Laparoscopic Multiport Inguinal Hernia Repair ina Male Infant

Here we describe the laparoscopic multiport inguinal hernia repair in a male newborn. The patient is placed supine. For a left-sided inguinal hernia, the surgeon is standing relatively high up next to the head on the right side. The patient's head is turned to the left to keep the surgeon's arm and the tube out of each other's way. A 5 millimeter camera port is placed at the belly button using the Hassan technique. 23 millimeter working ports are placed as shown. In small infants. These should be placed as high up and as laterally as possible. The needle is inserted into the abdomen through the camera port. Alternatively, a transabdominal wall stitch may be performed. The vas and the testicular vessels come together as an inverted V at the inner inguinal ring with the vessels being laterally and the vas being medially. The right-handed needle driver grasps a suture about 1 centimeter proximal to the needle. Then the left-handed needle driver grasps a needle between distal and middle third. The orientation of the needle can then be adjusted in the three-dimensional space. When the needle has the correct orientation, the right-handed needle driver grasps the needle between proximal and middle third. After incision of the peritoneum craniolaterally at the inner inguinal ring, the first stitch is performed. I prefer a purse string suture with the first stitch outside in at about 9 o'clock on the left and 3 o'clock at the right inner inguinal ring. In order to keep the orientation of the needle, the left-handed needle driver holds the needle in place while the right-handed needle driver pulls at the suture. We use a non-absorbable 4O polyfilament Ticron suture with the small needle. The next stitch is made inside out. Adjustments of the three-dimensional orientation of the needle may be performed as shown. The next stitch is made at the medial side of the inner inguinal ring, taking care not to harm the inferior epigastric vessels. Throw and sinating the surgeon's wrist helps to get in the correct plane and to use the given rotation of the needle with minimal harm to the tissue. A next stitch is performed just medially to the vast without injuring the vas. Next, the peritoneum between vas and testicular vessels is pulled up and a stitch is performed without injuring these structures. A last inside-out stitch is performed lateral to the testicular vessels grabbing more tissue to complete the purse string suture. In a female, the purse string is likewise performed. The inferior epigastric vessels are the only structures at risk. The round ligament should be included in the purse string suture. We use a sliding knot to pull the purse strings together. The suture end containing the needle and the suture part coming out of the tissue during the last stitch are pulled apart 180 degrees in order to make the knot sliding. Then the knot is slided and the purse string pulled together. The knot is fixed in place by pulling the free-ending suture end. Further knots are made as shown. It is important to have the suture held by the right-handed needle driver and the left-handed needle driver as parallel as possible. The suture is given to the right hand and kept parallel to the left-handed needle driver. The suture is then cut. Working ports are removed under direct vision, the camera port is removed and the perambilical fascia is closed using interrupted trio viral sutures.