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"Laparoscopic repair of inguinal hernia- Is it for everyone?" by Dr Andrew Grieve, Paediatric Surgeon, Johannesburg, South Africa

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Summary

Join Dr. Andrew Gree, a consultant pediatric surgeon at the Nelson Mandela Children's Hospital in Johannesburg, for a comprehensive talk on pediatric inguinal hernias. Covering not only the modern techniques for repairing these hernias, Dr. Gree shares his local perspective and practice's journey in management and patient outcomes. He explores the history of hernia repair from ancient Egypt to present day, and how our current understanding of hernia anatomy has evolved. Whether you are a general surgeon or specialized in pediatric surgery, this informative session will offer valuable insights into the world of pediatric inguinal hernias — and how to best treat them.
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This is an invited talk on "Laparoscopic repair of inguinal hernia- Is it for everyone?" by Dr Andrew Grieve, Paediatric Surgeon, Johannesburg, South Africa, as a part of the Zoom academic meeting of the Department of Paediatric Surgery in East London, South Africa. This video is for health professionals ONLY and NOT for the general public.

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Learning objectives

1. Understand the history, background, and evolution of pediatric inguinal hernias and their surgical repairs. 2. Understand the anatomy and physiology of the inguinal area, processus vaginalis and their relevance to the development of pediatric inguinal hernias. 3. Recognize the main types of pediatric inguinal hernias (direct and indirect) and how to diagnose them. 4. Understand the different options for surgical repair in pediatric inguinal hernias, the techniques involved, and the basis for choosing the most suitable approach. 5. Recognize the potential complications, recurrence rates, and long-term outcomes associated with different surgical approaches and how to manage them.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello, Andrew. Hi, how are you? Good, good and you? Yes, very well, thank you. Good. Do you just want to try uh sharing your screen and just make sure that uh so um 12. Yeah, that, that we can see it nicely. Maybe just forward uh one or two slides. Yeah, that's great. That looks perfect. Um Yeah, if you can just stop sharing, I've got like one slide to introduce you and then um uh I'll stop sharing again. Ok. No. Yes. Yes. That's, that's I for which this to. Ok. What? Ok. Yeah, I morning and we will start in about five minutes. Huh? Ok. No problem. Just, um, how long do you want me? How long do you want me to talk for? Uh, don't worry. I mean, how long is your talk? Half an hour? Yeah, about half hour there about, yeah, that's perfect. Yeah. And after that, then I'll just ask for some comments from our consultants if there are any questions. Ok, perfect. Yeah, let me know if, if we're running out of time or at the story. No, no, no, that's no, no, I mean, we, I mean minimum. It's one hour. Um, ok. Got lots of time. Ok. No, that's perfect. Cool. Good. No, no, it's, it's 5 to 6 at least 5 to 6. Ok. No, perfect. Cool. Yeah. Ok. Uh, wow. These, yes, sorry. Yeah. Oh, time problem. Nice. Oh, Andrew. Can you see my first slide? Yes, I can see it. Yeah, you can see it. Ok. It's just after five o'clock we can start. Um, hi, good afternoon everybody. Uh, thank you for attending our meeting of the Department of pediatric Surgery in East London today. Uh We have doctor Andrea Re uh who is going to give a talk on pediatric inguinal hernia is a laparoscopy for everyone and uh to introduce doctor Ree. Uh he is a consultant pediatric surgeon at Nelson Mandela Children's Hospital in Johannesburg. He is also a senior lecturer in pediatric surgery in um in uh uh wi wi senior city in Johannesburg. He did his MB CB uh in wit Senior City in 2002 and fellowship in pediatric surgery in 2012. She has keen interest in research. She has multiple articles published in peer-reviewed scientific journals and two chapters. Uh She has participated in multiple international collaborations for various research projects. She has started uh this Discover pediatric surgery podcast which I have published at least a dozen uh podcast on different common period surgical topics and um in his personal life, he is a keen mountain biker and enjoys time on the golf course. So we are really happy, uh, to have doctor grieve talking to us on, um, laparoscopic repair of inguinal hernia in Children. And I stopped sharing and I'll ask doctor grieve to give a talk. Ok. And you, we start, you start these shots. Yeah, afternoon everybody. Thank you very much for fitness for inviting me to come and speak with everybody today. Um, I'm just gonna talk to you about some of our sort of local experience and perspectives in terms of, you know, inguinal hernias and how we've changed our, our perspectives and how we manage these patients and you know, what some of our outcomes have been like. Um I'll give you a little bit of a brief introduction as well to some of the way things have been done in the past. Um, you know, what the potential laparoscopic options are. And as I said, what, what we are doing, um, in, in our center in, in Johannesburg, um, for those of you who don't really know me, I, I'm a surgeon as, as I mentioned, I do most of my practice at the Nelson Mandela Children's Hospital, which is a relatively new um hospital in, in Johannesburg. Um And uh yeah, it's quite exciting time. There's obviously been lots of teething issues as, as every new place has. Uh But yeah, it's, it's uh an exciting place, place to work. Um So, I mean, just a bit of background, I'm sure most people, most people remember um you know, the, the reason that we have these types of hernias in kids essentially is that the process of vaginalis sort of develops, you know, post conception and uh usually by the third trimester, the process of vaginalis invasion, thats right down into the scrotum assisting with testicular descent. Um you know, they reckon about obturation of about 80% of the process of uh vaginalis happens in males before birth. Um and probably about 60% in females. Um But in reality, nobody really knows what the obliteration rates are. Um And some centers reckon there's at least 63% of males still have a patent process of vaginalis for up to eight weeks of life um clinically. However, you know, it's, it's um the right side is definitely more common than the left and that's because it closes later and they reckon about 25% of premature boys might have a, a post that remains patent and up to about 5% in kids that are born at term. Um And we know that he is obviously responsible for developing inguinal hernias, hydroceles. Um And they are also implicated as well in testicular dissent issues uh in kids with unscented testes. So, I mean, the first description of inal hernias dates back to 1500 BC. Um And the Egyptians had quite good documentation of inguinal hernias. Um And there's even descriptions of uh the Egyptians operating on inguinal hernias. Um you know, thousands of years ago, you know, one of the mainstays of treatment was really pressure bandages and this is described routinely up until the 20th century where people would wear corset or bandages to, to keep hernias in place. And there's still many cultures in South Africa that still, you know, use pressure garments and those things for umbe hernias in young kids. So it's not an unknown phenomenon even to this day. Um, you know, there, as I said that the, you know, the pharaoh is described, um you know, in hernia, repairs being done. And there's a few mummies that have got, uh that we've discovered that have actually got ual hernias. Um, you know, when they opened them up and some of the pharaohs actually had uh fecal fistula there coming out their scrotum who obviously had strangulated hernia that then ruptured. Um And, and, uh, you know, it's probably the cause of these, of their death, ultimately. Um you know, surgery was obviously reserved in those days for, you know, inguinal scrotal hernias only and those that were reducible if it was incarcerated or strangulated. They thought that was in unmanageable and un operable. Um And even the routine sort of repairs, obviously, there was a high mortality rate. Um you know, as in today, you can see in this picture, you know, there's a, there's a, a large team that's involved in operating in inguinal hernia. And um obviously in those days that most of the people involved in assisting were there to hold the, the patient down. Whereas today we have the the help of the anesthetists to hold the patient down. So, in uh you know, uh uh Celsius, so obviously, you know, we use, you know, the degrees of CS. Um but it was also one of the first people that really described the different types of hernias, uh direct versus indirect hernias. Um And these descriptions are still used today, still very prevalent today. So it's, it's fascinating that, you know, these guys, even at the turn of the century, really started to have some understanding of what um was going on and what you know what hernias were were all about. Um And there's a surgeon in the, the early, early ad from Egypt who actually has got a really clear description of hernias and how to repair them. And it is interesting just to read it, an incision is made up to the peritoneum. The margins of the incision are kept separate by hooks, assistant pulls the testicle to one side while the operator carefully examines and separates the spermatic cord stops the bleeding. The testicle is placed in the scrotum before removing the sac adhesions are treated and intestines and lament are put back into place. The sac is lifted, twisted on itself and then cut. And I'm sure many of you can, you know, um uh um relate to this description of an he repair and say this was done at, at the turn of uh you know, ad um Galen in uh 100 and 76 ad started to actually have a good understanding of anatomy. And actually, it was one of the first people to really describe the differences between, you know, hernias, um hydrous eels, noncom hydro eels. And, you know, as time went on, obviously, people develop more and more of an understanding about what the anatomy was and how this um what this implied when it comes to actually fixing hernias. This is from a uh a textbook of surgery in the 1363. And these were the described methods about how one could fix a hernia in those days. Um And there are some very interesting descriptions, you know, from cauterization of the external swelling with a red hot iron. Um and you know, you, you sometimes shadow when you think about how these, how these were done, um especially with very primitive, you know, anesthetic applying of a transcutaneous suture around the spermatic cord, tying it on external wooden slats until the cord becomes sectioned. Um You know, there's, there's some obviously very effective methods but very crude when it comes to to repairing hernias. Uh But the last one is, is quite a quite an interesting one. After incision, they applied a golden thread around the spermatic cord to tie just enough to ensure closure of the hernia sac compromising the vascularization and the function of the testis and you start to see how people realize the importance of preserving other structures in the inguinal canal. And this was starting to shine through. And, but obviously, techniques were crude still at that stage with the, the modern era of surgery sort of coming to the forefront um in the, the in the 20th century, you know, they applied sort of basic principles when it came to hernia repair. And there are three basic rules where they start introducing, you know, focus on an antiseptic and aseptic procedures. A high ligation of the hernial sac and narrowing of the internal ring. Um And you know, the, one of the well known described methods, I'm sure, especially people who had trained in general surgery will know that basin was a very well described uh way of fixing hernias and the descriptions, you know, based on his technique um were used in Children as well as in adults. And there's a report of 371 cases published in 1898 from under 14 years of age and they only had three recurrences, which for those days was a remarkable, a remarkably low incidence of recurrence. Um but, you know, as time went on, you know, la and growth, uh also described, you know, inguinal hernia repairs and what this meant in Children. And II think they kind of, you know, really started to understand that there was a, a major difference between the pediatric inguinal indirect hernia and the directing hernias of adulthood. And they even tailored their surgery um to be less invasive, less um muscular, uh proposing and really focusing on this page and process of vaginalis and actually having very good results. Um, what they did do though is they, they closed their pages and process vaginalis at the external ring, uh, which they themselves later came to understand might be a reason to have a, a high recurrence rate for inguinal hernias. Um when it comes to uh you know, laparoscopic repair, um you know, the first laparoscopic hernia repair was actually described in, in adults, um mainly in females and it was in only in 1982 that the first described repair was done and you can see from the radiograph that they used uh clips the the canal um in pediatrics. The first one was done in females as well. Um And they basically sutured the ring closed. Um They did, you know, there was, they didn't have any recurrences in, in the Children that they did at this stage. But, and they were all done in females. The, the first real description about all encompassing pediatric surgical, inguinal hernia repairs was done by a group in Italy. Um and they essentially did purse string sutures. It was in 1998 1999. So just a, you know, not long after the first thing that the hernia repairs were done, but what they did find is that they had a relatively high recurrence rate using purse string sutures and it was about 4.5% that they had, whether it was related to the type of sutures that they were doing or the way that they did the purring technique. Um, they felt that, you know, it wasn't matching an open repair. So they weren't 100% convinced that most people around the world at this stage were a little bit skeptical about doing laparoscopic, you know, hernia repairs. So many different variations came about, you know, ways to try and improve or decrease the the recurrence rates. And there was, you know, very interesting uh names for these things. The flip flap, hernioplasty was essentially immobilized by the period, you know, flipped it over and closed it to try and, you know, cover the, the, the defect in the, in the canal. Um Sadly, also having a very high recurrence rate and some fair morbidity when it comes to, to bleeding and issues in these, in this particular style. Um you know, people have thought about real novel and interesting ideas when it comes to fixing these single hernia repairs. And uh a couple of a couple of, you know, um centers were, were trying um animal models using uh glue uh tissue adhesives to close patent process vag analysis. And these guys actually had very good um success. Uh The guys in, in Japan, yam Matua also published um a paper in 2005 using um dermabond to close inguinal hernia repairs. And you know, these looking for simple, easy ways to, to fix hernias, laparoscopically assisted um injecting derma bond in. And they found they had very good uh closure rates. Um but what they subsequently have found is that the actual tissue adhesive itself um can have some detrimental side effects when it comes to fertility down the line. And the, the, the glue itself seems to impact and damage the spermatic cord um of uh you know, in the kids that were, were treated with um with these injections of, of the agents. So it's probably kind of fallen out of favor and it's, it's, you know, whether we can look for other alternatives to make it simpler. Um you know, you know, it's something just to be aware of, I suppose when it comes to novel techniques and, and what the potential unexpected side effects may or may not be. Um you know, when we do these types of things, um there's, you know, very uh simple but novel and very effective um options that have, that have been done. Um an inversion of uh of uh the, the canal of n in females is a very, you know, a simple but effective and clever way of fixing this um essentially grabbing the canal e it putting an endoloop through and then just transecting it. Um There are some centers that um let me see if I can get this to play that essentially, um you know, through a single port, through the same principle, reverting, inverting, shall I say the canal just cauterizing it and essentially leaving it to that? And that's the end of their treatment and showing very good uh good results and low recurrence rates. I'm not sure if any of you guys have, have tried that technique is a single port incision. So, you know that after doing lots of reading and lots of sort of consideration, um the, you know, the pertain internal ring suture um was, was something that seemed to be gaining a lot of traction around the world. Um And there's been lots of publications around this and this was first described in, in 2016. Um very low recurrence rates much lower than a lot of the other sort of SUD versions. Uh about 1.4% recurrence rate which is probably close to most people's open experiences. Um They're interesting, they also found a, a contralateral hernia of about 16% in no, the repairs when they did them. Um I will just in just to for the script away. I'm not sure how many people have been experienced in this. Um But Professor Pons described this and he's going to be a nice video on this. Um So I'll just let it run just for a few minutes. I'm not sure if you guys can hear the audio or not. Uh No, we can't hear the audio, we can see the uh the video. OK? I'll just talk to you to it. So, essentially what they're doing is they use a tiny skin incision in the groin. Um And they put a 1 to 2 millimeter skin incision, uh use a a spinal needle, curved spinal needle, put a protein suture through uh and then put another pro through on the second side and basically use it as a snare to pull it through. And then what they do is they exchange the proline with epi bond. Um And what they found is that the epi bond is more durable in terms of the longevity of the repairs. Um but the proline slides better through the needles. So this is just an example of one of the ones that they, they have done, they is an 18 cage spinal needle. He just curves it gently. He says if it makes it too sharp to curve, then a proline doesn't really slide through. Um So they prefer using proline because it uh slides nicely and it's quite firm. So it's easy to manipulate um in interorally and then usually just trims the edges. So they put tips of us straight. So it's easy to place it in the needle. So what he does is he normally lines the tips, he sees the retrograde. He says he doesn't need to trim the suture at the end because at this way, he just pulls it up to the tip of the needle but tries not to pull it into the needle because then it's hard to push back into the abdomen. This is usually a three millimeter camera. So, so because of this, he uses a various uh needle and he puts in a strip step car to place it seven, about 15 millimeters of mercury. This is a new addition to his arm material where he puts in another three millimeter uh stab incision. And the reason that he did that is because they found that they caught drive or injure part of the, they find the durability um in their repair. So even if they cut the stitch out about six weeks or 6 to 12 weeks, they find that the hernia still stays intact. So what they've started doing now is scoring the anterior surface before doing the, the actual repair. One of these signs are um an incision just at the, at the canal, puts a little needle in. But once they found the location, they just make a tiny little neck and then they use some local anesthetic and hydrate. And the whole idea is to lift the pertin off the vessels and the, and the vas difference. So you start laterally and then goes immediately and then he put in this cur three needle and then, so basically saying he's always staying on the left hand side of the patient. So he starts to actually put uh put it in, it's above the reversal and then pushes for a loop inside the cavity, you can see pushing in and he pulls it out and then he crimps the to the, to the drape. And then he does immediately use the Merula just to help stabilize the Perea to help him do the dissection. I mean, it stays above the vas. And so if there's any worry about, you know, going either catching the vessels or the, so you can just skip a skip lesion and he put the needle through the loop, which is the push the, the pro in the second needle and then basically use it like a less just to prove uh you pull the deep around. I got to do proline all the way around. So some people do use proline, but they found better results better your uh with um with greater features. And also this is a lot but not, is a lot softer on the bo but then they rather use the, the bo. So he carries on showing a few different, he carries on showing a few different sort of versions of what he's done. Um So it's a very interesting, you know, a novel, relatively simple technique that you can use in, in almost all sort of indirect or who is, I mean, just to give you some idea, this was published um last year um by one of the endoscopic groups. And this is essentially all the current sort of described methods in terms of doing hernia repairs. Uh endoscopically, there's obviously a whole lot of intracorporeal suture techniques and then some extracorporeal suture techniques. Um and you can see there is, I mean, they've kind of, you know, changed over time. Um you know, with, for example, the Bernier technique was the one that you described, you know, with the inversion and cauterization. And then different people have changed the way that they use needles and describe different needles. Uh Pons has kind of added hydrodissection to this pertains internal ring suture. And now he has added cauterization as well to the to the uh eventual aspect of the of the retinal cavity to try and improve the durability. So, you know what we did, we, we started um at, at the Nelson Mandela Children's Hospital. So just to give you some idea, the hospital has only been open since 2017. Um They've only started admitting surgery care patients from about 218 after 2018. Um the hospital is equipped to hold about 220 patients. Uh About 56 of those are ICU beds, although it's not commissioned to that level at the moment, it's only commissioned to 100 beds. Um And essentially what they did in, in 2005 is they looked for, you know, where was the need for um pediatric services within Gauteng and within the country? Um And what they found is uh you know, a real ICU is a real rate limiting factor in a lot of hospitals as well as access to theater space. So that's where the hospital is primarily sort of focused on. Um There's obviously general surgery, there's neurosurgery, there's E NTS cardiothoracic surgery, and there's also cardiology, nephrology, neurology, radiology, P and NICU and obviously anesthetics, all those supporting services. Um So we started, as I said in, in June 2018. Um and we've, uh you know, it was the Nelson Mandela centenaries. We did a big push, you know, in July to kind of get a lot of cases done and we did lots of work from that perspective. Um um And then, you know, since then, we've been had lots of hiccups in terms of not being able to operating, having operational issues, but our general trend is to increase in the numbers year on year in terms of the, the work that we managed to do as general surgical units. Um So what we did a, you know, about two months ago is we just out of interest sake, we went back and looked at our subset of inguinal hernia repairs. And since we've opened, we've done 218 inguinal hernias. As you can see, the majority of those are done in males. Uh and uh small number in females. Interesting as a, as an aside, we did a little um an order just to see what the kind of waiting list was for the patients that we've managed to get onto the list and we took patients from the uh other academic hospitals within Gauteng. Um So, uh Pretoria and Johannesburg, uh we basically, you know, asked them for permission and we got patients from their waiting list. And what we found is that the average time for kids from being seen um at a pediatric surgical center until actually getting the operation, the average time was about 10 months. Um But some of the kids had waited up to six years for the operation before they managed to, to get a the operation done. And this is just for her is not looking at all the other subsets of, of um elective patients. Um in terms of the laterality, the majority of them were on the righthand side. Um uh about two thirds of those one third were on the left and then bilateral as well as about just over 40 kids that were there. When we looked at the age of the kids that we operated on, we found that over 31% of them were under one year of age. So you can see there's a a mark sort of pickup rate of kids at that particular age even with the the waiting times of of kids getting. So we only started um doing laparoscopic repairs um in earnest, I suppose from uh August 2020 before then, we kind of double intermittently with various techniques. But we started this pers technique then. Um, we did in the time period from, from the start our whole cohort, we did 100 and 70 open hernia repairs. Um We did 47 laparoscopic repairs. We've done quite a few more since then. Uh We had one laparoscopic uh that was converted to open in a, in a, in a, a surgeon who was doing it for the first time and they were feeling a bit nervous and there wasn't any backup with them um at that stage. So they felt more comfortable just to convert it to a to a an open procedure. Um This is just to show you that, you know, the textbooks describe these beautiful sort of simple repairs. Um but not all hernia repairs um are as they show in the textbook. Um This was a kid who had previous incarceration, had quite an injected uh peritoneum. Um But it gave us a nice opportunity to do the procedure laparoscopically. We hydrodissect it before and doing the same thing uh using the, the needle to go to go around uh just to hydrodissect and is the curved uh spinal needle. Um And those I know the orientation is a bit to the side. So that's why those look like the vessels, but those are not the vessels, the vessels are more medial, you can see them sitting there nicely over there. Uh The per was stuck to the vessel. So we actually did a, a skip over the vessels in the vs. So we've actually used the nylon, um 20 nylon for our um uh initial suture. And we do it basically just based on the cost thing. So we look for the cheaper version about what you could or couldn't potentially use. Um And then immediately the same thing. So hydrodissect and then put the spinal needle around and this kid it was quite, you know, stuck to the cavity. So we did the same thing, we did a, a skip over the vas and then into the uh the gap in between and then caught the go look, the point of the video was ready to show that they, you know, some of them can be a bit of a fiddle, it can be a bit of a learning curve to, to doing these. Um but it's, you know, it's a good experience and um we've had, you know, uh it's been good for all of our teams to, to get to grips with doing all of these types of things. So that was that and then we exchanged it for an Tibo suture as well. Um So at this stage, we've got no identified recurrences in all the patients that we've seen. Uh we've had very positive uh feedback. And the, the main thing really has been the, the decreased use of postoperative analgesia for these patients um cosmetically as well. The families have been very, very happy with the results. Um But it's remarkable how uh happy they are in terms of, I say the the pain. So we're doing a few more studies to look at um things going. Now we've got some undergraduate students looking at the costs um and looking at theater time. So the way our hospital works, we've got access to all that data. So we're going to basically see what the cost implications are of doing it open versus laparoscopically seeing what the theater utilization is like, what the time in theater is like. Um the cost of consumables, the anesthetic times, all those things you're going to look at. And we're also busy looking at a retrospective review and uh patient follow up to see, you know, if there's any other recurrences that have developed over time. Um So that's where we are at the moment. Um And I just wanted to leave this uh statement with you. I mean, this, this was written in the, the 13 100s, but, you know, I think this in many ways still holds true for, for surgeons and particularly I think in pediatric surgeons. Um And this gentleman talks about what the conditions are necessary for a surgeon to be. There's 44 states really, the first should be that the the surgeon should be learned. The second is that he should be an expert. Obviously, he she uh the third is that he should be ingenious. And the fourth is that he should be able to adapt himself. Um It is required for the first, the surgeon should know not only the principle of surgery but all those, also those of medicine in theory and practice. The second that he should have seen others operate. The third that he should be ingenious, good judgment and memory to recognize conditions. And for the fourth day, he should be adaptable and able to accommodate himself to circumstances as they let the surgeon be bold in all things and fearful and dangerous things. Let him avoid all faulty treatments and practices. He ought to be gracious to the sick. Consider associates cautious to his prognostications and let him be modest, dignified, gentle, uh pitiful and merciful. Uh Yeah, don't money but rather, you know, your reward is in your work. Um And to the means of the patient, the quality of the issue and to his own dignity. And I think those are very important things for us to remember, especially when trying no techniques, new ideas. Um We need to advance, but you also need to be cautious about what we're doing and where we're going. Thanks very much. I know, II see there's a few guys in the audience that have obviously had some experience in laparoscopic, you know, hear your repairs and those things. Um I'm gonna hand back to prop but I don't know if anybody's getting any comment or statement that they like to like to make. Yes. Yes, I will. I will invite their comments. Andrew. Thank you. That was an excellent talk uh overview about my hernia, uh the history of repair and uh the advent of uh laparoscopic repair. So I congratulate you for uh establishing pediatric surgery at the Mandela Children's Hospital. And uh and uh it's, it's, it was a new venture and uh it uh you really taken it uh forward. So I see Professor Sad. She is here and he has been here since the beginning. So I just uh asked him to come in first. So sad. Thank you. Uh Thank you, Andrew. I think this is a very good demonstration of how uh you should do things, especially new and novel things. Uh What Andrea has shown very nicely is that they saw an opportunity to learn a new technique that would probably benefit their patients. They went ahead and did that and now they are auditing exactly what they did. So in a couple of months, they will be able to make an informed decision as to where the this is a good decision, a bad decision or a decision that they can continue to uh promote. The other thing I really liked was uh the video clips. They were short and to the point, I'm sure they're very good for the junior stuff because it shows you all the important uh aspects that are there uh from my side. II don't I only do laparoscopic inguinal hernia repairs for recurrent inguinal hernias, which fortunately, in my case is very infrequently. The main reason for that is simply from a cost point of view. So I'd be very interested in finding out what an objective cost benefit to this. Uh entire procedure is uh based on private practice and medical aid figures. The cost of uh laparoscopic inguinal hernia repair uh about 3 to 5 times that of an open repair. Uh These are comparing uh light surgeons to light surgeons. So basically comparing my laparoscopic technique to open technique. And what we find there is that the time taken to do the procedure in an open fashion versus the time taken to do it laparoscopically is pretty much the same. So the cost comes in from the consumables related to the laparoscopy. So I think that would be a very interesting uh uh paper from uh Andrew's group once they've done the uh once they've looked at cost, but overall, I think it's a very good uh discussion. It is something that only registrars or adept at doing them open should endeavor to try. And it is a skill that I think all pediatric surgeons should have. So it was a good talk by Andrew. Thanks. Uh me. Yes. Uh Thank you so much. I think uh you have also brought out uh two important things. One is auditing and secondly, this is such a common problem that we need to be proficient in doing a safe opening hernia repair before you uh go to laparoscopic repair. Um I see there is a question from Doctor George knock. Uh And if I can answer that question, please, do you use the same skin incision when putting in the sutures? Yeah. So the, so the the groin or the uh right iliac fossa or left iliac fossa sort of stab incision. Uh So you saw uh um my brain is gone but you saw in the video. Um So where we do the hydrodissection, the local anesthetic uh that's the same place where we used to put the spinal needle in and then the sutures and then when we exchange it for the epi bond, it ends up being that same little two or one millimeter incision. Um Once you've tied the pi bond and snuck it down, we usually closed uh over the, the knot itself, just a, a subcutaneous uh suture with some b and then we usually just use tissue just to close that little edge. Um And then obviously the umbe port, you need to close as well. So essentially the patient is left with um you know, um like report plus the two small single growing incisions depending if it's unilateral or bilateral. So, yeah, pop out. I mean, in just to go back to pop shake's comments. Um So I think the, I think will be an interesting um thing. I think the biggest sort of time factor or biggest cost factor when it comes to especially private practice is theater time. Um So in our sort of, you know, the things that we've looked at so far, I suspect it may be very cost-effective for bilateral in LA. It may not be cost effective for uh single size her. But yeah, once you go to the data, we'll, we'll share it and it'll be very interesting one way or another. Um And the nice thing is that we cost all of our patients for everything and every, you know, uh whether they, they state or private patients, they're all in the same facility, the same as you would for private uh patients in a private facility. So we've got access to big numbers so we can look at all the data and see what's happening. Yeah. Ok. And that's very good. I see. Uh Doctor Derek Harrison has also been present. So Derek Derek Harrison is a consultant pediatric surgeon in, in hospital Johannesburg. So Derek your comments. Uh Hi Melin. Um So unfortunately, I haven't done this technique. I've actually heard Andrew's talk before, but I couldn't resist listening to it again. It's excellent and maybe it gives me a bit of motivation to try this at some point. But no, no, sorry. Unfortunately, I don't have any experience in, in doing it uh this technique. Ok. Ok. Derek, thank you. I see. Uh Doctor Hans pediatric surgeon from Peter Barts, he could join quite late, but I'm sure he has got experience and comments to make about uh laparoscopic repair of in vital hernia and see Lansi. Hello. Hi. Yes. Go ahead. Yeah. No. So, uh, so thanks uh to Andrea and yourself. And um, unfortunately I missed the beginning of the talk but, um, essentially just, um, on the similar line that uh Andres presented, I mean, we presented our stats um in 2019 at SAS using um the sort of p technique to close um inguinal hernias. And we've been doing it, I think we've got in excess of 200 cases now. And uh Sunil Moba has just published uh our experience in uh CJS that should come out sometime this month. But um essentially, uh you know, with regards to time, we are looking at an average of about seven minutes for unilateral and about 12 to 15 minutes for bilateral inguinal hernias. And that will definitely impact on uh the cost factor. The other thing is that um considering um local anesthetic versus uh regional. So in these kids, we were not, we're not doing um sort of corals as compared uh you know, to the open cases. And we, we're just doing local anesthetic over the, the wound sites. And um so a similar principle to what Andrew was talking about, but we're not, uh II haven't found the need to use hydro dissection, but I know it's uh one of the recommended techniques and um you know, it uh obviously will then depend on the surgeon's preference. And, um, we've had to use an additional port in, uh, one of the cases where the bladder then tracked into the inguinal canal. And, uh, you know, we had to sort of dissect that off. But, uh, apart from that, uh, recurrences we had so far were three. And, uh, you know, the, the other things that we, uh, we saw, uh, uh, you know, if you end up injuring the, the surrounding vessels and we ended up with, we had three hematomas and then just local uh sort of what side complications with the, with um a granulomas. But thanks for that. Ok, Hansen, thank you. Um I'll ask doctor Yasha Moni Chen, a consultant, pediatric surgeon in East London to give her comments. Yoda. Hi. Yes, thank you. And thank you for the talk. It was very fascinating to see the history of the repairs as well. Um Yeah, I haven't done the purse. Um I haven't tried the PURs technique but I II hear that Han, he has a lot of experience in the laparoscopic and I just wanna ask him if that's intracorporeal purring sutures that he's doing and not the PURs or um yeah, the technique that Doctor Gree is using cause I've done those and it seems to me the same kind of um Yeah, II don't see a big difference in um if you have two parts and you do an intracorporeal ping. Um Yeah, but it's really great to have uh different and novel techniques in a surgeon's Armamentarium. And um I also look forward to seeing the study and to see how much, how well they did. And then one question to him is what is the learning curve that he's finding? Especially with the juniors uh registrars in using the this the PS technique in particular be interesting to know. So maybe Andrea can answer about learning curve. Yeah. So I think, um, so we get a variety of registrars and obviously some are relatively junior and some are more senior. Um, I think there is a fair learning curve. I mean, the, it's, it's, um, I think those have got a fair amount of laparoscopic experience are pretty good. Um, but even for them, there's, there's the, the big learning curve really is around getting the needle to do what you wanted to do. Um, you know, we haven't had a lot of sort of issues in terms of complications or, you know, vessel injuries or those types of things with the, with the trainees, but it's really a time factor so that they understand what's happening on the screen, how that's relating to their hands at a, at a satellite sort of place as it were. Um, and I suppose it's all about sort of the dexterity and those types of things, um, because it's not really a direct view as it were. Um, so it's more a time factor. So it definitely takes the trainees for the first couple, you know, at least 2 to 3 times longer to do those procedures. And that may obviously influence some of our results when you come to actually audit the whole thing. Um But it's a very good thing to, to practice it, as you said, it's a good skill to have. Um I mean, I think, you know, it is controversial. I mean, it's hard to know why this technique has, seems to have a lower recurrence rate than an intracorporeal suturing technique. When in principle, you're doing virtually the same thing. Um I am not sure whether it is the, the as with the deep bite, you know, on the, on the ventral side, that sort of, you know, seems to hold better than, than just the periton cavity on the ventral side. Um I'm not sure it is hard to know why the one seems to be more successful than the other. Um But yeah, when I was a registrar, we, we, we actually did some intracorporeal laparoscopic hernia repairs. Um And I was very keen to do it, but um there was a lot of controversy around it and we, I, you know, we didn't get a lot of uh sort of support locally and we basically had to abandon doing which is why we, we eventually took it up a bit later to try and uh to get with it and see how things are going. So, yeah, it's interesting to hear what other people around the country are doing and what they, what the results are like and what their experience is like. Yeah. Um Andrew, before I ask you to answer this question from my friend, Doctor Beta Espinoza from Philippines. Um I just want to tell you that, uh we used to use this laparoscopic inhal hernia and, or hydrocele repair as a training uh procedure. So we used to have a laparoscopic trainer. We had set up uh uh levels. So each one of us had to attain a specific level before we were allowed to do a laparoscopic hernia repair. And we did intracorporeal suturing. And um we i it was a very nice training model but somehow later on with increasing time uh constraints and number of patients, we just lost uh that uh that skill, which is, which is a bit of a pity. Uh But I would like you to answer this question. Um Is there any indication to use mesh in laparoscopic coronary repair in older Children or adolescents almost who are close to adulthood? So I think it really depends on what you feel the mechanism is for the that hernia and that older group. Um I mean, uh pods skin and his group are using no mesh uh per technique in kids up to between 16 and 18 if they feel it's an indirect hernia. Um So I think the only ones we would consider using a mesh for in the pediatric population are those with some other comorbidities. So, um, connective tissue abnormalities, um, you know, recurrence, uh, hernias where, you know, there's no sort of a simple way to close the canal or a very, um, you know, a bleak open canal. Um, but, you know, I think the, you know, only in those cases it, it, um, you know, at what age do you stop doing this repair and, and do routine sort of adult type, you know, mesh uh you know, muscular bulking. Oh, it's also very controversial. Um I mean, in our experience, as you see, most of the kids are, are much younger and part of it is because we're in a pediatric hospital. So we don't really get exposed to the adult trainers and also the way our practices are set up in Johannesburg. So between 14 and 16, they migrate to adult services. So we don't really see those older kids to, to get that perspective. Um But yeah, and the younger kids it would be for those reasons. Yes, we have also not used uh mesh for inguinal hernia repair. Uh Ever. I think we have hardly used mesh only for ventral hernias. Uh that two like like a case or two cases at the most. I will now ask doctor Sell Maa our other consultant, pediatric surgeon in East London to give his comments. Sell. Uh Thanks for and thanks Andrew for the talk. Very enlightening. Um My question, uh, might end up being what your last, uh, comments on this topic. Um which is exactly what you asked initially is laparoscopic, uh inguinal hernia for everyone. Whether you should do it for unilateral bilateral or whether you should reserve it for patients where we're already doing laparoscopy for whatever reasons. And incidentally, they have an associated inguinal hernia and we fix it at that time. What, what do you think is the way, should we do it for everyone or should we select our patient population that we want to do this in? So, I mean, ii think if you've got the skills and you've got the, um, you know, the setup to do it and you're not constrained, you know, if it is a financial thing, I suspect you should do it for everybody. Um I mean, I think, you know, there's obviously, you know, that is the way there's a contraindication you're doing laparoscopy or something, you know, that's a different story. Um But ii, you know, the same as those other reports. I mean, you know, it, it's, uh, I mean, it's obviously a controversial thing but, you know, it is nice to be able to see the contralateral ring and see whether it is open or closed um without having to do an incision on the other side. Um We've been surprised and some kids were, you know, young kids, you know, uh females left sided hernias. We, we basically told the parents we, we were pretty sure we're going to fix the hernia on the right hand side and the, and the canal was closed. So, you know, there are um lots of benefits to doing it that way. Um Patient pain, patient recovery, cosmesis, you know, all of those things are very beneficial. Um So I, you know, I don't see a lot of reasons not to be doing it. So say if you've got the skill set and you've got the, the set up to do it. Um So I, you know, the, the guys in the States are advocating to not reduce um irreducible hernias um or incarcerated hernias and to just take them straight to theater and doing the repairs um laparoscopically there. And then, um you know, we haven't done that um to this stage. Uh There's some controversy about, you know, small patent process, vaginalis and Hydrocele. So we had three kids where we fixed their, their patent process, vaginalis with Hydrocele. They've got a recurrence in terms of a Hydrocele and we actually treat them conservatively and they resolve over time, but that's also a very controversial area when it comes to laparoscopic hernia repairs. Um But yeah, I don't see a lot of negativities unless there's um unless there's a contraindication to actually doing laparoscopy for a patient. Um Either way. So I think in, in, you know, in my practice, we offer it as a routine to every single patient. Um And we will continue to do that and yeah, see how, see how we go. OK. Um I see Doctor Hans Man has a comment, Hansen, go ahead. Uh Hi Melinda. I just wanted to respond to your shoulder's uh question was uh on the learning curve. That was the one the question and then she asked whether we're using the purse. So we, so we are using the purse as a single incision and a single port. So it's just an no port. And uh with regards to the learning curve, when you look at the principles of laparoscopy, this is a bit of a disjointed procedure because it's not, it's not related to triangulation or IZATION. And you are doing a procedure that you have to visualize on the screen. That's not, also doesn't, you know, sort of um take into account instrumentation apart from using the needle. So what we found with the registrars and uh you know, even, um I mean, we previously did the one sort of symposium in for the corner was even the consultants to, to conceptualize using that loop because we're using a single suture and creating a loop on the one end. And then we're using that loop to retrieve the other end and create that purse string. It was, was a bit difficult for some of them. And I think once that was sort of uh you know, gathered within their minds and uh uh they could understand that then uh we found that it wasn't as difficult. But, um, but I do agree that, I mean, some sort of laparoscopic experience is of value because you need to understand, I mean, the ergonomics of it and, uh, the, the one, just a response to what sell asked was, uh, will you do it when it's found as, as an incidental finding with other pathologies during laparoscopy? Then it depends on the pathology you're addressing because I will personally will not do uh elective inguinal hernia repair in a septic sort of abdomen with a perforated appendix. I would choose to rather sort out this appendicitis or the sepsis and then come back and treat the hernias at a later stage. Thanks, sir. Bye. Yeah. II mean, I would agree with that in terms of, you know, if you find that as an interdental thing when you're doing other laparoscopy, um you know, we would tend not to, well, it depends on what the, the indication is. Um But absolutely, if it's a septic abdomen, those types of things, we wouldn't consider repairing it simultaneously. Um So I misunderstood uh said those questions slightly uh from that perspective. But yeah, I mean, it's, yeah, it's, it's interesting to hear what you were saying about being it is a different kind of laparoscopy um and sort of, you know, technique as opposed to routine laparoscopy as you say, when you talk about triangulation and everything. Yeah, tha thank you, Hansen. Uh any of the juniors who are attending. Do they want to ask any question, please? Just unmute yourself and ask the question. Sorry, me to interrupt just a few, few more comments. Uh, the one is that, uh, you know, we li limited our practice, uh, to doing her on kids older in six months. Uh, and that's because we use that sort of, um, they use younger, younger Children as part of the training to do operative uh the, the open sort of operative technique. And uh the other, I just wanted to add that. Uh So Elliot uh long has set up a um the third laparoscopic symposium. Uh that's on the 27th to the 29th of October. And apparently he's lined up about 50 inguinal hernias. So we're gonna go up and uh you know, sort of uh conduct this uh symposium with him. If anybody's interested to join us, then you're welcome to contact uh Elliot. Uh That's, that's very good uh information. Uh Hansen, I think he's doing, he's doing good work there with uh support from you and support from Professor Ulla. Um So any, any junior wants to ask any question? It. Ok. I don't see any hands raised, anybody unmutated. So, Andrew, I'm going to ask you to just give final comments before we wrap up uh the meeting. Yeah, thanks and thanks for that. Um Yeah, II think I said as the beginning, I think, you know, we need to push ourselves to advance and uh to improve pediatric surgery for our patients. Um and for, you know, our ourselves and our colleagues and that, but I think it's, you know, it's with the, with the view of an understanding that we still need to be safe um surgeons and we still need to have the the outcomes of our patients um as the baseline as, as the most important fundamental, but we still need to push the boundaries and to, to get to, you know, the next level. Um And, but, you know, fortunately we work in, we don't work in isolation. There's lots of supporting people and lots of supporting services and, you know, there's people with more experience and it's good to draw on those, those experiences and those notes. Um And yeah, but thanks for the invitation, it's really nice to be able to chat and catch up with already and to hear what other, what other people are, are doing in the same sort of sphere. Thank you so much. Uh Thank you, Andrew and um I will uh uh post the recording of uh the link to the recording uh in a short while and for some unforeseen circumstances and reasons, we are going to hold these meetings for the time being and uh we will let you know when we restart the meeting. So in the present series, this is going to be the last meeting. So thank you, everybody. Um have a good uh, evening or, or good night wherever you are and you thank you. Once again, hope to see you physically sometime in the near future. Ok, thanks Doc. Good to see you. Bye bye bye, goodbye.