LAPAROSCOPIC REPAIR OF CONGENITAL INGUINAL HERNIAS
procedure. Also in Case 6, there was loss of abdominal distension through the laparoscopic cannula because of a broken valve at the beginning of laparoscopy. In Case 8, moderate bleeding from the body wall occurred upon portal creation, which abated when the trocar was placed.
Early postoperative period (<4 weeks)
The postoperative hospitalisation period ranged from 2 to 4 days (median 2, IQR 1). Postoperative antimicrobials were administered for 1– 11 days (median 2, IQR 7) and NSAIDs for 2– 5 days (median 3, IQR 2), respectively. Postoperatively, all foals were bright and alert and without fever. Only mild scrotal swelling was observed, and no re- herniation occurred in any of the cases at any time postopera- tively. The owner of Case 6 observed sporadic episodes where the foal was in dorsal recumbency upon return from the clinic. Accord- ing to the owner, the same foal also developed a painful swelling at one of the portal sites. However, the foal appeared otherwise healthy, and this resolved spontaneously without further interven- tion. Other than that, no signs of colic or problems with the portals were observed or reported for any other operated foal in the early postoperative period. The owner of Case 3 had the impression that the foal had a stiff gait of the hind legs in the first days following hospitalisation.
Long- term follow- up and outcome (>4 weeks)
Owners were contacted by telephone or email and interviewed using a standardised questionnaire. Five equids were still with the same owner at the time of the interview (Cases 1, 5, 6, 8 and 9). The remain- ing four had been sold 3– 8 months after surgery and, thereafter, lost to follow- up. The follow- up ranged from 3 to 93 months (median 8, IQR 16). All owners reported a fast recovery and that normal pasture turnout was resumed 4 weeks after hospital discharge. Case 2 was re- admitted to the hospital twice because of mild to moderate colic signs, 1 and 2 months postoperatively. In this foal, equine gastric ulcer syndrome was diagnosed at the second presentation. On both occa- sions, colic resolved with conservative treatment, including NSAIDs on the second presentation (metamizole 40 mg kg −1 bwt IV once), oral fluid and mineral oil administration on both presentations and gastro- protective therapy (omeprazole 4.4 mg kg −1 bwt PO SID and sucral- fate 20 mg kg −1 bwt PO BID) on the second presentation. Until lost to follow- up at the age of 8 months, no further colic episodes were observed. Recurrence of inguinal herniation did not occur in any case. Case 1 was castrated at the age of 5 years at a different clinic. At this stage, only the right testicle was descended into the scrotum. An at- tempt to bilaterally castrate the horse via an inguinal approach was made. Because the left testicle was not found in the inguinal canal, only the descended right testicle was removed. Standing laparoscopy was performed 2 weeks later. The left testicle was found to be lo- cated abdominally and was subsequently removed laparoscopically.
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The attending surgeon was not aware that the horse had been sub- jected to an inguinal herniorrhaphy as a foal. When asked about the appearance of the vaginal ring at the time of the laparoscopic castra- tion, the veterinarian stated that it looked unremarkable. The cas- tration history in the two unilaterally castrated foals (Cases 2 and 4) remains unknown, because these foals were sold as hemi- castrates and were thereafter lost to follow- up. Case 9 was 10 months old at the time of follow- up and had not been castrated at that time. All owners were satisfied with the outcome of the procedure.
DISCUSSION
The objective of this report was to describe the application of an automated suturing instrument in combination with a unidirectional barbed suture for laparoscopic herniorrhaphy in foals with congeni- tal inguinal hernia and to report the intra- and postoperative compli- cations and the outcome. The results of this case series indicate that this technique is efficient in preventing hernia recurrence and well tolerated with a low risk for intra- and postoperative complications. Various laparoscopic techniques to close the vaginal ring, thereby
preventing inguinal herniation, have been described. Laparoscopic herniorrhaphy may be performed in foals with congenital inguinal hernia or in stallions or geldings after resolution of an acquired ingui- nal hernia to prevent recurrence. In foals, this allows to spare the tes- ticles and unaltered masculine development (Mariën, 2001 ). In adult stallions that should stay intact, the surgeon ' s goal is to effectively prevent hernia recurrence while maintaining adequate blood sup- ply to the testis and physiological cremaster muscle function (Ragle et al., 2013 ; Schumacher, 2018 ). Laparoscopic methods to close the vaginal ring are considered more certain to achieve this goal com- pared to an external
inguinal ring closure (Freeman, 2018 ; Ragle
et al., 2013 ; Schumacher, 2018 ). Previously described laparoscopic herniorrhaphy techniques in foals include vaginal ring closure under general anaesthesia with intra- corporeal staples or interrupted su- tures and with or without concurrent laparoscopic castration (Caron & Brakenhoff, 2008 ; Klohnen & Wilson, 1996 ; Mariën et al., 2001 ). In adult horses, laparoscopic herniorrhaphy may be performed under general anaesthesia (Fischer et al., 1995 ; Klohnen & Wilson, 1996 ; Rossignol et al., 2007 ) or in the standing horse (Mariën, 2001 ; Ragle et al., 2013 ; Rossignol et al., 2014 ; Wilderjans et al., 2012 ; Wilderjans & Meulyzer, 2021 ). In adult horses, a variety of techniques and im- plants have been proposed to accomplish closure of the vaginal rings, including nonabsorbable mesh implants positioned in combination with a peritoneal flap (Fischer et al., 1995 ), cylindrical polypropylene mesh insertion into the inguinal canal (Mariën, 2001 ), peritoneal flap transposition (Rossignol et al., 2007 ; Wilderjans et al., 2012 ), cyano- acrylate gluing (Rossignol et al., 2014 ), direct suturing with regular or barbed sutures (Caron & Brakenhoff, 2008 ; Ragle et al., 2013 ), and most recently, a tacked intraperitoneal slitted mesh technique (Wilderjans & Meulyzer, 2021 ). Although the vaginal rings have been successfully closed in foals using staples (Klohnen & Wilson, 1996 ; Mariën et al., 2001 ), it has
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