Laparoscopic Percutaneous Extraperitoneal Closure (LPEC) for an Inguinal Hernia in a Pediatric Female

CHAPTER 1

I am Yuki Noguchi, a chief surgeon of pediatric surgery at Osaka Women's and Children's Hospital in Osaka, Japan. Our hospital is recognized as one of the five leading pediatric hospitals in Japan outside of university-affiliated centers. We cover nearly the full spectrum of pediatric surgery, including body surface, thoracic, gastrointestinal, hepatopancreaticobiliary, and oncologic procedures. We also play a leading role in neonatal surgery and minimally invasive approaches, among which is laparoscopic percutaneous extraperitoneal closure, or LPEC. As a chief surgeon, I routinely perform a large number of pediatric inguinal hernia repairs using both open and laparoscopic approaches. Recently, the laparoscopic approach has become the predominant method. Inguinal hernia is the most common condition in pediatric surgery, occurring in up to 5% of all neonates and at least twice as frequently in premature newborns, although reported rates vary across studies. Traditionally, repair is performed via a standard open approach to an inguinal crease incision. However, the laparoscopic approach offers several potential advantages for children, including superior visual exposure, minimal dissection that may reduce complications, comparable recurrence rates, lower risk of metachronous contralateral hernia, and improved cosmetic outcomes. Consequently, LPEC has become the preferred method for pediatric inguinal hernia repair in Japan. We perform LPEC in pediatric patients of all ages, although the average age is typically under 5 years. This particular case involved a four-year-old girl who presented with a bulging mass in the left inguinal region first noticed a few weeks prior to her initial visit. The mass would spontaneously reduce when the patient lay down, but it became apparent daily. We therefore decided to proceed with LPEC to prevent potential complications such as incarceration. For this procedure, we use a specialized device called Lapa-Her-Closure, which stands for laparoscopic hernia closure. As I briefly explained during the surgery, the instrument functions by opening and closing a looped wire within the needle. While the concept is simple, it requires practice to advance the needle tip smoothly into the preperitoneal space. As I mentioned during the surgery, one of the key techniques is to insert no more than three-millimeters of thread into the looped wire. Techniques differ slightly between male and female patients, and I will discuss the technique for male patients in a separate report. In female patients, such as this case, tip rotation is the most important step, clockwise on the right side and counterclockwise on the left. Unlike male patients, where care must be taken to avoid the spermatic vessels and the vas deferens, the primary structure to avoid in females is the external iliac vessels. By properly rotating the tip, the needle can be guided medial to the round ligament of the uterus, allowing retrieval of the raised thread from the medial route. Under optimal conditions, the procedure takes less than 20 minutes from skin incision to closure. In this case, however, the procedure took approximately 40 minutes. Therefore, it was not an ideal case, but demonstrating troubleshooting is considered helpful. Because an appropriately-sized instrument was not available, the laparoscopic forceps used this time differed from the usual one. It was designed for taller patients and was, therefore, too long, causing interference with the laparoscope and the suspension frame. This highlights the importance of using appropriately-sized instruments, as pediatric patients vary widely in body size. Additionally, the atypical conditions led to an accidental puncture into the abdominal cavity mid-procedure, which is basically one of the procedures that should be avoided. When this occurs, however, it is essential to retract the tip slightly and reinsert it correctly to encircle the internal inguinal ring without exposing the thread on the peritoneal surface. LPEC is typically performed in the morning, with patients discharged later the same day. The wound is assessed one week postoperatively during an outpatient visit, and until this visit, patients are advised to avoid immersing the wound in water. If healing is satisfactory at the visit, patients can resume normal activities. However, direct stress or stretching of the wound should be avoided for about one month. When it comes to complications, recurrence remains a main concern. The difference in recurrence rates between open and laparoscopic approaches is still debated. Some studies report higher rates with laparoscopy, while others show fewer overall complications. To reduce risk, non-absorbable sutures, such as Ethibond, are commonly used. In our own experience, we now perform LPEC in most cases, and we haven't seen an increase in recurrence compared with historical open repairs. Another important point is the presence of an asymptomatic patent processus vaginalis, or PPV, which is known to be a risk factor for developing an inguinal hernia later in adulthood. One advantage of the laparoscopic approach is that it allows us to treat the contralateral PPV at the same time, whereas the open method usually addresses only the affected side. To conclude, LPEC is a fundamental skill for pediatric surgeons, and it provides a simple, safe, and effective method for repairing inguinal hernias.

CHAPTER 2

This is a case of a four-year-old girl who presented with a bulging mass in the left inguinal region first noticed several weeks ago. According to her mother, it was initially difficult to reduce, but the bulge would spontaneously disappear when she was lying down. But since then, the bulge has been observed daily, prompting her mother to take the child to a local clinic where an inguinal hernia was suspected, and she was referred to our hospital for further evaluation. On physical examination, the bulge was clearly visible when she was standing, in contrast to the contralateral side, and ultrasound confirmed the diagnosis of a lateral inguinal hernia with the greater omentum protruding through a patent processus vaginalis. So we decided to proceed with laparoscopic percutaneous extraperitoneal closure, commonly known as LPEC, to prevent potential complications such as incarceration. And for this procedure, we usually use this specialized device, which is commonly used in Japan, called Lapa-Her-Closure. The term stands for laparoscopic hernia closure. And this instrument consists of two main components: a handle and a needle. And the inside of the needle has a looped wire, like this, which can be controlled by manipulating this handle like this, open, close, and lock. And during surgery, this looped wire is used to catch and release sutures for hernia repair. And it is important to note that if the thread extends too far into the looped wire, like this, then the maneuverability during surgery can be compromised. So we recommend inserting no more than three millimeters of thread, like this, to maintain smooth handling.

CHAPTER 3

We need to retract the base of the umbilicus adequately in the anterior direction, like this, and then make a minimal incision on the top, just necessary for a 5-millimeter port insertion. Okay. Okay, you hold. Okay. Can I have a Metzenbaum? And cut a bit. Okay, and then can I have a straight mosquito? Okay. So could you insert the muscle retractors? Between the two legs, okay? No. Okay. So, can I have a curved mosquito, please? So it is sometimes difficult to insert the straight mosquito. Okay. Can I have a Metzenbaum? Okay. Okay, straight mosquito. Mm. Mm. Okay. Mm-hmm. You insert. No, no, not that. Yeah, yeah. This way, the other way. Okay. Okay. Mm-hmm. Okay. Whoop. Here. Okay, good. And release it. Release it. Okay. Now we can see the intestine and the abdominal cavity. Okay. Mm. Let's check inside. Yeah. Okay. Okay, now we can see the intestine, so we're in the abdominal cavity. So, could you connect? And let's begin the pneumoperitoneum. Could you begin the pneumoperitoneum with medium flow at a pressure of 8 millimeter of Mercury? Okay. Let's check. Okay, no iatrogenic injury. Okay. Mm. Okay. First, let's observe both sides. So she has a bulging mass in the left inguinal region. But it looks open on the right side as well. Okay, and look, could you look at the other side? Okay, it's obviously open. So, this time we need to repair the both sides. And the next step, we need to determine the port placement site. But before finalizing the port placement, can I get the laparoscopic, no, laparoscopic forceps, please? Please make sure to confirm that the forceps can adequately reach the left side and at the same time, the right side is not too close. So here is the best place for this case. And can I get 2-millimeter port sleeve only. Here, so somewhere around here. Okay, here. And then 11 blade. Make an incision here. Can I get the straight mosquito? And the port with an inner cannula, please? Okay. So, show the... Show the tip, please. Where? Here, here. This way, this way. Okay. Okay. Okay, and then ask the anesthesiologist to place the patient in the Trendelenburg position. Could you head down, please? Okay, thank you, and use the forceps to move the intestine. We can see the external iliac vessels here and also here. Okay. And we also need to check the course of the round ligament of the uterus. Here and there. Okay, good.

CHAPTER 4

And then, the next step is to determine the puncture site. And in order to do this, externally compress the inguinal region at the planned puncture site, somewhere around here, to confirm its relation to the intra-abdominal structures just above the opening of the processus vaginalis. Okay, here. So... Around here. Okay? And then make a small incision with an 18-gauge needle. Because we believe it helps prevent unintended deep penetration with the Lapa-Her-Closure. So insert the Lapa-Her-Closure needle through the tiny hole until you can see the tip. And then, advance the needle laterally first. Okay. Okay, like this. And for this step, it is very important to avoid catching any preperitoneal fat on the needle tip, somewhere around here, as this fat may increase the resistance and hinders the smooth advancement of the needle thereafter. And this time, we don't catch any fat on the tip, so it looks good. And once entered the correct layer, then rotate the tip medially like this, I mean, clockwise on the right side, on the other hand, counterclockwise on the left side. And passing anterior to the external vessels like this and then posterior to the round ligament of the uterus. And once medial to the ligament, then puncture the peritoneum into the abdominal cavity to release the thread. Okay, and use the forceps to extract free into the abdominal cavity. Then close the loop and retract the needle just below the puncture site but without completely exiting the muscle layer. So you need to keep the tip visible through the peritoneum, like this. And then... Advance the needle medially next in the same fashion. Okay. Okay. And advance the needle to the same puncture site. Too long. So... Okay. So to the same puncture site, like this. We usually use more shorter forceps for this surgery, but this time it's too long, so it's a bit difficult to manipulate the handle. Okay. So same puncture site and then re-enter. Okay. Okay. And retrieve the thread. Okay. And close Lapa-Her-Closure. And retract the needle and pull the entire needle out completely but slowly and gently, not to close the opening of the processus vaginalis. So at the same time, you need to insert the forceps into the patent processus vaginalis to prevent premature closure with the suture tension. So, please make sure to confirm the thread encircles the entire opening of the processus vaginalis like this. Looks good. And then, have the assistant externally compress the inguinal canal, like this, to evacuate the gas from the sac before tying the knot. So, could you push here? Okay, can I have a scissors? Okay. Then, if the contralateral involvement is present, repeat the same procedure.

CHAPTER 5

Again, externally compress the planned puncture site from around here to check its relation to intra-abdominal structures just above the opening. Can I have a straight mosquito, please? Okay, here. Can I have an 18-gauge needle, mm-hmm? And make a small incision here. And insert the needle through the tiny hole until the tip is visible through the peritoneum like this. And again, make sure to avoid catching any preperitoneal fat on the tip. And once the correct layer, then advance the needle laterally first, like this. And then rotate the tip medially, this time counterclockwise because it's on the left side. Like this. And passing the external iliac vessels, anterior to them while avoiding any injury to them. And then, posterior to the round ligament of the uterus. Like this. And then puncture the peritoneum into the abdominal cavity to release the thread. And extract the thread free into the abdominal cavity, and then close the Lapa-Her-Closure and retract the needle just below the puncture site. But again, you need to keep the tip visible through the peritoneum without completely exiting the muscle layer. And then, advance the needle medially next. And, advance the needle to the same puncture site, oh, same puncture site. Okay, here, and re-enter the abdominal cavity to retrieve the thread. Okay. And close the Lapa-Her-Closure and pull the entire needle out slowly and gently, not to close the opening. And again, insert the forceps into the processus vaginalis to prevent, oh, to prevent premature closure with the suture tension. Okay. And let's check. Oh. Retract the round ligament medially and posteriorly to confirm the thread encircles the entire opening of the processus vaginalis without being exposed on the peritoneal surface, so it looks good. And again, have the assistant compress externally to the inguinal canal to evacuate the gas before tying the knot like this, okay. Mm. Can I have a scissors?

CHAPTER 6

Check again the complete closure on both sides. Retract the round ligament, okay, to confirm complete closure. Okay, looks good. Okay. And the other side. Yeah, looks good. And then, ask the anesthesiologist to return the table to the neutral position. And make sure to confirm no iatrogenic injury just below the umbilicus, okay? And then, look around. Could you look around to check any anomalies? We usually routinely do this, especially for female patients. Forceps. Forceps... Laparoscopic forceps, please?' Okay. Laparoscopic. Okay. Especially both ovaries, as we have an experience of a case with a disorders of sex development in which the patient didn't have any ovaries in the abdominal cavity. Okay, so this time, here is the right ovary. And this is the uterus. Okay, so looks good.

CHAPTER 7

Okay, then let's check the port insertion site, so that there is no bleeding from the site. Okay. Looks good. Okay, then... Yep, pull out. And the camera. And can I have a fine muscle retractors, okay, and expel the remaining gas.