Laparoscopic Inguinal Hernia Repair Using the Burnia Technique

Abstract

Inguinal hernia repair is one of the most frequently performed surgeries in pediatric surgery clinics. The primary objective of this surgery is to close the inguinal hernia sac. Several techniques have been established for inguinal hernia repair, and the efforts to develop more techniques continue. Minimally invasive procedures are preferred. The Burnia technique for repairing girls’ hernias is one of the latest approaches and offers advantages such as applicability, minimal recurrence, evaluation of the opposite inguinal canal, and simpler training. In the Burnia technique, the peritoneum at the inner mouth of the inguinal canal is thermally cauterized, which ensures the formation of fibrosis. In this section, how the Burnia technique is performed will be explained.

1. Introduction

1.1 Highlights

1. Inguinal hernia repair is one of the most frequently performed pediatric surgeries.

2. A wide variety of minimally invasive procedures are used to repair inguinal hernias in children.

3. Peritoneal traumas reportedly play essential roles in the obliteration of the internal inguinal ring.

4. In the Burnia technique, the peritoneum at the inner mouth of the inguinal canal is thermally cauterized, ensuring fibrosis formation that prevents recurrence.

1.2 Inguinal hernia repair history

Inguinal hernia repair is one of the most frequently performed pediatric surgeries. The main objective of this surgery is to close the inguinal hernia sac to prevent the abdominal organs from entering it. The first surgery of this kind dates back to 1500 BC. In 1871, Marcy described the high ligation of the hernial sac, which continues to be used today [1].

Considering the frequency of cases requiring this surgery, the use of laparoscopy, a relatively less invasive technique, for inguinal hernia repair was begun in the 1990s [1, 2]. It has many advantages, such as the examination of the internal genital organs to exclude testicular feminization syndrome in girls, reduction of incarcerated hernias under direct vision, as well as simultaneous examination of the intestine for signs of ischemia, thus enabling immediate repair of the hernia and reducing the risk of bladder injury [3], and better cosmesis. One of the many advantages of laparoscopy is that it can differentiate recurrent inguinal hernias from femoral hernias by evaluating the groin area. Less than one percent of all groin masses seen in children are due to femoral hernias [4]. In addition, the presence of bilateral patent processus vaginalis and urachal anomalies, which could not be detected preoperatively in this case, might be observed.

The various procedures described for inguinal hernia repair include placing sutures on the neck of the hernia sac while performing laparoscopy, performing subcutaneous endoscopically assisted ligation of the hernia sac (SEAL), and single-site techniques [1, 5]. Raveenthiran reviewed the different laparoscopic and open techniques for inguinal hernia repair [6].

The laparoscopic inguinal hernia inversion and ligation (LI-HIL) technique, originally described by El-Gohary in 1997 [7], is described for laparoscopic repair of indirect inguinal hernia in girls and consists of inverting the hernia sac into the abdominal cavity and ligating the base of the sac with an endoscopic loop [8].

Laparoscopic techniques in inguinal hernia repair in children can also be divided according to the division or ligation of the processus vaginalis. According to the processus vaginalis, there are those with and without peritoneal closure and many variations in the processus vaginalis division. There are hook, PIRS (percutaneous internal ring suturing), SEAL, and many variations in processus vaginalis ligation.

Surgery involving laparoscopic percutaneous extraperitoneal closure of the internal ring using an epidural needle for inguinal hernia in girls only requires a 5-mm laparoscopy, a simple internal ring mouth puncture technique, and a knotting technique, with no particular indication for the laparoscopic suture technique. The method is simple and easy to master, and the learning curve is short [9, 10, 11].

Percutaneous internal ring suturing (PIRS) is a method of laparoscopic herniorrhaphy, i.e., percutaneous closure of the internal inguinal ring under the control of a telescope placed in the umbilicus [12].

Laparoscopic techniques for inguinal hernia repair are also broadly divided into extracorporeal and intracorporeal approaches. Extracorporeal techniques are carried out as a laparoscopic-assisted procedure as they involve the introduction of a needle, under visual control, to create a loop of thread that closes the internal inguinal ring. The intracorporeal techniques, on the other hand, are performed using one or more trocars as well as the use of intracorporeal sutures [2, 13, 14]. The knot is buried in subcutaneous tissue using extracorporeal techniques [14].

In laparoscopic inguinal hernia repair, iliopubic tract repair (LIPTR) has been recommended in addition to internal inguinal ring closure for dilated inguinal rings. The iliopubic tract is approximated to the transverse arch by an interrupted suture to narrow the internal ring [15]. However, no distinguishing information is given on whether this repair was performed on girls in that study.

Although the laparoscopic treatment of pediatric inguinal hernia (PIH) offers more benefits than traditional surgery, it is difficult to avoid the problem of recurrence completely. Wang et al. investigated the causes of recurrence after laparoscopic percutaneous extraperitoneal repair (LPER) of PIH [16]. They recommended LPER for PIH as a safe and effective operation and advised that to reduce the recurrence rate of LPER. Surgeons should improve surgical skills, choose an appropriate ligature, and avoid using LPER for a huge internal inguinal ostium (especially over 25 mm). It is appropriate to be converted to open surgery for patients with a very wide internal inguinal ostium [16].

Laparoscopic techniques are constantly advancing toward increasing the application of extraperitoneal repair and decreasing the use of assistant instruments and trocars. Zhang et al. [17] used a simple hernia needle for single-port laparoscopic percutaneous inguinal hernia repair in children. Their study found that the technique requires special operating instruments, such as a multi-channel puncture device, Kirschner wire, epidural puncture needle, and abdominal wall suture straight needle.

O’Brien et al. added monopolar diathermy of the peritoneum at the superior aspect of the internal ring, which was performed. Following this, the peritoneum around the open internal ring was closed by purse-string technique using a 4.0 nonabsorbable monofilament suture. The knot was tied in an intracorporeal manner. The recurrence rate was 1.9% [18].

In the single-port technique, the ligation of the hernia defect could be achieved percutaneously without the need for intracorporeal manipulation of the needle and knot tying. Subcutaneous endoscopically assisted ligation (SEAL) is one of these reported single-port techniques, first described in 2005 [19] using only the camera port inserted via an umbilical incision and extracorporeal subcutaneous knotting, which decreases the number and size of skin incisions and reduces the operative time over the traditional three/two ports laparoscopic hernia repair due to the fewer number of ports and no need for intra-abdominal surgical maneuvers [20].

Multiple techniques exist for direct internal ring suture closure without sac dissection and excision. Internal ring suture closure may be achieved by intracorporeal or extracorporeal suturing. In the laparoscopic intracorporeal purse-string technique, sac dissection is avoided. An absorbable or nonabsorbable suture is used to make a purse-string stitch around the internal inguinal ring to approximate the crural arch and conjoined tendon after incising the peritoneum around the internal ring.

In larger hernias, one or more interrupted stitches are made. In laparoscopic percutaneous extracorporeal closure, under laparoscopic vision using a suture passer device transabdominal, a suture is passed through a 2 mm stab incision and guided around the lateral half of the circumference of the internal inguinal ring [19].

Salgaonkar et al. [19] explained the stages of laparoscopic inguinal hernia surgery as follows: marking the peritoneum at the internal ring with diathermy, incising the peritoneum at the level of the internal ring, dissecting and excising the hernial sac, purse-string closure of internal inguinal ring.

Sutureless laparoscopic inguinal hernia repair (LIHR) in children is increasingly being reported in the literature, although a specific technique has not yet been standardized [13].

Peritoneal traumas reportedly play essential roles in the obliteration of the internal inguinal ring [21, 22]. The Burnia Technique is one of the most recent techniques for inguinal hernia repair [10, 23]. In girls, the absence of cords and elements that must be protected in boys facilitated the applicability of this technique. In the Burnia technique, the peritoneum at the inner mouth of the inguinal canal is thermally cauterized, ensuring fibrosis formation [24].

Figure 1 generally shows the modifications that can be made in laparoscopic inguinal hernia.

Figure 1.

Modifications of laparoscopic inguinal hernia repair.

2. Inguinal hernia repair

2.1 Indications

The detection of inguinal hernia in children is an indication for surgery. Surgery is planned as soon as possible as the risk of incarceration is higher in infants. In cases of reducible hernia in premature babies, inguinal hernia repair can be postponed until the time of discharge.

2.2 Contraindications

The only absolute contraindication to laparoscopic repair is hemodynamic instability. A relative contraindication may be previous abdominal surgery [25].

2.3 Anesthesia

Either endotracheal intubation or laryngeal mask is planned for general anesthesia by the anesthesiologist, considering the child’s age and the presence of any other diseases.

3. Surgery

3.1 Patient positioning and operating room setup

The patient is placed in the supine position. It may be more appropriate for the patient to lie slightly obliquely on the table regarding ergonomics. If the patient has a full bladder, the bladder is first emptied using a Crede Maneuver, and the patient should be placed in the Trendelenburg position to provide a better viewing angle.

The layout of the surgery room is presented in Figure 2. If the left side has to be operated on, the opposite placement is also possible.

Figure 2.

Schematic of the surgical setup.

3.2 Trocar position and instrumentation

When the laparoscopic instruments are inserted into the patient’s abdomen, the abdominal wall’s anatomical structure must be considered, particularly regarding a.v. epigastrica inferior (Figure 3).

Figure 3.

Sketch of the anatomical structures and the possible port entry in laparoscopy.

The pneumoperitoneum is created either through direct puncture (Veress Needle Technique) or using the Open Technique (Hasson) (the technique preferred by the author) through the umbilicus. A pneumoperitoneum is created with CO₂ at a flow rate of 0.4 L/min and a maximum pressure of 12 mmHg [3].

The camera is gradually advanced through the 5-mm trocar placed through the umbilicus. After a general abdomen examination, the working instrument, such as a Maryland Dissector or Ligasure Device, is advanced into the abdomen through a stab incision or a trocar in the lower right quadrant or the lower left quadrant (Figure 4). The working instrument must have an electrocautery feature, with low-wattage used. Depending on the patient’s age, a 2-, 3-, or 5-mm instrument may be used. It must be considered that the peritoneum is quite flexible in children (Figures 5 and 6).

Figure 4.

Marking of stab incision and telescope entrance.

Figure 5.

The peritoneum remains quite flexible when the abdomen is entered through a stab incision.

Figure 6.

The scalpel visible inside the abdomen during the stab incision.

The instrument is entered from the same side in the case of a unilateral inguinal hernia. If the hernia is bilateral, entering from the side on which the internal inguinal ring is wide and the sac is larger should be prioritized. Instruments from both sides are not required to be inserted in bilateral inguinal hernias. Both inguinal sacs could be intervened by entering from just one side in our clinic. If a single-site has to be used, the instrument could also be entered from the umbilicus or just an infra umbilical incision. After entering the abdomen with the camera, it is essential to conduct a general evaluation of the inside of the abdomen. A right ovarian torsion was detected in the 2-month-old baby girl. After the detorsion, the inguinal hernia surgery was performed using the Burnia Technique, and no problems were observed in the follow-ups after the surgery [24].

3.3 The Burnia

After the working instrument is inserted, any organs that have entered the internal inguinal canal, such as the omentum, are removed (Figure 7). The right or left internal inguinal ring is then evaluated (Figures 8 and 9).

Figure 7.

Left inguinal hernia and the omentum that had entered the inguinal canal.

Figure 8.

Right inguinal hernia.

Figure 9.

Left inguinal hernia.

The hernia sac is held after entering the inguinal canal, pulled toward the peritoneal cavity, and cauterized using low-wattage monopolar diathermy or ligasure instrument (Figures 10–17). If the sac is large, it is held several times and then cauterized at the level of the internal inguinal ring.

Figure 10.

Maryland grasper being advanced toward the internal ring of the right inguinal hernia.

Figure 11.

Maryland grasper visible in the right inguinal canal.

Figure 12.

Right inguinal hernia sac being inverted and pulled into the abdomen.

Figure 13.

Cauterization of the right inguinal hernia sac.

Figure 14.

Right inguinal hernia after the cauterization.

Figure 15.

Left inguinal hernia sac involvement.

Figure 16.

Left inguinal hernia sac being inverted, pulled into the abdomen, and cauterized.

Figure 17.

Left inguinal hernia after the cauterization.

It is crucial to cauterize the internal ring level here. If the uterine tube enters the inguinal canal, the sac must be cauterized without damaging the tubes. Figure 18 shows the internal inguinal rings after cauterization of bilateral inguinal hernia with the Burnia technique.

Figure 18.

Bilateral inguinal hernia after the cauterization (a. right inguinal hernia; b. left inguinal hernia).

3.4 Closing

The operating instrument is removed, and the entry site is examined using the camera to detect any bleeding after the procedure is completed. The pneumoperitoneum is evacuated. The area entered through the umbilicus, and the stab incision are sutured appropriately. If the stab incision remains very small and appears wholly closed after removing the working instrument, it may not need to be sutured. At this point, a subcutaneous injection of bupivacaine hydrochloride (0.5%) helps reduce postoperative pain.

3.5 Intraoperative complications

Bleeding, bowel and urine bladder injury, and general surgical complications are infrequent if the rules of laparoscopy are followed and the anatomy is taken into consideration.

4. Postoperative care

The operated child may be discharged on the same day if no other indications are observed, and analgesics such as paracetamol may also be administered. In the case of older children, it is better to prevent the child from excessive physical activity until the pain is relieved.

5. Outcome

Postoperative complications are identical to those in all surgical interventions, with a low recurrence rate.

6. Discussion

Laparoscopic inguinal hernia repairs in children have many advantages. These include less pain, the ability to intervene in bilateral inguinal hernias from the same port, a good option for repairing recurrent and incarcerated hernias, excellent cosmetic results, and the ability to detect and repair femoral and direct hernias. However, disadvantages include increased cost, long operating time, prolonged learning curve, and recurrence [26]. A recent systematic review and meta-analysis focused on many outcomes and concluded that [27] concluded that the laparoscopic hernia repair is the preferred method for managing inguinal hernia in pediatrics over open herniotomy as it has a shorter operative time, lower risk of metachronous contralateral inguinal hernia development, postoperative hydrocele, and postoperative scrotal edema, and its major benefit is for the assessment of contralateral side of inguinal region to prevent development of metachronous contralateral inguinal hernia. The study [27] showed that hernia recurrence is not less prevalent in open repair than in laparoscopic repair. The correlation to which the laparoscopic approach is needed in further studies, as many approaches are described is a limitation that needs extended study.

Laparoscopic techniques have some features shown in (Table 1) [9, 10, 11, 26, 28, 29, 30, 31, 32, 33, 34, 35, 36].

Laparoscopic techniques		Devices	Complications	Recurrence	Operative time (minutes)	Study
Intraperitoneal
	Laparoscopic inversion ligation	Two working ports	No intraoperative complications and postoperative wound complications	0.8%	33.9 ± 7.8 (unilateral); 41.9 ± 11.6 (bilateral)	[28]
	Needlescopic inversion and snaring	Two working ports, requires 1,6 mm suture grasper device, modified polypectomy snare	No complications	No recurrence	11 ± 2 (unilateral); 15 ± 3 (bilateral)	[9]
	Suturing of the internal ring	Two working ports, intracorporeal suturing	Bleeding, surgical site infection, inguinal swelling	3.7%	19 ± 5.71 (unilateral); 26.38 ± 6.94 (bilateral	[29]
	Flip-Flap technique	Two working ports, intracorporeal suturing	Torning of the flaps requiring multiple sutures to close the defect, vas deferens injury	27%	47.5	[30]
	Disconnection of the sac and peritoneal ligation	Two working ports, intracorporeal suturing	No intraoperative complications, postoperative scrotal edema	No recurrence	45.1 (unilateral; 65 (bilateral)	[31]
	Disconnection of the sac, no ligation just resection	Two working ports	Hematom	No recurrence	35–72	[32]
	Muscular arch repair	Two working ports, intracorporeal suturing	Mild scrotal edema, port-site infection	No recurrence in girls	35–70	[33]
	Single-port intracorporeal knot tying	Reverdin needle	No complications	0.75%	12.5 ± 3.3 (unilateral); 17 ± 4.37 (bilateral)	[36]
	Burnia	Single working port or stab incision	Lateral port hernia	No recurrence	5–38 (unilateral); 11–65 (bilateral)	[10]
Extraperitoneal approaches
	Subcutenous endoscopically assisted ligation (SEAL)	Single working port	No complication is given	2.4%	No time is given	[34]
	Needlescopic hernia repair	Single working port	No complications	No recurrence	11 ± 2 (unilateral); 15 ± 3 (bilateral)	[11]
	Percutaneous internal ring suturing (PIRS)	Single working port	Omental evisceration, keloid scar, postoperative hydrocele, iliac vessel puncture, palpating the subcutanous suture	1.4%	14.3 (unilateral); 39.1 (bilateral)	[35]

Table 1.

Some of laparoscopic inguinal hernia repair techniques.

Studies have shown that extracorporeal suturing is easier to learn and perform, and has fewer complications [37]. For this reason, techniques involving intracorporeal suturing can be considered a disadvantage in inguinal hernia repair in children. Moreover, these techniques appear to prolong surgery time. However, as experience is gained, the operative time becomes shorter.

Single-port laparoscopic needle-assisted repair of inguinal hernia using a spinal needle, a safe, reliable, and effective technique with high parent satisfaction, was found compared to three port techniques [38].

The Burnia technique has a shorter operating time due to the absence of intracorporeal and extracorporeal suturing and fewer ports. The learning curve is easier, and recurrence due to peritoneal damage is reduced.

7. Conclusion

The Burnia technique appears to be preferable for hernias in girls because of its low recurrence rate and the advantages of laparoscopy. Additionally, this technique is a safer intervention that may be taught easily in surgical assistance training.

Acknowledgments

I would like to thank IPEG (International Pediatric Endosurgery Group), which has stimulating meetings on minimally invasive interventions and inspired this study.

Conflict of interest

The author declares no conflict of interest.