Closure of a direct inguinal hernia defect in laparoscopic repair with barbed suture: a simple method to prevent seroma formation?

To close, not to close, or to act bigger? Managing the defect of large direct inguinal hernia to reduce the risk of recurrence during laparoscopic TAPP repair: a retrospective cohort study

Hernia recurrence is a common complication after inguinal hernia repair. Recent studies suggest that laparoscopic mesh repair with closure of direct hernia defects can reduce recurrence rates. Our study examines the effectiveness of this approach. A retrospective, multi-center cohort study was conducted on cases performed from January 2013 to April 2021. Patients with direct inguinal hernias (M3 according to EHS classification) undergoing TAPP were included. Three groups were present: closed-defect group, non-closed placing a standard-sized mesh group or non-closed placing an XL-sized mesh group. A 2-year follow-up was recorded. A total of 158 direct M3 inguinal hernias in 110 patients who underwent surgery were present. After propensity score matching at a 1:1 ratio, 22 patients for each group were analyzed. The mean age of patients was 62 years (41-84); with the majority being male (84.8%). 22 patients (40 hernias) underwent closure of the defect; 22 patients (39 hernias) did not undergo closure and used a standard-sized mesh; 22 patients (27 hernias) did not undergo closure and used an XL-sized mesh. There were 5 recurrences at 1 year post-operatively: all in the non-closure group with standard-sized mesh. This difference was statistically significant (p = 0.044). There were 7 recurrences (6.6%) at 2 years post-operatively: 6 in the non-closure group with standard-sized mesh and 1 in the non-closure group with XL-sized mesh (p = 0.007). Closing large direct inguinal hernia defects has shown promise in reducing early recurrence rates. However, conducting larger RCTs in the future could provide more conclusive evidence that might impact the way we approach laparoscopic inguinal hernia repair.

The effect of internal orifice narrowing in laparoscopic inguinoscrotal hernia repair to prevent seroma formation: a prospective double-blind randomized controlled trial

OBJECTIVES

Seroma represents the most prevalent postoperative complication following laparoscopic inguinal hernia repair, particularly in the case of large inguinoscrotal hernias. This randomized controlled trial was undertaken with the objective of assessing the effects of internal orifice narrowing achieved by suturing the divided distal hernia sac in laparoscopic repair of indirect inguinoscrotal hernias.

METHODS

A total of 58 patients aged 18 years or older, were randomized into two groups: Group I, which underwent internal orifice narrowing, and Group II, which served as the control without narrowing. The study's primary endpoint was the incidence and volume of seroma in the inguinal region on postoperative days 1 and 7, as well as at 1, 3, and 6 months following the procedure. Secondary outcomes encompassed metrics like total operative time, acute and chronic pain levels, duration of hospital stay, recurrence rates, and the occurrence of any additional complications.

RESULTS

In comparison to the control group, the experimental group exhibited a significantly lower incidence of seroma formation at 7 days (P = 0.001). Furthermore, the ultrasonic assessment indicated a reduced seroma volume in the operative group on postoperative day 7 (8.84 ± 17.71 vs. 52.39 ± 70.78 mL; P < 0.001). Acute pain levels and hospital stay were similar between the two groups (1.22 ± 0.76 vs. 1.04 ± 0.53, P = 0.073; 1.22 ± 0.07 vs. 1.19 ± 0.08, P = 0.627, respectively). Notably, neither chronic pain nor early recurrence, nor any other postoperative complications were observed in either group throughout the follow-up period, which extended for at least 6 months (range: 6-18 months).

CONCLUSION

In the context of laparoscopic inguinoscrotal hernia repair, the incidence and volume of seroma can be significantly reduced through the implementation of internal orifice narrowing achieved by suturing the divided distal hernia sac. And, this reduction in seroma formation was not associated elevation in postoperative pain levels or recurrence rates.

Indocyanine Green Fluorescent Lymphography During Open Inguinal Hernia Repair: Relationship Between Lymphatic Vessel Injury and Postoperative Hydrocele

BACKGROUND

This prospective case series analyzed patients who underwent indocyanine green (ICG) fluorescent lymphography during open inguinal hernia repair. The aim of this study was to investigate the association between ICG leakage and postoperative hydroceles in patients who underwent inguinal hernia repair.

MATERIALS AND METHODS

Data were analyzed from 40 patients who underwent primary open hernia repair between October 2020 and June 2021 (44 cases in total). Hydroceles were categorized into two types: symptomatic and "ultrasonic" (detected only by ultrasound imaging).

RESULTS

In the univariate analysis, hernia type (p = 0.044) and ICG leakage (p = 0.007) were independent risk factors for postoperative ultrasonic hydroceles. Additionally, mesh type (p = 0.043) and ICG leakage (p = 0.025) were independent risk factors for postoperative symptomatic hydroceles. In the multivariate analysis, ICG leakage (p = 0.034) was an independent risk factor for postoperative ultrasonic hydroceles.

CONCLUSIONS

ICG leakage after inguinal hernia repair was independently associated with postoperative ultrasonic and symptomatic hydroceles. These findings suggest a relationship between lymphatic vessel injury and the incidence of postoperative hydroceles.

Clinical efficacy of laparoscopic closed hernia ring combined with a patch repair for Gilbert type III indirect inguinal hernia

Purpose

The incidence of seroma and postoperative pain after Gilbert type III inguinal hernia repair is high. To reduce postoperative complications, this study investigated the clinical efficacy of laparoscopic closed hernia ring combined with a patch repair for Gilbert type III indirect inguinal hernia.

Methods

Through a prospective randomized controlled study, a total of 193 patients with Gilbert type III indirect inguinal hernia admitted to Nanchong Central Hospital affiliated with Chuanbei Medical College from May 2020 to December 2021 were selected and randomly divided into the inner ring closed group (85 patients) and the inner ring non-closed group (95 patients). The patients in both groups underwent laparoscopic tension-free repair of their inguinal hernias. General information such as operative time, postoperative hospital stay, and hospital cost were compared between the two groups, and the patients were followed up at 1, 7, 14, 21, and 28 days and then 3, 6, and 12 months after surgery to compare complications such as incidence of seroma, volume of the seroma fluid, incidence of pain, and visual analogue scale (VAS) pain score.

Results

There was no conversion to open procedures in any of the patients. The operation time of the closed group was significantly longer than that of the non-closed group (64.2 ± 12.2 vs. 55.3 ± 9.5 min, P < 0.01). The proportion of patients with postoperative pain in the two groups was 39 (46%) vs. 59 (62%), P = 0.029 on 7 days; 17 (20%) vs. 33 (35%), P = 0.028 on 14 days; and 6 (7%) vs. 22 (23%), P = 0.003 on 21 days in the postoperative closed group and was significantly lower than that in the non-closed group, while we found that the non-closed group had a higher VAS pain score than that of the closed group (2.36 ± 0.61 vs. 1.95 ± 0.71, P = 0.003 on 7 days and 2.12 ± 0.49 vs. 1.65 ± 0.49, P = 0.002 on 14 days) after surgery according to the statistical results of the VAS pain score. The incidence of postoperative seroma and the amount of seroma fluid decreased gradually in both groups, but when comparing the two groups, the proportion of cases of seroma in the closed group on 7 days [45 (53%) vs. 79 (83%), P < 0.01]; 14 days [23 (27%) vs. 43 (45%), P = 0.011]; and 21 days [10 (12%) vs. 29 (31%), P = 0.002] after the operation were significantly less than that in the non-closed group. For the comparison of the amount of seroma fluid between the groups, the seroma fluid volume in the non-closed group was greater than that in the closed group (34.48 ± 20.40 vs. 43.87 ± 16.40 ml, P = 0.006, 7 days) and (21.79 ± 8.42 vs. 30.74 ± 10.39 ml, P = 0.002, 14 days) after surgery. There were no differences in the length of stay, total hospital costs, or postoperative complications (urinary retention, intestinal obstruction, nausea, vomiting, bleeding, and infection) between the two groups, and the differences were not statistically significant (P > 0.05). The postoperative follow-up period was 3-20 months, and no chronic pain or recurrence occurred during the postoperative follow-up period in either group.

Conclusions

Closure of the hernia ring is safe and effective for laparoscopic hernia repair for Gilbert type III inguinal hernia, and it significantly reduces the incidence of postoperative seroma and further reduces the postoperative pain without increasing the risk of postoperative infection and recurrence.

Testicular hydrocele postoperative laparoscopic inguinal hernia repair may be caused lymphatic leakage proved by indocyanine fluorescent dye: A case report

INTRODUCTION AND IMPORTANCE

Indocyanine green (ICG) fluorescent lymphography is reportedly a safe and effective method to diagnosis of lymphatic leakage. We report a case of a patient who underwent ICG fluorescent lymphography during laparoscopic inguinal hernia repair.

CASE PRESENTATION

A 59-year-old man was referred to our department for the treatment of both inguinal hernias, during which laparoscopic ICG lymphography was performed. The patient had a history of open left inguinal indirect hernia repair at the age of 3 years. Following the induction of general anesthesia, 0.25 mg ICG was injected into both testicles, and the scrotum was gently massaged, after which laparoscopic inguinal hernia repair was performed. During the operation, ICG fluorescence was observed in two lymphatic vessels in the spermatic cord. The ICG fluorescent vessels were injured only on the left side due to strong adhesion between lymphatic vessels and the hernia sac, possibly due to a previous operation. ICG leakage was observed on the gauze. Laparoscopic inguinal hernia repair (transabdominal preperitoneal approach [TAPP]) was performed. The patient was discharged 1 day postoperatively. He had a slight postoperative ultrasonic hydrocele only in the left groin that was detected at the follow-up clinic 9 days postoperatively during ultrasonic examination (ultrasonic hydrocele).

CLINICAL DISCUSSION

We report the use of ICG fluorescent lymphography during laparoscopic inguinal hernia repair in a patient who developed a postoperative ultrasonic hydrocele.

CONCLUSION

This case may indicate a relationship between lymphatic vessel injury and hydroceles.

Fascia defect closure versus non-closure in minimal invasive direct inguinal hernia mesh repair: a systematic review and meta-analysis of real-world evidence

PURPOSE

Laparoscopic and robotic inguinal hernia mesh repair are both common surgical procedures worldwide. Postoperative hernia recurrence and seroma formation are important concerns. In ventral hernia, primary defect closure in laparoscopic surgery reduces the recurrence rate. However, there is no synthetic evidence of direct inguinal hernia defect closure versus non-closure in minimal invasive surgery. Therefore, this study investigated the efficacy of defect closure in patients undergoing minimal invasive direct inguinal hernia mesh repair.

METHODS

Eligible studies were identified through a search of PubMed, Embase, Cochrane Library, and CINAHL from their inception until March 2022. Studies examining defect closure in laparoscopic direct inguinal hernia repair were included, and a meta-analysis was performed using the random-effect model. Sensitivity analyses were performed by removing one study at a time. The primary outcomes were hernia recurrence and seroma formation. Acute and chronic postoperative pain, operation time, and length of hospital stay were the secondary outcomes.

RESULTS

Five nonrandomized studies and one randomized controlled trial were included. Pooled analysis revealed defect closure might reduce the hernia recurrence rate (risk difference, - 0.02; 95% confidence interval [CI] - 0.04 to - 0.00; p = 0.02). The result of seroma formation (odds ratio, 0.49; 95% CI 0.17-1.46; p = 0.20) showed no significant difference. Moreover, no significant differences were observed in acute postoperative pain, chronic pain, length of hospital stay, and operation time.

CONCLUSIONS

Our study indicated defect closure seems to be an option to reduce the direct inguinal hernia recurrence rate. No significant benefits were shown in seroma formation and other secondary outcomes. Our study was mostly based on nonrandomized studies and underestimated the effect of defect closure; thus, further high-quality studies are required to draw definitive conclusions.

Efficacy of laparoscopic inguinal hernia in day surgery mode and inpatient surgery mode in China: A meta-analysis

BACKGROUND

In China, laparoscopic inguinal hernia repair (LIHR) under the day surgery mode (DSM) has developed rapidly as an important surgical method for inguinal hernia repair, and it has unique advantages in many aspects. Compared with inpatient surgery mode (ISM), there are some differences in intraoperative and postoperative related indicators, hospitalization costs, and patient satisfaction. Many studies have shown that LIHR in DSM can significantly shorten hospital stay, effectively reduce hospitalization costs, and improve patient satisfaction. Accordingly, this study aimed to compare the differences in intraoperative and postoperative related indicators, hospitalization costs, and patient satisfaction of LIHR between DSM and ISM in China.

METHODS

The PubMed/Medline, EMBASE, Cochrane Library, China National Knowledge Infrastructure, and Wan Fang databases were searched for randomized controlled trials, cohort studies from the establishment of the database to July 1, 2022. Odds ratio (OR), mean difference, standardized mean difference (SMD), and 95% confidence interval were selected as the effect scale indices for the evaluation of the difference in hospitalization costs, hospital stay, operation time, recovery time, complications, and patient satisfaction. All of these were compared using RevMan 5.3 Software (The Cochrane Collaboration, Copenhagen, Denmark).

RESULTS

Nine studies involving 1176 patients, 590 in the DSM group and 586 in the ISM group, were included. The hospital stay (d) (SMD = -7.27, 95% confidence interval, CI: -8.68 to -5.87, P  < .001), hospitalization costs (SMD = -7.89, 95% CI: -10.25 to -5.53, P  < .001) in DSM group were significantly lower than the ISM group. Additionally, the patient dissatisfaction (OR = 0.05, 95% CI: 0.01-0.17, P < .001) in DSM group was significantly lower than the ISM group. Nevertheless, no significant differences were found in the operation time (minute) (mean difference = -0.32, 95% CI: -1.78 to 1.14, P = .67), recovery time (h) (SMD = -3.27, 95% CI: -6.95 to 0.41, P  = .08), and postoperative complications (OR = 0.80, 95% CI: 0.47-1.36, P = .41) between the 2 groups.

CONCLUSION

In China, compared with ISM, LIHR under DSM can significantly shorten hospital stay, greatly reduce hospitalization costs, and significantly improve patient satisfaction. There were no significant differences in operation time, recovery time and postoperative complications.

Laparoscopic total extraperitoneal (TEP) inguinal hernia repair with preperitoneal closed-suction drainage reduced postoperative complications

BACKGROUND

Although laparoscopic total extraperitoneal (TEP) inguinal hernia repair has the advantages of less bleeding, less trauma, less pain, and fast recovery, there are several issues that need to be addressed. This study aims to evaluate the effectiveness of preperitoneal closed‑suction drainage on reducing postoperative complications in TEP inguinal hernia repair.

METHODS

A retrospective analysis of 122 patients who underwent TEP inguinal hernia repair between June 2018 and June 2021 was performed. The patients were divided into the drainage group and the non-drainage group according to whether the drainage tube was placed or not. Clinical data, surgical procedures and outcome of these patients were collected and analyzed to assess the effectiveness of drainage.

RESULTS

A total of 122 patients undergoing TEP surgery were screened, of which 22 were excluded. Most of the patients were male with right indirect inguinal hernia. There was no difference in the mean length of hospital stay between the two groups. Postoperative pain was alleviated by preperitoneal closed‑suction drainage 24 h after operation (p = 0.03). The rate of complications such as scrotal edema, seroma and urinary retention in the drainage group was significantly lower than that in the non-drainage group (p < 0.05). Multivariate regression analysis showed that drainage was beneficial to reduce postoperative complications (OR, 0.015; 95% CI, 0.002-0.140; p < 0.01). In addition, it was worth noting that in subgroup analysis, patients with hernia sac volume > 10 cm³ might receive more clinical benefits by placing drainage tube.

CONCLUSION

In TEP inguinal hernia repair, placing drainage tube is a simple and feasible traditional surgical treatment, which can promote postoperative recovery without increasing the risk of infection, especially in patients with large hernia sac volume.

A newer method of seroma reduction by fenestration of pseudo-sac during laparoscopic repair of direct inguinal hernia: A randomised, controlled pilot study

Background

Minimally invasive surgeries for inguinal hernia repair have been reduced post-operative morbidity. However, certain complications such as seroma formation are unavoidable. In this study, we introduce a newer technique of reducing seroma formation by fenestration of the pseudo-sac (thickened transversalis fascia) in patients undergoing laparoscopic hernia repair for uncomplicated direct inguinal hernia.

Patients and Methods

A randomised, controlled pilot study was conducted from January 2019 to December 2020 for the patients undergoing laparoscopic hernia repair for uncomplicated direct inguinal hernia. Study participants were randomised into interventional group and control groups. Demographics, operative duration and complications including post-operative pain and seroma on days 1, 10 and 30 were analysed between both the groups.

Results

A total of 20 cases with 30 hernias were included in the study. Demographic data were comparable between the two groups. The intervention group showed a statistically significant decrease in the incidence of seroma formation on the post-operative day 10 (13.3% vs. 46.6%, P = 0.046). The mean volume of seroma on day 10 was also less compared to the non-fenestration group (2.5 vs. 6.58 ml, P = 0.048). After the 30^th day, no patient had a presence of seroma. There were no statistically significant differences in terms of mean operative duration, post-operative pain and other complications.

Conclusion

Fenestration of pseudo-sac in laparoscopic hernia repair for uncomplicated direct inguinal hernia is a simple and effective technique. It has reduced the incidence and volume of seroma formation without any increased risk of infection, acute or chronic pain and recurrence.

Does closure of the direct hernia defect in laparoscopic inguinal herniotomy reduce the risk of recurrence and seroma formation?: a systematic review and meta-analysis

PURPOSE

Recurrence is a known complication to inguinal herniotomy with an incidence of 10 to 15 percent (Hernia Surge Group in Hernia 22:165, 2018). Previous studies have shown that direct hernia or large defects are risk factors for postoperative seroma formation (Morito et al. in Surg Endosc https://doi.org/10.1007/s00464-021-08814-2 , 2021). These types of defects are often closed during open herniotomy (Rosenberg et al. in Dan Med Bull 58: C4243, 2011). This is not routine during laparoscopic surgery. A recent study has indicated that closure of the medial defect during laparoscopy may reduce recurrence and seroma formation. As a result, we performed the present systematic review to evaluate the efficacy of this add on to the standard procedure.

METHODS

An extensive search was carried out in PubMed and Embase. All studies involving adults undergoing laparoscopic direct hernioplasty were enrolled and screened with predefined inclusion criteria, to be part of a systematic review with data synthesis and meta-analysis.

RESULTS

The search identified 108 publications of which four met the inclusion criteria. Two studies (Ng et al. in Hernia 24:1093-1098, 2020; Usmani et al. in Hernia 24:167-171, 2020) showed reduced risk of recurrence. The remaining studies (Zhu et al. in Surg Laparosc Endosc Percutan Tech 29:18-21, 2019; Li and Zhang in Surg Endosc 32:1082-1086, 2018) reported no recurrence in any of the patients included. Two articles (Usmani et al. in Hernia 24:167-171, 2020; Zhu et al. in Surg Laparosc Endosc Percutan Tech 29:18-21, 2019) showed a decrease in risk of postoperative seroma, one showed a significant increase (Ng et al. in Hernia 24:1093-1098, 2020). None of the included studies showed an increase in the risk of postoperative pain or postoperative complications.

CONCLUSION

This review suggests that closure versus non-closure of the medial hernia defect in laparoscopic inguinal hernioplasty reduces the risk of recurrence and seroma formation without an increase in postoperative pain or complications. Further randomized controlled trials are needed for further evaluation.

Curative effect of different drainage methods on laparoscopic inguinal hernia repair: A meta-analysis

BACKGROUND

Laparoscopic inguinal hernia repair has developed rapidly as an important surgical method for inguinal hernia repair; however, postoperative complications, especially postoperative seroma, are becoming an important factor hindering its development. Many studies have shown that placing a negative-pressure drainage tube in the preperitoneal space can effectively reduce postoperative seromas. Accordingly, this study aimed to compare differences in postoperative seroma between surgical procedures with drainage tubes (DRG) and those without drainage tubes (nonDRG).

METHODS

PubMed/Medline, EMBASE, Cochrane Library, China National Knowledge Infrastructure, and Wanfang databases were searched from the establishment of the database to May 1, 2021. Odds ratio (OR), mean difference (MD), standardized mean difference (SMD), and 95% confidence interval (CI) were selected as the effect scale indices for the evaluation of the difference in seroma, operation time, hospital stay time, blood loss, and recovery time. All of these were compared using RevMan 5.3 Software.

RESULTS

Sixteen studies involving 4369 patients, 2856 in the DRG group and 1513 in the nonDRG group, were included. The incidence of seroma in the DRG group was lower than that in the nonDRG group (OR = 0.16, 95% CI: 0.07-0.35, P < .001). Additionally, the operation time (min) in the DRG group was longer than that in the nonDRG group (MD = 3.67, 95% CI: 2.18-5.17, P < .001). Nevertheless, no significant differences were found in hospital stay (days) (SMD = 0.22, 95% CI: -0.10-0.54, P = .17), blood loss (mL) (MD = 0.28, 95% CI: -0.14-0.69, P = .19), and recovery time (h) (SMD = 0.54, 95% CI: -0.60-1.69, P = .35) between the 2 groups.

CONCLUSION

Despite the slightly prolonged operation time, negative pressure drainage in the preperitoneal space during laparoscopic inguinal hernia repair can significantly reduce the occurrence of postoperative seroma without increasing blood loss, recovery, and hospital stay.

Evaluating Pull-Out Strength of Barbed Suture In Vitro by Using Porcine Tissue and Polydimethylsiloxane (PDMS)

Using barbed thread lifting for facial rejuvenation has become popular these days due to its minimally invasive procedures with reduced complications. However, only limited studies regarding its mechanical properties for face suspension were published. The aim of this study was to evaluate suture-holding ability regarding its facelift property, and different specimens were tested in order to establish an in vitro model. Fresh porcine tissue and the synthetic material polydimethylsiloxane (PDMS) were selected to simulate human skin for evaluating barbed suture pull-out strength by the universal material testing machine. The results showed that the pull-out strength of barbs between different porcine tissues varied without consistency. By contrast, PDMS (30:1) showed more consistent pull-out strength in each testing, and the average maximum load force was close to porcine tissue. Furthermore, after submerging barbed sutures in PBS for 0 days (T0), 7 days (T7) and 14 days (T14), a trend of decreased average maximum load force, displacement and force of 1.5 mm/2 mm/3 mm displacement could be detected by in vitro testing with PDMS (30:1). These results provide support for using PDMS (30:1) to evaluate suture pull-out strength and holding/lifting capacities in vitro to obtain consistent and objective information for evaluating substantial equivalence of devices. The established in vitro method could be used for the future development of barbed thread lifting technology.

Effect of complete reduction of hernia sac and transection of hernia sac during laparoscopic indirect inguinal hernia repair on seroma

Introduction

This study investigated the effect of complete reduction and transection of the hernia sac during laparoscopic indirect inguinal hernia repair on seroma.

Methods

Retrospective analysis was performed on 1763 cases undergoing laparoscopic indirect inguinal hernia repair in three centers from January 2017 to September 2019, among them, 311 patients with transection of hernia sac and 1452 patients with reduction of hernia sac, the data of the two groups were tested by t-test. Logistic univariate analysis was performed on 233 cases of postoperative seroma, and variables p < 0.05 in univariate analysis were included for multivariate analysis. Then, the transection group and the reduction group were matched with 1:1 propensity score matching, and the caliper value was set at 0.05. Finally, 274 patients matched in each group were analyzed by univariate analysis again to evaluate whether the transection of hernia sac had an impact on postoperative seroma.

Results

The results of univariate analysis of 233 patients with postoperative seroma showed that: ASA-3 p = 0.031, classification-L3 p < 0.001, surgery-TEP p < 0.001, transect group p = 0.005. The results of multivariate analysis show that: ASA-3 p < 0.001, classification-L3 p < 0.001, surgery-TEP p < 0.001, transect group p = 0.020. The results of univariate analysis after propensity score matching showed that transection of the hernia sac is significant for postoperative seroma (p < 0.001).

Conclusion

Transection of the hernia sac during laparoscopic indirect inguinal hernia repair can significantly lead to postoperative seroma.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01599-8.

Indocyanine green fluorescent lymphography during open inguinal hernia repair in a patient who developed postoperative ultrasonic hydrocele: A case report

BACKGROUND

To our knowledge, no reports of indocyanine green (ICG) fluorescent lymphography during inguinal hernia repair currently exist. We report the case of a patient who underwent ICG fluorescent lymphography during open inguinal hernia repair.

CASE PRESENTATION

A 63-year-old man was referred to our department for treatment of a right inguinal hernia, during which an ICG lymphography was performed. The patient had a history of robot-assisted radical prostatectomy for prostate cancer. Following induction of general anesthesia, 0.25 mg of ICG was injected into the right testicle and the scrotum was gently massaged, after which an open inguinal hernia repair was performed. During the operation, fluorescence from the ICG was observed in two lymphatic vessels in the spermatic cord. The ICG fluorescent vessels were resected due to the strong adhesion between the lymphatic vessels and the hernia sac. ICG leakage was observed in the resected vessels. An open tension-free technique was performed using an open mesh plug. The patient was discharged one day postoperatively. The histological diagnosis of the resected vessel was a lymphatic vessel. He had a slight postoperative hydrocele that was detected at the follow-up clinic 10 days postoperatively during ultrasonic examination (ultrasonic hydrocele).

CONCLUSION

We report the use of ICG fluorescent lymphography during open inguinal hernia repair in a patient who developed postoperative ultrasonic hydrocele. This case may indicate a relationship between lymphatic vessel injury and hydrocele.

Investigation of risk factors for postoperative seroma/hematoma after TAPP

BACKGROUND

Seroma/hematoma formation is the most common postoperative complication after laparoscopic inguinal hernia repair. The occurrence of seroma/hematoma remains unclear. The aim of this study was to determine the risk factors for seroma/hematoma formation after transabdominal preperitoneal patch plasty (TAPP).

METHODS

The study enrolled 359 groin hernia patients treated by TAPP at Kumamoto Medical Center between 2014 and 2019. The primary outcome was risk factors for postoperative seroma/hematoma formation after TAPP. The secondary outcomes included recurrence of hernia, postoperative complications, and hospital stay.

RESULTS

Among the 359 patients, the incidence rate of seroma/hematoma was 16% (n = 69 patients), and the recurrence rate was 0.3% (n = 1 patient, both sides). In total, there were 452 lesions. Japan Hernia Society (JHS) type II was present in 23% (n = 106) of the total cases but was significantly more common in the postoperative seroma/hematoma group (40%; P = 0.0082). Meanwhile, JHS type I-3 comprised 27% of the total JHS type I group but was significantly higher in the postoperative seroma/hematoma JHS type I group (40%; P = 0.016). Compared with JHS type I, the multivariable odds ratio for postoperative seroma/hematoma formation in JHS type II was 2.77 (95% CI 1.54-4.95). Compared with JHS grade 1/2, the multivariable odds ratio for postoperative seroma/hematoma formation in JHS grade 3 was 2.27 (95% CI 1.28-4.03).

CONCLUSIONS

Internal inguinal hernia and hernia size ≥ 3 cm were considered risk factors for postoperative seroma/hematoma formation after TAPP.

Feasibility of modified-TEP technique for large inguinoscrotal and large femoral hernia and its advantages

PURPOSE

To describe the feasibility of modified-TEP technique in reducing dead space in large inguinoscrotal and large femoral hernia to prevent seroma, reduce recurrence and complications.

METHODS

This is a case series of patients who have completed a minimum of 9 months follow-up after undergoing elective endo-laparoscopic inguinal hernia repair with modified-TEP technique for large inguinoscrotal and large femoral hernia in a single institution from June to October 2020.

RESULTS

14 large inguinoscrotal hernia and 4 large femoral hernia were repaired using the modified-TEP technique in 15 patients. These patients reported minimal pain after surgery. There were no reported seroma, complications or recurrences up to 9 months follow-up period.

CONCLUSION

Modified-TEP technique for large inguinoscrotal and large femoral hernia has shown good outcomes and patients reported minimum levels of pain. In experienced hands, it is safe, feasible and effective in reducing seroma formation and hernia recurrence.

Robotic Direct Inguinal Hernia Repair: To Plicate or Not to Plicate?

BACKGROUND

Closure of the direct inguinal defect with plication in minimally invasive direct inguinal hernia repair may have potential benefits in terms of reducing postoperative surgical site events (SSEs) and recurrences. However, these advantages remain unclear, particularly in the robotic literature. This is the first comparative study to investigate the outcomes after robotic direct inguinal hernia repair (RDIHR) with defect plication.

MATERIALS AND METHODS

Among patients who underwent RIHR between 2013 and 2020, those who underwent RDIHR were selected. Patients were then stratified into 2 groups based on defect plication status, and univariate analyses were used to compare variables across preoperative, intraoperative, and postoperative timeframes.

RESULTS

A total of 225 RDIHRs were performed in 176 patients, where 74 were assigned to the Plication (+) group and 102 patients were assigned to the Plication (-) group. There was a significantly higher proportion of females in the Plication (-) group (10.8% vs. 1.4%, P=0.015), which accounts for the higher incidence of accompanying femoral hernias in this group. While most M1 hernia defects were left patent, most M2 and M3 hernias were plicated. Larger mesh sizes were used in the Plication (+) group (P<0.001). Three SSEs were observed in the Plication (-) group versus 2 SSEs in the Plication (+) group. No significant differences in postoperative outcomes were found between the 2 groups.

CONCLUSIONS

Postoperative seroma incidence, pain scores, and recurrence rates were similar between the 2 study groups. Multicenter studies with larger populations and higher complication counts are needed to establish the role of defect plication in RDIHR.

The Management of Indirect Inguinal Hernia Sac in Laparoscopic Inguinal Hernia Repair: A Systemic Review of Literature

BACKGROUND

The aim of this study is to investigate the current management strategy of indirect hernia sac during laparoscopic inguinal hernia repair.

OBJECTIVES

The aim was to evaluate the various indirect hernia sac management strategies when performing laparoscopic inguinal hernia repair.

DATA SOURCES

Major databases (PubMed, Embase, Springer, and Cochrane Library).

REVIEW METHODS

MeSH and free-text searching include "laparoscopic inguinal hernia" "TAPP," "TEP," "inguinal hernia," "indirect inguinal hernia sac," "distal sac," "sac transection," "sac ligation," and "sac reduction."

RESULTS

The present study enrolled 7 trials, 4 studies compared the results of indirect hernia sac transection and complete sac reduction. The pooled results indicated that indirect hernia sac transection was associated increased seroma formation (odds ratio=2.74, 95% confidence interval: 1.41-4.31), and there was no statistical difference in the incidence of postoperative pain, operative time, hernia recurrence, and time to return to normal activity between the sac transection and sac reduction groups. Two studies reported the application of adjuncts in the management of distal sac during laparoscopic large inguinoscrotal hernia repair. The seroma formation could be reduced by adjuncts of fixing the distal hernia sac to posterior abdominal wall with either suture or tacks.

CONCLUSION

Indirect sac transection during laparoscopic indirect inguinal hernia repair is associated with a higher incidence of postoperative seroma. Additional adjuncts to the divided distal hernia sac, including distal sac fixation with either suture or tacks, are effective methods to prevent postoperative seroma.

Drainage decreases the seroma incidence in laparoscopic transabdominal preperitoneal (TAPP) hernia repair for large inguinoscrotal hernias

BACKGROUND

Seroma is a common and inevitable postoperative complication in transabdominal preperitoneal (TAPP) hernia repair, especially in patients with large inguinoscrotal hernias. However, studies have rarely reported drainage in TAPP for large inguinoscrotal hernias.

METHODS

Sixty-five patients with 78 large indirect inguinoscrotal hernias who underwent TAPP procedure with drainage between September 2016 and December 2019 were enrolled in this study. 181 patients with Type Ⅲ indirect inguinal hernias (European Hernia Society (EHS) classification, hernia defect >3 cm) who underwent TAPP without drainage (no-drainage group) between January 2019 and December 2019 were included for a comparison. In the drainage group, a 12-Fr drainage tube was inserted into the distal hernia sac via the preperitoneal space to decrease the incidence of seroma.

RESULTS

There was no conversion to open procedures in all the patients. The operative time (56.5 ± 8.4 VS 54.8 ± 9.6 min, unilateral; 95.8 ± 10.4 VS 92.1 ± 13.9 min, bilateral), blood loss (5.9 ± 1.9 VS 5.6 ± 1.7 mL), visual analogue scale score on postoperative day 1 (2.3 ± 0.5 VS 2.2 ± 0.5) and postoperative hospital stay (1.1 ± 0.3 VS 1.0 ± 0.2 days) in the drainage group were equivalent to those in the no-drainage group (p > 0.05). The mean length of drainage was 5.2 ± 1.3 days. The drainage group had a significantly lower incidence of seroma than the no-drainage group (1.5% VS 9.4%, p = 0.037). The postoperative complications including haematoma, recurrence and chronic pain were comparable in the two groups.

CONCLUSION

Drainage with appropriate duration is a feasible, safe and effective measure to decrease the incidence of seroma in TAPP for patients with large inguinoscrotal hernias.

Current prevalence of perioperative early venous thromboembolism and risk factors in Chinese adult patients with inguinal hernia (CHAT-1)

Venous thromboembolism (VTE) is an important postoperative complication. We investigated and analyzed the current inguinal hernia treatment methods and occurrence of early postoperative VTE in Chinese adults. This study involved data for patients with inguinal hernia hospitalized in 58 general hospitals in mainland China from January 1st, 2017 to December 31st, 2017. Data were retrospectively analyzed using a questionnaire. After data inputting and cleaning, we stratified and statistically analyzed patients' data using Caprini scores to create a high-, middle-, and low-risk group. A total of 14,322 patients with inguinal hernia were admitted to the 58 participating hospitals. After data collation and cleaning, 13,886 patients (97.0%) met our inclusion and exclusion criteria. The percentages of laparoscopic surgery and open surgery were 51.2% and 48.8%, respectively. 16 VTEs occurred during the hospitalization, accounting for 0.1% of all adverse events (95% confidence interval (CI) 0.11-0.13). The incidence of VTE was 0.2% (95% CI 0.18-0.2) in the high-risk group and 0.02% (95% CI 0.01-0.03) in the middle-risk group, based on Caprini scoring, with a significant difference (p < 0.0001). No VTE occurred in the low-risk group. Only 3,250 (23.4%) patients underwent Caprini risk assessment regarding treatment, with 13.2% receiving any prevention and only 1.2% receiving appropriate prevention. The treatment of inguinal hernia in Chinese adults has progressed somewhat; however, the evaluation and prevention of perioperative VTE was seriously neglected, in our study, and the incidence of postoperative VTE was underestimated postoperatively. Risk factors continue to be inadequately considered.

Does primary closure of direct inguinal hernia defect during laparoscopic mesh repair reduce the risk of early recurrence?

PURPOSE

Hernia recurrence is an important complication following inguinal hernia repair. Primary closure of ventral hernia defects laparoscopically has been shown to reduce the risk of recurrence and seroma formation. The results for ventral hernias may potentially be applied to direct inguinal hernias. Our aim was to evaluate the value of primary closure of direct defects during laparoscopic inguinal hernia mesh repair in reducing the incidence of early recurrence.

METHODS

A retrospective, single-center cohort study was conducted on cases performed from August 2016 to February 2018. Patients with direct inguinal hernias undergoing elective laparoscopic mesh repair were included. When performed, the direct hernia defect was primarily closed with extracorporeal non-absorbable interrupted sutures followed by standard placement of a lightweight mesh covering myopectineal orifices. Early recurrence was defined as occurring within 1 year of surgery.

RESULTS

A total of 75 direct inguinal hernias in 53 patients who underwent surgery and completed at least 1 year of follow-up were analyzed. The mean age of patients was 63 years (range 44-82 years); with majority of patients being male (98.1%). There were no significant differences observed between the two patient populations in terms of demographics, mean operative time and risk factors. In 9 (16.9%) patients, the direct hernias were recurrent hernias and all underwent open mesh repair during the index hernia surgery. The majority of hernia repairs (63 hernias in 45 patients, 85%) were performed via the totally extraperitoneal (TEP) approach. 19 patients (35.8%) with 28 direct inguinal hernias underwent primary closure of the direct defect prior to mesh placement; while, 34 patients (64.2%) with 47 direct hernias did not undergo primary closure. There were 3 direct hernia recurrences (6.4%) at 1 year post-operatively, and all occurred in the non-closure group. In comparison, there were no recurrences in the closure group; however, this difference was not statistically significant (p = 0.289) in our study due to the small sample size.

CONCLUSION

Closure of direct inguinal hernia defects during laparoscopic mesh repair has been shown to reduce the incidence of early hernia recurrence in our retrospective study but future randomized controlled trials with large numbers would enable us to draw more robust conclusions and perhaps change the way we perform laparoscopic inguinal hernia repair.

Is tacking the lax transversalis fascia an easy, safe and effective way to reduce the occurrence of seroma after laparoscopic inguinal hernioplasty? A propensity score-matched and -adjusted analysis

BACKGROUND

Post-operative seroma formation rate is higher in laparoscopic hernioplasty as compared with open repair. Tacking of lax transversalis fascia of direct inguinal hernia is one of the many methods described to reduce the incidence of seroma after laparoscopic inguinal hernioplasty. Our objective is to investigate whether this technique is simple and reliable in reducing the incidence of seroma.

METHODS

A retrospective analysis of 548 patients who underwent laparoscopic inguinal hernioplasty between January 2011 and December 2017 was conducted. Patients demographics, operative data and post-operative complications were collected. 38 patients with transversalis fascia tacking were matched using one-to-one propensity score matching with another 38 patients without transversalis fascia tacking. Propensity score-matched analysis and propensity score-adjusted analysis were performed.

RESULTS

Patients who underwent transversalis fascia tacking (tacking group) had a significant lower incidence of post-operative seroma, compared to the non-tacking group tacking vs non-tacking: 5.6% vs 28.6% (p = 0.0097) in propensity-score matched analysis and 5.6% vs 21.3% (p = 0.0153) in propensity-score adjusted analysis. There was no difference noted in the duration of the operation and post-operative complications, in particular post-operative pain.

CONCLUSIONS

Tacking of lax transversalis facia to the symphysis pubis and Cooper's ligament is a simple yet safe and effective way to reduce the occurrence of seroma after laparoscopic inguinal hernioplasty.

Novel robot-assisted laparoscopic total extra-peritoneal repair with primary fascial closure plus pre-peritonea mesh for large groin defects

BACKGROUND

Since the introduction of robot-assisted laparoscopic surgery, a variety of conventional laparoscopic procedures have been explored via this approach. In the robotic era, most of the reported robot-assisted laparoscopic hernia repairs were performed with the trans-abdominal pre-peritoneal approach. According to the evidence extrapolated from laparoscopic ventral hernia repair, simultaneous fascial defect closure and mesh repair can significantly decrease the risk of seroma formation and recurrence over those without fascial closure. Therefore, we describe our novel technique of robot-assisted total extra-peritoneal (TEP) repair with primary fascial closure and pre-peritoneal mesh and its preliminary clinical outcomes.

METHODS

We retrospectively reviewed our prospectively collected hernia database from October 2017 to July 2019, which included 26 consecutive patients with primary or recurrent groin hernias. Patients' baseline characteristics and perioperative outcomes were compared and analyzed. Perioperative factors included operative time, visual analog scale (VAS) score (0-100), hospital stay, perioperative complications, time to return to normal activity, and the modified Medical Outcome Study (MOS; item 3-12/36 items) score.

RESULTS

All procedures were completed successfully without conversion to open or conventional laparoscopic surgery. The patients' age ranged from 28 to 74 years (median 57.5). The mean operative time was 115 minutes (range 95-172 min). There were no major procedure-related complications. Only four cases experienced asymptomatic seromas, which were detected by ultrasonography; and all resolved spontaneously within 6 weeks after the operation. The VAS and modified MOSs revealed quick recovery after robot-assisted endoscopic TEP repair.

CONCLUSIONS

Robot-assisted endoscopic TEP repair combined with primary fascial closure and pre-peritoneal mesh is a safe and feasible technique for groin hernia repair.

Effect of direct defect closure during laparoscopic inguinal hernia repair ("TEP/TAPP plus" technique) on post-operative outcomes

PURPOSE

Seroma formation and recurrence in large inguinal hernia still remain an important clinical complication despite decades since the advent of mesh repair.

METHODS

In our prospective comparative analysis, we want to evaluate the effect of direct hernia defect closure on surgical outcomes in patients undergoing laparoscopic inguinal hernia repair in two tertiary care institutions in Singapore. The direct hernia defects were closed with non-absorbable sutures incorporating the pseudosac.

RESULTS

A group of 241 patients underwent laparoscopic inguinal hernia mesh repair for a total of 378 direct defects from April 2014 to July 2018. Of these patients, 98 (40.6%) patients underwent hernia repair without closure of their direct defect while 143 (59.4%) patients underwent direct defect closure. No significant differences were observed between the two patient populations' demographic information and the mean operative time. A total of 219 direct defects were closed and 159 direct defects were not repaired. Compared to the group that did not undergo direct defect closure, the group that had closure of the direct defects demonstrated a statistically significant reduction in recurrence (4.4% versus 0.9%, p = 0.036) and seroma formation (12.6% versus 6.4%, p = 0.045).

CONCLUSION

Direct defect closure has proven to be effective in reducing recurrence and seroma formation post-operatively in patients undergoing laparoscopic inguinal hernia repair. Randomized controlled trials will be required to further evaluate these outcomes.

Intraoperative adjunctive techniques to reduce seroma formation in laparoscopic inguinal hernioplasty: a systematic review

BACKGROUND

Seroma formation is the most common postoperative complication after laparoscopic inguinal hernia repair. Recurrence and seroma formation may be difficult to distinguish. Many adjunctive techniques with which to reduce the incidence of seroma formation after laparoscopic inguinal repair have been described in the literature; however, the evidence for using intraoperative adjunctive techniques is limited. Therefore, the present systematic review was performed to evaluate the effects and limitations of adjunctive techniques used during laparoscopic inguinal hernia repair.

METHODS

Major databases (PubMed, Embase, Springer, and Cochrane Library) were searched using the terms "seroma," "laparoscopic inguinal hernia", "TAPP", "TEP", "inguinal hernia", "tack", "barbed suture", "drainage", "Endoloop technique", and "fibrin sealant". All studies involving adults undergoing laparoscopic/endoscopic inguinal hernioplasty with at least one intervention designed to reduce seroma formation were included.

RESULTS

Of the 965 studies identified, 8 met the inclusion criteria. Six adjunctive techniques were described in the literature. Transversalis fascia (TF) inversion with tacking: one prospective non-randomized controlled study revealed a lower incidence of postoperative seroma after TF inversion with tacking for direct inguinal hernias (4.17% vs. 14.29%, P < 0.05). Endoloop technique: one prospective study of 76 cases involving this technique revealed a low incidence of seroma formation (3.9% at 2 weeks) in direct hernias. Barbed suture closure of TF: one prospective study of 36 direct hernias reported only one clinical palpable seroma that resolved 1 month later. Surgical drains: three trials reported the results of drains, and the pooling results demonstrated significantly less seroma formation in patients with surgical drains (2.1 vs. 23.8%; odds ratio 0.12; 95% confidence interval 0.08-0.19; P < 0.0001). Fibrin sealant: one prospective clinical study of 40 patients with indirect inguinal hernias reported a lower volume (P < 0.001) and lower incidence (5% vs. 15%) of seroma formation in the fibrin group. Distal sac fixation technique: in one prospective study of six patients with large inguinoscrotal hernias, one patient developed a seroma on postoperative day 8.

CONCLUSION

Seroma formation is a natural process that cannot be completely prevented following laparoscopic inguinal hernioplasty, especially in patients with direct and large indirect inguinal hernias. Some intraoperative adjunctive techniques are effective in reducing clinically palpable seroma formation in select patients. More randomized controlled trials are needed for further evaluation.

Closure of Direct Inguinal Hernia Defect in Laparoscopic Hernioplasty to Prevent Seroma Formation: A Prospective Double-blind Randomized Controlled Trial

OBJECTIVES

Seroma is the most frequent postoperative complication after laparoscopic direct inguinal hernia repair. This randomized controlled trial evaluated the preventive effect of a simple technique by closing the direct hernia defect with barbed suture in laparoscopic direct inguinal hernia.

METHODS

In total, 60 patients aged 18 years or older who presented to the hernia center department in our hospital between October 1, 2017 and January 1, 2018 with primary direct inguinal hernia were randomized into the defect-closing group (by closing the transversalis) and the control groups. The primary outcomes were to compare the ultrasonic seroma number and volume at the inguinal region at 7 days, 1, and 3 months postoperatively. Secondary outcomes included total operative time, acute pain, chronic pain (pain lasting over 3 mo), hospital stay, recurrence, and any other complications.

RESULTS

There were no significant differences in baseline demographic characteristics between the 2 groups including age, sex, hernia type, size of hernia defect, surgical approach, and follow-up time. Compared with control group, there were significantly fewer patients with seroma formation at 7 days, 1, and 3 months after the operations in the defect-closing group (P<0.001, <0.001, 0.002, respectively). In addition, ultrasonic seroma volume was less in the defect-closing group on postoperative day 7 (13.33 vs. 30.45 mL; P=0.02). The acute pain and hospital stay were comparable (P=0.61, 0.85, respectively), and no chronic pain, early recurrence or other postoperative complications observed in both groups during the follow-up period.

CONCLUSIONS

The simple technique of direct hernia defect closure with barbed suture in laparoscopic direct inguinal hernia repair is a secure and effective method, which is easy to perform and could significantly reduce both incidence and volume of seroma formation without increasing the risk of recurrence, acute, and chronic pain.