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

Abstract

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.© 2017 Elsevier Inc. All rights reserved.Since the dawn of laparoscopy, minimally invasive surgery has been spreading worldwide. As the techniques evolve, new strategies have been applied, as the use of natural orifices, robotically assisted procedures and percutaneous laparoscopic assisted procedures, in a quest to be even less invasive. While the open techniques for indirect inguinal hernia correction, a common procedure in pediatric surgery, are well established and have had their own evolution, laparoscopic correction has emerged in this global context [1,2], peaking nowadays for some into a scar less percutaneous procedure [3].Simultaneously, the ultrasound technology has evolved greatly, with the technology becoming more available and being currently used in areas other than radiology and diagnostics. The ultrasound-guided loco-regional anesthesia is a well-established example of the ultrasound utility in a surgical setting [4,5]. Likewise, ultrasound imaging is for some the diagnostic exam for a groin hernia [6,7] as well as a resource that can be accurately used by a surgeon as a diagnostic tool [8,9].Aiming for an even less invasive procedure, based in the laparoscopic assisted procedure experience, we postulate that an ultrasoundguided internal ring suture (UGIRS) could be a reproducible, feasible, reliable and safe procedure for indirect inguinal hernia in pediatric female patients, avoiding the inherent risks of an abdominal cavity entry and pneumoperitoneum. Therefore we conducted this study in an animal model aiming to prove this concept. To accomplish this, we performed an UGIRS in a living rabbit model using a 20G peripheral IV catheter and a 2/0 monofilament non-absorbable suture, dividing th...

Current Image-Guided Interventions in Pediatric Surgery

“…A recently published study investigated the feasibility, reliability, and safety of US-guided percutaneous ligation of the internal inguinal ring in rabbits as a surrogate for indirect inguinal hernia repair in the female pediatric patient. 34 They performed the procedure using a 20-G peripheral IV catheter and a 2-0 monofilament nonabsorbable suture on 28 rabbits that were divided into two group-one that simulated the human female inguinal hernia and the second that simulated the male's morphology. The procedure was followed by laparoscopic exploration to evaluate the quality of the repair.…”