscopic treatment of congenital inguinal hernia in


children. J Pediatr Surg 34:420-423 (http://www.ncbi.nlm.nih.gov/pubmed/10211645)

6.        Schier F (1998) Laparoscopic herniorrhaphy in girls. J Pediatr Surg. 33:1495-1497


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