Suture choice matters in rabbit model of laparoscopic, preperitoneal, inguinal hernia repair

Addition of Transfixation Suture to Purse String Suture During Intraperitoneal Inguinal Hernia Repair Increases Peri-Hernia Sac Neck Collagen Formation

BACKGROUND

The worldwide accepted repair for indirect inguinal hernia in children is high ligation of the hernia sac with open herniotomy. However, laparoscopic pediatric inguinal hernia repair (IHR) has been gaining popularity in the last two decades. An experimental study was conducted to investigate the effects of different intraperitoneal IHR suture techniques on the collagen formation at the hernia sac neck.

METHODS

Present study was conducted on thirty-five male adult (3-6 months old) Wistar-Albino rats (260-300 g). Intraperitoneal IHR with different hernia sac neck suturing techniques (purse string suture only, transfixation suture only and purse string suture plus transfixation suture) were performed through median laparotomy using open operative techniques. Non-absorbable 2/0 braided polyester suture with 16 mm 1/2 curved round needle (Ti-cron, Covidien, MN) was used as suture material.

RESULTS

The highest collagen thickness around the suture was detected in intraperitoneal IHR with purse-string plus transfixation suture group. The collagen thickness of the intraperitoneal IHR with purse string suture only and IHR with tranfixation suture only groups were not statistically significantly different. The collagen thickness of the intraperitoneal IHR with purse string suture plus transfixation suture group was statistically significantly higher compared with the intraperitoneal IHR with purse string suture only and intraperitoneal IHR with transfixation suture only groups.

CONCLUSIONS

The combined usage of purse string suture and transfixation suture during laparoscopic intraperitoneal inguinal hernia repair further stimulates mesothelial fibrosis at the hernia sac neck compared with mesothelial fibrosis induced by purse string suture only or transfixation suture only.

Modified Laparoscopic Percutaneous Extraperitoneal Closure Using a Sledge-Shaped Needle for Inguinal Hernia and Hydrocele in 1199 Pediatric Patients

Background: The objective of the study is to determine the safety and efficiency of the modified laparoscopic percutaneous extraperitoneal closure (LPEC) to treat pediatric patients with inguinal hernia or hydrocele. Methods: From January 2014 to July 2018, the patients with inguinal hernia or hydrocele who were operated on using modified LPEC were included. We modified LPEC with a sledge-shaped needle and reinforcement flag. By means of medial umbilical fold, the reinforcement surgery should be performed on the patients with huge internal rings (diameter >1.5 cm). Operative time, complication rate, incidence of reinforcement, and contralateral patent processus vaginalis were described between inguinal hernia and hydrocele. Results: In this study, 764 patients with inguinal hernia and 435 patients with hydrocele were successfully performed by the modified LPEC. The 383 (50.1%) patients with inguinal hernia and 266 (61.1%) patients with hydrocele were identified with a contralateral patency of internal ring and underwent simultaneous prophylactic surgery. During surgical procedures, the medial umbilical fold reinforcement (inguinal hernia/hydrocele = 50/1) was performed on 51 patients. Hernia recurrence occurred in 2 cases. All patients had a good cosmetic appearance without additional dissection. Conclusion: Modified LPEC using a sledge-shaped needle and applying the medial umbilical fold reinforcement is a safe and effective surgical procedure.

Long-term absorbable versus non-absorbable suture in laparoscopic percutaneous extraperitoneal closure of internal ring for inguinal hernia in children

AIM

To compare the results of using long-term absorbable (LTAS) versus non-absorbable suture (NAS) in laparoscopic percutaneous extraperitoneal closure of internal ring (LPEC) for indirect inguinal hernia (IH) in children METHODS: Prospectively collected data from children undergoing LPEC for IH at our center were retrospectively reviewed to compare group A repaired with NAS (2.0 monofilament polypropylene or braided polytetrafluoroethilene) to group B repaired with LTAS 2.0 polydioxanone.

RESULTS

481 patients with 499 IHs in group A were compared to 277 patients with 283 IHs in group B. There were no significant differences in terms of age, bodyweight and laterality of IH between the two groups. At a median follow up period of 30 months, the incidence of suture knot reaction (SKR) and hernia recurrence were 3.1% and 1.0% in group A vs. 0% and 6.4% in group B with p = 0.002 and p<0.001, respectively. Monofilament NAS was associated with a low rate of both recurrence and SKR.

CONCLUSIONS

LPEC repair for pediatric IH using LTAS is associated with no SKR but a higher recurrence rate compared to NAS. Monofilament NAS such as Prolene could be a good choice in LPEC because of its low rate of both recurrence and SKR.

Pediatric inguinal hernia treated by single-port laparoscopic water injection hernia crochet needle

Introduction

Inguinal hernia is the most common disease in pediatric surgery and is induced by congenital processus vaginalis patency. Almost all inguinal hernias are inguinal indirect hernias, and herniorrhaphy has accounted for about 15% of all pediatric operations. In the past 20 years, with the development of minimally invasive technology, laparoscopic inguinal herniorrhaphy has been emerging in China and in other countries.

Aim

To introduce a new technique for treating inguinal hernia in children, and evaluate the feasibility and surgical efficacy of a transumbilical single-port laparoscopic water-injection hernia crochet needle in treating pediatric inguinal hernia.

Material and methods

Clinical data of 136 inguinal hernial children treated using a transumbilical single-port laparoscopic water-injection hernia crochet needle in our hospital from June 2017 to December 2018 were retrospectively analyzed.

Results

All procedures were successfully accomplished, and no case was converted to a different procedure; the average operation time was 16 min for one side and 35 min for both sides. Patients were followed for an average of 10 months after surgery. One patient had a line-knot reaction at the inguinal puncture point 3 months after surgery and recovered after conservative treatment, and no recurrent case was observed after surgery.

Conclusions

It is feasible to treat pediatric inguinal hernia through a transumbilical single-port laparoscopic water-injection hernia crochet needle, which is associated with safety, less trauma, rapid recovery, no obvious scar, and satisfactory efficacy. Therefore, it is worthy of being promoted and applied in clinical practice.

Meshes in a mess: Mesenchymal stem cell-based therapies for soft tissue reinforcement

Surgical meshes are frequently used for the treatment of abdominal hernias, pelvic organ prolapse, and stress urinary incontinence. Though these meshes are designed for tissue reinforcement, many complications have been reported. Both differentiated cell- and mesenchymal stem cell-based therapies have become attractive tools to improve their biocompatibility and tissue integration, minimizing adverse inflammatory reactions. However, current studies are highly heterogeneous, making it difficult to establish comparisons between cell types or cell coating methodologies. Moreover, only a few studies have been performed in clinically relevant animal models, leading to contradictory results. Finally, a thorough understanding of the biological mechanisms of mesenchymal stem cells in the context of foreign body reaction is lacking. This review aims to summarize in vitro and in vivo studies involving the use of differentiated and mesenchymal stem cells in combination with surgical meshes. According to preclinical and clinical studies and considering the therapeutic potential of mesenchymal stem cells, it is expected that these cells will become valuable tools in the treatment of pathologies requiring tissue reinforcement. STATEMENT OF SIGNIFICANCE: The implantation of surgical meshes is the standard procedure to reinforce tissue defects such as hernias. However, an adverse inflammatory response secondary to this implantation is frequently observed, leading to a strong discomfort and chronic pain in the patients. In many cases, an additional surgical intervention is needed to remove the mesh. Both differentiated cell- and stem cell-based therapies have become attractive tools to improve biocompatibility and tissue integration, minimizing adverse inflammatory reactions. However, current studies are incredibly heterogeneous and it is difficult to establish a comparison between cell types or cell coating methodologies. This review aims to summarize in vitro and in vivo studies where differentiated and stem cells have been combined with surgical meshes.

Algorithm of Laparoscopic Technique in Pediatric Inguinal Hernia: Results from Experience of 10 Years

BACKGROUND

Many laparoscopic techniques have been evolved along years for pediatric inguinal hernia (PIH) with no standardization of technique. No single technique suits all varieties of hernia.

PURPOSE

To propose an algorithm for allocation of PIH to laparoscopic technique based on internal ring (IR) diameter to improve outcomes.

PATIENTS AND METHODS

Along 10 years, 459 cases with unilateral PIH were treated in Tanta University Hospital. In the first 5 years (phase I), 214 cases included then an algorithm for stratification was designed and applied in the second 5-year period (phase II), where 245 cases managed. This algorithm included evaluation of the hernia based on IR diameter as measured by the laparoscope from inside by a piece of suture. When the IR diameter is from 4 to 15 mm, complete sac disconnection is used. When IR diameter lies from 15 to 25 mm a purse string is added. When IR diameter is >2.5 cm or recurrent cases, the interrupted muscular arch repair after sac disconnection is used.

RESULTS

In phase I, 170 boys and 44 girls from 6 to 180 months of age were treated. All cases managed by laparoscopy were 84 herniotomy, 82 by purse string, and 44 by interrupted muscular arch. In phase II, 180 boys and 65 girls from 3 to 180 months of age were included. Eighty were managed by herniotomy, 137 by purse string, and 25 by interrupted muscular arch. Recurrence rate decreased significantly in phase II.

CONCLUSIONS

Application of Tanta algorithm reduces the recurrence rate significantly. The laparoscopic technique should be tailored according to criteria of each group of PIH to get the best outcome and reduced recurrence rate.

Ultrasound-guided dissection and ligation of the internal inguinal ring for hernia repair in pediatrics: an experimental animal study

PURPOSE

We aimed to test the feasibility and reliability of ultrasound-guided percutaneous internal inguinal ring suture in rabbits, as a model for inguinal hernia repair in pediatric population.

METHODS

Twenty-eight rabbits were divided in 2 groups: group I (female morphology) - persistence of the peritoneal-vaginal duct with gonads placed in intraperitoneal position; group II (male morphology) - persistence of the peritoneal-vaginal duct with gonads kept intact inside the duct. Under exclusive ultrasound-guided image we tried to perform a complete pre-peritoneal ligation of the peritoneal-vaginal duct at the level of the internal inguinal ring using a 20G peripheral IV catheter and 2-0 non-absorbable suture. Afterwards, an exploratory laparoscopy was performed to evaluate the ligation.

RESULTS

Ultrasound allowed characterization of inguinal-crural structures. Group I - complete and reliable suture 66.7%, incomplete but reliable suture 16.7%, inappropriate ligation 16.7%; group II - complete but unreliable suture 76.9%, incomplete and unreliable suture 11.5%, inappropriate suture 11.5%. No acute complications were logged.

CONCLUSIONS

Percutaneous dissection and ligation of internal inguinal ring through exclusive ultrasound guidance was feasible and likely reliable, namely for female inguinal hernia repair.

The design of and chronic tissue response to a composite nerve electrode with patterned stiffness

OBJECTIVE

As neural interfaces demonstrate success in chronic applications, a novel class of reshaping electrodes with patterned regions of stiffness will enable application to a widening range of anatomical locations. Patterning stiff regions and flexible regions of the electrode enables nerve reshaping while accommodating anatomical constraints of various implant locations ranging from peripheral nerves to spinal and autonomic plexi.

APPROACH

Introduced is a new composite electrode enabling patterning of regions of various electrode mechanical properties. The initial demonstration of the composite's capability is the composite flat interface nerve electrode (C-FINE). The C-FINE is constructed from a sandwich of patterned PEEK within layers of pliable silicone. The shape of the PEEK provides a desired pattern of stiffness: stiff across the width of the nerve to reshape the nerve, but flexible along its length to allow for bending with the nerve. This is particularly important in anatomical locations near joints or organs, and in constrained compartments. We tested pressure and volume design constraints in vitro to verify that the C-FINE can attain a safe cuff-to-nerve ratio (CNR) without impeding intraneural blood flow. We measured nerve function as well as nerve and axonal morphology following 3 month implantation of the C-FINE without wires on feline peripheral nerves in anatomically constrained areas near mobile joints and major blood vessels in both the hind and fore limbs.

MAIN RESULTS

In vitro inflation tests showed effective CNRs (1.93  ±  0.06) that exceeded the industry safety standard of 1.5 at an internal pressure of 20 mmHg. This is less than the 30 mmHg shown to induce loss of conduction or compromise blood flow. Implanted cats showed no changes in physiology or electrophysiology. Behavioral signs were normal suggesting healthy nerves. Motor nerve conduction velocity and compound motor action potential did not change significantly between implant and explant (p  >  0.15 for all measures). Axonal density and myelin sheath thickness was not significantly different within the electrode compared to sections greater than 2 cm proximal to implanted cuffs (p  >  0.14 for all measures).

SIGNIFICANCE

We present the design and verification of a novel nerve cuff electrode, the C-FINE. Laminar manufacturing processes allow C-FINE stiffness to be configured for specific applications. Here, the central region in the configuration tested is stiff to reshape or conform to the target nerve, while edges are highly flexible to bend along its length. The C-FINE occupies less volume than other NCEs, making it suitable for implantation in highly mobile locations near joints. Design constraints during simulated transient swelling were verified in vitro. Maintenance of nerve health in various challenging anatomical locations (sciatic and median/ulnar nerves) was verified in a chronic feline model in vivo.

Laparoscopic Pediatric Inguinal Hernia Repair: A Pilot Study in a Novel Guinea Pig Animal Model

BACKGROUND

The purpose of this study was to compare different techniques for pediatric laparoscopic inguinal hernia repair. We hypothesize that the amount of dissection performed at the internal ring, with or without division of the peritoneum, will impact healing and thus long-term success of the repair.

METHODS

Following the Institution's Animal Care and Use Committee approval (708024-4), 20 Hartley guinea pigs underwent laparoscopic repair of their natural open internal rings. The guinea pigs were divided equally into four surgical groups: intracorporeal suture repair (IS), hernia dissection and division with intracorporeal suture (DDIS) repair, subcutaneous endoscopically assisted ligation (SEAL), and Yueng (HOOK) repair. After a 6-week survival period, a necropsy was performed. Repairs were evaluated and tested under pressures up to 30 mmHg. The suture was then removed to assess primary healing. Experimental data were analyzed using chi-square test.

RESULTS

There were no perioperative or postoperative complications. On initial evaluation, before suture removal, repair integrity was as follows: 5/10 IS, 10/10 DDIS, 7/10 SEAL, and 7/10 HOOK (P = .09). After suture removal, repair integrity was as follows: 3/10 IS, 10/10 DDIS, 5/10 SEAL, and 6/10 HOOK (P = .01).

CONCLUSION

Overall, dissecting and dividing the sac with intracorporeal suture (DDIS) closure had the best outcome. This method appears to best replicate standard open high ligation.