LAPAROSCOPIC REPAIR OF CONGENITAL INGUINAL HERNIAS
regarding the incidence or magnitude of abdominal adhesion for- mation (Einarsson et al., 2011 ; Giusto, Iussich, et al., 2019 ; Omo- tosho et al., 2011 ). Furthermore, the benefit of taking a minimally invasive laparoscopic approach may outweigh the risk associated with the suture material when compared to an open herniorrhaphy approach, where manipulation of any prolapsed small intestines may lead to a higher risk for abdominal adhesion formation. In one horse (Case 1), castrated at the age of 5 years, the left
testicle was located abdominally and subsequently removed in a standing laparoscopic procedure. This horse has had a left- sided congenital inguinal hernia and had been subjected to a bilateral vag- inal ring closure without castration at the age of 1 month. It can only be speculated, that at the time of laparoscopic vaginal ring closure, the surgeons may have missed that the left testicle and epididymis were either retained or drawn back into the abdomen during retrac- tion of herniated intestine from the inguinal canal. Sparing the testicles was highlighted as a key element of laparo-
scopic herniorrhaphy by one author (Mariën et al., 2001 ). However, little is known about the effects of neonatal castration on normal masculine development in horses. In the present retrospective study, one or both testes were spared in 4/9 individuals. In 5/9 colts, own- ers wished to castrate the foals at the time of herniorrhaphy to avoid the need of a future surgical procedure. As it was recommended be- fore (Mariën et al., 2001 ; Schumacher & Perkins, 2010 ), we advise against breeding with males that suffered from a congenital inguinal hernia, because of the possible heritability of the condition. Although the limited data from our study does not allow robust conclusions to be drawn regarding the development of early castrated foals, recent data suggest that castration at 3 days of age does not interfere with morphological or behavioural development (Cognie et al., 2022 ). Only three foals in this case series were originally intended to stay
intact. Therefore, the other six foals would have been candidates for a traditional open inguinal approach. The latter involves twisting and li- gation of the vaginal tunic with subsequent castration and, if deemed necessary, the additional closure of the external inguinal ring. After having operated the first two foals with a testicle- sparing technique, we continued to recommend the minimally invasive, laparoscopic technique also in cases for which owners requested castration. Arguably, this recommendation is driven by the minimally invasive nature of the laparoscopic procedure and technical simplicity of intra- corporal suturing with the help of the automated laparoscopic sutur- ing device and barbed sutures. Likewise, other investigators have described the advantages over an open inguinal approach as omitting inguinal dissection and potentially decreasing postoperative morbid- ity (Caron & Brakenhoff, 2008 ; Klohnen & Wilson, 1996 ) thus allow- ing for rapid return to normal pasturing. Another rational in favour of the laparoscopic approach is that the vaginal ring is the first structure traversed by herniated bowel and that its laparoscopic closure might be advantageous over external inguinal ring closure (Caron & Braken- hoff, 2008 ), which not entirely eliminates the risks of herniation into the inguinal canal (Jakobek et al., 2021 ). In the foals subjected to castration, retraction of extra- abdominally located testes into the abdomen was readily performed, with the
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exception of one foal (Case 4). This is not surprising in the subject that was operated in the first week of life (Case 5), given that the vag- inal rings are described to be incompletely contracted within the first weeks after birth (Bergin et al., 1970 ). Moreover, in older foals, abnor- mally large vaginal rings are usually present on the side of herniation (Schumacher & Perkins, 2010 ) and they are potentially dilated by the herniated content. However, under physiological conditions, the vagi- nal rings typically contract to a size small enough to preclude passage of the testis from either side within a few weeks after birth (Bergin et al., 1970 ). This explains why the testis contralateral to the hernia in Cases 4 and 9 (both about 3 months old at the time of surgery) was not readily displaced into the abdomen through traction on the spermatic cord. Nevertheless, retraction of the testis into the abdomen was easy on the contralateral side to the hernia in two foals at 10 weeks of age (Cases 7 and 8) and this might be attributable to an increased size of the vaginal ring on the unaffected side in these individuals. In cases where retraction of the testicle into the abdomen is not possible, sur- gical enlargement of the vaginal ring may be considered. Disadvantages of laparoscopic herniorrhaphy are the need for
specialised, expensive equipment and the need for expertise in laparoscopic surgery. Furthermore, Trendelenburg position during anaesthesia may predispose to development of peri- anaesthetic hy- poxemia (Binetti et al., 2018 ). Important limitations of this case series are its retrospective
nature and a low case number. In all but one case, follow- up was not available up to full maturity (median follow- up 8 months). There- fore, although unlikely, hernia recurrence during a longer postop- erative period cannot be ruled- out entirely. More importantly, this precluded identification of any unintended consequences of the herniorrhaphy procedure on later castration for Cases 2, 4 and 9. These were not at all or only hemi- castrated as part of the laparo- scopic inguinal hernia repair. Such consequences may be cryptorchid testicular structures, as observed in Case 1, or adhesion formation resulting from the vaginal ring closure. Foals in this case series were operated at a relatively young age
(median 9 weeks), although reducible indirect inguinal hernias that cause no abdominal distress can resolve spontaneously up to the age of 6 months (Schumacher, 2018 ; Tóth & Schumacher, 2018 ). One may therefore argue that, in the cases presented here, conservative management could have been successful. Nevertheless, the occur- rence of a previous episode of colic and fluctuating size or large size of the hernia were factors that led to the recommendation to pursue surgery in some of our cases. Furthermore, conservative manage- ment can be laborious for the owners and this is why in other cases, owners elected to have their foals operated after unsuccessful con- servative management for a certain period.
CONCLUSION
We conclude that laparoscopic herniorrhaphy using the EndoS- titch™ automated laparoscopic suturing device combined with V- Loc™ unidirectional barbed suture is technically less demanding
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