LAPAROSCOPIC REPAIR OF CONGENITAL INGUINAL HERNIAS INTRODUCTION
Congenital inguinal herniation is a presumably hereditary condition in newborn colts, where abdominal content protrudes into the in- guinal canal and the scrotum (Schumacher, 2018 ). Usually, the herni- ated tissue is a portion of ileum or distal jejunum (Schumacher, 2018 ; Tóth & Schumacher, 2018 ) but inguinal herniation of the large colon has been described (Mariën et al., 2001 ). If the herniated content passes through the vaginal ring and comes to lie within the vagi- nal process, the inguinal hernia is classified as indirect and this is the most common presentation in affected foals (Freeman, 2018 ; Schumacher, 2018 ). A so- called ‘ruptured inguinal hernia’ is pres- ent if the vaginal process tears and the herniated intestines come to lie within the subcutaneous tissues (Schumacher, 2018 ; Tóth & Schumacher, 2018 ). This condition is differentiated from the less common event of an inguinal rupture , sometimes also referred to as direct inguinal hernia (Schumacher, 2018 ). In this case, the small intes- tine and occasionally the testicle leave the abdominal cavity through a rent in the peritoneum and transverse fascia adjacent to the vaginal ring and come to lie outside the intact vaginal process in the inguinal and scrotal subcutaneous space (Freeman, 2018 ; Schumacher, 2018 ; Tóth & Schumacher, 2018 ). Congenital inguinal herniation can occur unilaterally or bilaterally
and, typically, scrotal or inguinal swelling is the only noticeable clini- cal sign. Indirect congenital inguinal hernias are most often reducible and nonstrangulating and, therefore, do not cause of abdominal dis- comfort (Mariën, 2001 ; Schumacher, 2018 ). Nevertheless, foals with nonreducible or with ruptured inguinal hernias can show depression and colic of variable degrees (Gracia- Calvo et al., 2014 ; Mariën, 2001 ). Indirect reducible congenital inguinal hernias often resolve sponta- neously by the age of 3– 6 months and this progression can be assisted by repeated manual reduction of the hernia or by applying a truss after manual reduction (Mariën, 2001 ; Schumacher, 2018 ). Surgical management is indicated in ruptured inguinal hernias and inguinal rup- tures, if the hernia is nonreducible, if the hernia fails to resolve or if the hernia is exceptionally large (Mariën et al., 2001 ; Schumacher, 2018 ). When taking an open approach, the superficial inguinal ring
is exposed, the hernia reduced, the vaginal tunic ligated, and the testicle removed. The external inguinal ring may be sutured as an adjunctive measure to prevent re- herniation (Mariën et al., 2001 ; Schumacher, 2018 ). Minimally invasive laparoscopic approaches to repair congenital inguinal hernias by closing the vaginal rings have been introduced and investigated by several authors (Caron & Brak- enhoff, 2008 ; Klohnen & Wilson, 1996 ; Mariën, 2001 ). These lapa- roscopic techniques are reported to be safe and effective with the inherent advantages of a minimally invasive approach such as de- creased incisional site morbidity, high level of postoperative comfort, rapid return to normal activity and excellent cosmetic outcome (Caron & Brakenhoff, 2008 ; Klohnen & Wilson, 1996 ; Mariën et al., 2001 ). Furthermore, the herniated intestine and the umbilical structures can be assessed visually. If wished so, laparoscopic herniorrhaphy allows to spare the testicles and unaltered masculine development (Mariën, 2001 ). Laparoscopic closure of the vaginal rings is either
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achieved using intra- corporeal staples or by direct intra- corporeal suturing. The latter incorporates a larger volume of tissue compared to a stapled closure, and it is therefore speculated that this results in a more secure seal of the vaginal ring (Caron & Brakenhoff, 2008 ). Intra- corporeal suturing, however, is technically demanding and re- quires considerable practice to be carried out efficiently. The use of automated suturing devices facilitates and accelerates
laparoscopic suturing (Adams et al., 1995 ; Hart et al., 2013 ; Nguyen et al., 2000 ; Pattaras et al., 2001 ), but knot tying remains challenging. The use of barbed suture materials can eliminate the need for intra- corporeal knot tying in laparoscopic procedures and, thus, effectively reduce the technical difficulties and duration of these procedures (Gardella et al., 2018 ; Greenberg & Goldman, 2013 ; Huhn, 2016 ). In barbed sutures, helically arranged barbs on the suture surface an- chor the suture in the surrounding tissue ' s collagen matrix, so that the suture holds tension on its own. This provides even tension dis- tribution along the apposed tissues without constricting them, there- fore reducing the risk for ischaemic necrosis and related dehiscence (Gingras et al., 2012 ; Ingle et al., 2013 ; Ruff, 2013 ). Furthermore, the surface area of adhesion between tissues is increased, which favours the healing process (Albanese et al., 2016 ) and the amount of suture material in the patient can be reduced (Giusto, Caramello, et al., 2019 ). After their initial introduction in human medicine for cosmetic procedures and cutaneous closure (Murtha et al., 2006 ; Ruff, 2013 ), barbed sutures gained wider acceptance in various sur- gical fields (Lin et al., 2016 ) and they proved to be especially bene- ficial for different laparoscopic procedures, including the urogenital (Einarsson et al., 2010 ; Gardella et al., 2018 ; Massoud et al., 2013 ) and gastrointestinal (Tsukada et al., 2016 ; Velotti et al., 2022 ) fields. In equine surgery, the use of barbed sutures has been investigated ex vivo as well as in clinical cases for different open and laparoscopic applications (Adler et al., 2020 ; Albanese et al., 2016 ; Corsalini et al., 2016 ; Gandini et al., 2017 ; Gialletti et al., 2021 ; Giusto, Cara- mello, et al., 2019 ; Kamus et al., 2022 ; Major et al., 2017 ; Nelson & Hassel, 2014 ; Ruzickova et al., 2016 ; Sinovich et al., 2020 ). Ragle and colleagues first described laparoscopic vaginal ring closure with an automated suturing instrument and barbed suture in an adult gelding with an acquired inguinal hernia (Ragle et al., 2013 ). The authors con- cluded that this simple and effective method should be considered as a treatment option for inguinal herniation in horses. Recently, barbed suture, although not used in combination with an automated suturing device, was also successfully applied for laparoscopic herniorrhaphy in a male sheep (Jakobek et al., 2021 ). The aim of the present report is to describe the application of an automated suturing instrument in combination with a unidirectional barbed suture for laparoscopic herniorrhaphy in foals with congenital inguinal hernia and to provide a long- term follow- up regarding the outcome.
MATERIALS AND METHODS
Medical records of all foals with congenital inguinal hernia treated surgically at two equine referral hospitals, Fethard Equine Hospital,
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