Infantile inguinal hernia occurs when the processus vaginalis fails to close after birth, and the increased abdominal pressure pushes the abdominal contents through the unclosed internal ring into the inguinal canal or scrotum, forming a bulge on the surface of the inguinal area [9]. If it cannot be reduced spontaneously, hernia incarceration will occur. The risk of hernia incarceration in children is about 4%, and it is as high as 8% in infants [10]. Therefore, it is clinically recommended to perform surgery as soon as possible after diagnosis. At present, the surgical treatment for pediatric inguinal hernia includes the traditional inguinal approach and the laparoscopic approach through the abdomen. The purpose of both operations is to close the internal ring [11,12,13]. Laparoscopic surgery has the advantages of minimal trauma, fast recovery, aesthetic incision, and low recurrence rate [14, 15], and it can also explore the bilateral internal rings simultaneously, which is widely used in clinical practice [16,17,18,19,20]. However, it still has a certain recurrence rate, which is related to the large hernia sac, incomplete ligation of the internal ring, and postoperative crying and constipation in infants and young children.
Giant indirect inguinal hernia, due to the long-term presence of intestines and other abdominal contents in the inguinal scrotum, leads to the dilation of the inguinal canal, enlargement of the canal lumen, reduction in elasticity of the inguinal canal fascia, and adhesion to surrounding tissues. During the open high ligation and dissection of the hernia sac, there is a risk of damaging the vas deferens and blood vessels around the sac wall. However, by using laparoscopic intra-ring purse-string suture, the dissection of the sac wall is avoided, which reduces the risk of injury and postoperative scrotal edema [21, 22]. At the same time, due to the different tissue tension and the growth and development potential in infants and young children, mesh repair is not necessary during the treatment of indirect inguinal hernia, unless the hernia sac is extremely large and there is a clear tendency for recurrence. In such cases, mesh can be used to reinforce the muscle layer to prevent recurrence.
[23].
The author has optimized the closure method of the internal ring and applied the transumbilical double-port laparoscopic surgery combined with extraperitoneal saline injection to treat huge indirect inguinal hernias in infants and young children, achieving good results. The following experiences are summarized: Firstly, the operating compression effect of the transumbilical double-port technique. Unlike the three-port laparoscopic approach, the double-port laparoscopy has a chopstick compression effect. Moreover, the abdominal cavity volume of infants and young children is small, which increases the difficulty of the operation. The surgeon needs to proficiently master laparoscopic technology, with the left hand holding the endoscope and the right hand operating the forceps. The endoscope lags behind the forceps, and the fiber optic angle is appropriately adjusted to expose the surgical field and ensure every step of the operation. Secondly, the extraperitoneal saline injection technique. A long needle is inserted into the extraperitoneal layer near the internal ring from the lateral side of the body surface under laparoscopic direct vision, and normal saline is gradually injected to float the peritoneal layer (Fig. 1C). This separates the peritoneal layer from important structures such as the genital vessels, iliac vessels, and vas deferens, avoiding damage to these vital structures, achieving a bloodless surgical field. After the peritoneum floats, it can also reduce the diameter of the huge internal ring at the same time, reducing the tension of the purse-string suture of the internal ring, which is of great significance for the firm knotting of the suture. Thirdly, the treatment of the medial folds of the huge internal ring. Infants and young children with huge internal rings often have wide medial folds. When suturing to this area, it is easy to miss and fail to suture completely, leading to postoperative hernia recurrence. For such cases, the author uses the operating forceps to clamp and open these folds during the operation, observe the width and shape of the folds, and then inject saline through the extraperitoneal injection to float and spread the folds, separating them from the vas deferens or the round ligament of the uterus to avoid damage. If the folds are too large to be spread at one time, the abdominal wall suture can be used to pull and spread the folds, and suture the internal ring under direct vision to avoid missing the needle. Fourthly, purse-string suture of the internal ring (Fig. 1F). When suturing the internal ring, it is important to only suture the peritoneum, that is, the needle passes through the back layer of the peritoneum, avoiding bringing in peritoneal fat or tissue behind it. When suturing and knotting the huge internal ring, if too much extraperitoneal tissue is brought in, it will cause problems such as a large knot, unstable knotting, and loose knots, increasing the risk of postoperative recurrence.
In this study, both groups successfully completed the surgery. The double-port group had lower pain scores at 24 h postoperatively compared to the three-port group, mainly because the double-port surgical approach is located at the umbilical ring, where the pain sensation from a single incision at the umbilical area is less than that from three abdominal incisions [24]. Additionally, the extraperitoneal saline injection creates an avascular area, and during purse-string suturing, the probability of damaging important structures such as nerves, blood vessels, and vas deferens is reduced, resulting in less pain compared to the three-port group. Regular follow-up after surgery showed no recurrence in the double-port group, while one case of recurrence occurred in the three-port group one week after surgery. The analysis of the cause suggested that the child had an upper respiratory tract infection with coughing postoperatively, and the preoperative indirect inguinal hernia was large, with a hernia sac diameter of 8.0 cm and an internal ring diameter of 2.8 cm. The medial folds were thick, and the purse-string suture knot was large during surgery, all of which were related to the postoperative recurrence. The child underwent a second surgery three weeks postoperatively, where the loosened suture at the internal ring was found, and the internal ring was resutured and closed. Follow-up for one year showed no further recurrence.
Compared to the traditional three-port laparoscopic surgery, the transumbilical double-port laparoscopic surgery offers several significant advantages [25]. The double-port approach reduces the number of surgical incisions, thereby decreasing surgical trauma and postoperative pain, while providing superior cosmetic results due to the incision site at the umbilicus. Moreover, the double-port surgery simplifies the procedural steps, although it demands that the surgeon possesses advanced laparoscopic skills to adapt to the smaller abdominal cavity of infants and young children. However, the limitations of double-port surgery include potential restrictions in the surgical field of view and range of manipulation, as well as interference between surgical instruments. In contrast, the three-port laparoscopic surgery provides a broader surgical field of view and higher operational flexibility, which is particularly suitable for dealing with complex or large hernias. The three operative ports reduce the interference of instrument manipulation, making the surgical process smoother. Nevertheless, the three-port surgery is relatively more invasive, may require a longer recovery time postoperatively, and may affect the cosmetic outcome [26].
For laparoscopic surgery on complex hernias, we have found it feasible in the hands of experienced surgeons and capable of reducing complications and improving patient prognosis. However, this necessitates appropriate training for the surgical team and a certain learning curve for the lead surgeon to ensure the safety and efficacy of the surgery [27]. Regarding antibiotic prophylaxis, our study adhered to current clinical guidelines; none of the surgeries used antibiotics, and there were no cases of incisional infection postoperatively.
In summary, for the treatment of large indirect inguinal hernias in infants and young children, the transumbilical double-port laparoscopic surgery combined with extraperitoneal saline injection is safe and reliable, especially in reducing postoperative pain and accelerating recovery. However, to achieve optimal results, professional training for the surgical team is required, and patient-specific considerations must be taken into account when making surgical decisions. Future research should focus on further reducing surgical costs and increasing the accessibility of the surgery.
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