Internal ring closure is a common surgical procedure for inguinal hernia in children [7, 8]. Open surgery has steadily been supplanted with laparoscopic surgery as less invasive surgery has become more common in kids. The laparoscopic approach is distinguished by little tissue injury and a quick recovery time. The vas deferens and spermatic vessels are also less at risk with laparoscopic percutaneous extraperitoneal closure, and a contralateral PPV, which is a potential metachronous hernia, is identified . SLPEC has made significant progress in recent years. SLPEC has only one puncture hole in the umbilical, causing less tissue stress and better cosmetic results than laparoscopic percutaneous extraperitoneal closure [10, 11].
SLPEC is currently preferred by the majority of surgeons. However, because to the lack of an intraoperative assist clamp, the technique is complicated. SLPEC has commonly utilized the hydrodissection approach to treat pediatric inguinal hernias. The suture can easily traverse the gap between the vas deferens / spermatic vessels and the peritoneum thanks to the hydrodissection technique. However, during the separation of the retroperitoneum, the hydrodissection technique affects and distorts the vas deferens and spermatic veins.
In view of this, our study explored the use of the reverse puncture technique to implement SLPEC instead of the hydrodissection technique. The suture was initially put into the abdominal cavity from the lateral aspect of the spermatic vessels in the reverse puncture technique. The needle was then rotated and turned with the bevel of the needle back to the operator before crossing the gap between the vas deferens / spermatic vessels and the peritoneum, while keeping the needle bevel close to the peritoneum. The assistant needed to position the lens close to the surgery site at this point so that the surgeon could view the needle and its angle in the retroperitoneal area through the thin, transparent peritoneum. With the needle's "bevel" feature at the tip, the needle was pushed and traversed the space between the vas deferens / spermatic vessels and the peritoneum without the obstruction of suture.Furthermore, in the place where the needle entered the abdominal cavity, the reverse puncture technique differed from the hydrodissection technique. The classic hydrodissection procedure allowed the needle to effortlessly pass the vas deferens and spermatic vessels following water injection, allowing the needle to puncture the abdominal cavity in either the pain triangle or the Doom area, depending on the surgeon's operating tendencies. The reverse puncture technique operation required that the needle without the suture crossed through the vas deferens and spermatic vessels so that the position of the needle punctured into the abdominal cavity could only be in the pain triangle area along the lateral aspect of the spermatic vessels. A space could be produced by gently sliding the needle tip up and down in the extraperitoneal area for complex inguinal hernias with folds or scars in the peritoneum on the medial edge of the internal ring. The operation had to be gentle at this point to prevent injuring the peritoneum or minor extraperitoneal arteries. Continue to slide the needle tip up and down in this space to separate the gap between the vas deferens / spermatic vessels and the peritoneum. It usually takes some patience for the tip of the needle to pass through this gap without being hindered by the suture.
To accomplish the surgical procedure of SLPEC in this investigation, we used a double-hook core needle. The ligature suture may be placed and captured using the outer and inner hooks of the double-hook core needle, and the needle does not need to be entirely removed from the body to transfer the suture. This procedure guarantees that both ends of the ligature suture are in a single channel and that the ligature is above the internal ring in the extraperitoneal area. Other auxiliary needles, such as the Kirschner wire or tuohy needle, should always be completely removed from the body and re-punctured while transferring the suture, in contrast to the double-hook core needle [12, 13]. It is difficult to ensure that both ends of the suture are in the single channel at this point. Non-single channel knots will inevitably ligate some of the subcutaneous tissue and muscle along with the peritoneum. Too much tissue ligation might cause the knot to relax, increasing the risk of postoperative hernia recurrence . Furthermore, ligating subcutaneous and muscle tissues can result in a superficial knot that does not extend into the extraperitoneal area. The majority of suture granulomas after SLPEC are caused by knots not being buried deeply enough, according to research . The design features of the double-hook core needle sconsiderably lower the risk of recurrence and suture granulomas following SLPEC, which is why we picked it.
Li et al.  used a two-hooked cannula device with a hydrodissection approach to operate SLPEC. The average operation time for unilateral hernia was 9.8 ± 2.1 minutes, and 13.6 ± 2.2 minutes for bilateral hernia. The average operation time for unilateral hernia was 9.9 ± 2.1 minutes, while for bilateral hernia was 15.4 ± 3.3 minutes in this study. Our surgery took a little longer than theirs, but the difference wasn't significant. It was difficult for the needle to penetrate the gap between the vas deferens / spermatic vessels and the peritoneum without hydrodissection, but it also avoided the vas deferens / spermatic vessels being damaged by hydrodissection.
SLPEC without hydrodissection is now being used by some pediatric surgeons to treat inguinal hernia in children . Their research used a device with a suture through the vas deferens / spermatic vessels, which differed from our reverse puncture approach. We also attempted to complete SLPEC using the conventional puncture method and without hydrodissection. We discovered the advantages of the reverse puncture procedure after closely comparing these two surgical techniques. Indeed, regardless of the type of puncture technology used, a trained pediatric surgeon may do SLPEC on an ordinary child with an inguinal hernia in a matter of minutes. The reverse puncture approach, on the other hand, provides clear advantages for children with complicated inguinal hernias. Many of these youngsters have a long history of inguinal hernia, and the peritoneum on the medial border of the internal ring has folds or scars.
It's tough for the needle to cross the distance between the vas deferens / spermatic arteries and the peritoneum because of folds and scars, but it's even more difficult when a suture is in the way. The peritoneum or minor extraperitoneal vessels may be injured at this point, resulting in an extended surgery time. Chen et al.  operated SLPEC without hydrodissection and the reverse puncture approach. Their average operation time for unilateral hernia was 12.5 ± 3.5 minutes, and 20.5 ± 4.5 minutes for bilateral hernia. Our treatment took less time than that of Chen et al., demonstrating the benefit of the reverse puncture technique. Furthermore, for a pediatric surgeon who is not experienced with SLPEC, the reverse puncture approach may be helpful. To get the needle through the gap between the vas deferens / spermatic vessels and the peritoneum, an inexperienced pediatric surgeon may have to repeat the procedure several times. Because the non-absorbable suture has a coarser look than the needle, it raises the risk of minor extraperitoneal vascular injury following several punctures. When a tiny vessel is torn, the blood collects in the extraperitoneal region, obstructing the surgical field. SLPEC utilizing the reverse puncture technique is safe and successful in the treatment of juvenile inguinal hernias, according to our findings.
This study did not include children under the age of three months who had inguinal hernias. To begin with, children under the age of three months have a tiny intra-abdominal volume, restricted maneuverability, and the vas deferens / spermatic arteries are frequently hidden by the intra-abdominal bowel. The surgical procedure is extremely dangerous if the vas deferens or spermatic vessels are not clearly seen. Second, young newborns frequently present with an incarcerated hernia that necessitates emergent surgery. The internal ring of an incarcerated hernia is compressed, generating local edema and unclear structures between the vas deferens / spermatic arteries and the peritoneum. Even if the implanted hernia contents are preoperatively integrated back into the abdominal cavity, completing SLPEC with a double-hook core needle alone is also difficult. Additional gripping tools are frequently required intraoperatively to complete the internal ring closure in these patients. We've conducted SLPEC on a number of children aged 1 to 3 months who had inguinal hernias, with the majority of them requiring additional grasping equipment to help the needle pass the gap between the vas deferens / spermatic arteries and the peritoneum. Because girls lack the vas deferens and spermatic arteries, surgery on some individuals could also be performed without the use of special grasping equipment.
In this study, SLPEC without hydrodissection was used in practice, which made the operation more difficult for the pediatric surgeon. The peritoneum had to be jacked up during the crossing of the space between the vas deferens / spermatic vessels and the peritoneum without the aid of hydrodissection drifting away from the peritoneum, allowing the needle tip to cross and penetrate slowly. The operation needed patience and dexterity. The procedure is delayed to some amount due to the difficulties of the operation and the psychological pressure on the operator. The operational time in this study was 9 - 15 minutes for unilateral hernias and 10 - 25 minutes for bilateral hernias in the first 5 instances, and thereafter rapidly decreased. The surgery approach in this study, like other laparoscopic operations in children, was shown to have a learning curve. The process time will be stabilized as the number of cases, operation proficiency, and experience accumulate.
Finally, 132 children with inguinal hernias were treated with SLPEC utilizing the reverse puncture approach, with positive clinical outcomes. In the treatment of inguinal hernia in children, this approach was found to be both safe and effective. SLPEC utilizing the reverse puncture technique did not raise the risk of surgical damage or other auxiliary operations when compared to hydrodissection, and it lowered the difficulty of the surgery when compared to the conventional puncture technique. The reverse puncture technique is conducted in the same way as the other puncture techniques, with the exception of the puncture sequence. After understanding standard SLPEC, the surgeon can be proficient without any more training. Surgeons can also study the surgical procedures of the reverse puncture technique first, even if they have no expertise with SLPEC. This research looks into the feasibility and safety of doing this operation in day surgery, and we'll continue to collect cases and map out the learning curve for this procedure in a single center in the future.