2026 Laparoscopic Pediatric Hernia Repair

I see, Oh, he, oh, my name, Hey, good afternoon, good evening. We are here again for the hernia course. I don't know um how many years we've been doing this now, but, um, I guess we all do a lot of hernias, so, um, still, it's something that people like talking about. So, um, I'm Todd Ponsky. Uh, we, I'm at Cincinnati Children's Hospital and We are gonna be talking about some of the controversies of inguinal hernias, but really gonna hit on the technique side of the laparoscopic technique. And this is really meant to be interactive. So if someone has a question, just put it in the chat, someone will ask me the question, and um we'll just go with the questions more than even the slides if need be. Um, If there's any glitch, um, I can ask Carolyn or Kiki what, I don't know what you're supposed to do, but, um, if there's a glitch, I think just restart your browser. I don't know, Carolyn or Kiki, if there's like a, a number, they'll put it in the chat. What do they do? It's in the chat on the conference page. Perfect. Awesome. And then this is all being recorded and um if uh we'll have the recordings available and uh always you can text or email me anytime uh if you guys have a question. Um, we'll, I'll put the contact information um in here somewhere, but anytime. So we're gonna start, just jump right into it and it never goes the same way twice because we kind of hit on what, what people have questions about, but Let's start with the, the more uh common questions here. Um, so, you know, we, we, believe it or not, still have questions about hernia, even though it's the most common thing we do. Um, it's the bread and butter. It's the thing that we do every single day. It's the most common thing we do, but yet still, there's questions and controversies about it. So, um, You know, we all think our way is the best, and uh we all say, you know, our hernia way is the best, but it's still often good. And for me, every day I hear someone with a technique. In fact, just this week, um, I learned of a new technique from, uh, we'll get to it later in the, in, in the presentation. So, just be open-minded and uh, you know, I'll be, I'll just say from the very beginning that there's no one way to do this, um, that, here, let me get this full screen. There's no one way to do it. Lap hernia is definitely not the best way, it's just one way. Um, so, um, I think the open technique is, is great. So, See if we get this here. All right. So let's start with a question and Carolyn, I don't know if we have polls, but if we do, I'm just curious how people would handle an eight year old boy with a good history of a groin bulge that comes and goes by the doc, the, the primary care doctor says it comes and goes, but when you examine the patient, you don't see much. So, do you do a groin exploration? Do you do a laparoscopy? Do you wait for a photograph from the mom? Uh, do you only operate with physical findings? So, Carolyn, do we have a poll? Yes, we do, and it looks like, um, groin exploration is at 65, 50%, and then wait for photograph is at 18%, now 25%, uh, laparoscopy is at 30, 35%, it's jumping, they're pretty even right now. So laparoscopy is even with groin exploration or with, with groin exploration and then wait for a photograph. OK. And then 10% only operate with physical findings. All right, so the fact that, um, the fact that we don't all agree is exactly what I love, and I'll say right now again, there's no, I will never say that the way I am talking about today is the right way. It's one way of doing it. And so none of these are right or wrong. I just always like to see how people do things. Um, so, um, I would put a laparoscope in, um, but we'll talk about that. So. Second question. All right, so you're doing a lap appendectomy. And now, I gotta think of a better case. I'll take another example later on. But you're doing a lapy and you, you put the scope in and you see a PPV, you see a patent prosthesis. And I'm gonna call it that because I call it a patent prosthesis and not a hernia cause if they've never had anything go through it, I don't call it a hernia yet. So it's a PPV. Would you do an open repair? Would you do a laparoscopic repair? Would you scrub out and go talk to the family? Would you close and tell the family that he's got an increased risk for hernia? Or would you plan for a delayed hernia repair? And Carolyn, talk me through what you're seeing. Yep, so getting some votes in. So, uh, the close, uh, close and tell family he has increased risk for hernia is 50%, um, and then the others are about 7, 13%. So definitely the close intel family, yep. Interesting. OK. This one, I have changed over the years. And again, if someone has Uh, an opinion you wanna say, um, definitely write out the opinion. If you really wanna come on camera, you can ask us and we could bring you in, um, too as well. But, um, so anyone can come in if you wanna talk. But, so, I would for sure not do A cause I don't do open hernias anymore. Um, the big question is, I used to do B. I would just fix it. And I don't anymore. And Uh, two reasons. Number 1, that's why I said this wasn't a good example. It's an appendectomy. So, theoretically, it's a dirty case. So for that reason, Uh, I'd love to hear it. I don't have the right answer on this. It's just my way. Um, but I don't repair these anymore because, first of all, it's only a patent prosthesis. It may never become a hernia. Now, there's evidence that these things may close uh on their own. I know I used to think they never did, that only umbilicals did, but some people are now saying that actually inguinals do, and there's even some data that we actually have a patient that had a second laparoscopy for something else and it was gone. So, They do sometimes close. Um, and the risk of anesthesia is so low now that I don't see much of a downside in bringing them back another time to do it. Um, none of these are wrong. Um, so, uh, I think, so, yes. So, D is what I do, which is what the majority do, is I don't do anything. I tell the family, there may be something, and I don't do the rest. If anyone did A, B, C, or E, we would love to hear your thoughts on it. Um, and, uh, um, Otherwise, we'll keep going. All right, contralateral evaluation. If you do it open. Do you do contralateral? Do I have a poll for this one, Carolyn? I don't think so, do I? Yes, I actually did make one, so I just put it up and see what everyone says. Carolyn, Kiki, and Aubrey, who are in the back end here, are the magic behind this. Carolyn works tirelessly for every one of these events. Every event you see is Carolyn doing this in the back end. So with Kiki, all right. What do we see, Carolyn? Yep, so 50, 60% for no, and then 41 for yes, and it's going more towards no, 63%. We all agree on everything, right, cause we all do hernias and we all agree on everything. So we're split down the middle. I don't do opens. When I did it, um, I was taught to do a contra uh, a contralateral evaluation, um, with a laparoscope, but I, it's not relevant for me anymore and probably. Uh, for anyone who does these or has a strong opinion, let us know in the comments. Um, hey Todd, there was a comment that they would do yes for females. Yes, on the contralateral for females. Yes, for females, yes. OK. I'm so curious. Is it because you think there's low risk of doing the repair? I'm curious why females. Um, love to hear that answer, actually. That's, I'm telling you, I learned more on these than I probably teach. Um, but while we're waiting for that, so the arguments for, for doing it are that The contralateral PPV is there 30 to 40% of the time. I don't know if this data is still accurate anymore, but this was from Witt's paper in 1994. And then physical exam alone is not reliable. We know that. We know that in babies, uh, a whole another controversy. I was trained in adults, you know, um, that you never operate unless you see or feel the hernia. In babies, so often, you don't see it in, in the exam. So you go on story. Um, and so, because of that, some people would say that's a reason to look. You have a 4 times greater risk of hernia. Um, you have a 3 to 11% risk of metachronous hernia. Um, and, um, this is, anyways, I, I think this is always pretty interesting. Um, You know, so, so we'll, we'll keep going. Uh, avoids cost, anxiety, and risk of second anesthesia. I don't think that's as relevant these days. All right. So, the argument against it is PPV is not the same as a hernia, 50% will be unnecessary repairs. 50%. Of PPVs. May not ever become anything. Um, there's a risk of bad injury, and I'm guessing that is why the comment said, um, That it would be, um, they would do females only. Did they say that they, yeah, they said that there's a thought that bilateral hernia is more common in females, and there's also a couple of comments that they would do it for preterms as well. So, it's interesting. So, I guess the point there is that then they, if you are looking, you're going to repair it, and so, that means you believe PPDs should be closed. And uh um and so, for the non-clinicians in the room, so Kiki, Claudia, Carolyn, Aubrey, what we're talking about is that some babies might have a hole there, but nothing ever went through it. So, do you fix it or leave it alone? And that's what we're all debating, and I'm curious what most parents would say. Um, but anyways, that's, um, that's interesting. Um, and then Claudia, if they write their name, tell me who it is that's making the comment. Um, and then there's a risk of testicular atrophy. Again, maybe another reason why, um, people would do this. Um, and, um, Um, I would not do it, and then the risk of infertility with repair. So, repairing is not without complication is the point. And so, why take the risk? Um, low risk of anesthesia these days, low risk of incarceration. Um, by the way, I think I showed this later. There's a high risk of incarceration in preemies. That's why someone said probably preemies. Once you get past 1 year of age, the risk is negligible after it goes to like 1, 3%, 2%, 1%, and then it's less than 1%, uh, each year after. Um, so timing of operation, I'm just curious, do people do in a neonate, in the, in the neonatal intensive care unit, Um, do you do an immediate repair or delayed repair? Um, there's a comment from Giovanni Rapuzzi. I agree with contralateral. Uh, contralateral. Exploration, um, in females below with under 3 years old, because there is no risk of vase injury, not in preterms due to anesthesiological risk. Wait, say that again. That, that, um, in a female, I agree with contralateral exploration in females below under 3 years. OK, that's, you know what, I think that's a great point. I buy that. I buy that. So female, so the risk of as injury is low. The risk of doing the operation is so negligible, and there is a risk of something happening I love that. I think, I'm gonna, I think I would say that's, if I did these open, that's probably what I would say too. But I wanna hear what you say, if you find it lap, cause I'm guessing, I make sure, Mario, that you respond when we get to the, the lap debate. Um, all right. Now, we're gonna get into the meat of the discussion. What do you do with a straightforward six year old with a reducible left inguinal hernia? Do you do an open repair? Do you do a trans umbilical laparoscopy, so you put a scope in. Um, do you do an open repair with a laparoscopic look on the other side? Um, do you do an intracorporeal laparoscopic repair, or do you do a percutaneous laparoscopic repair? So it looks like Todd, a open repair of left hernia is at 50%. Uh, now it's going lower 46%, um, percutaneous laparos laparos laparoscopic repair, sorry, is 25%. Um, intracorpoal laparoscopic repair is 18%, but the, the main one is a repair, open repair of left hernias at 47. And to spare you the pain of, of trying to, uh, deal with all of these like 100 syllable words you can just say A, B, C, or D or E, um, or I can't pronounce them either. All right, so, uh, perfect. So the most common was a. Yes, most common is 42%. Well, I'm just so curious. Um, OK. How that, OK. Good. That's the whole point of doing this. So, I'm gonna say it again, the open repair is great. If you do the open repair at the end of this, I'm not, it's great. If that's what you feel comfortable with. I am gonna show you why I like the lap repair, but the open repair is great. It's the way we've been taught, we know it works, it's great. Um, so why mess with it? Why mess with it if it's great? I'm gonna show you why. Um, why did I switch? Um, the argument for open is it's tried and true, low recurrence rate, low complication rate, small scars are hidden. So in this case, laparoscopy is not even better, maybe worse cosmetically. And in the lap repair, the sac is not removed by some people, by me, at least. I leave the sac. Um, and the lap repair may need to rely forever on a stitch. Maybe. Um, and then the lab takes an extraperitoneal operation and makes it intraperitoneal, so you could cause a bowel obstruction theoretically. That's the argument to do open. Very, very good arguments. Why do lap? So, number one, you're not touching the chord. And it's a node, you leave this alone. We know in some rabbit studies, just by grabbing the vase in a preemie size vase and giving it one grab, you can obliterate it and scar it. So, especially in preemies, especially for tough cases, you don't mess with the cord. That's still not the main reason. Yeah. Todd, there's a question from Enrique Hernandez. Five month boy, premature, use of oxygen, 3 L, um, hemoglobin 9.6. What is your management? Do you hospitalize, not ambulatory management, open versus lap? Do you wait and correct anemia? Uh, absolute, OK, so the baby's, uh, on oxygen in the hospital, right? OK. Uh, if I have this right, I would absolutely not touch the hernia right now if the baby is um not optimized. There's no hurry if they're in the hospital. And even if they went home, what I do is I teach the parents about checking it all the time and just making sure it's soft and reducible. And, um, so I would not, but if it felt like it was becoming an at-risk hernia, Then I would definitely do it lap. Um, I don't, the, the oxygen level, the, now if the baby didn't tolerate the insufflation, I do low pressure insufflation, then I would open, um, but that would not be a reason to do lap. Did I miss something, Enrique? Um, Enrique said not ambulatory is at home. Yeah. Again, I, so, that's the whole question, do we operate or we send them home? And I know there's been studies back and forth on that. Um, I don't know, you guys can probably teach me. I know that every year I do this, the data keeps changing. What's the latest data on this? Cause there's multiple studies showing different things. I know in Canada, the data is different than we've seen in the States, but, um, I do not have a problem. With, depending on the parents, if they feel comfortable watching it, paying attention to it, reducing it, I'm fine waiting. If I feel like it's stalling, the baby's not getting better, I would bring it in and do it. I would not be afraid to do it because of the oxygenation. Or the even the anemia, I mean, I think I would prefer to wait, but I think I would just use judgment. But I want this to be a disagreement for him because I don't want this to be like this is only one way, um, so please, uh, there were, there was another comment, uh, from Mote Alal rawli. I prefer percutaneous because it's more secure as double ligation with minimal or no touch to the cord and also to check contralateral side. Awesome. And we're gonna get into that. I love it. This is great. What about cosmesis? Like we do lap to minimize scar. I would tell you no, not here. I think lap is worse, cosmesis because you're, you have these tiny scars are for lap, which is great, but in open, they're under the underwear line, so there's no scar and you're gonna have an umbilical hernia. I mean, umbilical scar. Now, they are 3 millimeters, they're tiny. So I don't think anyone will see them. They look like freckles. But no one can make an argument that the lap hernia is a better cosmetic operation. I, I will not buy that. So, so far, I'm like, all right, then what's the reason to do lap? Like this, I'm not making a great case for lap here yet. What about pain? I forgot to change this to white. What about pain? I think this is real. I think in an adolescent especially. That is a very nerve, uh, dense area. And I think doing big open repairs in teenagers is painful. And I think there's absolutely a benefit of lap where you put a few 3 millimeters in, and there's no incision in all of this nerve dense area. That's why you, you, a lot of you hear me yelling about, we have to do this in teenagers. So, I'm getting to the end first, but my conclusion is we need to be doing this in teenagers. And adults, by the way. What about infertility? Can an open repair cause more infertility? Um, so there's been a couple of papers when Ben was just a little baby. Uh, Ben Zendejas did a paper when he was at Mayo as a resident, um, Impact of Childhood inguinal hernia repair in adulthood, and they did a fifty-year follow-up. And there was some evidence of infertility, but I don't know the general population infertility. So I'm not sure that's a real thing or not. Um, I think bilaterality would probably have a higher rate, depending on when they had a repair, how tough the repair was. Um, but as pediatric surgeons, we pat ourselves on the back a lot because we think we did a great job, but we never follow through into adulthood to see how they did. So, we don't really know infertility rates. Um, There was one study that looked at the morphology and the function of sperm after um 8500 patients had the fertility clinic, 6% had inguinal hernioplasty. The semen quality of these patients was markedly reduced in comparison to that of fertile men. I mean, it's interesting, right? Like, I don't know, I don't, it's really hard to get this data. Um, but I, I would, I'm still, I, I don't know how we would ever get really good data. All the studies are kind of weak, but I don't know, it's a, it's a good question. We never really know what it means when we're operating on this tiny little area that, the, the cord is tiny in these babies, and we don't know what impact we're doing with scarring afterwards. Uh, there's a couple of questions here in the comments. Um, the first comes from Abdallah Alabadla. Any age limits for Peer technique? And then there was also comments, um, with regard to, um, there was a study for less, less wound, um, infection for laparoscopic repair, especially because the scars are above the diaper zone. Um. And, um, wait, I'm gonna forget. I don't have a good enough memory. Let me do those two first. So the first one is age limit on peer technique, which is the laparoscopic any age limit on peer technique. I'm controversial here, so I'm gonna say my answer and we're gonna talk about it. 0. I will do this in any single age. The earth, first of all, I think it benefits the extremes of age better than the, the toddlers. I think preemies and adolescents benefit from this more than anyone. So, I feel strongly that anybody You'll see my last slide, even an 80 year old adult. With some caveats, should be getting this operation, and I'm gonna show you why. And again, I'm not trying to be dogmatic. It's just my opinion. So I don't think it's wrong to do anything else. I personally would do it in my family at extremes of age. The second question was, what again, Claude? Infection, yep, um, they were just, they were just saying yeah, less wound infection for lab. Yeah, next. There was a third question, yeah, uh, that they, uh, let's see there, um, mo tape said I do inject, I dilute local anesthesia when I do hydro dissection to decrease post-op pain and tears. Same, I do too. We'll, we'll show that in a second. I totally agree. I love it. Keep telling me your ways cause I guarantee you you're gonna teach me a lot here. So please offer any way you do it. So, uh, uh, we can try, but this slide is the reason. I do lap hernias. This slide, OK? Not any of the other stuff. This is why. So, Imagine you're out on a boat on a beautiful sunny day, and this is what the water looks like, OK? Underneath the ocean, this is what the water looks like. Beautiful, clear. Nice. But, imagine. It's a day like this. A stormy weather, terrible, dangerous waves. What does it look like under the ocean as you go deeper? It's still calm It's still calm under the surface. That's why I do lap hernias. Because no matter how bad it is out here, it's always easy. Always easy. And that sounds like a very cocky thing to say, it's always easy. No, it is always easy. At least, no matter, at least there's no relationship to how bad it is out here to how it is in here. In fact, some would say it's even easier when it gets worse out here. I'll show you. Because anyone that says that incarcerated premie hernias are easy operations, they're lying to you. Um, they're not. So, I would call this a nice sunny day. It's easy. Not preemie, it's not incarcerated, it's a nice sunny day. And so it's easy. On the inside To fix this with the Pierce technique. This is a stormy day. A big preemie incarcerated hernia. You're gonna go in there, it's gonna be scarred. You're putting the vase at risk. You are putting the cord at risk. And, and no matter how good you are, I'm telling you, you're putting the cord at risk in these patients. So, This is what it looks like on the inside though. No matter how bad it is on the outside, it's gonna look like this on the inside. So, you're taking one of the hardest operations. Believe it or not, we do TES, we do, we do biliary retrission, we do all these things. I think an incarcerated, long-standing preemie hernia can be challenging, and by doing it lap, you're taking away that risk. So, what about incarceration? So, I have a question for the audience. Just curious, and, and I know we have a very international audience. We have, I think, 1100 people or 1200 signed up for this from all over the world. Um, What would you do if you were on call at night, 2 in the morning, and a baby comes in with an incarcerated hernia? Um, actually, let's change it. Let's make it easier. Let's say it's 3 in the afternoon. Do, what do you do with this child? If, let's say, first question, if you can reduce it in the emergency room. And you get it reduced. You push on it, you reduce it. Do you wait and admit the child, or do you do it right then? Just curious, you know, hey, Carolyn, we should have this as a poll next year. Talk to me and we'll put it as a poll. OK, uh. So, if you can reduce it in the ER, do you operate right then or do you wait the next day? Or something else. If anyone comments, let me know. Otherwise, yeah, go ahead. Sure, Todd, a couple of comments before we get into the answers. Uh, Mahmud Moais said in lab hernia, if we are not dividing the peritoneum sac, there could still be vase handling if we do a sac closure in continuity with either the pinching of the purse string stitch, fibrosis resulting from it. Or spread from the, from the diathermy circumferential buzzing. Yeah, first of all, you shouldn't be doing diathermy circumferential. That you should not just be doing. You should never put the vase at risk in doing diathermy posterior, only anterior away from the vase. That's number 1. Number 2, totally agree with you. We don't know the data. That does this cause pinching? I'm gonna tell you why I don't think it does from a physics perspective. It's funny. I put a video on social media. I'm getting in trouble on social media. I put a video about why we don't need to spend a year doing physics, and everyone's blasting me saying, you're an idiot. Of course, we need to take physics. Maybe this is why they're right. Maybe we do need it, but I think from a physics perspective, you're not pinching it. We'll talk about it. Scarring absolutely could happen. But your extraperitoneal, I don't think it does, but I don't know, and I'll give you, uh, data that may suggest as a surrogate that we're not causing a problem. We don't know. This is just I guess, on, on logic, but I might be wrong. So you shouldn't be cauterizing posteriorly. It may scar, it may pinch. I just don't think it does, and we'll talk about why. But, did anyone answer about this? If you reduce it, do you go straight to the OR, or do you admit? Did anyone answer that, Claudia? Yes, we're getting a lot of different answers. So, um, uh, we're getting the same time, wait and do after a week, reduced or unreduced, repair as soon as possible. Um, there was a comment, Depends how you define incarceration. I define it as inability to reduce by attending pediatric surgeon or advanced trainees. If I can reduce it, I dismiss the patient and schedule the surgery in another moment. Um, so there's, so quite a, yeah, perfect, 24 to 48 hours. Um, here's what I would say. I was taught that. I love all those comments. That if it comes in difficult to reduce, let's call it that, that the emergency room couldn't reduce it. It was difficult, it was stuck. Let's just say, I should change it, stuck hernia. And Let's take, I'm gonna go through all these scenarios. Number one, It's, it's stuck, but after a lot of time, maybe even sedation, sweeties, whatever, you get it reduced. I was taught, admit and do it the next day, because it's gonna be very inflamed. That's what I was taught. I don't know what others do there. You can say yes or no, but that's what I was taught. And Um, if I can't reduce it, so. So here's my question. If that's the case, OK. I don't think you have to do any torture to the child of trying to reduce it. I would go straight to the operating room. With lap. Because remember, actually, the edema actually helps you. So, if the reason we try to push it and squeeze it is to delay the operation the next day because of inflammation, if that's the reason. I know there's a lot of other reasons like logistics, you don't have OR space, whatever. But if the reason you are reducing it and torturing the child in the emergency room is because you wanna postpone it till the next day, I don't think we need to torture the child anymore. We can stop. Emergency room reductions by just going to the operating room, if you have availability, if there's time, and you want to, you have the option of going to the operating room. And the reason is, because first of all, you can reduce it laparoscopically. And also, It's not hard to do the operation with the inflammation. It's actually fine. So why, let's change the paradigm. If you're doing it lap, and you're available and it's 3 o'clock and you're on call and it's there, just go to the OR. Don't tell them, don't try to reduce it. This is controversial. I told you, you guys know, like I say things to be a bit provocative, so push back, um, but that's my approach. I go to the OR if I have availability. If not, I'll reduce it and do it that later that day or the next day. But if I'm available, I don't try to reduce it. I said, leave it alone. So, by the way, if you're reducing it, it's good to do under the laparoscopy. You can see how the bowel looks and And You have to, by the way, make sure if you're pushing, and you don't want to pull too hard cause it's gonna be friable. You want to mostly do push and you're watching, you're just using the instrument slightly like an interception, just slightly to give a little traction, not really hard. It's mostly a push, and then you just put a stitch in. So, Uh, if there's some strong opposition to that, Claudia, um, you can tell me, otherwise, I'm gonna keep going. The only question is, uh, there was come, I think that is very reasonable, but what if the baby is very distended with a bowel obstruction? So, I still go lap, OK? If, if the reason is that the bowel obstruction is gonna be reduced as soon as you pull it. So if you put the camera in, you put the baby under anesthesia. With, if a true bowel obstruction, that bowel could be at risk. So you put the baby under anesthesia, put a laparoscope in safely, watch the reduction. If the bowel looks fine, you're done. Put, you can just put the stitch in. I, if the baby is very, I think they said if the baby's sick, if the baby has peritonitis or the baby's ill, then I probably would still put a laparoscope in to see what's going on. And then if there's a compromised bowel, do a, do a laparotomy. Um, I would not, I'm curious, probably some people would just do this all through the groin, but I would push it in and do it through an open belly anyways. So, put a laparoscope in, you know where the dangerous bowel is gonna be, you'll get a good look at it. If you can't cause it's too distended, Do what you feel comfortable with. The answer to that question is do what you feel most comfortable with. For me, I would put a laparoscope in. I feel comfortable evaluating the bowel, I feel comfortable doing the hernia repair. I don't see a reason to do a groin incision. Does anyone disagree with that on any of these things I've said? The one comment is, um, it is just domain. Sometimes with a very distended baby, visualization is difficult. Yep, totally. By the way, comment on that. Even in the adult world, there's a lot of debates and can you do laparoscopy for a bowel obstruction. I do lap lysis of adhesions. It's a separate question. I do lap bowel obstruction cases. A trick. If you can do an open, safely get a trocar in, not a virus, just safely get in. Insufflate and wait, insufflate and wait. And the reason for that is, you will find that when you cannot see anything and you just wait 5, 10 minutes, things spread out and you can see more. I don't understand. I got, I do have to take physics again, but somehow, it dissipates the, the distention of the bowel loops where you can see if you just wait. So as long as you feel like you can safely get in, I don't see the risk. Of insufflating, waiting and looking. If you don't see anything, then do what you need to do. Do what you need to do, but Again, I would sedate the baby, push it in. I would try to get a camera in so I could watch the bow. Just use your judgment. The summary is, I would not not do laparoscopy because of a bowel obstruction. OK. Um, So, Here's another argument of why do you laugh? Because for all of you there that answered the 50%, you do it open, you're doing it because you think you have good results. And I'm gonna challenge that. To say, you think you have good results as a child. This is a case I was that was sent to me. After they had had an initial hernia repair. I went in, and the surgeon who did it is an amazing surgeon. Like, taught me stuff. This surgeon is amazing. I go in, the indirect inguinal hernia repair was fixed. Now there's a direct hernia. So here's the controversy. Why? Is it that this was misdiagnosed or did this develop after? Or was this caused? Are we causing direct hernias in preemies, when we scoop up the cord and you have a transversalis fascia that is cellular layer deep, it is like see-through. It is so thin. You're telling me that out of the millions of open hernias that are done in these babies that no one is injuring the floor? You are, not everyone, but it happens because it's fragile, and we ignore the floor. We're like, who cares? We're protecting the vas, but what about the floor? Well, if you injure it, you get this. So, it's not a free gimme, because I think we're causing way more of these than we think. It makes sense. Like, it's, it's paper thin. So There's been studies that when you look at recurrence after a hernia repair, an inguinal open. Indirecting or repair. You have The most common recurrence is going to be a direct hernia, not an indirect. The most common recurrence after an indirect hernia repair is a direct. So that either means we misdiagnosed it, it developed later, or we caused it. I'm guessing it's all three. But even if this is part of it, that we caused it. There's a way to do this without putting the floor at risk. So you're not putting the vase maybe, but you're definitely not putting the floor at risk if you do a lap. I'm sure some of you want to throw a tomato at me cause you're so mad at what I'm saying. So please comment if you disagree. Um, if you disagree with me, probably half the other audience does too. So, I, I feel pretty strongly that The premium open hernia repairs are causing floor injuries, and that's why they're getting fixed as adults. Now, Anecdotally, my colleagues that are adult hernia surgeons say, we see so many that were fixed as babies, you guys don't even know about it. All right. It's cause we're just Lifting stuff off or messing with the floor. What about recurrence rate in lap hernias? So, we know that the immediate recurrence rate in babies of children in open is very low. And initially, when, when the initial lap hernias were first done, that recurrence rates were like super high. Now that we've done it for 2 or 3 decades, we are, we've refined the technique where it's less than 1%. You'll see, it's the same recurrence rate. And I would argue it's gonna be much lower in a lifetime. Maybe not. I have no way of knowing that, but you're not gonna have the direct hernias. If that was the most common, you're gonna have less for two reasons. You're gonna be able to, you won't make a misdiagnosis. So if I'm gonna say this again, if we believe that direct hernia, if we know that direct hernia is the most common occurrence, And if there are 2 of the 3 causes, our misdiagnosis or we caused it, you're eliminating both of those through a lap hernia. I say that again. The 3 ways you get the most common recurrence is a misdiagnosis, that develops later or because you caused it. The developing later, we can't stop. Misdiagnosis because you're going through the groin and you say, oh, this is just a typical indirect hernia, I'm gonna fix it, and you're wrong. A lot of the time, some of the time, it's a direct. And so it's just important to think we could be massively reducing the number one cause of recurrence by doing it last. Is anyone throwing tomatoes at me, Claudia? Yeah, there's a question. I'm curious why the seal technique was abandoned if recurrence rates were so low. Yep, I don't like it. I'm gonna show you why I abandoned it. It didn't work for me. I switched. I loved how easy it was. I actually still use it in certain situations. Actually, Enrique, I think it was Enrique that said that, that baby that like had low in that baby, I do a seal technique cause it's so fast. But it's not as good as the others, in, in my opinion. So I'm gonna talk about why I, I only did seal in the very beginning of my career. I have not done it in over 20 years. I'm getting, I'm old. All right. Um, recurrence rate, we have big studies, 1700 children almost in Kaiser. Doing the PRS technique, which is the percutaneous laparoscopic one. Um, the, the, the, the recurrence rate, um, was 0.9% of lap unilateral patients. The recurrence was 0.8% of open, 0.3% in lap. So this is the big thing. The recurrence rate in large series in the new ways is, if anything, less, but it's definitely not more. Now, there are people that I incredibly respect as phenomenal surgeons that adamantly say that they had a really high recurrence rate. But what I would argue is, you're an outlier because the majority of people in the world are not reporting that. And um, So All I can tell you is my recurrence rates. I guarantee you, I have a lot more recurrences that I know of, that I have never seen cause they go to another doctor. So, no one will ever know the true recurrence rate unless you have a captive patient, um, captive patient audience. I will tell you that I've never re-operated. On a hernia repair, except for my first case that I'm gonna show you, and that was a seal technique. Other than that first case, we had an immediate recurrence. In 20 years, I have never re-operated. I've never had someone come back to me. Actually, I did have one that I re-operated, but it wasn't a hernia. I went in, it was not a hernia. Um, it was, it was closed. So, interesting point about that one. But it was a lipoma, which could make the argument for doing open, by the way. Um, but I've not had a hernia recurrence come back to me. That's all I can tell you. So it's reasonable data. Um, Another study, same thing. So the studies keep showing now that the recurrence rate is very low. Now, technique, this is what we want to know. How do we do it? Claudia, any controversies, questions, arguments before I jump into the techniques, and that's gonna be. The, the only comment was, I think groups with high lap recurrence rates do not publish results. Um, yeah, uh, I think that's a good point. Um, People don't like publishing bad results, um, but, um, Yeah, Montreal did. And that's where they showed 10% recurrence rate, which is very different than others. And the question is, why did that happen there? Um, everyone else is less than 1% that, that, yeah, but that's a good point. We never know. People either lie or there's something like we don't, we don't know that you just have to kind of use your judgment on, do you trust the data. This is a beautiful technique. So CK Young. Um, he uses what's called an a, and it's meant for like ortho, but now he made a hernia hook. Stuartz, Carl Stuart sells it. So he makes this hernia hook, and you basically put, thread it, and you just thread this thing. Under the peritoneum, and you're gonna go over the vessels. Always easy to go over the vessels. You can just lift up and watch how easy it always slides. It's not sticky. So it's easy to go over the vessels. Now, the vase is sticky. We're gonna talk about how to manage the vase, so that you don't put it at risk. If it goes over easily like it did there, then do it. Just slide right over it, and then pop out on the other side, and he'll, you'll see he'll pop out here. Then he grabs the suture, and then he goes around the other way, threads the suture and pulls it back out. I tried this a few times cause it looks so pretty and CK's my hero, but I could not make it nearly as easy as the Pierce technique. You have to watch out for the epigastrics and, and injuring them, but then he goes through the same exact opening. He's a beautiful surgeon. And watch how easy he threads it. Uh, this will give you Angelina watching the residents do this for hours trying to feed the hole. Um, and then when you let go, it shoots back up. I just found it really hard. It was really annoying. But then finally, if it stays there, you grab it and then you just pull it right back up. And, and then he pulls, he always says you have to pull the perineum to make this go right at the internal ring. And um you tie it down. I don't use a prolene anymore. I'll show you why. I use it to make the thread around, but I changed it to a braided suture. I'll show you. Um, OK. This is, I don't think anyone does this much anymore. Oh, let me go back. Um, this is, uh, uh, you can't even play it. Good. OK, let's go on. Um, this is the seal technique. I wanna stop for a second because I really want to thank Craig Albanese. He's a CEO. I can't remember what hospital anymore. Um, but he, I spent a day with him when I was just in my first few months as being a pediatric surgeon to watch him and And, and learn how to do this. Him and Doctor Data, um, they did this seal technique invented by Doctor Harrison, and we all know that anything Doctor Harrison does is amazing. So I love this. It's so easy. But the problem with it is that it grabs a lot of tissue, it causes a lot of pain. I think you can get nerve entrapment, and I had a recurrence in the, in, in early on. So I stopped doing it. They had terrible pain, and, and maybe I was doing something wrong. I'm gonna describe it first, the best I can before I play the video, and then I'll play the video. So, you take a big needle driver, and uh, I mean, a needle driver and a big CT needle, like a, a big, not that big, but like a big needle. And you go from the skin, you pop in through the skin, and you watch laparoscopically as you pop into the preperitoneal space, and you go around, you skip over the vas and vessels, or you go over them, and then you go back in again, up through the skin again. So let me pause. So now you have a needle going from the outside through the skin down inside, under the peritoneum, back up to the skin. So on the outside, you see the tail of the needle here and the tip of the needle here. So the way you get them coming through the same hole is you completely push all the way through to the last second. So you have just a little bit of the last part of that needle that hasn't pulled all the way through yet. And before you pull it out of the skin, and it's just sitting underneath the skin, you actually put the needle driver and you back. You back it through, you back the tail of the needle through till it comes out through the original stick site. And when you pull it up, now you have the beginning and the end of the, the, the tail and the beginning of the suture both coming through the same hole and you tie it down. So, I'm gonna show it. It's so hard after all these years, I still I'm not good at explaining it. But, um, Kiki, remind me something. I think we could animate this. But anyways, uh, let's watch this. So here it goes. Oh man, hold on. I'm gonna hit play. So, needles on the outside. This is Doctor Albanese teaching me. I was recorded the case. This is the first one I ever saw. And he at that time skipped over the vas and vessels. They did not do preperitoneal, OK? That's an important point. That I want to make. I actually think we get really worried about getting that perineum. I think it doesn't matter if you skip it. So then watch, they go over and then they bring this back out to the skin again. Why is it good? It's good cause it's so fast. So, if you have a baby who's not doing well on the table, boom, up and out, you're done. It's so fast. I just don't know how well it works, but it's worked good enough. I mean, they had good data, and I know a lot of people use it. So please, anyone comment their thought on seal. Why do we abandon it? Because I had pain and recurrence, and I really like the concept of the Pierce technique because it doesn't gather so much stuff up here. It doesn't gather all this muscle and nerves and just, it just, I don't know, there's a lot of stuff here that gets grabbed. So, that's why I don't do it, um, but. There are a couple of questions, um, with regard to the first technique. Which needle are you using in the first technique? Um, uh, one, another, uh, physician also said, I use a spinal needle, 18 gauge, and it worked fantastic. Um, and then specific to your critique of seal, it begs the question, oh yeah, wait, I, I can't remember that many. So, um, first question, so. CK Young's technique is the, it's a sorts. Hernia hook or hernia hook. So just look it up on Google. I don't know what it's called, but it, when he did it, it wasn't an official hernia hook. It was called an A, AWL for orthopedics. But now they've made one that is that. So, um, I'm sure they'll let you try it. And I, please send me a note if you do something and it works, I would love to hear if, if it worked and, and what you did to make it work easier. The 18 gauge we're gonna show in a second. That's different. That's what this is, and we're gonna talk about, I use an 18 gauge as well, but for the first one, yeah, um, that, and then Claudia, what was the next question? Um, the next question was, uh, your critique specific to the seal, um, begging the question, the recurrence rates were still reported as very low, but most surgeons had. High recurrence rates. So how can we believe published recurrence rates? We can't, unfortunately, I think it's not that they're dishonest. I, I, my wife gives me a hard time because I believe everyone is honest intention. I don't, I don't think there's bad people. I think when we think they're bad, it's cause misunderstanding. She thinks I'm an optimist and she thinks there's bad people. Anyways, when you have bad data, I don't think, I don't think it's intended. I think it's A, it's teaching us about being good at something and that your recurrence rates. And if you look at Steve Rothenberg's data on laparoscopy, his data is different than everybody else's cause he's so good. He's got, he does it over and over again. So, if you do the same thing over and over again, your data is gonna be better than people that are just starting. So, I think it has to do with experience and doing the same thing over and over again. Second thing is, we don't know true recurrence cause it depends on your health system if there's a lot of other places they could go. I don't think people lie. I think it's either they don't know or they have different outcomes, uh, because they've been doing it a while. So, I'm an optimist, that's why. I wonder that if I had kept doing seal, I might have a low recurrence rate. I gave up quickly because I saw this technique, and I liked it better. So I didn't give it a fair shot. Next question. Uh, you did the seal from medial to lateral. Lateral and medial. OK. But I don't think it matters. You do it any way you want. Um, the other question they had was, um, skipping over the vase and vessels in the seal will predispose to recurrence. That was from Mohan Nalusami. So Mohan, I'm gonna push back. Um, I've believed this, we all believe that. And I'm, I try never to skip it. I'm gonna challenge and say, if you do anterior cautery, um, I'm not sure it causes increased recurrence. I have no idea. None of us do. It's just my thought is that if you can safely get under the peritoneum. Do it. If you can't. I don't think it's worth putting things at risk. Just skip it. That's my feeling. I think the risk is so low with what we've seen that use judgment. If you're worried about what you're gonna do there, you just can't get safely over it, stop. Just skip over that 0.5 millimeter of perineum over the vase. I really don't think it causes a problem, but I don't know. So, I do always try to include that perineum, but if I can't, I will skip it. All right, I wanna Oh, Claudia, was there more? Uh, there's just 2 more. Uh, Mahmud Marais, I have an issue with not interrupting the sack. I've seen hydrocele developing after seal and heard of ascending testes occurring as the remaining PPV does not elongate proportionate to the child's growth. Yup, OK, we can talk about those now. First, the hydroseal. Um, it is interesting when we talk about data. Um, all I can tell you guys is you, you have to decide who to trust. Um, I think you've seen me enough over the years that I will tell everyone how bad I am at things. I have no reason to ever, um, make any of my data. In fact, I will be the first person to tell you if I'm terrible at something or if I have bad outcomes cause I love other people making me better. So, all I can say is try to trust me at least, and I will tell you that I've been doing this for 20 years, my whole career, I've been doing And I have had Maybe 2 hydroseals, and they both resolved. So, if others have had different outcomes, let me know. But I have not, and I remember calling Craig Albanese and saying, I have a hydrocele. He's like, just wait. He was right, it went away. So, I think I know why. I think it, I think you eventually killed the sack. I think the sac dies from ischemia. And It, it just absorbs. I don't know, and please, someone who's had this experience, tell me if I'm wrong, but I just personally, and I've had a lot of cases over many years, and I have not seen it as a problem. Now, the ascending thing is, is a concern that Um, Again, I, I haven't done a follow-up to, to study this. So I don't know my data, but it hasn't come to me and I'm, I'm curious if others have looked at the data. Does this cause an ascending testicle? But my argument would be, Wouldn't the same happen if you're ligating and causing scar with an open? I guess, I haven't seen it. It's definitely a risk. Um, It's not a big enough problem that I would change my practice, because I haven't seen it, but please comment if others have, or tell me how I can. I mean, I have not done the best job at evaluating my data, so it's anecdotal, but better people than me have. Um, so, other questions, Claudia? Uh, the only other question I had prior, um, I, um, McKenzie Lee's, I was originally taught with the seal technique and always warned to avoid any holes in the, um, in the peritoneum because that increased the risk of recurrence. What are your thoughts on that with the Pierce technique? Same, we, as we just said, I, I try to always include it. I don't think the fear is founded enough to put the court at risk. It is. If you do cautery, if you cause scar, I don't think 1 millimeter of that sac. is gonna cause, I don't think, cause I think it just scars and obliterates down. So I don't think, but I would say, if it was my child and you're operating on them and you're having trouble, I'll take the, the risk to skip that millimeter, and I'll deal with it later, but I don't think it's a problem. But I might be wrong. I don't know. All right. Let me go back to this. So, I have tried every hernia technique. I started off, actually, the first thing I did, actually, before I worked with Craig was with Rothenberg, we were doing intracorporeal. I didn't like it. This is awkward for me, going upside down. Then I tried the seal. I liked it. But then I had the pain and the recurrent, I don't know, I gave up quickly because I heard, I read Petkowski's paper. Now, I call this the Darius Petkowski technique. And those of you who watch our podcast, our webinars, you know that I am in love with Darius Petkowski. I think he's one of the best surgeons of our era. Um, from hernia to esophageal resia, he's incredible. And I love this technique. I think it was brilliant. But I've been challenged when I was in Japan, that actually, Takahara may be the one that first, I think they both came up with it around the same time or maybe one. So I always call it the Takahara Petkowski technique, and now there's maybe even others, maybe Endo and others, but I don't know who gets the credit. They're all brilliant if you ask me, because it totally changed how I fix hernias. And this is Piers, this is the idea. It's a percutaneous thing. Now, this is my feeble attempt, I think I made this like 20 years ago, this video, of how to explain how to do it. It's a lasso technique. And this is how you do it. You basically pass the suture, but as a loop, the same way you saw CK do it, you pass the suture so that the, the suture comes in and there's a loop inside and the two tails are coming out through the, the, the percutaneous hole. And then through the other side, through the same hole, you then go medial and put the suture through that loop. And when you pull up the loop, it's a snare and it pulls it all the way through. That's how it works. You pass a loop, you pass the suture through that loop, you snare the thing all the way through. So, it works as a snare technique. So now I'm gonna try to show you. First, we're going to start off with an animation that demonstrates the basic operation. Actually with an 18 gauge spinal needle. Carolyn, should I um mute this or let's see. Yeah, through the needle and pull the needle out. Then entering through the exact same incision, we come medially and and slide another loop prowling through the first loop. Then when we pull the first loop up, it acts like a snare pulling the second loop. Around the If anybody out there, and Keith can remind me on this, has a student or is really good with computers and animation, please help me make this better because this is terrible. But I need to make this animation better with AI. It's gotta be possible. But that at least gives you the idea. You put a loop and you put it through. OK. Now, first This is a video. It's a terrible video, but I made it, they were filming the screen. This was in uh Uh, Argentina. And I'm just, I'm, I'm hydro dissecting. This is with local anesthetic, OK? Now, if they did a spinal or something, then I'll use saline. But I hydro dissect. Now, here, I'm putting the eighteen-gauge needle with a little bend in it through the little tiny incision. Don't make this too small because if you have a skin bridge, you ruin the whole operation. So, then, I've hydro dissected, not everyone does. And it's so easy, look at the appendix. It's so easy to, um, to get through. I've skipped over the chord structures here, OK? And then, I take the needle out, so the sutures in, oh sorry, the needle's in, now I push the, the loop forward through. I'll talk about how to do this. It can get stuck, so there's a trick around this. So you push the loop through, then you pull out the needle. And then you go the other way. This is just peritoneum. You just go straight down. Just don't hit the inferior epigastric. You go straight down. You can try to get through the same hole. I don't care if you do or not. I don't think it makes a difference. Again, if it does, it's like, uh, so look, you put it through the, the hole. Now, the video stopped, so I took another case to end it. So I'm through the hole, then you push out, and you pull up, and now you've snared it all the way through. OK? So, Put the 18 gauge needle in. Thread a loop through. I'm gonna show this again and again. Pull out the needle, put the needle in through the same incision, but through medial, pop it through that loop, push out a suture, pull out that needle, pull out the first one, and you snared it through. OK. There's gotta be a better way for me to teach this after all these years, I'm still so bad at explaining it. But, um, How does this work? Is it that you have to rely on the stitch forever, or does a scar form, or and obliterate and kill the sac because it becomes ischemic and dies? Like, how does this work? So, or does it work like a Seton, where it actually just cuts right through and it divides the sack eventually. So, I don't know. Um, and I was visiting these three guys in Chile. So, Miguel Gilfan, Pato Varela, and Jorge Godoy. And we were doing a course or a conference there, and they said, Jorge goes, come, let me show you something. And he takes me in the OR and he goes, this is how we treat female hernias. You'll see I'm answering my question with this video. So he reaches in and he grabs the PPV. He grabs the perineum, he pulls it in. I go, what are you doing, Jorge? He goes, watch. And He, he steps on the cautery and it burns it. And it obliterated it. And he lets go and it's gone. I was like, you know what? So I go, we should call this bernia. And it's stuck. It's still called bernia today. So the idea is that you destroy it with cautery. So I'm thinking, if that's true, Then can we use that even on a male, but in a different way. So, first of all, this is proven by Mario Roqueme and uh I think Enrique and others do a pure sac resection. They just take out the sack and that's it. They don't, there's, there's a full resection of the sac, um, with no, anything else. And you don't have to stitch anything. Um, and they have incredible results. Montra Haddad does it as well. There's a lot of people that say you can just, so if that happens, and you have a big opening there, and all you do is resect it, same with an orchidopexy. It closes its scars. So scar is probably why hernias get fixed. Whether you're doing it open or lap or whatever, it's scar, I think. So to prove that, we did a study. Um, we took Rabbits that have these openings. And New Zealand white rabbits, they have a congenital hernia. And what we did is, On one side, we did just suture, and on the other side, we caused injury anteriorly. Do not go here, just anterior. I don't even go that low. It's like just here. And then we did seal, cause this was when I first started. I was doing seal, and um I use the scissors for this, by the way, not cautery. And we did 2 and 4 weeks survival. Watch this. This says suture repair alone, and this was trauma. So, on the suture repair alone, We looked after 2 and 4 weeks. We viewed it at, we put in a tiny bit of pressure. So we waited 2 weeks, survived the rabbits, came back after 2 weeks, put a laparoscope in. Then we removed the stitch on both sides, cut it out, no more stitch. 2 weeks. Then we increase the pressure to 36 millimeters of mercury, like super tight and distended. At 2 weeks, with the suture out, 25% stayed closed on the suture repair alone, 75% popped open. On the side where we caused injury, when we cut it out. Almost 90% stayed closed, even with 36 millimeters of pressure, even with no suture there. But watch this, at 4 weeks, 100%. At 4 weeks, by causing anterior injury alone, and blowing 36 millimeters of pressure, and taking out the stitch, they all were completely reperitonealized. So, this is it. It's, it's injury. It's, it's not all these other things, it's injury. This is what changed everything for me. That's why I don't care if you skip the vase, the, the perineum or the vase, just cause injury, just not by the vase. So We found that there are a couple of questions. I figured, OK, um, you said you don't use prole anymore. Which suture do you prefer? Do you use Ehabo suture? I'm gonna get to that. I'm gonna get to that. I use prole to do the. The operation and then I exchange it for a, anethebo or a non-absorbable braided suture and I know a lot of you are gonna say, if you just showed this, why don't you use absorbable, we'll talk about it. Keep going. That's all I had. That's it. So does suture matter? Great question. So we studied that and we did ligation with a silk, a vicro, and a prolene. So a braided, non-absorbable, a braided, um, uh, absorbable, I mean a monofilament, uh, no, braided absorbable, and then a prolene, which is a monofilament. And we found that the, this is in rabbits, that the, we cut them out, and we wanted to see what happens when you cut out these sutures. If we do vicro, um, 80% failed if you take out the suture, it means it reopened. Prolene. 75% failed, silk, 10% failed after we cut out the stitch. It's going against what I said, that it stays reperitonealized. So, it would make sense that vicro would work great. And But we do know braided. Works better than monofilament. So that's why I use a prolene and I exchange it for a braided. Keith Jorgeson taught me how to, how to do that. It's a great idea. I'll explain. So when you pass that second suture, instead of a straight suture, at the end, I have two tails and a loop at the end. And I do that because now I can thread a braided suture through there and pull it back and now I've just exchanged it. So, I use a non-absorbable ethebond. I think someone better than me, cause I tried studying this, I'm gonna show you. Needs to do this study with absorbable suture. But when we tried it in rabbits with absorbable. Now, I was not a good mentor because my residents were doing the, the, the work without me in the lab. So I didn't watch, maybe there was a technical thing, I don't know. They had recurrences. Like when we took out the vic, like we went in, they all popped out. So I don't get what's going on. I don't know, it should make sense that we can use Virol. So, maybe someone really good out there should do this study and figure out what I did wrong. Because one study shows it should stay closed. Another study I did shows that the vicro didn't work. And people have told me they've had recurrences. Claudia. Uh, Abdallah Alababalla said, I use 16 gauge cannula to introduce ethebo 2 slash O thread and snare it through the prolene loop. Yup, you can do that. Absolutely. Great idea. Um, so, the reason I do a loop. It's a double ligation. You get two sutures instead of one. You don't have to do that. Uh, it's just, but I will tell you, I'll say it now, in babies, I don't do that. I do the single like you just described because they put, they will spit the stitch. You can get a granuloma. I get a lot of calls about that. Granuloma, what do I do? I wait, I cut out the suture. So far, I have not had a single person tell me that they've had a recurrence because it scars shut. So, but I still only use one suture in babies cause it's such a short distance from the skin down to the knot. But in older kids, I do a double ligation, so I pass a loop through, and I'll show you how. All right, so, so, blah, blah, blah. We already talked about this. So how do we do it now? So this is the one video. Now this video is on YouTube, and you can watch it after this as much as you want. So, so don't worry if you don't get it here. Just watch the video. I usually tell people just type in my name and the word hernia and you'll find it probably. It's called like lap non-mesh, whatever. So, I'm gonna play this. And explain it through. We start with an 18 gauge spinal needle. Some people use a needle, which has a more blunt curved tip. I then curve the tip. It's a gentle curve because if you make it too sharp of a curve, the pulling won't slide through. I like to use a prolene suture initially because it's firm and it slides easily down the needle. I cut the needle of the suture off and then you'll see these little curved tips. I cut those off also, so you're left with two straight tips, which more easily slide through the end of a needle. Here I line the tips up and I put it through the tip. Some people crimp the loop and put the loop through the back end of the needle. That works fine as well. But I have had that tear of the suture before. So I like to go retrograde like this. The two ends come out to the back, as you can see, and then I pull the loop. And I pull the loop just till it stops at the tip of the needle. If you pull it too far, sometimes it is a little difficult to advance. Then I inject marcaine into the inferior portion of the umbilicus, and I usually use a 3 millimeter camera. So this is a 3 millimeter incision. Because of that, you have to use a V approach. Here's a 3 millimeter step trocar, and I insufflate the admin usually to 15 millimeters of mercury. In a large adult-sized patient, I use a 5 millimeter camera. Then I've added this instrument, which I used to not have in my procedure, but this is an extra 3 millimeter Maryland detector that I put into a stab incision. No matter how large the patient is, I always use a stab. And we do this because in our study in rabbits, we found that in the rabbits that we caused injury and then did the repair. It was much more durable. In fact, even if we cut out the stitch after 12 weeks, the, the closure remained intact. Uh. So the, the injury really keeps things closed. So here you can see the cord vessels, the vase, and the vessels. Then we find exactly where we want to make our incision in the groin. The incision is ultimately going to be the size of a needle, but to find the spot, we're looking laparoscopically. We match up to find the 12 o'clock position on the outside, and then we make a 1 millimeter nick with a knife just enough to get the tip of the needle through. Then prior to doing that we start with an 18 gauge spiral hold on, I wanna, I wanna stop for a second before I keep going, um, I want to explain. So here, here you can see the um we start I guess I can't pause it, um, so, so I only am anterior. I don't cauterize down here. I just do here. And the second thing to show you is what I meant with this is I'm looking laparoscopically, and I keep poking around to find exactly at 12 o'clock right above the top of the hernia. And that's, so I'm, I'm using this as a marker to know where to make my incision. To find the spot, we're looking laparoscopically. We match up a 1 millimeter nick with a knife, just enough to get the tip of the needle. Now, I've made a mistake here, where if you make it too small because I try to get super cocky, like, oh, I can make it tiny. But remember, you have to put the, the two needle. The, the spinal needle through this twice. Make sure you don't make a skin bridge or you ruin the whole operation. So make it just enough that you don't struggle, especially if you're with a trainee to, to, who's never done a lot of them, to go ahead and, and get it in there, uh, with, in through the same hole. By the way, even though this operation is easy, it's actually a surprisingly difficult learning curve. And I would find someone, you know, line up a whole day of hernias, 2 days of hernias, and bring someone there who's done them a lot and do them with you. That's the best way to learn this. Line up. 10 hernias. By the end of a day, you'll feel very comfortable doing it. It, that's a great way with this operation to learn it. All through. Then prior to doing the repair, I hydro dissect with bupivacaine. Wait, so did you notice when I hydro dissect, I don't put the needle through that same little incision. I go way out lateral to make it easy for me to hydro dissect. People think you have to go through that hole. You don't. In fact, I was visiting Kansas City and I watched Sean Saint Peter. He actually goes straight from the skin through the, let's see if I can do this, through the, um. Oh wait, can I do this? Hold on. Maybe not. Um, through the top of the, I don't know if that shows up for you guys, probably not. Never mind. But through, he comes through here and injects like that. It just crosses over the hole. I come way out lateral, like almost like straight lateral and inject, so it's like a straight shot. And I almost do the entire dissection from lateral to medial. I rarely do much on this side. Sometimes I'll go straight down and inject a little bit here, but You can do, or you can put the needle right here and just get a little under the perineum and inject. So whatever works, it doesn't matter. Just try your own way of lifting that peritoneum off. Larger patient. This dissects the chord structures away from the peritoneum, as you can see here. Sometimes if it's a very small patient, I may even dilute out the marking so I can do both sides with a bilateral hernia. Then I take the threaded. So just to say that point again, if it's like a preemie, they have a limited amount of local anesthetic you can give. So I take like 10 cc's of fluid and mix it in there. So I do 5 cc's on each side. So it's very diluted. Um, otherwise, you'll have Marcaine on one side and nothing on the other. So. 18 gauge needle and I pass it first laterally. I, uh, you can see here that I'm clearly dissecting above the cord structures. I'm always standing on the patient's left left side facing their feet. I have the monitor at the foot of the bed. That's whether it's a right or a left side hernia. I always, I, I always stand on the left. It does not matter. It's your body. You, you decide. Some people switch sides, some people always stand on the other side. It's whatever. Uh, works for you. For me, my dominant hand is my right, so I wanna be that, the operating hand, so I'm holding with my left and I'm operating with my right, so I always stand on the patient's left. sand that way and I always go lateral to medial first. Here you can see I'm clearly above the chord structures. I usually stop just short of the vest deference when I'm going from lateral to medial, and I thread the loop through. And I pull the needle out. And then I secure that with a hemostat. You want to make sure that if you push the loop through the needle, you don't pull it back into the needle because then sometimes it's hard to push it back through. You want the loop just at the very tip of the needle. Then I go immediately. I will use the Maryland to help me give tension on the peritoneum. And you can see here that I keep making sure that I'm above the vase. If there's any question, I will skip out over the vase and leave 1 millimeter of tissue. I think that that is not a real problem to leave 1 millimeter of tissue. That needle goes through the first loop and I snug the first loop around it. And then after it's snugged around, I pushed the thread through the second needle, through the needle. I just want to stop for that point. So that's a trick that I did because uh one mistake that happened once when, uh, We were letting the trainees try to learn how to do it, which is a, a whole another discussion on how to do that. The loop popped off of the needle because they weren't like, they, so what I would do is Put the 2nd loop. Over the needle and tighten it so you don't have a bunch of spaghetti and it won't flip off. So that's what you saw that I did there is I didn't leave it lax. I, I dug the first loop around it, and then after it snugged around, I pushed the thread through the second needle through the needle. I'm sorry, let me go here. the first loop and I snug the first loop around, um, snug the first loop around. Let's see. That needle goes through the first loop and I snug snug it around it. And then after it's snugged around, then I push out through the second needle through the needle. So it's tight. Then I pull the needle out. So now my second loop is threaded through the loop of the 1st loop, and I pull that first loop up like a snare and it pulls. That second proline all the way through circumferentially. So now you have the loop prowling and all the traversing all the way through. Now, you could be done and just tie this down, but I don't like the thick feeling uh of a, of the knot of a prowling the patients complain. Plus, we've shown that when we use a braided, non-absorbable suture, the repair is better, at least in rabbits. So once we've got this around, we will exchange the prolene for anethe bond. You do have to start with a prolene because the etha bond is not stiff enough to be threaded through the needle. So we do this and then just do a quick exchange at the end. Like I said, you don't have to do this, but then you just pull it right through. It takes just a minute. You do have to evacuate the air out of the scrotum, an inguinal canal prior to doing this. So I usually have an assistant push down. And then I cut the Uh, ethabo, which releases the prolene. And now you have the 3 ends of the Ahabo suture. You can use silk or Ticron or any suture you want. I do think you need to use an um a non-absorbable suture. Um, although, like I said, if you had injury, you may not even need to. Then I cut this right above the knot. And uh I usually put about 4 or 5 knots in. On each and then I pulled the skin. So that's a double ligation actually, because we've looped it and cut it. And then here you can see that just to say, so again, you then you have to like pull the skin so it pops, so it releases, so it's not dimpled down. And you can see like, so cord structures are well away from the. So the question is, are we injuring it? So there's been studies to look at blood flow of the cord after lap hernia repairs by Felix Shear, and there was never any impedediment. Of the blood flow. That's maybe a surrogate for the fact that there's not any. Because if you look at physics, if there's a circle, and there's something under the circle, and you tighten the circle, it shouldn't be messing with this. So, I don't think we've ever seen pinching. Now, might it scar outside of that circle? Maybe, but again, I don't know. Um, technical considerations, um, do you do a block local? We talked all of this. I, I, I, I went through all these pre-bend the needles and preload them. Um, Again, email me if you have any questions I didn't make clear. Um, Um, Kiki, can you put my we have, we have several questions in the comment in the chat. Um, the first was from Tal Koppelman. Do you add Bernia to all repairs? Yes. But again, only an interior. But if it's a female, I do the full thing. Now some would say, why do you even put a stitch? Cause I don't totally trust it. I think Jorge Godoya is one of the smartest guys ever, but I just put belts and suspenders, so I fully burn a female the way you saw in the video, and in a male, I only do anterior. Yep. And then Nikola Kartilev, which size as a bond do you use? Yup. I use a 3, a 30 ha bond. Um, but I wanna make one thing clear. I burn before I put any sutures in cause I get afraid that I would injure. So I burn, I then do uh the local, and then I do the stitching, OK? Uh, Bianca Grassano, we don't have Efa bond in our hospital. Would you recommend silk as a second option? Sure. Any non-absorbable braided suture. OK, um, Abdullah Alabala, do you recommend cauterizing anterior only? Yes. OK, um, Gabriel Anthony Villa, in your opinion, how many cases should a trainee do to achieve the learning curve? Oh, someone should study that. I don't know. It. It is really funny cause some people, cause it's percutaneous on camera. Like, we're good with laparoscopy, we're good with open, but this is a whole new thing. It's like watching a needle laparoscopically. Some people get it instantly. The, the literal best surgeons that I would send my children to struggled with it. Um, so, I think I think what I like, like I said, I would schedule hernia days. And do it a few times. Like, we have so many hernias, like this should not be one that has a learning curve problem. Just go watch someone do it or schedule the cases, bring someone there, have all your partners, your residents, and just do it. And we've made hernia models. I don't know if I could, I haven't used them in years. I'd have to find it, but I'm sure other people have them. You could practice that way, but just bring someone there. What else? And then the final question, which I think you answered, Jose Ricardo Ortiz Hernandez, do you close the skin with a single stitch? So, the groin incisions, I don't stitch closed. I just stretch and glue, stretch and glue. The umbilical one, I put one stitch. But I don't, these holes are so small, you don't need to put a stitch in them. Just, just pinch it and put glue on it or Steri-Strip. Um, oh, the V. So, OK, when you're putting your spinal needle through, people struggle cause you have to pop through the fascia. It's like a struggle. So I just pop in and sometimes you'll go through the perineum, who cares? Pop in, then pull back and get into the preperitoneal space. It's really hard to, to get that through the fascia into the perineal space on one shot. The second thing is, My video is a little misleading. It's not like you go around in a circle. I do a V. So, um, if I go back, Um, And I go here, see. Like, I'll put a stitch. Here and here, if that makes sense. I don't, it's really hard to make a turn. So I just go here and kinda out here, and then here and, and here. So it's a V. It's a lot easier to do. That's the hardest part I think for people as they try to make a circle percutaneously, and that's hard. Um, Uh, OK. The, I go, I start lateral. I will skip the vase if I need to. I use a Maryland to help put the peritoneum on stretch. The babies are hard because their peritoneum is so floppy. So you definitely need it. The older the kids, the easier it is to do. Um, and I pulled the first loop. I told you all this, small holes are tough, so make it big enough. In neonate, I pull the ethymon all the way through. I only do a single ligation as we talked about cause they spit the knot. Um, and then make sure someone's pushing on the scrotum before you tie it down or they'll have air. If you forget, just put a little needle in and suck out the air out of the scrotum. Uh, we have one more question. Um, Mahmud Nore, any tips about the angulation of the deep ring or its obliquity, as in some cases, especially small babies and infants, its plane is not facing you directly. In those, at which level do you get the stitch around? So I, this is for indirect this is in, OK, we have a video of Marcello Rambali, I don't know if he's here, who's doing directs. I only do indirects. Todd Marcel is here if you'd like him to come on if we wanna play the video. I do want him to come in, but I'm gonna wanna show that in a minute. I have a pro I have a question. Can you ask the audience, is it OK if we go over, cause I, I can go over. I just don't. And if anyone has to go and we go over. And Aubrey, I don't know my calendar or Claudia, do, do I, am I able to go over? And if so, we can send you this recording, so you can watch it later, but I would like to just keep going and then we can show, so, let me see if I can walk back what I was saying. So, For what I'm showing, it's just the peritoneum you're closing. It doesn't matter about the direct, the, the, the ring, the, because you're, you're, you're not closing muscle with this. It's just the peritoneum. So, just make that closure of the peritoneum and cause injury, or do what Mario Roqueme does and Enrique and just remove it. Um, and then, but we're gonna show Marcello's video. I'm gonna let him show it. Um. And then, as I said, you can close the sack or remove it. So I closed the sack, but some people remove it, and the argument is this, that how can you just remove the sac without stitching it? And the thought is that it's not a muscle problem. The peritoneum is in the way, blocking the muscles from shuttering closed. There's no actual defect. It's just muscles that were sort of pushed out of the way. So I always do this analogy in the hotel, I put a towel on the door to show it. It's like if you remove the towel, the door shuts. So if you just And that's why I think the purse technique works cause I think it sans it, it cuts it, and then the muscles close. And that avoids the risk of, of removing the sack for people because I think that can be painful. I think it can cause injury. I think putting a stitch and tying it tight will cut through the sack and allow the door to close. Um, that's how I think this works. But this is the, uh, Mario's paper. Hydroseal real quick before we get to, so, I do hydroseals this way if you can. I put the scope in, and then, um, if, so this was a mixed, um, communicating, non-communicating, but you'll see I'll push the hydroseal. Let's see if I can speed through this. Um, and if you see me pushing from the outside, that's the hydrocele. So then I pop it, I remove the safe anterior part of the hydrocele or the sides where I feel safe. I find the vase. If I don't see the vase, I don't cut, remove anything. Find the vase, I burn a hole or I cut a hole with the scissors, and I drain it. I remove it, and then I just do my hernia repair. Um, then I pop in with the Maryland if I need to, and watch it just squirts out. And I have not had a recurrence. Now, I haven't done a lot of these, to be honest. But, um, the ones I've done have not recurred. And then I do my hernia repair, which we don't need to show. Um, but, you know, it's the same thing we just showed before. And then, Uh, femoral hernia is a trick. So I put the camera in. Jeff Lucas taught me this. If you see the femoral, you go in and you're like, oh man, this is a femoral hernia. I defer to others if they've done this laparoscopically, but what I do is I'll put the Maryland based on how I was taught by Jeff. Put it into the femoral hernia, and then I feel on the outside, I cut on top of my Maryland and I do it open. That's how I do a femoral, but I would love ideas. Do we have to operate? Maybe not, because look what happens um over time that we were talking about that um incarceration rate, uh, the incarceration goes down, but also the, the, this is incarceration, it goes way down after time. So do we really need to operate if the risk of incarceration is less than 1%? So, I don't think so. I think you could tell parents, maybe we don't have to do anything. There's such low risk after they get, you know, around this age. Um, what about adolescences? Um, can we ask this poll question? What would you, um, and then, um, Marcello, can, I don't know if he's here, but does he have to leave, or Marcello, do you have to leave, or can you wait a few minutes? I don't know. We can. I can wait. No problem. All right, thanks, buddy. All right, so, um, I'm just curious how you would fix this big tall guy, send to an adult general surgeon, open lap, lap mesh, open mesh, open muscle. Yep, so Todd, people are voting right now. So number 3 is at 43%. That's the most. Um, number 4 is at 25%. We have number 1 at about 10%, um, and then a mixture of number 6 and number 2 low, but the majority is number 3, lap high ligation. Do you know why that's incredible? Because more than half of the audience said they do open repair an hour ago. So I think We've convinced some of you that this is a good operation because now, the majority of are saying lap. So this is very controversial. I am very interested in this topic about how to handle um uh an adult-sized patient. And this is, this will bring us to Marcello in a second. So, we did a study, we looked at two groups that managed this patient very differently. In fact, one group said they would do high ligation and the other group said they would do a, a muscle repair. And the only difference between these groups is how they were trained, pediatric surgeons and adult surgeons. So, if we have the same patient, and he happens to come see us, we're gonna do one operation. If he goes down the hall to the adult surgeon, they'll do a different operation. So, let's figure this out. So, how do we do a baby versus, this is a baby, we call it a PPV. And what about this guy, right? We say, well, this is a hernia. It needs to be fixed with muscle or mesh, and we do mesh. So all adults get mesh. All adults get mesh, and my argument is, why do they all get mesh? Because some of them are indirect hernias, and they could just be fixed with peritoneal, and that's my argument to the adults. That's why I talk more about hernias at adult meetings than PS meetings cause I I believe they should be doing this operation in indirect hernias, OK? Not this, OK? Because they put mesh in everybody. They don't go, oh, is this direct? I'll do this. Is it indirect? They go, oh, there's a hole, I'm gonna do it. I'm not faulting them. I'm just saying that seems to be what they do. They just put mesh in everybody. And I'm saying that if it's this, we don't need mesh. And um some would argue that, I'm just gonna skip ahead. Some would argue that even if it's a indirect, um, The area around it is weak. So even if this is the hole, the area around, so they should get a muscle or mesh repair, even if It's just an indirect, and I would say I don't think so. I think it's more like this fishing hole where it's solid around it and you could just close the hole. So I think anyone with an indirect hernia can get a high ligation. Um, Todd, there's a question. How do you repair a direct hernia if you find you're gonna get to that. That's what Marcello is here for. So, um, at what age? I'm just curious with the audience, and I don't know if we have a poll for this, but I hope we do. What age would you, we do? What would you do a mesh repair and would you do an adult repair in this one? Like, I guess the question is, when, when do you, how did I ask the question? At what age is it inappropriate? To do a high ligation. I'm not saying lap or open. I'm just saying high ligation. Is it inappropriate to do a high ligation in this child? I think we would all say no, we would do high ligation. Open or lap. Same. So the question is, when do we decide? That we decide to go, oh, now I'm gonna do mesh. I'm not gonna, I'm gonna do a muscle repair or a tissue repair. But we, when do we decide? What is the uh answer? Yeah, so it looks like um F has 50% and A has 50%. Um, it has not moved. Did we have a choice of none of the above? No, not on this. We should add that. Yeah, we should add that because I don't have that choice because I would, for me, none of the above. But my point is. How do we decide? Is, is it like, oh, well, they're 1 inch taller now. Now they're gonna get a like, What, is it their weight? What's the cutoff? Is it their height? Is it their age? So, I think it's very nebulous. And so, how do we decide? So, first, we looked at High ligation open in adolescence, and we did any child between 13 and 18 that had a high ligation, two-year follow-up, 2% recurrence rate, only 0.9% confirmed in adolescence. OK? This isn't open or lap, this is just all comers. Actually, I think these were probably all open because it was done a long time ago. But we wanted to know, is there a way to know when it changes? So we took adult and a pediatric center and we evaluated what hernias they had. At time of operation. And this is indirect, and this is direct. And then we asked our statisticians, is there a point where direct hernias start, um, so, sorry, this is direct, this is indirect. So in babies, they're all indirect, and then direct start developing. So is there a point that statistically tells us there's a change that we should go, OK. There must be something happening with the floor around these ages that we should start doing muscle repairs. And so, the answer is 40. That maybe, but still, almost all of them are indirect. Maybe around this age, floors start getting weak enough that we should treat it as a direct. But actually, some have even said maybe even it's at this age. So, there's no answer to really know, but there must be some point where we have to treat them as a muscle problem. I just don't know when for sure, uh, for sure here. Uh, but this is, I think, So this is an adult patient. And I was just showing that this was done, this is like 60, 80 year old patient done by an adult surgeon. Patients did great. So we did a study in Norway, and they had no recurrences. They just published it and we mentored them. So this is the mentoring. So first, they watched this course. Look, I had hair back then. Um, first they watched courses, then I went to Norway and did a simulator training. Then I did the case and they watched. Then they did the case and I watched. Then I went to a tablet and mentored them in the room. Then I went to another part of the hospital and mentored. Then I went home and mentored them. So we did a whole mentorship program, and then they started doing it. I mean you can go like, yeah, and then. Um, zero recurrences in adults. So I think we can start doing this. So, um, I wanna introduce Marcello and then so I should stop sharing, right, Carolyn, or how do you want me to do this? Nope, you're good. You can keep it on screen if you want, um, and then can I interject with just a couple of comments from the, from the people attending. Um, Giovanni Rapuzzi said, Personally, I place a lap mesh after 16 years of age if they have never had abdominal open procedures. Otherwise, an open mesh. Laparoscopically, we can check if we have a pantaloon hernia, high ligation below 16 years of age. Um, I would just ask, why did you choose 16? Is that just a number you chose? Is there some reason that you chose 16? Why not 17? Why not 15? Why not? Like, how do you decide? It seems arbitrary. That's the frustration I'm having. Um, and then the, uh, the next comment, I think you really need to highlight exactly where burn the anterior ringing boys. I travel and get folks who burn near the vase. They shouldn't. I mean, I go to 3 o'clock and 9 o'clock. I go, That's it. I go, I burned the top and the 3, I don't go, if, if, if you're thinking you're near the vase, then you're too close. Like, I am pretty far away. Um, and because when you squeeze it down, the scar just all comes together. So I, I don't get that close. Um, what else? Um, motif Ira really. One point I found it useful when I make the tie and before tightening it, I ask my assistant to pull the testes in the same side to the bottom of the scrotum, and then I tighten the knot. It pulls the vase and vessels to avoid entrapment in the knot. Yeah, agree. And we do the same thing if we think of it. Um, we don't, I probably need to do it more, but if the scrotum, like we towel it off, but if it's there, we pull it, but I always check it. And I've never had, like, I always go, yeah, scrotum's here, but that's not a bad idea. Always pull it down, then do your stitch. I haven't had to be a problem when I don't though. What else? Um, that's all I had. Now, the big problem I have here, guys, is what to do with an adolescent or an adult or a child when you go in and you find a direct hernia. When I was a general surgery resident, so in the states, we trained general surgery first. Um, when I was a general surgery resident, we did tap and tap, mass repairs, and open. We did um Liechtenstein. And I have not done that in 2 decades. So, the, the rarity of a child to get a direct attorney is so rare that the number of times you'll see it, I don't think I am skilled enough to remember how to do it well. Maybe I'm wrong. Maybe it's easier than I think. But I always get uncomfortable. What am I gonna do when I see it? So I would open and do an open repair. A should ice or a shouldini, a Bassini should ice. So that's what I would do. Um, now, the, the question that comes up is, is there a way to do it? So number one, if I find a direct hernia, I'll either open or close and send an adult surgeon, which is not great. Or if you suspect it, which I don't think you can tell, some people are doing studies to see if you can tell preoperatively, if it's open or la, I mean, uh, direct or indirect. But if you can't, or if you're suspicious, then maybe have an adult hernia, hernia there or you go there. I don't know. It's not a good solution. So what I have been trying to figure out is what do we do? At IPEG and SAGs, I think we're gonna start having courses for pediatric surgeons to learn how to do it. But Marcello Rombaldi, who's gonna come talk to us, sent me this video, I think a couple of months ago. Um, and, um, I was like, he's, he's doing it lap. Now, everyone I've been seeing over the years that does what I showed you, the Petkowski and the Takahara, anyone that does it lap, I get frustrated. I'm like, you cannot do this for, I'm sorry, if they do it for a direct. I'm like, you cannot do this operation for a direct hernia, because this is just peritoneum. And I think you're gonna get a recurrence if you're trying to stitch the perineum and think it's gonna close a direct hernia. Marcello sent me a video of a laparoscopic repair for, for direct that does get the fascia and the muscle. So, I wanted him to talk about it, play his video, cause I think maybe we all need to learn this from Marcello instead of maybe learning the mesh repair. So, Marcello, And Michelle, Michelle, you're in Argentine you're in, no, where do you live? Um, can you guys hear me? Just, I, I was having a problem here, OK, uh, from Brazil, yes, Brazil, Sao Paulo, yes, yeah. Uh, so, OK, by the way, Marcello, congratulations. Just had a beautiful baby boy. Uh, so congratulations. Thank you, no sleep, uh, and, uh, Marcello, I shouldn't say this out loud because I, I, I, I want this for myself. He's so, he's a brilliant magician at animating technique videos. Uh, so, um, I'm gonna mute because I can hear it echoing, but Marcello, go ahead. OK, so thank you, thank you, Todd, thank you for the team for this opportunity. Uh, I'll show you, I'll show you guys a video, you can, you guys can just go on and play and I'll just narrate. So this, this was a. This was a big child, I think, uh, he's, yeah, he's 6 years old, uh, male, he presented with a bulging, uh, we, we did not suspect any direct hernia before, uh, the, the, the laparoscopy. So I usually do laparoscopic repair in almost all children. Uh, you can notice, uh, if you guys can just pause a little bit, the video for me. Uh, you can notice that I, I, I usually don't like, but it's, this is, this is my, just my personal preference. I don't like to use the, to do the pierce repair in boys. Because I, I'm more confident. I, I usually do uh the, the repair, even if it's just uh an indirect hernia. I try to think that I'll do the same repair as I would do it open, so I'd like to dissect, uh, just like uh loosen the, the vase and the vessels from the peritoneal and I'll do an, and uh, uh, a loop suturing. Uh, with a manual internal, uh, suturing, so I usually always put in boys, I usually always put the 23 millimeter ports or just the, the, the stab incisions, uh, in the, in the abdomen, uh, and when we entered the, this, this boy, we did see, uh, this, this big, uh, posterior wall defect. So I do this, I incise the, the, the internal ring and I separate and I dissect with blunt dissection only the, the vessels and the vas deferens. Here you can see. A little bit more, a little bit better, the vast difference, and this is the dissection that I usually do, not, uh, I don't use cutlery. I use, I had to use in this case because the adhesions weren't allowing me for, uh, weren't allowing me to visualize all the posterior wall. So if you can just pause a little bit now, come back. Uh, here, here guys, you can see the, the inguinal ligament, and above you can see this is a big, uh, posterior wall defect. And Todd was uh asking me about, but could you actually visualize the conjoint tendon for the surgery because if you get just the muscle, it probably will tear up when the child wakes up and coughs and anything, maybe like uh you get a, a recurrence early. So I had to do a very careful dissection. I don't do this for uh in uh indirect hernias alone. So I did this dissection. I wanted to really see the inguinalar ligament, so I can put it in the stitch. You can, you guys can just play the video. It's it's a little, and, and here, if you guys see, you can see the white fascia, uh this time when I grab it, uh, when I grabbed it with the. And then here I, I did these drawings, you can, you can pause this. So here is the anatomy. He, he had uh also a lipoma that I didn't include here in this uh summary video and I reset the, this uh cord lipoma before trying to dissect the, the, the posterior wall, and here usually is the anatomy we can see, right? The, the the vessels, the spermatic cord. The, the, sorry, the deference in inferior pediatrics, and here we can see a big uh defect. I've, uh, unfortunately, I don't have a pointer, uh, but this is all the muscle and the inguinal ligaments and so the chondrut tendon is above, so we have to open the peritoneum a little bit more than I usually do just for indirect hernias and dissect all the fat and the tissue so I can actually visualize the conjoint tendon. And uh uh as a basin, the, the bassine repair, we do a stitch between the conjoint tendon and the inguinal ligament. So we do this stitch laparoscopically and repair the posterior wall. I think, uh, guys, you can. Go on with the video. Uh, the stitches are, um, a little quick, so. But we We did a very thick stitch there. To the posterior wall and the inguinal ligament. And that should be it, and the, the repair, and then this is the, the same suturing that I do when I do the uh. Indirect hernia law. And I closed up here tenure. I don't know if it's clear. It, it is, but here's the thing. First of all, thank you for showing us. I'm gonna move here. Um, I have a question for you though. Um, The problem with this repair is that you don't know when you're going in if it's gonna be direct or not. And yes, so people can't bring you there to help them because they don't know till they get there. So you really have to know how to do this. So you, what we need you to do is, is figure out a course or some way to make a lot of these. I mean, the problem is you probably don't have many of these videos because it happens rare. But um it may be interesting to partner with some of the adult hernia surgeons and, and try this with them because uh it's hard to do. So I thank you, Marcello. I, I, are there questions Claudia from from Marcello from the audience. The, uh, one comment, um, from Doctor, from Dan Aaronson, why not send an over 18 year old to the general surgeon? We'd also hate to see the adult surgeon operate on a baby. Um, so, I think we do it better. I have to say that if it's, the reason I say that is I think they're putting mesh in people that don't need it. What I would always do, by the way, so I always offer to the families, I say, you're a teenager, always, every time I give them a name of an adult hernia surgeon, every single time. And I say, adolescence is controversial. We've done a study where we studied the results of the lap hernia repair in adolescents and um it's, uh, it's, the results are pretty good. I mean, really impressive, a lower recurrence rate than the adults. So I think that um if I go to the adult hospitals and I will do it with them, but I think they don't need to be putting mesh, but some of them choose to go with mesh. Um, there's also a question for Marcello, for the indirect hernia, do you also repair intraperitoneal? Yes. Uh, this is the, the, the, the beginning and the end of the procedure of this procedure is usually what I do for boys. For girls, I do the peers because I feel more confident. I don't feel very confident with the uh hydro dissection with and um the depth and the cord, the sporadic cord, so I prefer to do a manual dissection and uh a blunt dissection. This is usually very easy to do. I can just separate uh and get a good peritoneal tissue, so I can do a loop suturing inside, and usually a very quick procedure as well. Uh, the next question, uh, Nora, Norafisa, thank you for sharing any reason for the patient you shared to have a direct inguinal hernia. No, uh, he, I mean, uh, he had, didn't have any other, uh, malformations or syndromes, anything. It just, uh, a laparoscopic finding. We didn't, we didn't preoperatively, we, we didn't suspect a direct hernia for me. He just have, uh, he just had an inguinal bulging the same as, uh, the other patients. I had no suspicion. And then, um, Gabriel Anthony Vila asked, how do you address tension with this technique? Uh, honestly, this, uh, I mean, I did like maybe 3 cases because it's rare, uh, as Todd said, it's hard to get a lot of cases, uh, but honestly I didn't feel any tension when, uh, did, when doing this suturing. Uh, of I did 3 stitches in this case because I felt like 2 stitches alone, uh, were leaving some sort of tension. Uh, and also like, I mean, doing the dissection and uh right dissection with the conjunct tendon being, uh, well, put in the stitch, I think, I think it should be OK. This patient I, I operated like a, a year ago, maybe he didn't, uh, have any sign of recurrence for now. Um, one, another question from Mahmoud Morayis. How did you identify the defect or that there is a muscle weakness? Um, I suspected when you see the beginning of the video, you can see there's uh, the, the peritoneum is like from the intraperitoneal pressure with the gas, you can see it, it's, I, I mean, it's just not the same image you, you get from like the, the indirect hernia when. You can see the sac going inside the inguinal canal. Uh, you can just see the, this bulging from inside out. Uh, so as I opened the, the, what should be the internal ring because it was not actually the internal ring was all open, uh, the, the muscles were all open, I noticed that, uh, we didn't have any, any posterior wall there above the ligament. So actually it was just like the, the initial image, uh, as I said, I, I do almost all my hernias uh corrections uh via laparoscopy. So I have this image how it should be, uh, how the anatomy should be. So when I went in and this patient and I noticed something was different. Um, Marcello, have you tried to close the muscles with stapler instead of stitches? Uh, with staplers, uh, I mean, uh, like laparoscopic stapler. Um, he didn't verify. Have you tried to close the muscles with stapler instead of stitches? I don't know Um, maybe you, you think maybe like laparoscopic, uh, the, the, the ones for like mesh fixation, the ones with, you know, the, the, yeah, the tacker, thank you. I don't know, maybe I, I didn't think because I mean it's, uh, you, you, you would put another piece of material there. I think I'd, I'd prefer using the, the Ati bone suturing that I'm used to. Uh, but, uh, if you mentioned that, if you think about this, the attacker, I don't know, it should be OK, but I mean, you have less control, right? This is a very, this is a very dangerous area where stitching, uh, uh, there because we have a lot of vessels, we have the femoral vessels and, you know, uh, uh, if you go more deeply than the inguinal ligament there with the stitches, you can, you can maybe get a, uh. Laceration or anything, I would not, I, I mean, I would not do use, I, I would not use decker or. Any other statements? Mahmoud Morayis wanted to know, in those cases, do you consider lateralization of the deep ring as in to repair the defect from medial to lateral to elongate the inguinal canal. Yes, I think it's in this, in this patient, I try, I mean, the dissection like very medial, uh, along with the inguinal ligament and to the pubis. It's not that easy. We have, you have to, or, or you, you, you either incise all the, the peritoneal uh tissue there so you can go deeper. Uh, there, uh, but in this case, I tried to go inside this open that I did, and, uh, the muscle was actually fixed there. I didn't have a defect going much longer down, so this was, these 3 stitches that I did were enough for treating this, this hernia. Um, Adelia Eshel Furer wanted to know how do you insert the needle through the trocar? Uh, no, I, I put through the, the, the abdominal wall because I think there's, uh, I, I'm, I usually use a 30 Etibone, and, uh, and it, it, it, it doesn't go inside because I use 3 millimeter ports, so it doesn't go inside. I, I put it through the abdominal wall. And then these are the last two general questions. Uh, Liz Winter wanted to know, what is the downside to mesh? Is the use of mesh related to pubertal development? So, um, there's been a lot of studies looking at problems with mesh. First of all, the incidence of chronic pain is pretty substantial. Now, there was a VA cooperative study that showed it was as high as 30%. Um, and, um, it's, it's substantial. And second of all, remember that the adults are operating on people at any age in life. They could be 60s, 70s. We're operating on pre, um, Children, patients, like they, they still need to use their vats. And so, they don't care as much because they put it on top and it could, it, it works by scarring. So, I don't think um mesh, I think it causes pain, it causes, it can migrate. The adults would agree. I mean, they'll tell you like, we don't like, there's a lot of hernia surgeons that spend their entire career. Just taking out mesh. So I think many would agree that if there was a non-mesh repair that worked as well, they would all switch. And I think they're very intrigued. That's why they keep asking, uh, you know, us, for us to talk to them because they're intrigued on our data as we go further and further to show that actually you don't necessarily always need mesh. And then Janani A wanted to know, can you share the technique of intraperitoneal repair? Whether to remove sac or not. Some of our surgeons just excise sac and leave it. They don't suture. What are your thoughts on it? Um, so, um, Uh I've done all of them now, and you have a great situation here cause Marcello and I do it different. I did not like the intracorporeal repair. He does. Perfect. There's no right way. Um, you do which way you feel most comfortable with. I, given that I've tried them all, I prefer to gravitate towards the Pierce technique. Um, um, I have not, I don't feel the need to resect the sac. I think it adds risk to the, to the patient adds pain without any better outcomes. So I, I just personally don't do it. Um, we probably need to get, I was thinking during this, we should get Marcello or anyone out there, we should get an international. Half day of hernia, because otherwise, it's just one voice talking. We need to get other opinions debating this. And um I don't know your opinion, Marcello. Uh, I, I also, when I do this, even I, I separate the whole sack, I don't go after the sack that, I mean, I just leave it. And, uh, uh, honestly, I always did this. I didn't have any like hydrocele, any other, um, like. Uh, scrotal complications and just uh in terms of uh discussion, there was a recent paper, maybe last year uh late last year, this year, of adult patients of open inguinal hernias. They were comparing like this huge uh you know, scrotal hernias, and uh either if you leave the sac, like abandoning the sac because laparoscopically, the surgeon, the, the adult surgeon doesn't also resect the this huge hernia sacs, and they were. Comparing if there were any differences between resecting or not, this is a very recent, uh, paper, and they, and they they discovered that there was no difference in resecting the second and abandoning, uh, the, the, the remaining sack didn't, didn't, um, increase complications, and I also don't do that. I also think that if, if we want to do it laparoscopically and I mean we want to reduce trauma, uh, and also this is one of the, the main uh main objectives we have, so I don't go after that sack. I just separate and ligate, it's a very quick uh procedure as well. I, um All right, uh, Claudia, do we have a lot more? I think we should, no, that was the, uh, that was the only other comment I had. OK, I, I, I, you know, it's funny, we joke that I think we've been doing this for over a decade, and I keep thinking no one's gonna come anymore cause, like, everyone has seen it, but It's something that, that is of interest and I think um we should just do these with other opinions, um, and, and maybe make this better. But I really appreciate everybody um joining. Um, I don't know who just joined there. Oh, it's Kiki. I think, um, I really appreciate everyone joining, taking your time out of your day, your morning, your evening, whatever time it is. Like I said, Marcello, thanks for joining. I know you've been busy with your baby, so, and in the OR so thank you. And then, Um, let us know. Contact me anytime and I'll connect you to the right people if there's a question. Um, but I really appreciate Carolyn, Kiki, Aubrey, Marcello, Claudia. Thank you so much. And everybody, as always, have a good morning, good afternoon, and good evening. We'll see you next time. And please fill out the survey if you have time, uh, right underneath the polls. It'll help out our research fellows. Um, so thank you, thank you. Thank you. Thanks, Kiki. All right, thanks. Thank you all the thank you.