Laparoscopic Ligation of Internal Ring-Three Ports Versus Single-Port Technique: Are Working Ports Necessary?

Background: From three ports, technical refinements in laparoscopy have facilitated the ligation of the internal ring (IR) with a single port. Objectives: The aims of this study were to determine whether, when, and where working ports are needed by assessing the differences in outcome between the three-port technique (TPT) and the single-port technique subcutaneous endoscopically assisted ligation (SEAL). Methods: Short-term outcomes of 163 children operated on by either technique (51 with TPT, and 112 with SEAL) were audited. Technical difficulties, operation time, intra- and postoperative complications, and postoperative stay were studied. Results: IR could be ligated faster by SEAL than TPT (unilateral: 15 vs. 25 minutes; P = 0.0005; bilateral: 25 vs. 40 minutes; P = 0.001). SEAL proved cosmetically more appealing (one 5-mm vs. three 5-mm scars). Complication rates, recovery, and hospital stay were similar. Recurrences were marginally higher following SEAL (4.8 vs. 2.98%; P = 0.49). Intracorporeal suturing and knotting were the limiting steps in TPT, while wide rings (> 10 mm) and thick abdominal wall were the limitations of SEAL. Conclusions: Both TPT and SEAL are safe and efficacious day-care procedures. In the ligation of average-sized IR of thin patients, working ports may not be necessary, as SEAL proves cosmetically and temporally efficacious over TPT. However, patients with wide rings and thick anterior abdominal walls may need the placement of working ports for successful laparoscopic repair.