Inguinal hernia is a common surgical condition in pediatric surgery with an incidence between 0.8% and 4.4% 10. SLPEL was first described by Takehara in 2006 for the treatment of inguinal hernias11. In the minimally invasive era, there has been an increasing trend among pediatric surgical centers to correct anomalies using fewer and smaller incisions12,13. Therefore, a considerable number of surgeons have started to perform SLPEL for pediatric inguinal hernia11.
However, complications associated with the ligation knot require advanced modification of the surgical instruments or the procedure itself. Preventive measures should be applied to avoid unnecessary ligation of subcutaneous tissues14. The C-SLPEL uses a simple hernia needle and involves twice hernia needle insertions; the first insertion is used to pass the medial semicircle of the internal ring and introduce the thread tail, while the second insertion is used to pass the other semicircle of the internal ring and retract the tail from the peritoneal cavity with a wire loop11. Because most postoperative complications are caused by the ligation of extra tissues into the knot as a consequence of repeated puncture of the abdominal wall, we developed a one-puncture approach(Fig. 3). In the M-SLPEL procedure, the needle is pulled back to the space just outside of the peritoneum layer after the only puncture and continually passed through the outside half ring instead of being removed and performing a second puncture༈Fig. 3C-D༉. Then, the wire loop, which has some elasticity (we prefer the Prolene line), is introduced to retract the thread tail through the same peritoneal puncture. The grasper is essential during this procedure for flattening the peritoneum fold around the internal ring and retracting the thread tail into the wire loop༈Fig. 3E༉. In addition, to prevent the ligation of abdominal wall tissue around the puncture route, the abdominal wall is pulled once after the placement of each knot starting with the second knot. However, these maneuvers cannot be as easily accomplished without a well designed hernia needle before9.
The recently reported recurrence rate of laparoscopic inguinal hernia repair in children is 0.3–1.2%15. Many factors can cause hernia recurrence. Some are due to technical problems, including leaving a peritoneal gap when the thread is passed through the internal ring, ligation loosening due to inappropriate or inadequate knotting, and using absorbable sutures2,16−18. According to the data, this series had a very low recurrence rate. The possible reasons were as follows: first, we performed a complete extraperitoneal ligation without a peritoneal gap, and the puncture hole caused tissue adhesion; second, we applied a single puncture procedure without ligating any tissue of the abdominal wall.
A significant advantage of laparoscopic ligation is the ability to inspect contralateral defects, which potentially avoids a second operation and additional incision19–22. In pediatric patients, the incidence of recessive hernia is 20.0–43%23. In this series, the overall incidence of contralateral PPV was 19.4%, which is consistent with the reported data.
The cosmetic result is an important aspect for assessing the improvement of a modified operation7. Parent’s satisfaction regarding wound appearance is significantly better after laparoscopic surgery than open surgery1,2. In either procedure, the 5-mm trocar incision scar and the other 3-mm incision for the forceps along the umbilical ring were hidden within the umbilicus fossa. The stab incision in the inguinal area was on the abdominal transvers striae. By reducing the number of incisions and making them in hidden areas, a better cosmetic result was achieved. No obvious scar was visible at one month after the operation.
In conclusion, the M-SLPEL procedure is a safe and effective approach with a low recurrence rate, fewer postoperative complications and a better cosmetic appearance. The hernia needle is simple and easy to obtain, making the procedure suitable for promotion in wider regions.