European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009;13:343-403. [PMID: 19636493 PMCID: PMC2719730 DOI: 10.1007/s10029-009-0529-7]

The transition from open to laparoscopic surgery for bilateral inguinal hernia repair: how we did it

PURPOSE

To describe the transition process from open repair (OR) to laparoscopic repair (LR) of bilateral inguinal hernia in a small basic general hospital METHODS: We describe the technical details and training strategy used to facilitate the transition to systematic LR of bilateral inguinal hernia. We conducted a retrospective analysis of prospectively collected data from all patients undergoing bilateral inguinal hernia repair between January 2017 and December 2020. We analysed the evolution of LR and compared the surgical outcomes: complications, acute pain (24 h), chronic pain (> 3 months), and recurrence (1 year) of the patients operated on by OR and LR.

RESULTS

We performed 132 bilateral inguinal hernia repairs, 55 (41.7%) ORs, and 77 (58.3%) LRs. A significant difference was observed in the choice of LR over time (2017: 9%, 2018: 32%, 2019: 75%, 2020: 91%, p < 0.001). The mean operative time was shorter in the OR group than in the LR group (56 min vs. 108 min, p < 0.001). However, the operative time of the LR decreased over the years. No significant differences were observed in complications or recurrence. LR was associated with lower acute postoperative pain at 24 h (2.2 vs. 3.1 points, p = 0.021) and lower chronic groin pain than OR (1.3% vs. 12.7%, p = 0.009).

CONCLUSION

A structured and systematized training process made the transition from OR to LR of bilateral inguinal hernias feasible and safe in a small basic general hospital. This transition did not increase complications or recurrence. Additionally, LR was associated with a decrease in postoperative pain and chronic groin pain.

Evaluating the Role of Glove Changing Before Mesh Application During Herniorrhaphy Surgery to Reduce Surgical Site Infections

Background: Prevention of surgical site infection (SSI) in hernia repair with mesh remains the main concern. Many risk factors have been proposed; however, the role of changing the glove remains to be elucidated. Methods: This longitudinal study was conducted on adult inguinal hernia cases referred to elective repair using mesh reconstruction. Two hundred cases were enrolled and classified into two groups, including the group that surgeon and his assistants changed the glove and the group in which the gloves remained unchanged. Age, gender, surgery duration, and the side of hernia were compared between those who developed SSI and those without this complication. Moreover, the infection rate was compared between the two study groups. Results: One hundred and two males (51.0%) and 98 females (49.0%) with a mean age of 42.60 ± 15.79 years old were enrolled in the study. None of the variables showed a significant difference between SSI cases and non-SSI cases. Moreover, the rate of infection was not significantly different between the two study groups. Conclusions: Glove changing before mesh application indicates no considerable role in reducing SSI rate; however, further studies are needed to confirm these findings.

Mesh size may not affect recurrence in laparoscopic totally extraperitoneal repair of inguinal hernias

A mesh is usually employed to cover defects when performing laparoscopic totally extraperitoneal repair (TEP) of inguinal hernias. However, there is insufficient evidence for an appropriate mesh size. Therefore, we aimed to compare the recurrence rate between large- and medium-mesh laparoscopic TEP. Patients who underwent laparoscopic TEP for primary inguinal hernias from January 2012 to March 2020 were included. We retrospectively reviewed electric medical records. The primary outcome was the difference in recurrence rate between the large and medium meshes. The large mesh was 10.3 × 15.7 cm, and the medium mesh was 7.9 × 13.4 cm or 9 × 13 cm. In total, 446 patients were included in the study. Of these patients, 177 were in the large-mesh group, and 269 were in the medium-mesh group. The average ages of the large- and medium-mesh groups were 58.4 and 56.9 years, respectively (P = .361). In both groups (large vs medium), males were dominant (93.2% vs 93.6%, P = .850), and indirect hernias (87.0% vs 88.1%, P = .740) were dominant. There was no difference in body mass index (P = .883) or hernia side (P = .770). Peritoneal tearing as an intraoperative complication occurred frequently in the large-mesh group (13.6% vs 3.3%, P < .001). During the mean follow-up period of 28 months, recurrence occurred in 3 (1.7%) and 13 (4.8%) patients in the large- and medium-mesh groups, respectively. However, there was no statistical significance (P = .262). Mesh size may not affect recurrence after laparoscopic TEP of primary inguinal hernias.

The sensitivity of ultrasound in the clinical diagnosis of inguinal hernias in adults: a comparative study

OBJECTIVE

Ultrasonography (US) is a non-invasive, non-ionizing radiation modality highly successful at diagnosing inguinal hernia. The aim of this study is to demonstrate the accuracy of ultrasound in evaluating defects of fascia in inguinal hernias and compare with surgical findings.

MATERIAL AND METHODS

A total of 33 patients with a sonographic diagnosis of an inguinal hernia are included to study. After US, all patients underwent a blinded surgery and the surgical findings are compared with the US results.

RESULTS

The sensitivity of US was found to be 100% and 80% for indirect and direct types, respectively. The mean size of the defect was found to be 22 mm (max: 70 mm, min: 6 mm) with US; and 27 mm (max: 50 mm, min: 4 mm) at surgery. The size of defects at US and in surgery were correlated with each other (p = 0.001).

Evaluation of the Factors Influencing on Intraoperative Difficulty Scores of Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair

Background: Inguinal hernias are the leading surgical diseases in the world. There are different surgical procedures reported for the treatment. Some problems are thought to be encountered when performing laparoscopic surgery in these patients, such as risk of severe complications and the prolonged operative duration. Aim: The objective of this study was to specify the complexity of the transabdominal preperitoneal (TAPP) procedure by using an intraoperative scoring system and examine the scores with these patients' predictive factors. Materials and Methods: A prospective study was conducted in patients who underwent inguinal hernia surgery with TAPP. Previous lower abdominal surgery, previous (open) hernia surgery, body mass index (BMI), type of hernia, duration of the surgery, scoring the difficulty of the operation in five various stages using the visual analog scale (VAS) score (1. Mobilizing the peritoneum/dissection of the inferior peritoneal flap. 2. Dissection of internal ring or vas deference or hernia sac. 3. Visualization of Cooper's ligament. 4. Mesh placement. 5. Peritoneal closure.) and the time of discharge were recorded. Results: In this study, 137 patients were included. "BMI" and "previous lower abdominal surgery" have significantly higher scores, time of surgery, and hospital stay compared with other risk factors (P < .005). Conclusion: This study showed that patient's BMI and previous lower abdominal surgery could create technical difficulty with the TAPP procedure, but it is not necessary to avoid this laparoscopic technique because of these situations and can be performed safely.

Risk of bowel resection in incarcerated inguinal hernia: watch out for ASA score and hernia type

PURPOSE

Incarcerated inguinal hernias can promote bowel ischemia. Emergent bowel resection is associated with increased postoperative morbidity. Risk factors for bowel resection might identify patients who benefit from elective inguinal hernia repair.

METHODS

Sixty-five consecutive patients undergoing emergency inguinal hernia repair between 2012 and 2018 at our institution were entered in a prospective database. Data analysis was approved by the local ethics committee. Patient characteristics, surgery data, and postoperative outcomes were compared between patients with and without bowel resection. Risk factors for bowel resection were assessed with univariate and multivariate analysis.

RESULTS

Patients requiring bowel resection were more often female (87%, P = 0.004) and presented in 67% with a femoral hernia. Postoperative complications occurred more often after hernia reduction and bowel resection compared to no resection (67% vs. 36%, P = 0.035). ASA score 3-4 and femoral herniation were independent predictors of bowel resection (P = 0,046 and P = 0,047, respectively).

CONCLUSION

Highly comorbid patients can profit from early elective hernia repair to prevent bowel resection.

Positive predictive value of ultrasound in correctly identifying an inguinal hernia: a single-centered retrospective pilot study

Objectives

To determine the clinical utility of preoperative ultrasound imaging for predicting an inguinal hernia in need of surgery. In addition, we aimed to identify factors associated with false positive (FP) ultrasound examinations.

Methods

In this retrospective pilot study, we included all 175 patients who underwent inguinal hernia surgery in our hospital in 2019 and of whom a positive preoperative ultrasound examination of the groin area was available. The positive predictive value (PPV) of the ultrasound examination was determined using inguinal hernia detected during surgery (yes/no) as golden standard. To identify possible predictive factors, we compared the characteristics of patients with a FP ultrasound with patients with a true positive (TP) ultrasound.

Results

PPV of ultrasound examinations to identify an inguinal hernia in need of surgery correctly was 90.9% (159/175). The patients with a FP ultrasound examination had a significantly higher body mass index (BMI) than the patients with a TP ultrasound examination (27.6 ± 4.2 vs 25.8 ± 2.3, p = 0.043).

Conclusions

With a false positive percentage of 9.1%, there is still room for improvement of preoperative diagnostic imaging. Studies with larger cohorts are necessary to establish prediction models that have the potential to reduce FP ultrasound results.

Indications and Outcomes of a Hybrid Method Combining Laparoscopic and Anterior Approaches for Inguinal Hernia Repair

Introduction

Surgery for complex inguinal hernia (IH) (recurrent IH or IH after radical prostatectomy (RP)) may be difficult because of the presumed scar or adhesion in the retropubic space. A hybrid method combining the laparoscopic and anterior approaches (HLAA) in a bidirectional surgical technique may be an option in complex IH cases.

Methods

Patients at our institution who underwent IH repair for complex IH using HLAA from April 2018 to November 2019 were included. We retrospectively evaluated the patient characteristics, IH diagnosis, intraoperative variables, complications, and hernia recurrence during the follow-up period.

Results

Twenty patients were involved in this study. Seven patients underwent hLAA for recurrent IH, whereas the remaining 13 underwent hLAA for IH after RP. Five patients had bilateral IH, all of whom had IH after RP. The type of IH was lateral in 21 patients, medial in six patients, and lateral and medial in two patients. Hernia repair was performed using a patch alone in two patients and a plug and patch in 18 patients. Seroma or hematoma was observed in five patients, and one patient experienced chronic pain. No hernia recurrence was observed during the median follow-up period of 24 months.

Conclusion

hLAA could facilitate precise diagnosis and intraoperative confirmation of repair for recurrent IH and IH after RP. The intraoperative findings and the cause of recurrence can be easily shared among surgeons in hLAA. Further investigations are necessary to determine the long-term efficacy of hLAA in a larger cohort.

Laparoscopic bilateral inguinal hernia repair: Should it be the preferred technique?

Inguinal hernias are amongst the most common conditions requiring general surgical intervention. For decades, the preferred approach was the open repair. As laparoscopy became more popular and available and more surgeons became familiarized with this modality, laparoscopic inguinal hernia repair became an alternative. The aim of this study is to assess the effectiveness of laparoscopic inguinal repair, with a focus on bilateral inguinal hernias. Initial reports have shown promising clinical outcomes compared to those of conventional repair of bilateral hernias. However, there are only a few studies concerning laparoscopic repair of bilateral hernias. It is yet to be proven that laparoscopy is the “gold standard” in the treatment of bilateral inguinal hernias. So far, the choice of an inguinal hernia repair technique has been up to each surgeon, depending on their expertise and available resources after taking into consideration each patient’s needs.

Mesh-fixation technique for inguinal hernia repair: umbrella review

Background

Mesh-based repair is the standard of surgical care for symptomatic inguinal hernias. Many systematic reviews and meta-analyses (SRMAs) addressed various aspects of these procedures. This umbrella review aimed to report the evidence from all previous SRMAs for open and laparoscopic inguinal hernia repair.

Methods

SRMAs were identified from MEDLINE, Scopus, Cochrane, Embase, DARE, PROSPERO, CINAHL, JBISRIS, EPPI-Centre, Wiley Online Library and ScienceDirect database according to PRISMA guidelines. Data including mesh-fixation techniques and surgical approach were extracted from selected SRMAs. The corrected covered area was calculated to address study overlap across reviews, and an excess significance test was used to assess potential bias. The outcomes of interest were hernia recurrence, chronic groin pain, operating time, postoperative pain, duration of hospital stay, return to daily life activities, and postoperative complication.

Results

Thirty SRMAs were included between 2010 and 2019: 16 focused on open repair, and 14 focused on laparoscopic repair, with a high degree of overlap (open repairs, 41 per cent; laparoscopic repairs, 30–57 per cent). Sufficient evidence was available on hernia recurrence, chronic groin pain, and operative time. Effects of glue on hernia recurrence were inconclusive in open and laparoscopy approaches, P = 0.816 and 0.946 respectively. Glue was significantly associated with lower persistent groin pain, in open repair (versus suture) and in laparoscopic repair (versus tack). SRMAs suggested that self-gripping mesh was associated with shorter operating time in open surgery, although with only a few minutes of improvement (0.36–7.85 min, P < 0.001).

Conclusion

In this umbrella review, chronic groin pain and operating time were the only outcomes for which there was sufficient evidence supporting the effectiveness respectively of glue and self-gripping mesh.

Analyzing material changes consistent with degradation of explanted polymeric hernia mesh related to clinical characteristics

BACKGROUND

Proposed mechanisms that potentially contribute to polypropylene mesh degradation after in vivo exposure include oxidizing species and mechanical strains induced by normal healing, tissue integration, muscle contraction, and the immediate and chronic inflammatory responses.

METHODS

This study explores these potential degradation mechanisms using 63 mesh implants retrieved from patients after a median implantation time of 24 months following hernia repair surgery (mesh explants) and analysis of multivariate associations between the material changes and clinical characteristics. Specifically, polypropylene mesh degradation was characterized in terms of material changes in surface oxidation, crystallinity and mechanical properties, and clinical characteristics included mesh placement location, medical history and mesh selection.

RESULTS

Compared to pristine control samples, subsets of mesh explants had evidence of surface oxidation, altered crystallinity, or changed mechanical properties. Using multivariate statistical approach to control for clinical characteristics, infection was a significant factor affecting changes in mesh stiffness and mesh class was a significant factor affecting polypropylene crystallinity changes.

CONCLUSIONS

Highly variable in vivo conditions expose mesh to mechanisms that alter clinical outcomes and potentially contribute to mesh degradation. These PP mesh explants after 0.5 to 13 years in vivo had measurable changes in surface chemistry, crystallinity and mechanical properties, with significant trends associated with factors of mesh placement, mesh class, and infection.

Varying convalescence recommendations after inguinal hernia repair: a systematic scoping review

PURPOSE

The most recent international guideline on inguinal hernia management recommends a short convalescence after repair. However, surgeons' recommendations may vary. The objective of this study was to give an overview of the current convalescence recommendations in the literature subdivided on the Lichtenstein and laparoscopic inguinal hernia repairs.

METHODS

In this systematic review, three databases were searched in August 2021 to identify studies on inguinal hernia repairs with a statement about postoperative convalescence recommendations. The outcome was convalescence recommendations subdivided on daily activities, light work, heavy lifting, and sport.

RESULTS

In total, 91 studies fulfilled the eligibility criteria, and 50 and 58 studies reported about convalescence recommendations after Lichtenstein and laparoscopic repairs, respectively. Patients were instructed with a wide range of convalescence recommendations. A total of 34 Lichtenstein studies and 35 laparoscopic studies recommended resumption of daily activities as soon as possible. Following Lichtenstein repairs, the patients were instructed to resume light work after median 0 days (interquartile range (IQR) 0-0), heavy lifting after 42 days (IQR 14-42), and sport after 7 days (IQR 0-29). Following laparoscopic procedures, the patients were instructed to resume light work after median 0 days (IQR 0-0), heavy lifting after 14 days (IQR 10-28), and sport after 12 days (IQR 7-23).

CONCLUSION

This study revealed a broad spectrum of convalescence recommendations depending on activity level following inguinal hernia repair, which likely reflects a lack of high-quality evidence within this field.

Evaluation of Regional Geospatial Clusters in Inguinal Hernia Repair

Introduction

There is significant variation in how inguinal hernia repairs are conducted across the United States (US). This study seeks to utilize national public data on inguinal hernia repair to determine regional differences in the use of ambulatory surgical centers (ASC) and in the choice of laparoscopic or open technique.

Methods

Medicare provider billing and enrollee demographic data were merged with US census and economic data to create a county-level database for the years 2014-2019. Location, technique, and total count of all inguinal hernia repair billing were recorded for 1286 counties. Moran’s I cluster analysis for inguinal hernia repairs, percent laparoscopic technique, and percent ACS were conducted. Subsequent hotspot and coldspot clusters identified in geospatial analysis were compared using ANOVA across 50 socioeconomic variables with a significance threshold of 0.001. 

Results 

There were 292,870 inguinal hernia repairs, of which 39.8% were conducted laparoscopically and 21.3% of which were in an ACS. Inguinal hernia repair coldspots were in the Mid-Atlantic and Northern Midwest, while hotspots were in Nebraska, Kansas, and Maryland (3.85 and 36.53 repairs per 1000 beneficiaries, respectively). Compared to coldspots, hotspot areas of repair were less obese, had less tobacco use, older, and less insured; there were no differences in gender, white population, or county urbanization (p<0.001). Laparoscopic technique coldspots were in the Mid-Atlantic, Michigan, and Great Plains, while hotspots were in the Rocky Mountains and contiguous states from Florida to Wisconsin (6.14% and 75.39%, respectively). ACS coldspots were diffusely scattered between Oklahoma and New Hampshire, while hotspots were in California, Colorado, Maryland, Tennessee, and Indiana (0.51% and 48.71%, respectively).

Conclusions

Inguinal hernia repair, the surgical setting, and the choice of technique demonstrated interesting geospatial trends in our population of interest that have not been previously characterized.

Learning curve analysis using the cumulative summation method for totally extraperitoneal repair of the inguinal hernia

PURPOSE

The totally extraperitoneal repair (TEP) technique has been widely performed, and compared with open surgery, TEP results in less postoperative pain and similar surgical outcomes in the treatment of inguinal hernias. However, TEP has a longer learning curve than does conventional surgery.

METHODS

The data for patients who underwent TEP for inguinal hernias by a single surgeon between April 2017 and July 2019 were analyzed retrospectively. The cumulative summation (CUSUM) method and the following two variables were used to analyze the learning curve: (1) the operation event (OE), including intraoperative complications and conversion to open surgery; and (2) the operation score (OS), as calculated by the operation time, patient body mass index, and disease characteristics.

RESULTS

The CUSUM chart showed three phases for both the OE and OS. The former reached a first inflection point after the 85th case and decreased after the 200th case, and the latter reached a plateau after the 101st case and decreased after the 203rd case. The operation time was longer in phases 1 and 2 than in phase 3 (64.2 min versus 47.9 min versus 31.1 min; p < 0.001), and the OS was lower in phase 3 than in the other phases (71.9 points versus 106.4 points versus 142.7 points; p < 0.001). Ten cases of intraoperative complications were observed, all in the first and second phases (p = 0.011).

CONCLUSION

At least approximately 100 cases are required for the initial learning period, and an additional 103 cases are required for the accumulation of additional experience. Surgical competency can be gained after 203 TEPs are performed.

Outcome of inguinal hernia repair after previous radical prostatectomy: a registry-based analysis with 12,465 patients

INTRODUCTION

Following radical prostatectomy, the rate of inguinal hernias is fourfold higher compared to controls. Laparo-endoscopic repair after previous radical prostatectomy is considered complex. Therefore, the guidelines recommend open Lichtenstein repair. To date, there are limited data on inguinal hernia repair after prior prostatectomy.

METHODS

In a retrospective analysis from the Herniamed Registry, the outcomes of 255,182 primary elective unilateral inguinal hernia repairs were compared with those of 12,465 patients with previous radical prostatectomy in relation to the surgical technique. Furthermore, the outcomes of laparo-endoscopic versus open Lichtenstein repair techniques in the 12,465 patients after previous radical prostatectomy were directly compared.

RESULTS

Comparison of the perioperative complication rates for primary elective unilateral inguinal hernia repair with and without previous radical prostatectomy demonstrated for the laparo-endoscopic techniques significantly higher intraoperative complications (2.1% vs 0.9%; p < 0.001), postoperative complications (3.2% vs 1.9%; p < 0.001) and complication-related reoperations (1.1% vs 0.7%; p = 0.0442) to the disadvantage of previous prostatectomy. No significant differences were identified for Lichtenstein repair. Direct comparison of the laparo-endoscopic with the open Lichtenstein technique for inguinal hernia repair after previous radical prostatectomy revealed significantly more intraoperative complications for TEP and TAPP (2.1% vs 0.6%; p < 0.001), but more postoperative complications (4.8% vs 3.2%; p < 0.001) and complication-related reoperations (1.8% vs 1.1%; p = 0.003) for open Lichtenstein repair.

CONCLUSION

Since there are no clear advantages for the laparo-endoscopic vs the open Lichtenstein technique in inguinal hernia repair after previous radical prostatectomy, the surgeon can opt for one or the other technique in accordance with their experience.

Conservative treatment of partial testicular artery injury during transabdominal preperitoneal hernioplasty (TAPP)

Inguinal hernias are common conditions in general surgery. Laparoscopic approach, whether transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP), is favored for its lower rate of surgical site infection, shorter hospital stay, and faster return to daily activities. Complications still occur, albeit in a small percentage, but can prolong hospital stay or be fatal. We present a case of a 55-year-old male patient who underwent TAPP procedure with proposed iatrogenic testicular artery injury resulting in a bilateral retroperitoneal hematoma. The treatment was conservative, and the patient was discharged in good general condition after 13 days. Six months postoperatively, no signs of hernia recurrence were observed. According to available literature, this is the first conservatively treated occult testicular artery injury during TAPP inguinal hernioplasty.

Surgical Management of Pediatric Inguinal Hernia: A Systematic Review and Guideline from the European Pediatric Surgeons' Association Evidence and Guideline Committee

INTRODUCTION

 Inguinal hernia repair represents the most common operation in childhood; however, consensus about the optimal management is lacking. Hence, recommendations for clinical practice are needed. This study assesses the available evidence and compiles recommendations on pediatric inguinal hernia.

MATERIALS AND METHODS

 The European Pediatric Surgeons' Association Evidence and Guideline Committee addressed six questions on pediatric inguinal hernia repair with the following topics: (1) open versus laparoscopic repair, (2) extraperitoneal versus transperitoneal repair, (3) contralateral exploration, (4) surgical timing, (5) anesthesia technique in preterm infants, and (6) operation urgency in girls with irreducible ovarian hernia. Systematic literature searches were performed using PubMed, MEDLINE, Embase (Ovid), and The Cochrane Library. Reviews and meta-analyses were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement.

RESULTS

 Seventy-two out of 5,173 articles were included, 27 in the meta-analyses. Laparoscopic repair shortens bilateral operation time compared with open repair. In preterm infants, hernia repair after neonatal intensive care unit (NICU)/hospital discharge is associated with less respiratory difficulties and recurrences, regional anesthesia is associated with a decrease of postoperative apnea and pain. The review regarding operation urgency for irreducible ovarian hernia gained insufficient evidence of low quality.

CONCLUSION

 Laparoscopic repair may be beneficial for children with bilateral hernia and preterm infants may benefit using regional anesthesia and postponing surgery. However, no definite superiority was found and available evidence was of moderate-to-low quality. Evidence for other topics was less conclusive. For the optimal management of inguinal hernia repair, a tailored approach is recommended taking into account the local facilities, resources, and expertise of the medical team involved.

Zig Maneuver in Total Extraperitoneal Inguinal Hernia Repair

BACKGROUND

The difficulties in the hernia sac dissection in repairing large inguinal hernias with the endoscopic total extraperitoneal (TEP) technique prolong the operation and increase the risk of injury. This study investigates the effectiveness of the Zig maneuver (ligation of the hernia sac at the deep inguinal ring) in TEP in male patients with L3 inguinal hernia by European Hernia Society classification.

MATERIALS AND METHODS

A total of 224 male patients with L3 inguinal hernia who underwent laparoscopic TEP surgery in 2018 and 2019 were retrospectively screened and included in the study. The patients were divided into 2 groups as Zig group (n=99) and the non-Zig group (n=125), depending on whether the Zig maneuver was performed during TEP application.

RESULTS

The mean patient age was 45.49 for the non-Zig group and 47.12 for the Zig group. The median operative time was 50 minutes in the non-Zig group and 43 minutes in the Zig group (P<0.005). The median value of the postoperative first 24 hours pain score was 3 in the non-Zig group and 2 in the Zig group (P=0.033). Scrotal edema was 7.2% in the non-Zig group and 1% in the Zig group (P=0.023). According to logistic regression analysis, the Zig maneuver reduced the probability of scrotal edema by 87% in almost the entire population (odds ratio=0.130, 95% confidence interval: 0.016-1.047). There was no statistically significant difference between the groups in terms of early and late recurrence.

CONCLUSIONS

Zig maneuver shortened the operative time and significantly reduced the feeling of pain in the first 24 hours postoperatively in male patients with indirect L3 hernia who underwent endoscopic TEP. It also significantly reduced the likelihood of scrotal edema in almost the entire population. As a result, the Zig maneuver is an effective method that could be applied during endoscopic TEP.

Risk Factors for Conversion in Laparoscopic Totally Extraperitoneal Inguinal Hernioplasty

BACKGROUND

Conversion is a surgical concern because the surgical technique can change during surgery. Surprisingly, there is no study in the literature on the causes and risk factors leading to conversion in laparoscopic total extraperitoneal inguinal repair (TEP). There is also no consensus on the prevention and causes of this condition in TEP. The aim of this study was to evaluate the risk factors underlying the development of conversion during TEP.

MATERIALS AND METHODS

We recruited 962 consecutive patients who underwent TEP between May 2016 and May 2021. All data were collected retrospectively. The outcomes of patients who converted to open surgery were compared with those without conversion. Multivariate analysis identified independent risk factors for conversion.

RESULTS

The overall incidence of conversion was 4.05% (n=39). The median age was 42 years (18 to 83) and body mass index was 25.2 kg/m2 (15.67 to 32.9). Significant clinical factors associated with conversion included old age, American Society of Anesthesiologists (ASA) score, large peritoneal tear (PT), Charlson comorbidity index, previous surgery, large hernial defects, presence of scrotal hernia, and the defect size of inguinal hernia. Multivariate analysis identified independent risk factors for conversion: large hernial defect, large PT, previous lower abdominal surgery, previous hernia surgery, and scrotal hernia.

CONCLUSION

Conversion is a minor complication seen during TEP and its incidence varies depending on many factors. Previous lower abdominal surgery and a large PT carries a 6-fold increased risk for conversion from laparoscopic to open surgery during TEP.

Cost-Utility Analysis of Open Hernia Operations in Bulgaria

Background: Hernia surgery procedures are among the most frequently performed in Bulgaria. An open, mesh-based repair is a standard method for hernia repair. From a societal perspective, a cost-utility analysis of open hernia surgical procedures performed in Bulgaria is necessary in light of the economic and social burden that poses this health issue. The aim of the study was to perform an economic evaluation of the quality of health results after a conventional elective hernia operation with implanted light and standard meshes.

Methods: The cost of elective hernia operation with standard and light meshes was calculated as a sum of direct and indirect costs. Incremental cost-effectiveness ratio (ICER) for conventional hernia operation was calculated as health improvement was measured in quality-adjusted life years (QALY) reported in a previous study. Deterministic sensitivity analysis was applied to evaluate the changes in the ICER values in case of planned inguinal hernia operation.

Results: The cost of operation with standard meshes is less than operation with light meshes. The difference is in the range 55-200 EUR. The additional costs per one QALY gained for light meshes are far below the recommended threshold values which identified these meshes as cost-effective.

Conclusions: The study presents evidence for cost-effectiveness of light meshes.

Laparoscopic approach in emergency for the treatment of acute incarcerated groin hernia: a systematic review and meta-analysis

PURPOSE

Minimally invasive approach for acute incarcerated groin hernia repair is still debated. To clarify this debate, a literature review was performed.

METHODS

Search was performed in PubMed, Embase, Scopus, Web of Science, and Cochrane databases, founding 28,183 articles.

RESULTS

Fifteen articles, and 433 patients were included (16 bilateral hernia, range 3-8). Three hundred and eighty-eight (75.3%) and 103 patients (22.9%) underwent transabdominal preperitoneal and totally extraperitoneal repair, respectively, and in 5 patients, the defect was buttressed with broad ligament (1.1%) (not specified in 3 patients). Herniated structures were resected in 48 cases (range 1-9). Intraoperative complications and conversion occurred in 4 (range 0-1) and 10 (range 0-3) patients, respectively. Mean operative time and hospital stay ranged between 50 and 147 min, and 2 and 7 days, respectively. Postoperative complications ranged between 1 and 19. Five studies compared laparoscopic and open approaches (163 and 235 patients). Herniated structures were resected in 19 (11.7%) and 42 cases (17.9%) for laparoscopic and open approach, respectively (p = 0.1191). Intraoperative complications and conversion occurred in one (0.6%) and 5 (2.1%) patients (p = 0.4077), and in two (1.2%) and 19 (8.1%) patients (p = 0.0023), in case of laparoscopic or open approach, respectively. Mean operative time and hospital stay were 94.4 ± 40.2 and 102.8 ± 43.7 min, and 4.8 ± 2.2 and 11 ± 3.1 days, in laparoscopic or open approach, respectively. Sixteen (9.8%) and 57 (24.3%) postoperative complications occurred.

CONCLUSION

Laparoscopy seems to be a safe and feasible approach for the treatment of acute incarcerated groin hernia. Further studies are required for definitive conclusions.

Results of robotic TAPP and conventional laparoscopic TAPP in an outpatient setting: a cohort study in Switzerland

Purpose

Recently, robotic surgery has been increasingly performed in hernia surgery. Although feasibility and safety of robot-assisted inguinal hernia repair in an inpatient setting have been already shown, its role in outpatient hernia surgery has not yet been investigated. Thus, this study aimed to compare robot-assisted TAPP (r-TAPP) and conventional laparoscopic TAPP (l-TAPP) in an outpatient setting.

Methods

A prospective database of patients with inguinal hernia treated by l-TAPP or r-TAPP in an outpatient setting during a 1-year period was analyzed in a comparative cohort study. All patients underwent a check-up appointment with their surgeon within 3 days and 6 weeks postoperatively. Data on surgical time, perioperative complications, and postoperative pain were collected. Pain was recorded by using a Verbal Rating Scale (VRS).

Results

Overall, outpatient laparoendoscopic inguinal hernia repair was performed in 58 patients (29 l-TAPP; 29 r-TAPP). Mean age was 57 years (21–81), mean BMI 24.5 kg/m2 (19–33) with no differences between both groups. Most patients reported none or only a low postoperative pain level in both groups (89.6% in l-TAPP group; 100% in r-TAPP), while there was a trend for less pain after r-TAPP. In both groups, there was one case of postoperative hematoma, which was successfully treated by conservative means. No other complications occurred during follow-up in either group and there was no 30-day-readmission, no unplanned overstay or any 30-day mortality in the cohort.

Conclusion

Robot-assisted inguinal hernia surgery can be safely performed in an outpatient setting with a tendency to less pain when compared to the conventional laparoscopic technique. Cost-effectiveness and cost-coverage of outpatient robot-assisted inguinal hernia surgery must be further investigated in times of limited health cost resources and diagnosis-related medical reimbursements.

Acute Scrotal Abdomen: An Epitome of Negligence in Rural India

An inguinoscrotal hernia is considered to be giant when it passes beyond the midpoint of the thigh in a standing position. It is a rare condition that can lead to complications such as obstruction and perforation. Here, we present the case of a 35-year-old male who was diagnosed with a giant inguinoscrotal hernia with transverse colon perforation peritonitis. The patient presented with acute abdomen and septic shock. On presentation, resuscitation was started and an emergency laparotomy was performed. Resection of the gangrenous bowel segment and end jejunostomy was done as damage control surgery. However, despite intensive care and efforts, the patient succumbed due to multiorgan dysfunction syndrome (MODS). This is a rare case of a giant inguinoscrotal hernia with transverse colon perforation peritonitis, leading to MODS and mortality.

The risk of inguinal hernia repair after radical prostatectomy - a population-based cohort study

OBJECTIVES

A nationwide population-based register study will evaluate the risk of postoperative inguinal hernia repair after primary curative-intent treatment of prostate carcinoma (PCa).

BACKGROUND

Several previous studies have suggested an increased risk of inguinal hernia repair after prostatectomy. Only a few studies have compared the risk by PCa treatment modalities.

METHODS

Data were collected between the years 1998 and 2016 from the national hospital discharge database HILMO and between the years 1998 and 2015 from the Finnish cancer registry to identify all men with prostate cancer with data on primary treatment available and information on inguinal hernia diagnoses and procedures among them. The risk of inguinal hernia repair among men managed with prostatectomy was compared to those treated with radiation therapy. Participants treated with prostatectomy were analyzed as a whole and separately stratified into subgroups managed with mini-invasive or open surgery. Multivariate Cox regression with adjustment for age and comorbidities was used for analysis.

RESULTS

A total of 7207 cases of PCa were included in the study. 4595 men were treated with radical prostatectomy and 2612 with radiation therapy. Overall, the risk of hernia repair was higher among men treated with prostatectomy compared to men who received radiation therapy as the primary PCa treatment (HR 1.42, 95% CI 1.14-1.77). The risk did not differ markedly by the prostatectomy method.

CONCLUSION

Prostate cancer treatment with prostatectomy is associated with an increased risk of inguinal hernia surgery than external beam radiation therapy treatment. This risk should be taken into account when planning PCa treatment.

Retrospective analysis of open preperitoneal mesh repair of complex inguinal hernias

PURPOSE

The open posterior approach in the form of either a Stoppa or Wantz operation may be a good alternative technique particularly in the repair of complex inguinal hernias. The term "complex inguinal hernia" designates hernias with a combination of arduous features including large hernia defects, large to giant hernia sacs, multiple recurrences, and bilaterality. In this retrospective analysis, we investigated our results of open posterior repair in view of its feasibility in patients with complex inguinoscrotal hernias.

METHODS

From a series of 845 inguinal hernia patients, we retrospectively reviewed the records of 60 patients with complex inguinal hernias whom were directed to open preperitoneal repair by either a Stoppa or Wantz procedure.

RESULTS

More than 80% of cases were males with large to giant inguinoscrotal hernias. One half of patients had bilateral hernias, and one fourth had recurrent hernias. Early postoperative complications occurred in almost half of patients; however, most of them were minor. The most important early complication in this series was the full recurrences we encountered in the very next morning in two patients. Eighty-three percent of patients left hospital in the first 2 days averaging 1.8 days of hospital stay. The mesh:defect area ratio is < 7 in recurrent hernias while it is > 9 in nonrecurrent cases.

CONCLUSION

The open posterior approach to complex inguinal hernias facilitated both handling and repair of difficult hernias. It was very well tolerated by the patients, and yielded favorable postoperative results. We think the open posterior repair may be a method of choice in the repair of complex inguinal hernias.

Effect of perineural bupivacaine infiltration on reducing inguinodynia in patients undergoing inguinal meshplasty - a randomized controlled trial

INTRODUCTION

Inguinodynia after inguinal meshplasty is a notable complication with an incidence of 13-37%. We wanted to determine if a perineural infiltration of bupivacaine given intraoperatively would reduce the incidence of immediate postoperative pain and inguinodynia.

METHODOLOGY

We have conducted a single-blinded randomized controlled trial including 100 patients with inguinal hernia. Patients in the control group received only spinal anaesthesia. The intervention group received perineural bupivacaine infiltration in addition to spinal anaesthesia. Intraoperatively Ilioinguinal, iliohypogastric, and genital branch of the genitofemoral nerve was identified and 2 mL of 0.5% bupivacaine was given perineurally along these identified nerves. Presence of inguinodynia, immediate post-operative pain scores using the Wong-Baker faces pain scale, duration of analgesics use, use of additional analgesics along with Paracetamol 500 mg tablet, and the length of hospital stay between the groups were recorded.

RESULTS

100 patients were randomized in the study, 49 in control and 51 in the intervention group. Both the group was comparable in terms of demographic characteristics. The intervention group had significantly lower median pain score at 3 h [4 ± 1.662 vs. 6 ± 1.55; p = .0001] and 6 h [4 ± 1.33 vs. 6 ± 1.307; p = .0001]. The incidence of inguinodynia did not significantly differ between the two groups (p-value = .12).

CONCLUSION

Intraoperative Perineural bupivacaine infiltration significantly reduces the immediate postoperative pain. However, there was no significant reduction in the incidence of inguinodynia or additional analgesic requirement.

A Comparative Study of Desarda's Versus Lichtenstein's Technique for Uncomplicated Inguinal Hernia Repair

Purpose Since mesh-related long-term morbidity like chronic groin pain and vas entrapment in patients with an inguinal hernia is a concern, tissue-based repairs should be revaluated. There have been few prospective studies comparing the outcomes of Lichtenstein's technique and Desarda's technique for the repair of uncomplicated inguinal hernias. So, we conducted this prospective study comparing the two techniques. Methods This is a single-center prospective observational study conducted for a period of one year (2019). The patients who underwent surgery for uncomplicated inguinal hernia either by Lichtenstein's technique or Desarda's technique were included in the study. The two techniques were compared with respect to recurrence rates, immediate postoperative pain, chronic groin pain, wound infection, and the time taken to return to activities of daily living (ADL). Results There was no significant difference in the recurrence rates, chronic groin pain, wound infection, or return to ADL between Lichtenstein's technique and Desarda's technique of inguinal hernia repair. The mean duration to return to ADL was lesser when patients underwent Desarda's repair though this difference was not significant. Conclusion Desarda's tissue repair was found comparable to Lichtenstein's mesh repair in terms of recurrence and postoperative morbidity, immediate postoperative pain, chronic groin pain, wound infection, and the time taken to return to ADL. Desarda's technique may be considered as an alternative to mesh-based repairs to avoid long-term mesh-related morbidity for uncomplicated indirect hernias in the younger population.

Lichtenstein versus transabdominal preperitoneal (TAPP) inguinal hernia repair for unilateral non recurrent hernia: A multicenter short term randomized comparative study of clinical outcomes

Background

The repair of inguinal hernia is still one of the most prevalent surgical procedures done worldwide. Among all repair techniques, open Lichtenstein repair is the most globally conducted. In the past few decades, laparoscopic technique for inguinal hernia repair has increased technical demand. Trans-abdominal pre-peritoneal (TAPP) technique is the main approach, which is featured by less postoperative pain and early recovery.

Objective

The current work is a short-term study to make a comparison between open Lichtenstein repair of inguinal hernia as well as laparoscopic trans-abdominal preperitoneal repair of inguinal hernia (TAPP) for unilateral non recurrent hernia regarding intraoperative, postoperative complications and hospital stay.

Patients and methods

The present prospective randomized study recruited 100 male subjects from General Surgery Department of Al-Azhar University Hospitals and Ain Shams university hospitals suffering from oblique inguinal hernia (unilateral non recurrent hernia) with an age above 18 years and good overall health, who were randomized into two groups: Group A: 49 cases were subjected to laparoscopic trans-abdominal pre-peritoneal repair (TAPP). Group B: 51 cases were subjected to open Lichtenstein repair.

Results

This study detected less post-operative pain day 0, day 1, day 7 and 1 month postoperatively. There was no significant difference at 6 months post-operatively.

Conclusion

Finally, we concluded that TAPP repair for inguinal hernia (unilateral non recurrent hernia) safer with less early post-operative pain. Also, it has fewer complications, with a significantly longer operative time.

•

Inguinal hernia can be treated with either open surgical technique (Lichtenstein) or laparoscopic technique (transabdominal preperitoneal repair).

•

TAPP repair for inguinal hernia safer with less early post-operative pain.

•

There is no statistical difference as regard to surgical complications and post-operative recurrence.

Asymptomatic inguinal hernia: does it need surgical repair? A systematic review and meta-analysis

BACKGROUND

The aim of this review is to compare the outcomes of surgical repair versus watchful waiting in asymptomatic or minimally symptomatic inguinal hernias.

METHODS

Preferred reporting items for systematic reviews and meta-analyses guidelines were employed. We analysed primary outcomes: pain, quality of life, pain during daily activities and visual analogue scale (VAS that measures pain at rest and on movement) and secondary outcomes: postoperative complications and recurrence.

RESULTS

Pain and quality of life were not comparable due to differences in the parameters used in different articles. Pain interfering with normal daily activity was evaluated in one study and appears more favourable in the post-repair group respect to the watchful waiting (WW) group (5.1% versus 2.2%). VAS, measured in one study, at 6 months was more favourable in the surgery group (37% versus 44%). After 12 months the outcome was better in the control group than in the repair group (28% versus 30%). Conversion rate of the patient cohorts from watchful waiting to elective surgery was between 35.03% and 57.8%. The meta-analysis did not find significant statistical differences in the two groups examined for postoperative complications [RR = 0.95, 95% CI (0.50, 1.80), P = 0.88], as for hernia recurrence [RR = 1.01, 95% CI (0.50, 2.02), P = 0.98].

CONCLUSION

WW seems to be an acceptable option for the patient with asymptomatic or minimally symptomatic inguinal hernias. Delaying surgical repair until symptoms appear is safe. Acute hernia incarcerations are not particularly frequent. The incidence of chronic pain after the repair is high. Physicians must select patients carefully and explain to them the risks and benefits of surgery.

Implementation and Validation of a Novel and Inexpensive Training Model for Laparoscopic Inguinal Hernia Repair

Purpose: The aim of this study was to develop and validate a reproducible low-cost model useful for the development and acquisition of skills and competencies required for endoscopic hernia repairs. Methods: Ten general surgery residents (PGY3) were instructed to construct the model and perform the maneuvers necessary for the simulation of laparoscopic inguinal hernioplasty by the trans-abdominal pre-peritoneal (TAPP) technique. They practiced for 4 weeks in the model, and the time required to perform simulated hernioplasty by the laparoscopic TAPP technique in the initial session was compared to the time required after 4 weeks of training. Results: The time required to perform the exercise was significantly lower than in the initial session (p < 0.01). The time required by residents to complete the exercise in the initial session was significantly longer than that used by expert surgeons in the same task (p < 0.01), and although a significant difference persisted, this difference was substantially reduced to 3.60 min after the residents completed 4-week training in the model (p < 0.01). An independent expert, blinded to the level of training of the person who performed the exercise, could recognize all residents as novices and all experienced surgeons as experts in the initial session of the exercise with the model, but after 4 weeks of training, they did not recognize 4 of the 10 residents as novices (p < 0.05). Conclusion: The routine implementation of training in this model could be very useful in the laparoscopic inguinal hernioplasty teaching-learning process.

Guidelines for Treatment of Umbilical and Epigastric Hernias From the European and Americas Hernia Societies-A Web-Based Survey on Surgeons' Opinion

Background and aims: The European and Americas Hernia Society's (EHS and AHS) Guidelines on the treatment of primary midline ventral hernias were launched to guide surgeons. As a part of a dissemination plan of the guideline, this study aimed to evaluate the level of consensus between recommendations and the current surgical practices of EHS and AHS members before implementation. Material and methods: A questionnaire was constructed including questions on the current practice of the members and nine selected key recommendations from the guidelines. An on-stage consensus voting was performed at the EHS Congress in Hamburg 2019 followed by a SurveyMonkey sent to all EHS and AHS members. Consensus with a recommendation was defined as an agreement of ≥70%. Results: A total of 178 votes were collected in Hamburg. A further 499/1,754 (28.4%) of EHS and 150/1,100 (13.6%) of AHS members participated in the SurveyMonkey. A consensus was reached for 7/9 (78%) of the recommendations. The two recommendations that did not reach consensus were on indication and the technique used for laparoscopic repair. In current practice, more AHS participants used a preformed patch; 50.7% (76/150) compared with EHS participants 32.1% (160/499), p < 0.001. Conclusion: A consensus was achieved for most recommendations given by the new guideline for the treatment of umbilical and epigastric hernias. Recommendations that did not reach consensus were on indication and technique for laparoscopic repair, which may reflect the lack of evidence on these topics.

BMI: does it predict the need for component separation?

PURPOSE

Patient optimization and selecting the proper technique to repair large incisional hernias is a multifaceted challenge. Body mass index (BMI) is a modifiable variable that may infer higher intra-abdominal pressures and, thus, predict the need for component separation (CS) at the time of surgery, but no data exist to support this. This paper assesses if the ratio of anterior-posterior (AP): transverse (TRSV) abdominal diameter, from pre-operative CT imaging, indicates a larger proportion of intra-abdominal fat and correlates with a hernia defect requiring a component separation for successful tension-free closure.

METHODS

Ninety patients were identified who underwent either an open hernia repair with mesh by primary closure (N = 53) or who required a component separation at the time of surgery (N = 37). Pre-operative CT images were used to measure hernia defect width, AP abdominal diameter, and TRSV abdominal diameter. Quantitative data, nominal data, and logistic regression was used to determine predictors associated with surgical group categorization.

RESULTS

The average hernia defect widths for primary closure and CS were 7.7 ± 3.6 cm (mean ± SD) and 9.8 ± 4.5, respectively (p = 0.015). The average BMI for primary closure was 33.9 ± 7.2 and 33.8 ± 4.9 for those requiring CS (p = 0.924). The AP:TRSV diameter ratios for primary closure and CS were 0.41 ± 0.08 and 0.49 ± 0.10, respectively (p < 0.001). In a multivariate analysis including both defect width and AP:TRSV diameter ratio, only AP:TRSV diameter ratio predicted the need for a CS (p = 0.001) while BMI did not (p = 0.92).

CONCLUSION

Intraabdominal fat distribution measured by AP:TRSV abdominal diameter ratio correlates with successful tension-free fascial closure during incisional hernia repair, while BMI does not.

Evaluation of long‐term chronic pain and outcomes for unilateral vs bilateral circular incision transabdominal preperitoneal inguinal hernia repair

Aim

This study has two aims: to evaluate long‐term chronic pain and complications after circular incision transabdominal preperitoneal inguinal hernia repair (C‐TAPP) and compare outcomes of unilateral and bilateral inguinal hernia cases.

Methods

A postoperative patient questionnaire was used to evaluate pain and complications in 1546 patients who underwent C‐TAPP for simple inguinal hernia. Questions concerned satisfaction with surgery, pain at rest, pain at movement, mesh discomfort on a 10‐point scale, and complications, such as recurrence. Patients were classified into unilateral (U Group) and bilateral (B Group) groups, and propensity score matching was performed to compare long‐term chronic pain and complications.

Results

The questionnaire return rates were 77.5% (1034 cases) and 79.9% (135 cases) in unilateral and bilateral cases. The frequency of moderate‐to‐severe (≥4 points) pain at rest, pain at movement, and mesh discomfort were 3.2%, 3.6%, and 4.5%, respectively. After propensity score matching, no significant differences in pain at rest (P = .726), at movement (P = .712), or mesh discomfort (P = .981) were detected between the U and B groups. Postoperative complications occurred in 2.1% of all patients, and the recurrence rate was 0.3%. In the post‐match comparison, no differences in complications with Clavian‐Dindo classification ≥III (U Group 0.7%, B Group 2.1%, P = .622) were detected.

Conclusion

C‐TAPP, which focuses on the layered structure, showed acceptable results for long‐term chronic pain. Bilateral cases did not have worse pain or complications compared to unilateral cases.

Emergency hernia repair in the elderly: multivariate analysis of morbidity and mortality from an Italian registry

PURPOSE

The incidence of inguinal hernia is higher in elderly because of aging-related diseases like prostatism, bronchitis, collagen laxity. A conservative management is common in elderly to reduce surgery-related risks, however watchful waiting can expose to obstruction and strangulation. The aim of the present study was to assess the impact of emergency surgery in a large series of elderly with complicated groin hernia and to identify the independent risk factors for postoperative morbidity and mortality. The predictive performance of prognostic risk scores has been also assessed.

METHODS

This is a prospective observational study carried out between January 2017 and June 2018 in elderly patients who underwent emergency surgery for complicated hernia in 38 Italian hospitals. Pre-operative, surgical and postoperative data were recorded for each patient. ASA score, Charlson's comorbidity index, P-POSSUM and CR-POSSUM were assessed.

RESULTS

259 patients were recruited, mean age was 80 years. A direct repair without mesh was performed in 62 (23.9%) patients. Explorative laparotomy was performed in 56 (21.6%) patients and bowel resection was necessary in 44 (17%). Mortality occurred in seven (2.8%) patients. Fifty-five (21.2%) patients developed complications, 12 of whom had a major one. At univariate and multivariate analyses, Charlson's comorbidity index ≥ 6, altered mental status, and need for laparotomy were associated with major complications and mortality CONCLUSION: Emergency surgery for complicated hernia is burdened by high morbidity and mortality in elderly patients. Preoperative comorbidity played a pivotal role in predicting complications and mortality and therefore Charlson's comorbidity index could be adopted to select patients for elective operation.

A study of the effectiveness of the bilateral and contralateral occult inguinal hernia repair by total extraperitoneal repair with intraperitoneal examination

PURPOSE

Of the various methods used, the laparoscopic surgical repair of inguinal hernias is widely performed. We aimed to estimate the incidence of bilateral and contralateral occult inguinal hernias in our surgical population and to compare the results of total extraperitoneal repair (TEP) for bilateral and unilateral inguinal hernias, occult and non-occult hernias.

METHODS

We retrospectively reviewed data of patients who underwent TEP for the repair of adult inguinal hernias from January 2012 to November 2018 in our hospital.

RESULTS

Of the data of 259 patients included, 134 (51.7%) and 125 (48.3%) had unilateral and bilateral inguinal hernias, respectively, while 70 patients (27%) were found to have a contralateral occult inguinal hernia, intraoperatively. The mean operative time was 129 ± 48 minutes (range, 43-300 minutes) and 167 ± 55 minutes (range, 85-390 minutes) for the unilateral and bilateral groups, respectively, indicating a significantly longer duration of surgery for the bilateral group (P < .05). Recurrence occurred in 1.5% (5/134) and 0.4% (1/250) of the operated hernias in the unilateral and the bilateral groups, respectively, indicating a significantly lower rate of recurrence in the latter group (P < .05). The two groups showed no statistically significant differences with respect to the remaining perioperative data. The incidence of postoperative complications in occult hernias was not significantly different from that in non-occult hernias.

CONCLUSIONS

Our TEP method, involving a laparoscopic exploration from the intraperitoneal side, can be safely and effectively utilized for the repair of both bilateral and contralateral occult inguinal hernias.

Outcomes After Laparoscopic Transabdominal Pre-Peritoneal Repair (TAPP) For Groin Hernia In A Single Consultant Series

AIM

TAPP repair is an established minimally invasive approach for groin hernia repair. The objective of this study was to report post-operative outcomes after TAPP repair in a single surgeon series and benchmark these against reported outcomes in the literature.

METHODS

All patients who had an elective or emergency TAPP repair of a groin hernia from September 2016 to March 2020 in a district general hospital were retrospectively analysed from the electronic care record (ECR) for post-operative morbidity, re-admission, recurrence and length of hospital stay. The primary outcome of interest, chronic post-operative pain, was assessed via telephone interviews using the European Registry for Abdominal Wall Hernias Quality of Life (EuraHS-QoL) questionnaire.

RESULTS

164 patients, incorporating 190 hernia repairs were included. 155 (94.5%) were men and 9 (5.5%) were women. The median age was 51 (range: 20-81). 160 (97.6%) patients had an elective repair and 4 (2.4%) had an emergency repair. 157 (95.7%) patients underwent a primary inguinal hernia repair, of which 26 (15.8%) had a bilateral inguinal hernia repair. 7 (4.3%) patients had a femoral hernia repair. All procedures were performed by a single consultant surgeon. One emergency patient required conversion to open to allow for resection of ischaemic small bowel, however, the hernia itself was repaired laparoscopically. 94 (57.3%) patients were successfully contacted to provide EuraHS-QoL scores. 13/94 patients (13.8%) complained of chronic pain at rest on an average follow-up of 32.7 months (range: 16-43m). 2/94 (2.1%) patients had mild pain, 9/94 (9.6%) had moderate pain and 2/94 (2.1%) patients had severe pain at rest. 131 (79.9%) TAPP repairs were performed as day case procedures. Median length of stay in those patients who were not day cases was 1 day (range=1-11 days). Post-op morbidity rate was 7.9% (n=13), however, these were minor complications (Clavien-Dindo I/II). Incidence of seroma and haematoma was 1.8% (n=3) each. Re-admission rate was 3% (n=5). Mean follow-up of patients was 21 months (SD 12.6m, range=1-43m). Two patients (1.2%) had a recurrent groin hernia during this time period and one patient (0.6%) had a port site hernia.

CONCLUSION

The outcomes of chronic post-operative pain and rate of recurrence were comparable to those reported in the literature. Re-admission rate was low and there were no major complications. The majority of patients were performed as a day case.

Concurrent laparoscopic totally extraperitoneal inguinal hernia repair and transurethral resection of prostate: Breaking with convention - A retrospective study

AIM

This study aimed to evaluate concurrent laparoscopic totally extraperitoneal (TEP) inguinal hernia repair and transurethral resection of the prostate (TURP) with determination of outcomes.

MATERIALS AND METHODS

This retrospective study was conducted at our hospital, from June 2011 to June 2020. Over 9 years, 17 patients with co-existing uncomplicated unilateral or bilateral inguinal hernia (primary/recurrent) and significant benign prostatic hypertrophy were operated in the same sitting. The following outcomes were compared: duration of the surgery, conversion to open hernia surgery, intraoperative and post-operative complications, duration of hospital stay, recurrence, time taken to resume normal activity and cost of the treatment.

RESULTS

This study included 17 patients with a mean age of 65 years (range of 50-87 years). The average time taken for the surgery was 115 min with no conversion to open hernia repair. The mean post-operative stay was 3.7 days. There were four patients (23.5%) with seromas identified at day 10, only two remained at 6 weeks and none at 12 weeks. None had significant bleeding intraoperatively or postoperatively. There was no superficial or deep wound infection (including mesh infection). There was no recurrence of inguinal hernia. Two patients (11.7%) developed post-TURP urethral stricture and underwent cystoscopic stricturoplasty, 3 and 2.5 months after the initial procedure. The time taken to resume normal activity was 7 (±1) days. The hospital cost is reduced by 25% as compared to the sum of costs when both the operations are done separately.

CONCLUSION

Concurrent TEP inguinal hernia repair and TURP is a practical, safe and cost-effective procedure.

ARE THERE DIFFERENCES IN CHRONIC PAIN AFTER LAPAROSCOPIC INGUINAL HERNIA REPAIR USING THE TRANSABDOMINAL TECHNIQUE COMPARING WITH FIXATION OF THE MESH WITH STAPLES, WITH GLUE OR WITHOUT FIXATION? A CLINICAL RANDOMIZED, DOUBLE-BLIND TRIAL

ABSTRACT BACKGROUND: Regarding postoperative pain, it remains unclear whether non-fixation of the polypropylene prosthesis in transabdominal preperitoneal inguinal hernia repair produces the same outcomes as mesh fixation with glue or tackers. In addition, hernia recurrence is another aspect to be assessed in the comparison between non-fixation and mesh-fixation techniques (tackers and glue). AIMS: This study aimed to evaluate the incidence, quality of pain, and recurrence in patients undergoing laparoscopic inguinal hernioplasty (transabdominal preperitoneal) technique, comparing the fixation of the mesh with tackers versus with glue versus without fixation. METHODS: This is a prospective, double-blind study in which 63 patients presenting with primary unilateral inguinal hernia underwent laparoscopic transabdominal preperitoneal inguinal hernia repair and were randomized into three groups: no mesh fixation (n=21), mesh tacked (n=21), and mesh fixed with fibrin glue (n=21). Patients also responded to questionnaires in order to assess pain and pain quality and were followed up for 2 years. RESULTS: Neither mesh-fixation nor non-fixation techniques were found to affect postoperative chronic pain (p=0.535), but patients undergoing tacker fixation reported more pain descriptors (p=0.0021) and a higher pain index (p=0.002) on the McGill scale in the first 15 postoperative days (T0 and T1). No hernia recurrences were observed. CONCLUSIONS: Both mesh-fixation techniques (tackers and glue) used with the transabdominal preperitoneal approach did not influence the onset of inguinodynia, but tacker fixation was more likely to increase patient sensitivity to pain. Mesh placement without fixation produced the same pain and recurrence outcomes as mesh-fixation techniques. Also, no recurrence was observed in patients without mesh fixation in this study. Consequently, it has become an alternative therapy deserving consideration for hernia repair.

First experience of junior surgeon with laparoscopic totally extraperitoneal herniorrhaphy: Comparison with experienced surgeon in single institution

BACKGROUND/OBJECTIVE

Laparoscopic totally extraperitoneal (TEP) herniorrhaphy is among the current leading inguinal hernia repair methods. This study aimed to investigate the safety and feasibility of a junior surgeon's first experience with laparoscopic TEP herniorrhaphy.

METHODS

A retrospective review was performed between January 2017 and December 2019 to analyze the medical records of patients with inguinal hernia who underwent laparoscopic TEP herniorrhaphy. The operative outcomes and complications of patients undergoing surgery by an experienced surgeon (group A, n = 100) were compared with those undergoing surgery by a junior surgeon (group B, n = 100).

RESULTS

The mean operative time for group B was significantly longer than that for group A (52.0 ± 15.1 min vs 60.1 ± 17.4 min; P = 0.03). A statistical difference was also found in the mean postoperative stay (1.1 ± 0.3 d vs 1.4 ± 0.7 d; P = 0.02) between the two groups. There were 2 and 3 cases of recurrence in these two groups respectively (P = 0.72). Considering the operating time as a variable of learning curve, significant stabilization can be achieved after 30 cases (67.3 ± 17.8 min vs 53.1 ± 11.1 min; P = 0.02).

CONCLUSIONS

The surgical outcomes of laparoscopic TEP herniorrhaphy performed by a well-trained junior surgeon were similar to the outcomes of an experience surgeon.

Modified Halsted's operation for inguinal hernia repair: A new technique

Background

Inguinal hernia is a frequent problem presented to surgical clinic in Iraq. Surgical treatment options for inguinal hernia are numerous, selecting the appropriate method or technique depends on different factors.

Aim of study

To find a new technique for open inguinal hernia repair with no recurrence even in recurrent cases, without major complications during or after surgery, and can be used even by new surgeons with little experience.

Patients & methods

A retrospective cross sectional study conducted in the Medical City teaching hospital and Private Hospitals in Baghdad, during the period from January 1, 2000, to December 30, 2016 on convenient sample of 408 Iraqi patients with inguinal hernia. The patients were treated by modified Halsted's technique by open surgery applying polypropylene mesh. The patients were followed up through frequent visits and phone calls to assess the recurrence and complications.

Results

No recurrence of inguinal hernia was reported after 5-10 years follow up, while 94.9% of patients reported postoperative complications commonly oedema of spermatic cord. There was a highly significant association between male gender hernia patients and post Modified Halsted operation complications (p < 0.001). A highly significant association was observed between direct hernia and post Modified Halsted operation complications (p < 0.001). The significant risk factors related to complications were anemia and collagen disease.

Conclusions

The modified Halsted's operation for inguinal hernia repair is effective in treatment of inguinal hernia with low recurrence and complications rate.

Treatment of recurrent inguinal hernia after TransInguinal PrePeritoneal (TIPP) surgery: feasibility and outcomes in a case series

BACKGROUND

TransInguinal PrePeritoneal (TIPP) inguinal hernia repair (IHR) combines an open anterior approach with a preperitoneal position of the mesh. Advantages include reduced chronic postoperative inguinal pain, low recurrence rates and quick recovery. Critics have expressed concerns that recurrent IHR after TIPP could be difficult and with an increased risk of complications due to the formation of scar tissue in both the anterior and posterior anatomical inguinal planes. This study reports feasibility and outcomes of recurrent IHR after TIPP repair.

METHODS

Patients who underwent recurrent IHR after TIPP between January 2013 and January 2015 in a single hernia-dedicated teaching hospital were included. Exclusion criteria were femoral hernia, incarcerated hernia and reasons for unreliable follow-up. Electronic medical records were assessed retrospectively to register surgical outcomes and complications.

RESULTS

Thirty-three patients underwent surgical repair of recurrent inguinal hernia after TIPP. Twenty patients were treated with a "re-TIPP when possible" strategy; resulting in 13 successful re-TIPPs and 7 conversions to Lichtenstein repair. Eleven patients underwent a primary Lichtenstein's repair, the remaining two patients underwent recurrent IHR using other techniques (TransREctus sheath PrePeritoneal and TransAbdominal PrePeritoneal repair). Mean time of surgery was 44.7 min (standard deviation 16.7). There was one patient (3.0%) with a re-recurrent inguinal hernia during follow-up. Other minor complications included urinary tract infection.

CONCLUSION

These results indicate that after TIPP it is feasible and safe to perform re-surgery for recurrent inguinal hernia with an anterior approach again. For these recurrences, a Lichtenstein repair can be performed, or a "re-TIPP if possible" strategy can be applied by experienced TIPP surgeons, tailored to the intraoperative findings. Whether a re-TIPP has advantages over Lichtenstein should be evaluated in a prospective manner.

Comparison of Common Postoperative Complications Between Lichtenstein Open Repair and Laparoscopic Transabdominal Pre-peritoneal (TAPP) Repair for Unilateral Inguinal Hernia

Introduction

Laparoscopic transabdominal pre-peritoneal (TAPP) repair is a minimally invasive technique that is becoming the procedure of choice among surgeons for inguinal hernia repair and research work is still going on comparing TAPP repair with Lichtenstein open mesh repair. The objective of our study is to compare common postoperative complications in Lichtenstein mesh repair and laparoscopic TAPP repair for unilateral inguinal hernia in our unit.

Methods

Between August 2016 and August 2018, patients with unilateral inguinal hernia and ASA grade I/II were selected in the surgical outpatient department (OPD) and prospectively randomized into two equal groups. Lichtenstein open mesh repair was done in Group-I and laparoscopic TAPP repair in Group-II. The visual analog scale (VAS) was used for the assessment of the intensity of pain.

Results

A total of 100 patients with a diagnosis of unilateral inguinal hernia were included in the study. Overall, our study showed that there was less postoperative pain in those patients who underwent TAPP repair as compared to patients with Lichtenstein mesh repair (p= <0.05). There were more postoperative complications in Group-I as compared to Group-II.

Conclusion

Laparoscopic TAPP repair for inguinal hernia is associated with less postoperative pain and other postoperative complications in addition to a shorter hospital stay as compared to Lichtenstein mesh repair. Thus, this is helping in the early return of patients to daily life activities.

An inguinal hernia that arose after robot-assisted radical prostatectomy and the repair of an intraoperative external iliac vein injury: A case report

This case involved a 63-year-old man. He underwent robot-assisted radical prostatectomy (RARP) for prostate cancer. One year after the operation, he consulted our hospital about left inguinal swelling. Under a diagnosis of a left external inguinal hernia, transabdominal preperitoneal repair (TAPP) was performed under general anesthesia. The inside of the hernia orifice had been damaged by the RARP, and the resultant fibrosis was so marked that it was difficult to dissect the preperitoneal space. Furthermore, an external iliac vein injury occurred during the operation. The bleeding was controlled, and we used laparoscopic continuous non-absorbable sutures to repair the external iliac vein injury. The number of TAPP procedures performed after radical prostatectomy has been increasing in recent years, but dissecting the preperitoneal space inside a hernia orifice is difficult. Although external iliac vein injuries are rare complications of TAPP procedures, they can be laparoscopically repaired.

Non reducible inguinal hernias in Malawi: an occupational hazard

PURPOSE

Inguinal hernias are one of the most common surgical conditions worldwide. Due to limited surgical access in low- and middle-income countries, many hernias present emergently; however, data on the resultant outcome disparities is limited. We, therefore, sought to describe the epidemiology, clinical features, and outcomes of incarcerated inguinal hernias at a tertiary center in Malawi.

METHODS

This is a retrospective analysis of the acute care surgery registry at Kamuzu Central Hospital in Lilongwe, Malawi. All patients > 13 years admitted with a non-reducible inguinal hernia from 2013 to 2019 were included. The primary outcome was in-hospital mortality. A Poisson multivariable regression determined factors associated with increased risk of mortality.

RESULTS

A total of 297 patients presented with non-reducible inguinal hernias, the majority of which were young (median age 38), male (93.6%), farmers (47.8%). Of the 81% who underwent surgery, 55% were delayed ≥ 24 h. 19.5% of hernias were strangulated. Overall mortality was 5.4%. Increased age (RR 1.06, 95% CI 1.01-1.12), shock index ≥ 1 (RR 4.82, 95% CI 1.45-16.09), and delay ≥ 24 h from presentation to operative intervention (RR 11.24, 95% CI 1.55-81.34) resulted in an increase in relative risk of mortality.

CONCLUSION

Non-reducible inguinal hernias largely affect young male farmers in Malawi. Delays to care can limit economic productivity for this rural population, as well as, yield considerable risk of mortality. While specific patient and institutional factors must be further elucidated, increased awareness, public health prioritization, and surgical capacity building is needed to reduce further hernia-related morbidity and mortality.