title: "Double N": Evolution of the Surgical Technique for Laparoscopic Herniorrhaphy After 10-Year Experience in a Single Center.
abstract: BACKGROUND
  We describe our experience with the use of a modified technique for laparoscopic internal inguinal ring closure (peritoneal incision and double "N" stitch placement). We evaluate the technique in terms of feasibility, efficacy, and safety.
  
  
  METHODS
  From November 2003 to March 2014 we performed 1700 herniorraphies by laparoscopy. We selected 123 patients treated with the "double N" technique by the same surgical team, and we reviewed their notes analyzing demographic data, operative times, intra- and postoperative complications, and recurrence rate. The technique used is a modification of the Schier technique. Our technique consists of a partial lateral peritoneal 180° incision around the internal inguinal ring and in the placement of a double stitch. The first stitch is used to approximate the muscles with the inguinal ligament, and the second one is used to close the peritoneum above them.
  
  
  RESULTS
  The female to male ratio was 22:101. Mean age at surgery was 4.3 years (range, 1 month-12 years). Mean operative time was 30 minutes (range, 20-50 minutes). There were 60 bilateral cases. There were no intraoperative complications. Two patients had reactive hydrocele treated conservatively, and 1 patient developed umbilical infection. We did not identify any recurrence.
  
  
  CONCLUSIONS
  Our early results suggest that the "double N" laparoscopic technique to close the internal inguinal ring in children is safe and efficient. We therefore suggest using this approach in children with a patent internal inguinal ring of >1 cm. The recurrence rate is low, but it should be better assessed by studies with longer follow-up.
authors.affiliation: Department of Paediatric Surgery, S. Orsola Hospital, University of Bologna , Bologna, Italy .
authors.forename: Michele
authors.initials: M
authors.lastname: Libri
authors.affiliation: Department of Paediatric Surgery, S. Orsola Hospital, University of Bologna , Bologna, Italy .
authors.forename: Francesca
authors.initials: F
authors.lastname: Destro
authors.affiliation: Department of Paediatric Surgery, S. Orsola Hospital, University of Bologna , Bologna, Italy .
authors.forename: Noemi
authors.initials: N
authors.lastname: Cantone
authors.affiliation: Department of Paediatric Surgery, S. Orsola Hospital, University of Bologna , Bologna, Italy .
authors.forename: Stefania
authors.initials: S
authors.lastname: Pavia
authors.affiliation: Department of Paediatric Surgery, S. Orsola Hospital, University of Bologna , Bologna, Italy .
authors.forename: Mario
authors.initials: M
authors.lastname: Lima
mesh_terms: D002648:Child; D002675:Child, Preschool; D005260:Female; D006552:Hernia, Inguinal / Q000601:surgery*; D059685:Herniorrhaphy / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D007223:Infant; D007264:Inguinal Canal / Q000601:surgery*; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods*; D008297:Male; D061646:Operative Time; D010537:Peritoneum / Q000601:surgery; D012008:Recurrence; D013530:Surgical Wound Infection / Q000209:etiology; D013536:Suture Techniques; D006848:Testicular Hydrocele / Q000209:etiology; D016896:Treatment Outcome; D014472:Umbilicus