Needlescopic Versus Traditional Laparoscopic Inguinal Hernia Repair in Pediatrics

Patients and methods:

* Place of the study: The study will be held in Department of Pediatric surgery in Sohag University Hospital. * Type of the study: Prospective comparative Cohort study. * Duration of the study: The study will last for 6 to 9 months starting from the date of acceptance of the protocol. * Ethical considerations: The study will be carried out after approval by scientific and ethical committees of Sohag faculty of medicine. * Method of the study:

Preoperative assessment:

1. Demographic data: e.g. name, age, sex …. etc. 2. History: e.g. complaint, present history and past surgical and medical history…etc. 3. General and local examination: e.g. laterality, associated anomalies …. etc. 4. Investigations:

Routine labs. Imaging: to confirm diagnosis in the affected side, to evaluate contralateral side, bilateral testicular volume as volumetric stander to evaluate testicular atrophy postoperative and other anomalies.

Operative technique:

Operative steps:

A. Traditional laparoscopic repair.

* STEPS:

1. A 5mm port for the camera is introduced at umbilicus by open technique. 2. Using triangulation rule to introduce two working ports. 3. The abdomen is insufflated with carbon dioxide to 6-8 mmHg pressure in patients under 1 year of age and to 8-10 mmHg in older children. 4. Diathermize the neck of the hernia sac with a diathermy hook. 5. A 10-15 cm absorbable suture is passed into the peritoneal cavity through the abdominal wall next to the lateral port under vision. 6. The purse-string stitch commences at the 2 o'clock position of the internal hernia opening. 7. ensure that a "complete ring" of peritoneum has been included in the purse-string stitch without significant gaps. 8. The purse-string suture is tied tightly using intracorporeally knot tying.

B. Needlescopic Internal Ring Suturing. * EQUIPMENT/SUTURE:

1. One 5-mm trocar and 5-mm lens 30° or 0° telescope. 2. Epidural needle. 3. Non absorbable suture. 4. Fascial closure instrument. * STEPS:

1. A 5mm port for the camera is introduced at umbilicus by open technique. 2. The abdomen is insufflated with carbon dioxide to 6-8 mmHg pressure in patients under 1 year of age and to 8-10 mmHg in older children. 3. The suture is introduced through the barrel of the epidural needle. 4. Maintaining both ends of the preloaded suture extra peritoneal, the needle is advanced under the peritoneum around lateral half of the internal ring. 5. The peritoneum is entered and the suture advanced into the abdominal cavity, creating a loop. 6. Fascial closure instrument is introduced directly through anterior abdominal wall to help to maintain suture loop. 7. The needle is removed, leaving the loop in place. 8. The needle is entered again through the same skin puncture site around the medial half of the ring and enter the peritoneum, leaving a small space above the vas deferens and testicular vessels to avoid injury. 9. The loop of suture is introduced into the hollow of the needle again and advance the suture into the first loop by the help of fascial closure. 10. Withdraw the needle. 11. Catch the suture end in the loop and withdraw them together then the suture is tied extra corporeally.

Patient outcomes:

Patients assessment and follow up:

1. Primary outcome measures:

Operative time. Intraoperative complication. Rate of conversion to open surgery. 2. Secondary outcome measures:

1 and 3 months after the surgery to asses:

1. Cosmetic appearance: according to (The Scar Cosmesis Assessment and Rating "SCAR" Scale) \[7\]. 2. Recurrence. 3. Hydrocele. 4. Testicular atrophy (postoperative imaging: \> 50% loss of testicular volume or \< 25% of volume of contralateral testis) \[8\].

• Cosmetic appearance [Time frame: 1 and 3 months after the surgery]
• Recurrence [Time frame: 1 and 3 months after the surgery]
• Hydrocele [Time frame: 1 and 3 months after the surgery]
• Testicular atrophy [Time frame: 1 and 3 months after the surgery]