Laparoscopic Percutaneous Extraperitoneal Closure (LPEC) for an Inguinal Hernia with Concomitant Umbilical Hernia Repair in a Pediatric Male

CHAPTER 1

My name is Yuki Noguchi, Chief Surgeon of Pediatric Surgery at Osaka Women's and Children's Hospital in Osaka, Japan. As I mentioned in the previous female case, laparoscopic percutaneous extraperitoneal closure, or LPEC, has become the preferred method for pediatric inguinal hernial repair in Japan. This is due to several advantages, including better possibility of pain control, and superior cosmetic outcomes. In addition to inguinal hernias, umbilical hernias are also one of the common conditions managed by pediatric surgeons. These two conditions often coexist in the same patient, and we frequently perform LPEC and umbilical hernia repair simultaneously. And the incision for umbilical hernia repair can also be utilized for LPEC. This particular case involved a 1-year and 8-month-old boy who presented with a large, dome-shaped, bulging mass at the umbilicus, first noticed about five months earlier. A cotton ball with external pressure had been applied to the umbilicus, which resulted in near complete reduction of the bulge. However, his parents also noticed swelling in the right scrotum, which was diagnosed as a lateral inguinal hernia by ultrasonography. Since spontaneous resolution was unlikely, we decided to perform LPEC along with umbilical hernia repair as a small umbilical defect still remained. For LPEC, as described in the previous female case, we use a specialized device called Lapa-Her-Closure, which stands for laparoscopic hernia closure. Although the device is the same, the surgical technique differs slightly in male patients. In females, I emphasize that tip rotation is the key step after inserting the device into the preperitoneal space. In males, however, rotation must be avoided to prevent injury to the spermatic vessels and the vas deferens. Instead, the needle tip should cross these structures perpendicularly at the shortest possible distance. It is also critical to confirm that these structures are not caught within the suture loop before ligation. By minimizing dissection between these important structures and the peritoneum, we can reduce the risk of testicular atrophy by injury to the spermatic artery or vas deferens stenosis. For such minimal dissection, slight side to side or up to down movements of the Lapa-Her-Closure tip are effective. Another important point is to retract the testis caudally and compress the hernial sac externally to evacuate the gas within the sac. This maneuver helps prevent high fixation of the testis, which can occasionally occur postoperatively. When the ligation is completed properly, the scrotal bulge completely disappears, confirming full closure of the patent processus vaginalis as shown in this video. Even under optimal conditions, the procedure for males takes slightly longer than for females because of the fine needle manipulation it requires. On average, it takes approximately 30 to 40 minutes for one side and 50 to 60 minutes for bilateral side from skin incision to closure. For umbilical hernial repair, unlike LPEC, a curved incision along the lower half of the umbilical ring is made. The first step is to secure the hernia sac and enter the abdominal cavity by opening it. Because this site corresponds to the camera port for LPEC, it can be used for that purpose if needed. When closing the fascial defect, it is important to sufficiently trim the weak tissues surrounding the umbilical hiatus until the natural fibers of the rectus abdominis are exposed. Insufficient trimming can lead to a recurrence. To achieve an ideal umbilical depression, it is also necessary to adequately thin the subcutaneous tissue in the umbilicus base, allowing deep fixation of the base onto the fascia. However, excessive trimming may cause bleeding and postoperative hematoma leading to possible wound infection, so meticulous hemostasis is essential. This procedure alone typically takes about 60 minutes. If these two procedures were performed separately, the total operative time would be approximately two hours. However, by combining them, the total time can usually be reduced to about 60 minutes as some steps overlap. In this case, the entire operation took about 60 minutes.

CHAPTER 2

First, I would like to briefly introduce this case. This patient is a 1-year and 8-month-old boy whose parents first noticed a bulging mass at his umbilicus about five months ago. They considered taking him to a local clinic, but before they could do so, they also observed a bulging mass in his right scrotum. At that time, the child did not show any particular discomfort. However, the parents noted that both bulges tended to become more prominent when he was constipated or required an enema. This prompted them to seek medical attention. At the clinic, the bulges were persistently present. An umbilical hernia and an inguinal hernia were suspected and the patient was referred to our hospital for further evaluation. On examination, the umbilical bulge was large, dome-shaped, and clearly visible, while the right scrotal bulge was apparent in all positions. Ultrasound revealed a right-sided lateral inguinal hernia with a portion of the small intestine protruding through a patent processus vaginalis, and this could be easily reduced with gentle pressure. The hernia sac measured more than 30 millimeters in diameter, and ultrasound also confirmed an umbilical hernia with a portion of the greater omentum protruding through the hernia ring, which could likewise be reduced easily with gentle pressure. After initial visit to our hospital, he was followed for several months to allow for further growth and to ensure that general anesthesia could be administered more safely. During this period, a cotton ball with external pressure was applied to the umbilicus, which resulted in near complete reduction of the bulge at the umbilicus. Since spontaneous reduction of the inguinal hernia was unlikely, we decided to proceed with laparoscopic percutaneous extraperitoneal closure, or LPEC, to prevent any complications such as incarceration and at the same time to perform umbilical hernia repair. Okay, so let's begin.

CHAPTER 3

Can I have an Adson with teeth? And when performing - could you wait? When performing the simultaneous repair of the umbilical hernia, instead of usual vertical umbilical incision used for LPEC, make a curved incision along the lower half of the umbilical ring and secure the hernia sac first with 8-French Nelaton catheters. Gauze, please. Gauze, gauze. And can I get a muscle retractors? Muscle retractor? Okay. Mosquito. Mostly fascia. Can you see? Okay. Okay. Can I get a Nelaton catheter? Nelaton catheter, please. So we now have secured the hernia sac. Okay. Mosquito, please.

CHAPTER 4

And then the hernia sac is cut. And, once the hernia sac is opened, then you can see intestines or greater omentum through the hole. Yeah. Yes. Yeah, gonna put another... Mosquito? Another mosquito here. Yeah. Okay. Then, the intestines are now identified.

CHAPTER 5

And insert a 5-millimeter port through the incision. Okay. And if the incision is wider than the port diameter, then fix the port with 2-0 silk suture to prevent gas leakage. Can I get a scissors? Let's inspect the inside. Okay, now we're in the abdominal cavity, so let's begin. Pneumoperitoneum with medium flow at a pressure of eight millimeters of mercury. Okay. And as for the LPEC procedure, before manipulating with forceps, first observe the patent processus vaginalis on the affected side and also check for the other side. Okay. So it seems closed. But when a patent processus vaginalis is present on the other side, we usually do not treat it if the opening is very small due to the potential impact of the procedure on the spermatic vessels and the vas deferens. But if the opening is sufficiently wide, we usually treat it at the same time, but this time it seems closed. So we can focus on the affected side. And the next step is to determine the port insertion site. And as I mentioned in the previous female case, it is important to confirm that the laparoscopic forceps can adequately reach the internal inguinal wing on the left side, and at the same time, the right side is not to close. Okay? And it's also important to use the instruments of the appropriate size. Okay? Okay. So for this case, here is the best place. Okay. Good. And after the port insertion, 2-millimeter port insertion, then ask the anesthesiologist to place the patient in the Trendelenburg position and then use the forceps to move the intestines cranially to secure the operative field. And in a male patient in particular, it is also important to confirm the causes of the spermatic vessels and the vas deferens. And this case, yeah, that is the spermatic vessel, and this is the vas deferens on the right side. And let's check the other side. Yeah. Could you move the intestines cranially a little bit? Yeah. Here is the spermatic vessels, and that is the vas deferens. Okay.

CHAPTER 6

Okay. And the next step is to determine the puncture site. And to do so, externally compress the planned puncture site with a straight mosquito, like this, to confirm its relationship to the intra-abdominal structures, especially the internal inguinal ring. And here is the best place for this case. And make a small incision with 18-gauge needle. And we believe this helps prevent unintended deep penetration during the actual puncture with Lapa-Her-Closure in the next step. And then insert Lapa-Her-Closure into the the tiny hole until the tip becomes visible through the peritoneum. And I cannot stress enough how important it is to avoid catching peritoneal fat on the tip. You know, it's a good layer. and once the tip is in the correct layer, then advance the tip a little bit laterally and adjust the tip so that it crosses the spermatic vessels perpendicularly at the shortest distance. Yeah. Like this. And at this point it is also important to use a forceps to expose the crossing paths which facilitate the smooth passage of the needle. Yes. And in a male case, it is really important to dissect the space between spermatic vessels and the peritoneum by gently removing the tip side to side or with slight up-and-down movement. And then, oh, retract the needle a bit. A little bit. Okay. Yeah. And pass the needle across the vessels. And after crossing the vas deferens... Then proceed similar to cross the vas deferens. Oh. Yeah. Okay. And in this step, it is also important to take care to avoid injury to the external iliac vessels just under the needle. Yeah. Here is the external iliac vessels. And after crossing the spermatic vessels, then proceed similarly to the vas deferens. Again, perpendicularly at the shortest possible distance. Oh. Yeah. Yeah, that is the vas deferens. Yeah. But it is sometimes very difficult to cross the vas deferens. And if unable to cross the vas deferens, then you can first puncture the peritoneum just above the vas deferens to allow the pneumoperitoneum to create separation between the two structures, the vas deferens and also the peritoneum for easier manipulation from the other side. And then release the thread. And close the Lapa-Her-Closure. And fully extract the thread into the abdominal cavity. Okay. Close the Lapa-Her-Closure. And retract the needle just under the puncture site. Without completely exiting the muscle layer. In other words, ensure the needle tip remains visible through the peritoneum at all times, like this. And then advance the needle medially next. While avoiding injury to the vessels just under the abdominal wall. And reach the same puncture site. Yeah. Advance the needle laterally a bit, a bit more. Yeah. No. Medially. Sorry, medially, a bit more. Alright. Okay. Yeah. Advance the needle tip to the same puncture site, like this, and reenter the abdominal cavity to retrieve the thread. Okay. Good. Okay. Close the Lapa-Her-Closure and retract the needle and pull the entire needle out. But it is important to use the forceps and insert it into the internal inguinal ring to prevent premature closure with the suture tension. Okay. And the most important step in a male case is to ensure the thread fully encircles the internal inguinal ring like this without being exposed on the peritoneal surface. And at the same time, spermatic vessels around here and the vas deferens are not caught within the loop. Yeah, it seems good. There is no, those structures on the thread. Okay. And then have the assistant retract the testis caudally like this. And at the same time, compress, externally compress, apply pressure to the groin to evacuate the gas from the hernia sac before ligation. Yeah. Seems good. And we believe this maneuver helps prevent high fixation of the testis, which can sometimes result from the LPEC. Good. And then... Grab the surrounding tissues gently to confirm the complete closure. Okay. Yeah, looks good.

CHAPTER 7

And repeat on the opposite side if necessary, but this time it seems closed so we don't have to treat it. Okay. And then... There is no iatrogenic injury, which may have occurred during the first port insertion, especially just below the umbilicus. around here, there is no injury. And conduct a full intra-abdominal survey for anomalies. Yeah. Looks good. And then... Confirm there is no bleeding from the port insertion site before terminating pneumoperitoneum. Okay. Can I have, yeah, muscle retractors? Could you press the abdomen to evacuate the remaining gas? And then the umbilical hernia repair is performed.

CHAPTER 8

Okay. One more. Yeah. Sorry. Return the table back to the natural position and then start on the umbilical hernia repair next. And for the procedure, the hernia sac at the umbilicus is carefully trimmed until the rectus abdominis muscle is fully exposed. And then the repair is performed by closing the firm fascial edges with 3-0 Vicryl sutures. Yeah. Now we're trimming the hernia sac at the umbilicus. Until rectus abdominis is exposed. Muscle retractor, please. Muscle retractor. Muscle retractor, please. Good. Okay, so now we're done. We have done the trimming procedure and then close the opening. Again, it is important to close the firm fascial edge. Can I have a scissors? Get this back. Can I have a scissors? Mosquito, please. Do you want me to release it? Scissors? Can I have a muscle retractor? Another mosquito, please. Can I get a curved one? Where is it? Okay. Can I have a curved mosquito? Scissors. Okay, good. Now we have done the closure of the firm fascial edges. And next, the portion of the hernia sac adherent to the subcutaneous tissue of the umbilicus is excised as much as possible. And then meticulous hemostasis is achieved along the dissected surface. Can I have an Adson with teeth? Okay. So, this process is very important as inadequate hemostasis may result in a postoperative hematoma beneath the umbilicus leading to elevation of the umbilical base or surgical site infection. Again, ensure that there is no bleeding. If there's any, perform hemostasis again. You think it's enough? And finally, a 5-0 absorbable monofilament suture is placed at the deepest point of umbilicus and anchored to the underlying fascia, or slightly caudal to it to form a natural umbilical depression. Can I have a scissors? Okay.

CHAPTER 9

And then close the dermis with interrupted sutures using the same 5-0 absorbable, monofilament sutures. And then, place a cotton ball with gentamicin ointment into the umbilicus and apply waterproof dressing on it. And close the 2-millimeter port and the puncture site in the groin with surgical tape followed by waterproof dressing for added protection. Okay. All done.

CHAPTER 10

Although there were some technical difficulties as in the previous female case, demonstrating troubleshooting is considered educationally valuable. First, several extensive punctures into the abdominal cavity occurred during the procedure resulting in bleeding within the preperitoneal space. This should generally be avoided as explained in the previous case. When this happens, the tip should be withdrawn slightly and reinserted correctly to encircle the internal inguinal ring without exposing the suture on the peritoneal surface. Second, in this case, puncturing into the abdominal cavity before crossing the vas deferens was unavoidable, though this is not inherently problematic. In some cases, the crossing is difficult due to needle induration. When this occurs, puncturing the peritoneum just above the vas deferens, allows the pneumoperitoneum to create a space between it and the peritoneum, precipitating easier medial side handling. Third, when performing LPEC together with umbilical hernia repair, the camera port site may be slightly wider than its nominal diameter leading to gas leakage and inevitable pneumoperitoneum. This occurred even after securing the port with two silk sutures. However, having the scope as to hold the base of the camera port, prevents funnel leakage, allowing the procedure to continue smoothly. In male patients, the major concern remains potential injury to the spermatic vessels and the vas deferens. In contrast, in female patients, an asymptomatic patent processus vaginalis, or PPV, is known to be a risk factor for developing an inguinal hernial later in adulthood. Therefore, we routinely close the contralateral PPV in females. However, in males, we perform contralateral closure only when the contralateral opening is comparable to or larger than the affected side to avoid unnecessarily risk to these critical structures. Postoperative care and follow up for male patients are similar to those for females, we routinely assess testicular size and position at one week and one month after surgery. If high testicular fixation is observed, orchiopexy may be required. In conclusion, LPEC in male patients is slightly more technically demanding than in females, but remains a fundamental skill for pediatric surgeons. It provides an effective, minimally invasive method for repairing inguinal hernias. Simultaneous performance of LPEC and umbilical hernia repair is also a reasonable approach and it reduces the overall frequency of surgical interventions for pediatric patients.