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Hitman T, Bartlett ASR, Bowker A, McLay J. Comparison of bilateral to unilateral total extra-peritoneal (TEP) inguinal hernia repair: a systematic review and meta-analysis. Hernia 2023; 27:1047-1057. [PMID: 37010657 PMCID: PMC10533595 DOI: 10.1007/s10029-023-02785-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 03/24/2023] [Indexed: 04/04/2023]
Abstract
PURPOSE Laparoscopic herniorrhaphy (LH) has become the treatment of choice in many centers for patients with inguinal hernia (IH). Our aim was to compare the morbidity outcomes of bilateral vs unilateral IH repair using the laparoscopic total extra-peritoneal (TEP) technique, to determine whether undertaking bilateral IH repair places patients at additional risk. METHODS Manuscripts published up to the end of 2021 on PubMed/MEDLINE, EMBASE, Cochrane Library, Scopus, and Web of Science were searched. Patients (> 16 years) undergoing a primary elective unilateral or bilateral TEP operation, using the standard 3-port laparoscopic technique, were identified. Quality of evidence was assessed using the GRADE criteria. Meta-analysis was conducted where possible. Where this was not possible, vote counting was conducted using effect direction plots. RESULTS Eight observational studies, with a total of 18,153 patients were included. Operative time was significantly longer for bilateral operations. There was no significant difference in conversion to open, post-operative seroma, urinary retention, haematoma, and length of hospital stay. There was an increased rate of hernia recurrence in patients undergoing bilateral IH repair. CONCLUSION Although limited by the observational nature of the included studies, there is no conclusive evidence to suggest a differential burden of morbidity between unilateral and bilateral TEP IH repair. As all included papers are from observational studies only, evidence from all outcomes is at best very low quality. This manuscript thereby highlights a need for randomized controlled trials to be conducted in this area.
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Affiliation(s)
- T Hitman
- School of Medicine, University of Auckland, Auckland, New Zealand.
| | - A S R Bartlett
- Department of Surgery, University of Auckland, Grafton, Auckland, New Zealand
- Department of General Surgery, Auckland City Hospital, Grafton, Auckland, New Zealand
- Laparoscopy Auckland, Epsom, Auckland, New Zealand
| | - A Bowker
- Laparoscopy Auckland, Epsom, Auckland, New Zealand
| | - J McLay
- Faculty of Science, Statistics, University of Auckland, Auckland, New Zealand
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Niebuhr H, Köckerling F, Fortelny R, Hoffmann H, Conze J, Holzheimer RG, Koch A, Köhler G, Krones C, Kukleta J, Kuthe A, Lammers B, Lorenz R, Mayer F, Pöllath M, Reinpold W, Schwab R, Stechemesser B, Weyhe D, Wiese M, Zarras K, Meyer HJ. [Inguinal hernia operations-Always outpatient?]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:230-236. [PMID: 36786812 PMCID: PMC9950173 DOI: 10.1007/s00104-023-01818-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 06/17/2023]
Abstract
Inguinal hernia operations represent the most frequent operations overall with 300,000 interventions annually in Germany, Austria and Switzerland (DACH region). Despite the announced political willingness and the increasing pressure from the legislator to avoid costly inpatient treatment by carrying out as many outpatient operations as possible, outpatient treatment has so far played a subordinate role in the DACH region. The Boards of the specialist societies the German Hernia Society (DHG), the Surgical Working Group Hernia (CAH of the DHG), the Austrian Hernia Society (ÖHG) and the Swiss Working Group Hernia Surgery (SAHC) make inroads into this problem, describe the initial position and assess the current situation.
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Affiliation(s)
- H Niebuhr
- Hamburger Hernien Centrum, Eppendorfer Baum 8, 20249, Hamburg, Deutschland.
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Diagnostic Accuracy of Imaging Modalities on Occult Groin Hernias According to Hernia type and a Surgeon-centered Individualized Groin Hernia Management Algorithm. SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2023; 33:79-83. [PMID: 36728685 DOI: 10.1097/sle.0000000000001137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 12/01/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND The purpose of this study is to evaluate the diagnostic performance of imaging techniques for the identification of groin hernias based on the type of hernia and to demonstrate the efficacy of an algorithm based on the surgeon and surgical technique. MATERIALS AND METHODS Medical records of 561 patients who were operated on for groin hernia were retrospectively analyzed. A total of 102 patients who had both pelvic computed tomography (CT) and ultrasonography (USG) recordings preoperatively and underwent transabdominal preperitoneal repair were included in the study. RESULTS A contralateral asymptomatic occult groin hernia was detected in 25.5% of all patients. The overall sensitivity of USG and CT on contralateral asymptomatic occult hernia was 42.3% and 65.4%, respectively. The sensitivity of USG according to the contralateral occult hernia type was 66.7%, 35.7%, 33.3%, and 50% for direct, indirect, femoral, and pantaloon hernias, respectively. The sensitivity of CT according to the contralateral occult hernia type was 0%, 57.1%, 100%, and 100% for direct, indirect, femoral, and pantaloon hernias, respectively. CONCLUSIONS The handicap created by the variability in the diagnostic sensitivity of imaging modalities can be overcome with the choice of transabdominal preperitoneal repair in the surgical technique.
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Park JB, Chong DC, Reid JL, Edwards S, Maddern GJ. Should asymptomatic contralateral inguinal hernia be laparoscopically repaired in the adult population as benefits greatly outweigh risks? A systematic review and meta-analysis. Hernia 2022; 26:999-1007. [PMID: 35435597 PMCID: PMC9334391 DOI: 10.1007/s10029-022-02611-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/19/2022] [Indexed: 11/04/2022]
Abstract
PURPOSE When laparoscopically repairing a symptomatic inguinal hernia, surgeons will discover a contralateral asymptomatic hernia in 22% of patients. It is estimated 30% of asymptomatic hernias become symptomatic and require repair. Thus, should they be repaired in a 2-for-1 operation? The main purpose is to examine the evidence and make a recommendation for the need to repair the contralateral asymptomatic inguinal hernia prophylactically in the adult population during unilateral inguinal hernia presentation. METHOD A systematic literature search was conducted up to 15 February 2021 using PubMed and the Cochrane Library. Management pathway taken, mean operating time, duration of follow-up, pain, duration of hospital stay and perioperative complications were extracted. Risk of bias was assessed using the ROBINS-I tool. RESULTS Six non-randomised studies (1774 patients) were included; 978 patients had both hernias repaired, 796 patients had only the symptomatic hernia repaired. There was no significant difference in length of hospital stay, return to activities of daily living nor complications. Mean operating time was slightly lower for patients who had unilateral hernia repair (mean difference = - 14.57 min, 95%CI - 25.59, - 3.45). Reported pain scores were lower for patients who only had one hernia repaired (- 0.33 units, 95%CI - 0.48, - 0.18). The overall risk of bias for the six studies were low-to-moderate risk. CONCLUSION Asymptomatic inguinal hernias can be repaired when found. While there is minimal increase in operation time and pain, no significant difference to total hospital stay. Importantly, this is likely to prevent the need for another operation in almost a third of patients.
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Affiliation(s)
- Jung B Park
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, 5000, Australia
| | - Darren C Chong
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, 5000, Australia
| | - Jessica L Reid
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, 5000, Australia
| | - Suzanne Edwards
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, 5000, Australia
| | - Guy J Maddern
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, 5000, Australia. .,The Queen Elizabeth Hospital, Woodville, SA, 5011, Australia.
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The Value of Preoperative Ultrasound in the Detection of Contralateral Occult Inguinal Hernia in the Treatment of Symptomatic Inguinal Hernia. SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2021; 32:35-40. [PMID: 34369480 DOI: 10.1097/sle.0000000000000987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/04/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The true incidence of contralateral occult inguinal hernia (OIH) is a debate. The repair of contralateral OIH in the treatment context of clinical symptomatic unilateral inguinal hernia (IH) is controversial. This study aimed to assess the effect and clinical benefit of preoperative ultrasound (US) in the diagnosis of contralateral OIH performed before surgery. METHODS The retrospective data of 155 consecutive male patients who underwent IH repair between January 2014 and January 2020 were analyzed. The surgical procedures for IH and the clinical outcomes of the US were evaluated. RESULTS Of 155 patients, 29 (18.7%) presented with bilateral IH. Preoperative US was performed in 73 cases of clinical unilateral IH (n=126), and 30 (23.8%) patients were found to have a contralateral OIH. The totally extrapreperitoneal (TEP) or Lichtenstein repair was conducted. Bilateral IH repair was proposed for all, but only 28 agreed and underwent bilateral repair. Patients with clinically bilateral hernia had more complications compared with patients diagnosed to have occult contralateral IH after the US (n=3 vs. n=0). In the overall group, the TEP procedure resulted in shorter hospital stay (P=0.001) and less pain (P=0.021). CONCLUSIONS The preoperative US may be recommended to assess the presence of a contralateral OIH as it is a noninvasive, radiation-free, widely available, relatively cheap diagnostic method. The preoperative US may change the surgical approach in up to 1/4 patients with a clinical unilateral IH. Either Lichtenstein repair or TEP repair can be performed with an acceptable complication rate in the case of OIH.
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GOMES CA, GOMES FC, PODDA M, BRAGA APF, RIBEIRO SC, VAZ LF. LIECHTENSTEIN VERSUS CORREÇÃO DE HÉRNIA LAPAROSCÓPICA TRANSABDOMINAL PRÉ-PERITONEAL (TAPP): UM ESTUDO COMPARATIVO PROSPECTIVO COM FOCO NOS RESULTADOS PÓS-OPERATÓRIOS EM UMA UNIDADE DE CIRURGIA GERAL. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2021; 34:e1642. [PMID: 35107504 PMCID: PMC8846489 DOI: 10.1590/0102-672020210002e1642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/01/2021] [Indexed: 12/01/2022]
Abstract
Three surgical techniques for inguinal hernia repair are currently validated. Few
studies have compared results among Lichtenstein and transabdominal
preperitoneal (TAPP) laparoscopic approach obtained at an early step of the
learning curve.
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Dhanani NH, Olavarria OA, Wootton S, Petsalis M, Lyons NB, Ko TC, Kao LS, Liang MK. Contralateral exploration and repair of occult inguinal hernias during laparoscopic inguinal hernia repair: systematic review and Markov decision process. BJS Open 2020; 5:6045324. [PMID: 33688950 PMCID: PMC7944513 DOI: 10.1093/bjsopen/zraa020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 09/09/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Contralateral clinically occult hernias are frequently noted at the time of laparoscopic unilateral inguinal hernia repair. There is no consensus on the role of contralateral exploration and repair. This systematic review assessed the safety and efficacy of operative repair of occult contralateral inguinal hernias found during unilateral repair. METHODS PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception to February 2020. Adults diagnosed with a unilateral inguinal hernia undergoing laparoscopic repair were included. The primary outcome was the incidence of occult contralateral hernias. Summative outcomes of operative and expectant management were reported along with development of a Markov decision process. RESULTS Thirteen studies (1 randomized trial, 12 observational cohorts) with 5000 patients were included. The incidence of occult contralateral inguinal hernias was 14.6 (range 7.3-50.1) per cent. Among patients who underwent repair, 10.5 (4.3-17.0) per cent experienced a postoperative complication. Of patients managed expectantly, 29 per cent later required elective repair for symptoms. Mean follow-up was 36 (range 2-218) months. Using a Markov decision process, it was calculated that, for every 1000 patients undergoing unilateral inguinal hernia repair, contralateral exploration would identify 150 patients with an occult hernia. Repair would result in 15 patients developing a postoperative complication and 105 undergoing unnecessary repair. Alternatively, expectant management would result in 45 patients requiring subsequent repair. CONCLUSION Contralateral repair is not warranted in patients with occult hernias diagnosed at the time of elective hernia repair. The evidence is largely based on observational studies at high risk of bias.
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Affiliation(s)
- N H Dhanani
- Department of Surgery, Lyndon B. Johnson General Hospital, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - O A Olavarria
- Department of Surgery, Lyndon B. Johnson General Hospital, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - S Wootton
- Department of Pediatrics, Memorial Hermann Children's Hospital, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - M Petsalis
- Department of Surgery, Lyndon B. Johnson General Hospital, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - N B Lyons
- Department of Surgery, Lyndon B. Johnson General Hospital, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - T C Ko
- Department of Surgery, Lyndon B. Johnson General Hospital, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - L S Kao
- Department of Surgery, Lyndon B. Johnson General Hospital, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - M K Liang
- Department of Surgery, Lyndon B. Johnson General Hospital, McGovern Medical School at UTHealth, Houston, Texas, USA
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Tiwary SK, Kumar S, More R, Shankar V, Kumar S, Dwivedi AND. A study of contralateral occult inguinal hernia in adult male patients undergoing total extraperitoneal herniorraphy. J Family Med Prim Care 2020; 9:2975-2979. [PMID: 32984158 PMCID: PMC7491803 DOI: 10.4103/jfmpc.jfmpc_207_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/13/2020] [Accepted: 03/23/2020] [Indexed: 02/05/2023] Open
Abstract
Background: The incidence of contralateral occult hernia (COH) varies from 4.2% to 57.5%. Total extraperitoneal (TEP) gives us opportunity to visualize contralateral groin for occult hernia and its simultaneous repair. Ultrasonography (USG) helps to diagnose occult hernia preoperatively with detection rate of 96.6% with specificity 84.4%. Objective: The aims of this study were to identify the incidence of contralateral occult inguinal hernia in clinically diagnosed unilateral inguinal hernia patients using USG as diagnostic modality and to compare the clinical outcomes of unilateral TEP vs. bilateral TEP with respect to pain, duration of hospital stay, time for return to normal work, and postoperative complications. Setting and Design: This was a prospective observational, single-center study. Materials and Methods: A total of 30 male patients were included in the study who was having clinically diagnosed unilateral hernia. All patients were assessed by USG for contralateral occult inguinal hernia. Results: Incidence of COH was 10%, two (6.7%) had indirect defect, and 1 (3.3%) had direct defect. Two (6.7%) patients underwent bilateral TEP and 28 (93.3%) underwent unilateral TEP. No significant difference was observed in terms of mean duration of hospital stay, duration of surgery, and visual analog scale score for pain in both unilateral and bilateral TEP. The mean for resuming daily work in unilateral TEP was 4.86 ± 0.833 days and in bilateral TEP the mean was 7.50 ± 0.70 days and this showed statistically significant difference (P < 0.001). Conclusion: Patients with COH should be counselled for synchronous repair as there is no significant difference in clinical outcomes of unilateral and bilateral TEP. On the basis of this pilot study, it can be concluded that preoperative USG is mandatory for diagnosis and simultaneous management of preexisting contralateral hernia.
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Affiliation(s)
- S K Tiwary
- Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Satendra Kumar
- Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Raghunath More
- Department of Anatomy, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Vijay Shankar
- Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Sandip Kumar
- Department of Pathology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - A N D Dwivedi
- Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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Olavarria OA, Bernardi K, Holihan JL, Lyons NB, Shah P, Ko TC, Kao LS, Liang MK. Prevalence and Impact on Quality of Life of Occult Hernias among Patients Undergoing Computed Tomography. J Surg Res 2020; 253:121-126. [PMID: 32353637 DOI: 10.1016/j.jss.2020.03.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/27/2020] [Accepted: 03/09/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND With the widespread use of advanced imaging there is a need to quantify the prevalence and impact of hernias. We aimed to determine the prevalence of abdominal wall hernias among patients undergoing computed tomography (CT) scans and their impact on abdominal wall quality of life (AW-QOL). METHODS Patients undergoing elective CT abdomen/pelvis scans were enrolled. Standardized physical examinations were performed by surgeons blinded to the CT scan results. AW-QOL was measured through the modified Activities Assessment Scale. On this scale, 1 is poor AW-QOL, 100 is perfect, and a change of 7 is the minimum clinically important difference. Three surgeons reviewed the CT scans for the presence of ventral or groin hernias. The number of patients and the median AW-QOL scores were determined for three groups: no hernia, hernias only seen on imaging (occult hernias), and clinically apparent hernias. RESULTS A total of 246 patients were enrolled. Physical examination detected 62 (25.2%) patients with a hernia while CT scan revealed 107 (43.5%) with occult hernias. The median (interquartile range) AW-QOL of patients per group was no hernia = 84 (46), occult hernia = 77 (57), and clinically apparent hernia = 62 (55). CONCLUSIONS One-fourth of individuals undergoing CT abdomen/pelvis scans have a clinical hernia, whereas nearly half have an occult hernia. Compared with individuals with no hernias, patients with clinically apparent or occult hernias have a lower AW-QOL (by 22 and seven points, respectively). Further studies are needed to determine natural history of AW-QOL and best treatment strategies for patients with occult hernias.
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Affiliation(s)
- Oscar A Olavarria
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.
| | - Karla Bernardi
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Julie L Holihan
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Nicole B Lyons
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center Houston, Houston, Texas
| | - Puja Shah
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center Houston, Houston, Texas
| | - Tien C Ko
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center Houston, Houston, Texas
| | - Lillian S Kao
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Mike K Liang
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
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Long-term outcomes after bilateral transabdominal preperitoneal (TAPP) repair for asymptomatic contralateral inguinal hernia. Surg Endosc 2020; 35:626-630. [DOI: 10.1007/s00464-020-07425-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 02/10/2020] [Indexed: 10/25/2022]
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Management of Occult Contralateral Inguinal Hernia: Diagnosis and Treatment With Laparoscopic Totally Extra Peritoneal Repair. Surg Laparosc Endosc Percutan Tech 2020; 30:245-248. [PMID: 32032331 DOI: 10.1097/sle.0000000000000765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Up to 33% risk of occult contralateral inguinal hernia has been reported. This study aims to evaluate diagnostic and treatment modalities in the case of occult contralateral hernia and the role of ultrasonography (USG). MATERIALS AND METHODS Patients who had undergone inguinal hernia repair between 2009 and 2018 were studied retrospectively. The detection rate of occult inguinal hernia by USG and results of laparoscopic totally extra peritoneal repair (TEP) were evaluated. RESULTS Of 295 patients, USG was performed to the contralateral site in 80 with clinically unilateral hernia and occult hernia was detected in 44 (55%). Bilateral TEP was performed for these patients. There was no recurrence and no significant complication. CONCLUSIONS As it is noninvasive, easily accessible and has high sensitivity, USG is recommended in diagnosis. In the case of occult contralateral inguinal hernia, bilateral TEP is considered as a safe procedure. Thus, the need for a second operation and related complications can be prevented. We recommend routine USG to detect whether contralateral occult inguinal hernia is present.
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Kwee RM, Kwee TC. Ultrasonography in diagnosing clinically occult groin hernia: systematic review and meta-analysis. Eur Radiol 2018; 28:4550-4560. [DOI: 10.1007/s00330-018-5489-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 04/09/2018] [Accepted: 04/16/2018] [Indexed: 11/30/2022]
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