The preperitoneal approach to the groin and the inferior epigastric vessels

Preperitoneal pelvic balloon tamponade-an effective intervention to control pelvic injury hemorrhage in a swine model

Objective: This study aimed to estimate the effects of the volume of preperitoneal balloon (PPB) on arterial and venous hemorrhage in a swine pelvic fracture model. Methods: Twenty-four swine were randomized into 0-mL, 500-mL, 800-mL, and 1000-mL intra-hematoma PPB groups. They were subjected to open-book pelvic fracture and reproducible injuries in the external iliac artery and vein. The pelvic binder and IH-PPBs with different volumes of fluid were applied to control the active hemorrhage after arterial and venous injuries. The survival time and rate during 60-min observation and digital subtraction angiography (DSA) images were the primary endpoints in this study. Secondary endpoints included survival rate within 70 min, peritoneal pressure, hemodynamics, blood loss, infusion fluid, blood pH, and lactate concentration. Results: Our results indicated that the 800-mL and 1000-mL groups had a higher survival rate (0%, 50%, 100% and 100% for 0, 500, 800, and 1000-mL groups respectively; p < 0.0001) and longer survival time (13.83 ± 2.64, 24.50 ± 6.29, 55.00 ± 6.33, and 60.00 ± 0.00 min for 0, 500, 800, and 1,000 groups respectively; p < 0.0005) than the 0-mL or 500-mL groups during the 60 min observation. Contrastingly, survival rate and time were comparable between 800-mL and 1000-mL groups during the 60-min observation. The IH-PPB volume was associated with an increase in the pressure of the balloon and the preperitoneal pressure but had no effect on the bladder pressure. Lastly, the 1000-mL group had a higher mean arterial pressure and systemic vascular resistance than the 800-mL group. Conclusion: IH-PPB volume-dependently controls vascular bleeding after pelvic fracture in the swine model. IH-PPB with a volume of 800 mL and 1000 mL efficiently managed pelvic fracture-associated arterial and venous hemorrhage and enhanced survival time and rate in the swine model without evidences of visceral injury.

Open preperitoneal vs. open anterior repair for the treatment of emergency femoral hernia: a bicentric retrospective study

PURPOSE

The aim of this study is to compare the postoperative results, in terms of complications and recurrence, between the anterior and open preperitoneal approaches in emergency femoral hernia.

METHODS

This bi-centric retrospective cohort study included patients who underwent emergency femoral hernia repair between January 2010 and December 2018. Postoperative complications and recurrence were analyzed comparing anterior and open preperitoneal approaches. The predictors of complications, mortality and recurrence were investigated using multivariate logistic regression.

RESULTS

A total of 204 patients met the inclusion criteria. Open anterior approach was performed in 128 (62.7%) patients and open preperitoneal was performed in 76 (37.3%). Open preperitoneal approach was associated with lower rates of recurrence (P = 0.033) and associated midline laparotomies (P = 0.006). Multivariable analysis identified patients with chronic nephropathy (OR, 3.801; 95%CI, 1.034-13.974; P = 0.044), preoperative bowel obstruction (OR, 2.376; 95%CI, 1.118-5.047; P = 0.024) and required midline laparotomy (OR, 12.467; 95%CI, 11.392-102.372; P = 0.030) as risk factors for complications and ASA ≥ III (OR, 7.820; 95%CI, 1.279-47.804; P = 0.026), COPD (OR, 5.064; 95%CI, 1.188-21.585; P = 0.028), necrotic contents (OR, 36.968; 95%CI, 4.640-294.543; P = 0.001), and required midline laparotomy (OR, 11.047; 95%CI, 1.943-62.809; P = 0.007). as risk factors for 90-day mortality. Male gender (OR, 4.718; 95%CI, 1.668-13.347; P = 0.003) and anterior approach (OR, 5.292; 95%CI, 1.114-25.149; P = 0.036) were risk factors for recurrence.

CONCLUSION

Open preperitoneal approach may be superior to anterior approach in the emergency setting because it can avoid the morbidity of associated midline laparotomies, with a lower long-term recurrence rate.

Open Emergent Groin Hernia Repair: Anterior or Posterior Approach?

Introduction: The current literature has not yet provided a definitive conclusion on the best emergency groin hernia repair. The aim of this study was first to compare the short and long-term outcomes between open preperitoneal and anterior approach in emergency groin hernia repair and second to identify risk factors for postoperative complications, mortality, and recurrence. Materials and Methods: This retrospective cohort study included patients who underwent emergency groin hernia repair between January 2010 and December 2018. Short and long-term outcomes were analyzed comparing approach and repair techniques. The predictors of complications and mortality were investigated using multivariate logistic regression. Cox regression multivariate analysis were used to explore risk factors of recurrence. Results: A total of 316 patients met the inclusion criteria. The most widely used surgical techniques were open preperitoneal mesh repair (34%) and mesh plug (34%), followed by Lichtenstein (19%), plug and patch (7%) and tissue repair (6%). Open preperitoneal mesh repair was associated with lower rates of recurrence (p = 0.02) and associated laparotomies (p < 0.001). Complication and 90-day mortality rate was similar between the techniques. Multivariable analysis identified patients aged 75 years or older (OR, 2.08; 95% CI, 1.14-3.80; p = 0.016) and preoperative bowel obstruction (OR, 2.11; 95% CI, 1.20-3.70; p = 0.010) as risk factors for complications and Comprehensive Complication Index ≥26.2 as risk factor for 90-day mortality (OR, 44.76; 95% CI, 4.51-444.59; p = 0.01). Female gender was the only risk factor for recurrence. Conclusion: Open preperitoneal mesh repair may be superior to other techniques in the emergency setting, because it can avoid the morbidity of associated laparotomies, with a lower long-term recurrence rate.

Cure of inguinal hernias with large preperitoneal prosthesis: Experience of 2,312 cases

It is clear that the recurrence rates after nonprosthetic methods for the repair of inguinal hernias, like McVay, Bassini or Shouldice techniques, are high (6–10%). Since 20 years, we are convinced, in the GREPA-EHS group, about the advantages of the use of a prosthetic mesh in majority of patients for repairs of primary or recurrent inguinal hernias and incisional hernias. We describe our typical technique for the cure of all inguinal hernias. We place a large supple mesh, by open inguinal route, posterior to the transversalis fascia and anterior to the peritoneum. We have made a double modification in the initial technique of Rives - the use of a very large unsplit prosthesis (15 × 17 cm) and the parietalization of the spermatic cord helped by a wide opening of the Fruchaud's orifice by diversion of the epigastric vessels. The positioning of the mesh is about the same as in the TEP technique but with the advantages of reduction in the vital laparoscopic risks and reinforcement of the wall by a short tension-free McVay technique.

For this prospective study, we repaired 2,312 consecutive hernias in 1,828 patients, 284 of which were recurrent. We present our results in terms of quality of repairs, recurrence rates (0.4%), morbidity rate (8%), and mortality rate (0.8%).

This technique involves the placement by an open incisional route of a large preperitoneal sheet of mesh for initial treatment of all inguinal hernias - including scrotal, giant or femoral - to ensure a definitive solid muscular wall, even for recurrent hernias.

Meta-analysis of randomized controlled trials comparing laparoscopic with open mesh repair of recurrent inguinal hernia

BACKGROUND

Although there is plentiful evidence regarding the use of laparoscopic surgery for primary inguinal hernia, there is a paucity of literature concerning its role after recurrence. There has been no quantitative review of the evidence, despite suggestions that pooled analysis of existing data is required.

METHODS

Medline, Embase, trial registries, conference proceedings and reference lists were searched for controlled trials of laparoscopic versus conventional open surgery for mesh repair of recurrent hernia. The primary outcomes were recurrence and chronic pain. Secondary outcomes were operating time, visual analogue pain score, superficial wound infection, haematoma or seroma formation, time to return to normal activities and serious complications requiring operation. Pooled odds ratios were calculated for categorical outcomes and weighted mean differences for continuous outcomes.

RESULTS

Four trials were included in the analysis. There was no effect on recurrence or chronic pain. Laparoscopic surgery was associated with significantly less postoperative pain, a quicker return to normal activities and fewer wound infections, at the cost of a longer operating time. There was no difference in haematoma formation or the need for additional operations.

CONCLUSION

Careful patient selection and surgeons' experience are important in the selection of technique for recurrent inguinal hernia repair.