Ikeda Hitoshi, Hatanaka Masahiro, Suzuki Makoto, Fujino Junko, Tahara Kazunori, Ishimaru Yuki
Department of Pediatric Surgery, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama 343-8555, Japan.
J Pediatr Surg. 2009 Aug;44(8):1666-71. doi: 10.1016/j.jpedsurg.2009.04.017.
To achieve satisfactory surgical and cosmetic results with minimal surgical invasiveness without laparoscopic assistance in childhood inguinal hernia repair, a novel technique, the selective sac extraction method (SSEM), was devised. The technical feasibility of this method was retrospectively examined.
The method was applied to 162 consecutive hernia repairs in 153 patients, 79 boys and 74 girls, excluding patients with incarcerated or irreducible hernia, sliding hernia of the ovary (hernia with palpable ovary at repair), or hernia associated with an undescended testis. Hernia repair was performed by several young surgeons under the guidance of one teaching surgeon.
Patients' ages ranged from 1 month to 12 years (median, 3 years), and their body weights ranged from 2.9 to 41 kg (median, 14.4 kg). The SSEM was accomplished in 149 (92%) of 162 repairs, and lengths of incision at the end of the procedure were less than 10 mm in all repairs. The success rate was 72 (88%) of 82 repairs in male patients and 77 (96%) of 80 repairs in female patients. In the remaining 13 (8%) repairs in 13 patients, 10 males and 3 females, the procedure was converted to a conventional open method by extending the incision to 10 mm or longer. The ages of the 13 patients ranged from 1 month to 8 years (median, 3 months), being significantly younger than patients whose repair was accomplished by the SSEM (P = .006). The reason for conversion in 9 repairs was a huge or thickened sac that could not be extracted from the small incision, of which 6 involved male infants younger than 11 months. Obesity (the body mass index was 22.2 and >97th percentile for the patient's age) and thick subcutaneous tissue characteristic of early infancy were also reasons, both of which hindered the approach to the inguinal canal. Other reasons included malpositioning of the skin incision and difficulty in sac identification. The lengths of incision at the end of the 162 repairs ranged from 4.5 to 13.0 mm (median, 7.0 mm). Those in female patients, 4.5 to 11.5 mm (median, 6.5 mm), were significantly shorter than in male patients, 5.0 to 13.0 mm (median, 7.5 mm) (P < .001). The median length of the operation was 25 minutes. A follow-up interview revealed that there was no hernia recurrence with a median follow-up time of 20 months (range, 12-29 months). No postoperative complications were reported by the parents. As for the parents' satisfaction with wound cosmesis, 93% of them rated it as good or excellent.
Inguinal hernia repair with the SSEM through a minimal skin incision is technically feasible, with very satisfactory surgical and cosmetic results. As it has the potential to be a standard method for inguinal hernia repair in children, a prospective study to confirm the safety of the procedure should be carried out.
为在小儿腹股沟疝修补术中在无腹腔镜辅助的情况下以最小的手术创伤实现满意的手术和美容效果，设计了一种新技术，即选择性疝囊提取法（SSEM）。回顾性研究该方法的技术可行性。
该方法应用于153例患者的162例连续疝修补术，其中男孩79例，女孩74例，排除嵌顿性或难复性疝、卵巢滑动疝（修补时可触及卵巢的疝）或与隐睾相关的疝患者。疝修补术由几位年轻外科医生在一位带教医生的指导下进行。
患者年龄从1个月至12岁（中位数为3岁），体重从2.9至41千克（中位数为14.4千克）。162例修补术中149例（92%）成功完成SSEM，所有修补术结束时切口长度均小于10毫米。男性患者82例修补术中72例（88%）成功，女性患者80例修补术中77例（96%）成功。其余13例患者（10例男性和3例女性）的13例修补术通过将切口延长至10毫米或更长而转为传统开放手术。这13例患者年龄从1个月至8岁（中位数为3个月），明显小于通过SSEM完成修补术的患者（P = 0.006）。9例转为开放手术的原因是疝囊巨大或增厚，无法从小切口中取出，其中6例为11个月以下的男婴。肥胖（体重指数为22.2，高于患者年龄的第97百分位数）和婴儿早期特有的厚皮下组织也是原因，这两者均阻碍了进入腹股沟管。其他原因包括皮肤切口位置不当和疝囊识别困难。162例修补术结束时切口长度为4.5至13.0毫米（中位数为7.0毫米）。女性患者的切口长度为4.5至11.5毫米（中位数为6.5毫米），明显短于男性患者的5.0至13.0毫米（中位数为7.5毫米）（P < 0.001）。手术中位时间为25分钟。随访访谈显示，中位随访时间为20个月（范围为12 - 29个月），无疝复发。家长未报告术后并发症。关于家长对伤口美容效果的满意度，93%的家长将其评为良好或优秀。
通过最小皮肤切口采用SSEM进行腹股沟疝修补术在技术上是可行的，手术和美容效果非常令人满意。由于其有可能成为小儿腹股沟疝修补的标准方法，应进行前瞻性研究以确认该手术的安全性。
