Groin hernias in women

Round ligament management during minimally invasive groin hernia repair in women: a systematic review and meta-analysis

BACKGROUND

Female sex has been associated with worse outcomes after groin hernia repair (GHR), including a higher rate of chronic pain and recurrence. Most of the studies in GHR are performed in males, and the recommendations for females extrapolate from these studies, even though females have anatomy intricacies. The round ligament of the uterus (RLU) is associated with pelvic stabilization and plays a role in sensory function. Transection of the RLU during GHR is controversial as it can allow easier mesh placement but can favor genitourinary complications and chronic pain. As no previous meta-analysis compared preserving versus transecting the RLU during minimally invasive (MIS) GHR, we aim to perform a systematic review and meta-analysis evaluating surgical outcomes comparing the approaches.

METHODS

Cochrane Central, Embase, and PubMed databases were systematically searched for studies comparing transection versus preservation of the RLU in MIS groin hernia surgeries. Outcomes assessed were operative time, bleeding, surgical site events, hospital stay, chronic pain, paresthesia, recurrence rates, and genital prolapse rates. Statistical analysis was performed using RevMan 5.4.1. Heterogeneity was assessed with I2 statistics. A review protocol for this meta-analysis was registered at PROSPERO (CRD 42023467146).

RESULTS

1738 studies were screened. A total of six studies, comprising 1131 women, were included, of whom 652 (57.6%) had preservation of the RLU during MIS groin hernia repair. We found no statistical difference regarding chronic pain, paresthesia, recurrence rates, and postoperative complications. We found a longer operative time for the preservation group (MD 6.84 min; 95% CI 3.0-10.68; P = 0.0005; I2 = 74%).

CONCLUSION

Transecting the RLU reduces the operative time during MIS GHR with no difference regarding postoperative complication rates. Although transection appears safe, further prospective randomized studies with long-term follow-up and patient-reported outcomes are necessary to define the optimal management of RLU during MIS GHR.

Comparison of outcomes between preservation or division of the uterine round ligament in laparoscopic groin hernia repair in females: a meta-analysis and trial sequential analysis

PURPOSE

The purpose of this study was to perform a meta-analysis comparing the short-term and long-term outcomes in laparoscopic groin hernia repair with or without preservation of the uterine round ligament (URL) in females.

METHODS

We searched several databases including PubMed, Web of Science, Cochrane Library, and and CNKI databases. This meta-analysis included randomized clinical trials, and retrospective comparative studies regarding preservation or division of the URL in laparoscopic groin hernia repair in females. Outcomes of interest were age, BMI, type of hernia, type of surgery, operating time, estimated blood loss, time of hospitalization, seroma, concomitant injury, mesh infection, recurrence, uterine prolapse, foreign body sensation, chronic pain, and pregnancy. Meta-analyses and trial sequential analysis were performed with Review Manager v5.3 and TSA software, respectively.

RESULTS

Of 192 potentially eligible articles, 9 studies with 1104 participants met the eligibility criteria and were included in the meta-analysis. There were no significant difference in age (MD-6.58, 95% CI - 13.41 to 0.24; P = 0.06), BMI (MD 0.05, 95%CI - 0.31 to 0.40; P = 0.81), blood loss (MD-0.04, 95% CI - 0.75 to 0.66; P = 0.90), time of hospitalization (MD-0.22, 95% CI-1.13 to 0.69; P = 0.64), seroma (OR 0.71, 95% CI 0.41 to 1.24; P = 0.23), concomitant injury (OR 0.32, 95% CI 0.01 to 8.24; P = 0.68), mesh infection (OR 0.13, 95% CI 0.01 to 2.61; P = 0.18), recurrence (OR 1.13, 95% CI 0.18 to 7.25; P = 0.90), uterine prolapse(OR 0.71, 95% CI 0.07 to 6.94; P = 0.77), foreign body sensation (OR 1.95, 95% CI 0.53 to 7.23; P = 0.32) and chronic pain(OR 1.03 95% CI 0.4 to 2.69; P = 0.95). However, this meta-analysis demonstrated a statistically significant difference in operating time (MD 6.62, 95% CI 2.20 to 11.04; P = 0.0003) between the preservation group and division group. Trial sequential analysis showed that the cumulative Z value of the operating time crossed the traditional boundary value and the TSA boundary value in the third study, and the cumulative sample size had reached the required information size (RIS), indicating that the current conclusion was stable.

CONCLUSION

In summary, laparoscopic groin hernia repair in women with the preservation of the round uterine ligament requires a longer operating time, but there was no advantage in short-term or long-term complications, and there was no clear evidence on whether it causes infertility and uterine prolapse.

Sex-based differences in inguinal hernia factors

BACKGROUND

Much of our knowledge about inguinal hernias is based on males. Meanwhile, it is established that women have worse outcomes after inguinal hernia repair, with more chronic pain and higher recurrences. Pediatric literature shows inguinal hernias in females are more likely to be bilateral, incarcerated, and carry a stronger genetic predisposition than males. We aimed to evaluate sex-based differences in inguinal hernia factors in adults, to help supplement the paucity of literature in the adult population.

METHODS

An institutional database of patients undergoing repair of primary inguinal hernias was queried with focus on preoperative risk factors and operative characteristics. Multivariate analysis was performed looking for independent variables associated with a greater number of hernia defects found intraoperatively.

RESULTS

Among 494 patients, 202 (40.9%) were female. Number of risk factors among females was significantly higher than males (1.53 vs 1.2, p = 0.003). Females had significantly more constipation, GERD, and asthma and lower BMI than males. Family history of hernias was similar between both sexes. As expected, females had significantly less direct hernias (12.9% vs 32.9%, p < 0.001) and more femoral hernias (38.5% vs 12.2%, p < 0.001) than males. Bilaterality was similar. Females undergoing inguinal hernia repair averaged 1.23 prior deliveries. Regression analysis showed age, sex, BMI, and number of deliveries were not correlated with the number of defects.

CONCLUSIONS

Females undergoing primary inguinal hernia repair had more preoperative risk factors for inguinal hernia than males. In our population, there was no higher incidence of bilaterality or significant genetic predisposition in females as noted by family history of hernias. Age, sex, BMI and number of deliveries did not correlate with the number of hernia defects found. Our study promotes awareness of inguinal hernias in females and presents new data to quantify sex-based differences and predispositions to inguinal hernias.

Retrospective study of preservation and transection of the round ligament of uterus during laparoscopic transabdominal preperitoneal inguinal hernia repair in adult women

PURPOSE

The processing of the round ligament of uterus in laparoscopic transabdominal preperitoneal (TAPP) repair of inguinal hernia in women has contended. This study aimed to explore whether there is any difference in the surgical outcome and postoperative complications between the two processing modalities, preservation, and transection of the round ligament of uterus, in adult female inguinal hernia patients undergoing TAPP.

METHODS

Retrospective analysis of 84 female patients (117 sides) who underwent TAPP in XXX Hospital from July 2013 to August 2022. Patient characteristics and technical details of the surgical procedure were collected and divided into two groups according to whether the round ligament of uterus was severed intraoperatively or not. There were 52 cases (77 sides) in the group with preservation of the round ligament of uterus and 32 cases (40 sides) in the group with transection of the round ligament of uterus, comparing the general condition, surgical condition, and the occurrence of postoperative related complications between the 2 groups.

RESULTS

The operative time for unilateral primary inguinal hernia was (129.2 ± 35.1) and (89.5 ± 42.6) minutes in the preservation and transection groups, respectively. There were no statistical differences between the two groups in terms of age, length of hospital stay, ASA, BMI, history of lower abdominal surgery, type and side of hernia, intraoperative bleeding, and time to surgery for primary bilateral hernia (P > 0.05). In addition, there was likewise no statistical difference in the occurrence of postoperative Clavien-Dindo classification, VAS, seroma, mesh infection, labia majora edema, chronic pain or abnormal sensation in the inguinal region, and hernia recurrence in the two groups as well (P > 0.05).

CONCLUSION

There is no evidence that the transection of the round ligament of the uterus during TAPP has an impact on postoperative complications in patients. However, given the important role of the uterine round ligament in the surgical management of patients with uterine prolapse and the high incidence of uterine prolapse in older women, hernia surgeons should also be aware of the need to protect the round ligament of uterus in older women.

Ovary and fallopian tube as contents of indirect inguinal hernia: A case report

Introduction and importance

Ovarian and fallopian tube indirect inguinal hernias are rare hernias encountered on surgical floor. Herein, we are reporting a rare happening of obstructed ovarian and fallopian tube indirect inguinal hernia in an unmarried female.

Presentation of case

A 19 years old unmarried female presented to surgical emergency with complain of swelling in left inguinal region that was about 3 × 3 cm on visual inspection from last 4 days that was associated with menstruation. Abdominal ultrasound (USG) was showing left ovarian and fallopian tube indirect inguinal hernia with preserved internal follicles and intact vasculature. The diagnosis of obstructed ovarian and fallopian tube indirect inguinal hernia was made and diagnostic laparoscopy and left sided hernioplasty was performed. Ovary was retrieved back into abdominal cavity and stitched to lateral pelvic wall.

Discussion

Inguinal hernia itself is a rare happening in females and the presence of ovary and fallopian tube along with other hernial content can become a topic of discussion due to rarity of this case. It is of paramount significance to diagnose such cases with great expertise in order to avoid long term complications in terms of preserving fertility among females. Early utilization of radiological investigations like USG abdomen and laparoscopic retrieval of adnexal structures are standard approach in management of such cases.

Conclusion

Presence of ovary and fallopian tube in indirect inguinal hernia is a rare happening that need to be diagnosed and treated at earliest to avoid infertility among females.

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Presence of ovary and fallopian tube as content of indirect inguinal hernia is a rare happening.

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Management of ovary and fallopian tube indirect inguinal hernia should be ascertained in timely manners.

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Colour doppler USG is of great significance in determining the presence of blood flow to ovary and fallopian tube.

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Laparoscopically diagnosis and retrieval of hernial contents is standard of care protocol.

Prevalence and associated factors of external hernia among adult patients visiting the surgical outpatient department at the University of Gondar Comprehensive Specialised Hospital, Northwest Ethiopia: a cross-sectional study

OBJECTIVES

This study was aimed to assess the prevalence and associated factors of external hernia among adult patients visiting the surgical outpatient department (OPD) at the University of Gondar Comprehensive Specialised Hospital (UOGCSH), Northwest Ethiopia.

STUDY DESIGN

Institution-based cross-sectional study was conducted from 5 April 2020 to 22 June 2020.

STUDY SETTING

UOGCSH.

PARTICIPANTS

All adult patients above 18 years of age who visited the surgical OPD at the UOGCSH.

OUTCOME

Prevalence of external hernia.

RESULT

A total of 403 study participants were involved in this study with a response rate of 100%. The prevalence of external hernia was 11.7% (95% CI 8.8% to 15.1%). The epigastric hernia had the highest prevalence 16 (34%), followed by inguinal hernia 14 (29.8%). Old age (adjusted OR (AOR) =2.47, 95% CI 1.06 to 5.78), constipation (AOR 3.67, 95% CI 1.68 to 8.11), chronic cough (AOR 5.18, 95% CI 2.17 to 12.3) and lifting of heavy objects (AOR 7.39, 95% CI 3.36 to 16.2) had a statistically significant association with external hernia.

CONCLUSION

Regardless of hardly any significant gender difference, the overall prevalence of external hernia was high. Old age, constipation, chronic cough and lifting of heavy objects were found to have a significant association with an external hernia. Patients who have constipation and cough should get appropriate treatment early.

Long-standing groin pain syndrome in athletic women: a multidisciplinary assessment in keeping with the italian consensus agreement

BACKGROUND

Long-standing groin pain syndrome (LSGPS) is a form of groin pain syndrome in which the cohort of symptoms reported by patients is experienced for a long period, typically for over 12 weeks, and is recalcitrant to any conservative therapy. The aim of this prospective epidemiological study was to describe the clinical causes of LSGPS in 37 female athletic subjects in Italy through the Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment in groin pain in athletes classification and guidelines.

METHODS

Thirty-seven female athletes affected by LSGPS were evaluated following the guidelines issued by the Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment of groin pain in athletes.

RESULTS

In the considered population, each patient presented only one pathological cause for LSGPS. The most frequent aetiologies were inguinal pathologies (54.05% of the cases), acetabular labrum tear (18.92%) and pelvic floor disorders (8.11%). Adductor tendinopathy represented only 2.70% of cases.

CONCLUSIONS

Female athletic patients affected by LSGPS show a similar incidence of inguinal and hip pathologies as in male populations. However, these clinical situations do not seem to be associated in women unlike in the male population. This difference is probably due to particular anatomical differences related to gender. For this reason, women affected by LSGPS represent an important subset of patients. Moreover, adductor tendinopathy is probably overrated as an etiopathogenetic source of LSGPS in women.

Inguinal hernia detected using radiography

There are various clinical presentations of inguinal hernia. Computed tomography is a well-known tool to help diagnose inguinal hernia; however, radiographs are rarely reported to be useful in this aspect. We present a rare case wherein radiographs helped in the diagnosis of inguinal hernia.

Comparison of laparoscopic transabdominal preperitoneal hernioplasty and laparoscopic iliopubic tract repair for Nyhus type II hernia in women

BACKGROUND

Indirect inguinal hernia with a dilated internal ring but an intact posterior inguinal wall is classified as Nyhus type II. Females have a higher incidence of indirect hernia than direct hernia. The purpose of this study was to evaluate the efficacy of laparoscopic iliopubic tract repair (IPTR) compared with laparoscopic transabdominal preperitoneal (TAPP) hernioplasty in treating women with Nyhus type II hernia.

METHODS

This retrospective study included 318 women aged ≥ 20 years who were treated for Nyhus type II hernia from January 2013 to December 2018. The patients were categorized into two groups in accordance with the operative technique: the TAPP group (33 patients) and the IPTR group (285 patients). In the IPTR group, intraabdominal suturing of the iliopubic tract and transversalis fascia arch was performed without mesh implantation.

RESULTS

The mean operation time was shorter in the IPTR group (17.2 ± 3.9 min) than the TAPP group (20.5 ± 8.1 min, p = 0.028). The postoperative complication rate was higher in the TAPP group than the IPTR group [6.1% (2/33) vs. 0.4% (1/285), respectively; p = 0.001]. Inguinodynia occurred in one patient in the TAPP group and no patients in the IPTR group. The hospital stay did not significantly differ between the two groups. The numeral rating scale pain scores at 1 day and 1 week postoperatively did not significantly differ between the two groups. There was no recurrence in either group.

CONCLUSIONS

Laparoscopic IPTR was safe and feasible for treating Nyhus type II hernia in women.

Groin abscess, a rare complication of strangulated femoral hernia: Case report

Femoral hernias account for 8%–11% of all groin hernias and 3%–5% of all anterior abdominal wall hernias. While groin hernias are more common in males, femoral hernias are developed more commonly in female, accounting for 22%–34% of all groin hernias compared with 1.1% in male. The lifetime risk of developing groin hernia in male is approximately 25% but in female less than 5%, so in all female patients with groin hernias, femoral hernias should be included in the differential diagnosis until proven otherwise. The main concern of a femoral hernia is the higher risk of bowel strangulation, presenting emergently in 32%–39% of patients. We report a case of strangulated femoral hernia in a 78-year-old female who was presented to emergency department with groin abscess based on ultrasound image; patient was then diagnosed as having strangulated femoral hernia and taken to the operating theater, where she was found having strangulated segment of small intestine, so the patient underwent bowel resection and anastomosis with repair of the defect extraperitoneally, and ultimately, the patient improved and discharged from the hospital. Strangulated femoral hernia can present with groin abscess. Furthermore, femoral hernia should be ruled out in elderly patient presented with groin abscess, especially female patients.

Groin Hernia in Females Routinely Treated by Totally Extraperitoneal Laparoscopic Approach

Background and Objectives:

There is a dearth of studies on laparoscopic treatment of female groin hernia. Our study assessed the outcome of groin hernia repair in females employing the totally extraperitoneal laparoscopic (TEP) access.

Methods:

Data of all females who were subjected to laparoscopic groin herniorrhaphy, from August 1998 to February 2020 were retrospectively obtained. Groin hernia repair was routinely started with TEP access.

Results:

A total of 2,399 patients who underwent laparoscopic groin herniorrhaphy, 254 (10.6%), were females. Most females (n = 191; 75.2%) had single hernia and the remaining (n = 63; 24.8%) had bilateral hernias, making a total of 317 hernias operated. Indirect inguinal hernia was the most common hernia type (72.5%), followed by femoral hernia (17.4%) and direct hernia (10.1%). Prior lower abdominal operations were recorded in 97 (38.2%) patients. Conversion to a laparoscopic transabdominal preperitoneal procedure was performed due to technical difficulties to dissect the preperitoneal space in 17 patients (6.7%) and to open procedure in only one patient (0.4%) with incarcerated femoral hernia in whom an incidental perforation of the small bowel occurred. Intra- and postoperative complications occurred in 12 (4.7%) and 15 (5.9%) patients, respectively. There was no mortality. Most patients (n = 221; 87%) were discharged on the same day of the operation. Hernia recurrence was diagnosed in 6 patients (2.4%).

Conclusion:

It is concluded that females with groin hernia may be successfully treated with totally extraperitoneal laparoscopic access, with low conversion and complication rates.

Hematemesis Secondary to Complex Incarcerated Pantaloon Hernia

Hematemesis with concomitant small bowel obstruction is an uncommon emergency department presentation. We report the case of a patient who presented with hematemesis and an incarcerated pantaloon hernia. While the patient initially had intact bowel movements and flatus, he eventually developed complete obstruction that required open surgical repair. In a patient with an incarcerated hernia and a history of recurrent small bowel obstruction, predicting strangulation or compromised bowel and the need for rapid surgical intervention can be difficult. Hematemesis concurrent with hernia incarceration may be suggestive of impending complete bowel obstruction and ischemia.

A rare case of herniated duplex collecting system causing obstructive uropathy

BACKGROUND

An inguinal hernia is the protrusion of intraabdominal organs through an opening in the abdominal wall. Structures such as small and large intestines are commonly contained within inguinal hernias. However, uretero-inguinal hernia of the native collecting system is an extremely rarely reported entity. If unrecognized, acute kidney injury due to obstructive uropathy or serious intraprocedural ureteral injuries during hernia repair can occur. A duplex collecting system is a congenital kidney anomaly with an incidence of 0.8%. A uretero-inguinal hernia involving duplicated ureters has not been previously described in literature. Here we report a case of obstructive uropathy secondary to uretero-inguinal hernia involving duplicated ureters.

CASE PRESENTATION

A 78-year-old male known to have a left sided inguinal hernia presented to the Emergency department with two weeks of intermittent suprapubic tenderness, dysuria, frequency, urgency, frothy urine as well as nausea and vomiting. Workup on admission revealed an elevated creatinine of 2.8 mg/dl. CT imaging revealed duplicated left sided ureters with left inguinal hernia containing the ureters. There was cystic ureteral dilation within the herniation sac as well as moderate left hydroureteronephrosis. Patient had an elective inguinal hernia repair with left ureteral stent placement. Following the surgery, he had recovery of kidney function to the previous baseline serum creatinine of 1.5 mg/dl.

CONCLUSION

A duplex collecting system arises when two ureteral buds are formed during fetal development. However, diagnosis can be made in rare instances during adulthood when duplex collecting systems are usually found incidentally. Uretero-inguinal hernias have been reported as a common complication of renal transplant. However, uretero-inguinal hernias in native kidneys are considered an uncommon finding, especially with a duplex collecting system. When patients present with herniation and acute kidney injury, it is important to rule out the possibility of uretero-inguinal hernia to minimize complications such as obstructive uropathy and kidney failure. CT scan providing cross-sectional imaging is the ideal modality for identification of the site and etiology of urinary tract obstruction and site of herniation. If during imaging, an obstructive uropathy is observed, a nephroureteral stent or nephrostomy tube can be inserted to protect the ureter as well as relieve the obstruction, respectively.

Randomized Trial Comparing Self-Gripping Mesh with Polypropylene Mesh in Female Lichtenstein Hernioplasty

Several randomized trials comparing self-gripping mesh with polypropylene (PL) mesh in Lichtenstein hernioplasty revealed that the self-gripping mesh significantly reduced the operation time. In these studies, some enrolled only male patients, and in others, the proportion of women was extremely low. The aim of this research was to compare outcomes after self-gripping mesh repair with PL mesh secured with sutures in female Lichtenstein hernioplasty. Female patients with primary unilateral inguinal hernia were assigned randomly to undergo Lichtenstein hernioplasty with a self-gripping ProGrip (PG) mesh or a sutured PL mesh, followed-up at one week, one month, three months, one year, and two years. Demographics, hernia characteristics, and operative outcomes data were analyzed. Pain was assessed with a visual analog scale (0–10), and quality of life (QOL) was estimated by a 36-item short-form general survey (0–26). Forty eight patients in the PG group and 51 participants in the PL group completed the follow-up. The operation time of the PG (54.1 ± 12 minutes) group was significantly shorter than that of the PL (60.9 ± 11.3 minutes) group ( P = 0.045). At the one-month follow-up, the incidence of foreign body feeling in the PG group was significantly higher than that in the PL group ( P = 0.031), whereas no significant difference was observed in visual analog scale ≥3 and QOL. In a follow-up of three months, one year, and two years, there was no significant difference in foreign body feeling, chronic pain, QOL, and recurrence between two groups. The surgical outcomes of self-gripping mesh are comparable to those of the ordinary PL mesh with a reduced operation time in female Lichtenstein hernioplasty. Registration number: ChiCTR1800017360 ( http://www.chictr.org.cn ).

Consensus on international guidelines for management of groin hernias

BACKGROUND

Groin hernia management has a significant worldwide diversity with multiple surgical techniques and variable outcomes. The International guidelines for groin hernia management serve to help in groin hernia management, but the acceptance among general surgeons remains unknown. The aim of our study was to gauge the degree of agreement with the guidelines among health care professionals worldwide.

METHODS

Forty-six key statements and recommendations of the International guidelines for groin hernia management were selected and presented at plenary consensus conferences at four international congresses in Europe, the America's and Asia. Participants could cast their votes through live voting. Additionally, a web survey was sent out to all society members allowing online voting after each congress. Consensus was defined as > 70% agreement among all participants.

RESULTS

In total 822 surgeons cast their vote on the key statements and recommendations during the four plenary consensus meetings or via the web survey. Consensus was reached on 34 out of 39 (87%) recommendations, and on six out of seven (86%) statements. No consensus was reached on the use of light versus heavy-weight meshes (69%), superior cost-effectiveness of day-case laparo-endoscopic repair (69%), omitting prophylactic antibiotics in hernia repair, general or local versus regional anesthesia in elderly patients (55%) and re-operation in case of immediate postoperative pain (59%).

CONCLUSION

Globally, there is 87% consensus regarding the diagnosis and management of groin hernias. This provides a solid basis for standardizing the care path of patients with groin hernias.

Femoral hernia in the era of TAVI - a potential obstacle for transfemoral approach: a case report and literature review

Background

Transcatheter aortic valve implantation (TAVI) via total percutaneous transfemoral approach is an increasingly common technique for aortic stenosis treatment. It is primarily indicated in elderly with serious comorbidities. The epidemiology of these patients tends to overlap with the incidence of femoral hernia (FH). The appearance of hernia sac at the approach site and insufficient preoperational examination can lead to serious complications. We present the first-ever reported case of subsequent femoral hernia repair during transfemoral TAVI.

Case presentation

This report presents a case of FH/TAVI coincidence and literature review of its epidemiology. Literature review was performed to analyze similarities of femoral hernia and TAVI. The case describes an 84-year old female referred for elective TAVI. Intraoperation incarcerated femoral hernia was noticed and directly repaired. Further TAVI steps were performed on regular basis. A 2-year follow-up reported no local and general complications related to procedures.

Conclusions

Unsuspected femoral hernia found subsequently with transfemoral TAVI may become a growing problem. The number of TAVI performed rises with indications expansion. Femoral hernia repairs constitute from 2 to 4% of all groin hernia. Both TAVI and FH are connected with elderly. Despite the fact of low FH incidence, growing number of TAVI performed and ageing of population, corresponds with higher possibility of complications. Most of these complications may end up fatal as they would involve high-risk patients. Insufficient attention is paid by cardiologists to the possible hernia appearance in the access site as this issue has been hardly ever presented in literature. Concomitant FH in TAVI patients should always be excluded in order to avoid serious complications. The case we report presents a successful subsequent FH repair during TAVI procedure. Further studies have to be conducted to provide data on how such problems ought to be managed.

Groin Hernias in Women-A Review of the Literature

Background: To date, there are few studies and no systematic reviews focusing specifically on groin hernia in women. Most of the existing knowledge comes from registry data. Objective: This present review now reports on such findings as are available on groin hernia in women. Materials and Methods: A systematic search of the available literature was performed in September 2018 using Medline, PubMed, Google Scholar, and the Cochrane Library. For the present analysis 80 publications were identified. Results: The lifetime risk of developing a groin hernia in women is 3-5.8%. The proportion of women in the overall collective of operated groin hernias is 8.0-11.5%. In women, the proportion of femoral hernias is 16.7-37%. Risk factors for development of a groin hernia in women of high age and with a positive family history. A groin hernia during pregnancy should not be operated on. The rate of emergency procedures in women, at 14.5-17.0%, is 3 to 4-fold higher than in men and at 40.6% is even higher for femoral hernia. Therefore, watchful waiting is not indicated in women. During surgical repair of groin hernia in females the presence of a femoral hernia should always be excluded and if detected should be repaired using a laparo-endoscopic or open preperitoneal mesh technique. A higher rate of chronic postoperative inguinal pain must be expected in females. Conclusion: Special characteristics must be taken into account for repair of groin hernia in women.

Inguinal hernias appearing after lateral lymph node dissection via extraperitoneal approach for advanced lower rectal cancer

PURPOSE

Lateral lymph node dissection (LLND) is performed for advanced lower rectal cancer (ALRC) in Japan. The LLND in laparotomy is performed via the extraperitoneal approach, which is similar to radical retropubic prostatectomy (RRP). Inguinal hernias (IHs) appearing after RRP are common. However, there are few reports about IHs appearing after LLND.

METHODS

In part A, we retrospectively investigated 108 patients who underwent LLND for ALRC between January 2004 and December 2014. In part B, we compared 13 patients who underwent IH repair after LLND and 57 patients who underwent IH repair after RRP in the same period.

RESULTS

In part A, the incidence of IHs after LLND was 7% (8/108). All eight patients who developed IHs were male, and their median age was 60 years. More than 80% of IHs observed were the unilateral lateral type. In part B, the interval between the previous operation and IH occurrence was 4.9 years on average. Furthermore, 2 out of the 13 patients developed additional IHs occurring on the opposite side within 2 years.

CONCLUSIONS

The characteristics associated with developing IHs after LLND were similar to those after RRP. Any pelvic operation via the extraperitoneal approach has a risk of IHs, and surgeons should pay attention to IHs after surgery.

Orientações da Sociedade Brasileira de Hérnia (SBH) para o manejo das hérnias inguinocrurais em adultos

RESUMO As hérnias inguinais são um problema frequente e o seu reparo representa a cirurgia mais comumente realizada por cirurgiões gerais. Nos últimos anos, novos princípios, produtos e técnicas têm mudado a rotina dos cirurgiões que precisam reciclar conhecimentos e aperfeiçoar novas habilidades. Além disso, antigos conceitos sobre indicação cirúrgica e riscos de complicações vêm sendo reavaliados. Visando criar um guia de orientações sobre o manejo das hérnias inguinais em pacientes adultos, a Sociedade Brasileira de Hérnias reuniu um grupo de experts com objetivo de revisar diversos tópicos, como indicação cirúrgica, manejo perioperatório, técnicas cirúrgicas, complicações e orientações pós-operatórias.

Recurrence Rates After Repair of Inguinal Hernia in Women: A Systematic Review

Importance

To our knowledge, a systematic review has not yet been performed that specifically addresses the management of inguinal hernia in women. Recurrence after repair of inguinal hernia is not unusual in women and may be a previously undiagnosed femoral hernia, which is rarely seen in men.

Objective

To investigate rates and types of recurrences in women who had undergone repair of primary inguinal hernia.

Evidence Review

PubMed, Embase, and the Cochrane databases were searched in September 2017 for studies reporting recurrences after repair of primary inguinal hernia in women. Crude rates of recurrence (number of recurrences/number of women) were calculated after open and laparoscopic repairs, and the type of recurrent hernia was registered, if noted in the studies. This review is reported according to the PRISMA guideline.

Findings

A total of 55 studies were included, comprising 43 870 women (mean age, 42-69 years; median age, 57 years). Five studies were randomized clinical trials, 14 were prospective cohort studies, 7 were prospective database studies, and 29 were retrospective cohort studies. Twenty studies reported recurrence after laparoscopic repair, with a crude recurrence rate of 1.2% (27 of 2257) (range, 0%-5%) and a median follow-up of 24 months. Thirty-seven studies reported open repair, with a crude recurrence rate of 2.4% (818 of 33 971) (range, 0%-12.5%) and a median follow-up of 36 months. The crude recurrence rate in randomized clinical trials and prospective studies was 1.2% (18 of 1525) after laparoscopic repair compared with 4.9% (490 of 10 058) after open repair. The recurrent inguinal hernia was a femoral hernia in 203 of 496 patients (40.9%) after open repair, compared with 0% of patients after laparoscopic repair. Recurrence rates were similar when open mesh vs nonmesh techniques were used.

Conclusions and Relevance

Recurrence rates after repair of primary inguinal hernia in women are lower after laparoscopic repair compared with open repair. Intraoperative findings during repair of recurrent inguinal hernia are often femoral hernias in women.

Laparoscopic Repair for Groin Hernias in Female Patients: A Single-Center Experience in 15 Years

BACKGROUND

Our objective was to investigate the clinical characteristics of laparoscopic repair for groin hernias in female patients.

STUDY DESIGN

The clinical data of 316 female patients (341 hernias) who underwent laparoscopic inguinal hernia repair at Shanghai Minimally Invasive Surgery Center between January 2001 and December 2015 was analyzed retrospectively. The operation-related data were to provide an overview of female groin hernias, preferred surgical approach, and the management of round ligament of uterus.

RESULTS

There were 274 transabdominal preperitoneal patch plastic repairs and 67 total extraperitoneal repairs performed on 257 and 59 patients, respectively. The median follow-up period was 48 months. Fifty-eight femoral hernias were noted in 52 patients, of which 18 femoral hernias were incarcerated. Cysts on the round ligament of uterus were found in 39 patients, and most of them underwent laparoscopic resection. Round ligaments of uterus were preserved in 152 patients and transected in 162 patients. The preservation group requires longer operation time and trickier surgical technique. None of the cases was converted to laparotomy. All patients returned to normal activity soon and no recurrence was noted during follow-up.

CONCLUSIONS

Laparoscopic inguinal hernia repair is well adopted around the world. Meanwhile, there still remain questions to be discussed in female patients. Based on this study, the round ligament cyst could be resected while the operation. Either "open and suture" or keyhole technique will be available to preserve the round ligament of uterus.

Gallbladder protrusion through the groin region-a very unusual femoral hernia

Groin hernias are among the oldest recorded afflictions of mankind. Most of them protrude through the inguinal canal, and only a few through the femoral canal. Usually, they are present as a painful lump in the groin region, and their complications arise if they become incarcerated or strangulated. Incarcerated hernias may contain a variety of contents, such as the omentum, small bowel, colon, bladder, appendix, stomach, or ovary as previously described. Usually, the history and a physical examination are sufficient to make the diagnosis. However, the wide use of CT has become an effective instrument to identify the contents of hernias and has helped surgeons program the best management. This article reports, for the first time, the case of an 81-year-old female with an incarcerated femoral hernia that contains the gallbladder.

International guidelines for groin hernia management

INTRODUCTION

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

METHODS

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

A rare case of adult ovarian hernia in MRKH syndrome

Inguinal hernias containing ovary have a documented incidence of 3%. Most of the cases are associated with congenital anomalies of genital tract such as Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. A 20-year-old female presented with primary amenorrhoea, normal secondary sexual characteristics and genetic karyotyping showing 46XX chromosome. On USG abdomen and pelvis examination complete absence of uterus, cervix and vagina was found. Both the ovaries were seen away from normal anatomical location in bilateral inguinal canal without significant complication. MRI study confirmed agenesis of uterus, cervix and vagina; bilateral inguinal hernia with ovaries as contents. Type 1 MRKH syndrome with bilateral ovarian hernias was diagnosed.

The clinical effectiveness and cost-effectiveness of open mesh repairs in adults presenting with a clinically diagnosed primary unilateral inguinal hernia who are operated in an elective setting: systematic review and economic evaluation

BACKGROUNDS

Current open mesh techniques for inguinal hernia repair have shown similar recurrence rates. However, chronic pain has been associated with Lichtenstein mesh repair, the most common surgical procedure for inguinal hernia in the UK. The position of the mesh is probably an important factor. The Lichtenstein method requires dissection of the inguinal wall and fixation of the mesh. In contrast, in the open preperitoneal approach the mesh is placed in the preperitoneal space and held in place with intra-abdominal pressure. Currently, there is no consensus regarding the best open approach for repair of inguinal hernia.

OBJECTIVES

To determine the clinical effectiveness and cost-effectiveness of open preperitoneal mesh repair compared with Lichtenstein mesh repair in adults presenting with a clinically diagnosed primary unilateral inguinal hernia.

DATA SOURCES

We searched major electronic databases (e.g. MEDLINE, MEDLINE In-Process & Other Non-Indexed, EMBASE, Cochrane Controlled Trials Register) from inception to November 2014 and contacted experts in the field.

REVIEW METHODS

Evidence was considered from randomised controlled trials (RCTs) that compared open preperitoneal mesh repair with Lichtenstein mesh repair for the treatment of inguinal hernia. Two reviewers independently selected studies for inclusion. One reviewer completed data extraction and assessed risk of bias for included studies, and two reviewers independently cross-checked the details extracted. Meta-analyses techniques were used to combine results from included studies. A Markov model was developed to assess the cost-effectiveness of open mesh procedures from a NHS health services perspective over a 25-year time horizon.

RESULTS

Twelve RCTs involving 1568 participants were included. Participants who underwent open preperitoneal mesh repair returned to work and normal activities significantly earlier than those who underwent Lichtenstein mesh repair [mean difference -1.49 days, 95% confidence interval (CI) -2.78 to -0.20 days]. Although no significant differences were observed between the two open approaches for incidence of pain [risk ratio (RR) 0.50, 95% CI 0.20 to 1.27], numbness (RR 0.48, 95% CI 0.15 to 1.56), recurrences (Peto odds ratio 0.76, 95% CI 0.38 to 1.52) or postoperative complications, fewer events were generally reported after open preperitoneal mesh repair. The results of the economic evaluation indicate that the open preperitoneal mesh repair was £256 less costly and improved health outcomes by 0.041 quality-adjusted life-years (QALYs) compared with Lichtenstein mesh repair. The open preperitoneal procedure was the most efficient and dominant treatment strategy with a high (> 98%) probability of being cost-effectiveness for the NHS at a willingness to pay of £20,000 for a QALY. Results were robust to a range of sensitivity analyses. However, the magnitude of cost saving or QALY gain was sensitive to some model assumptions.

LIMITATIONS

Overall, the included trials were of small sample size (mean 130.7 participants) and at high or unclear risk of bias. Meta-analyses results demonstrated significant statistical heterogeneity for most of the assessed outcomes.

CONCLUSIONS

Open preperitoneal mesh repair appears to be a safe and efficacious alternative to Lichtenstein mesh repair. Further research is required to determine the long-term effects of these surgical procedures as well as the most effective open preperitoneal repair technique in terms of both clinical efficacy and costs.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014013510.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Sonographic prevalence of groin hernias and adductor tendinopathy in patients with femoroacetabular impingement

BACKGROUND

Femoroacetabular impingement (FAI) is a common debilitating condition that is associated with groin pain and limitation in young and active patients. Besides FAI, various disorders such as hernias, adductor tendinopathy, athletic pubalgia, lumbar spine affections, and others can cause similar symptoms.

PURPOSE

To determine the prevalence of inguinal and/or femoral herniation and adductor insertion tendinopathy using dynamic ultrasound in a cohort of patients with radiographic evidence of FAI.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This retrospective study consisted of 74 patients (36 female and 38 male; mean age, 29 years; 83 symptomatic hips) with groin pain and radiographic evidence of FAI. In addition to the usual diagnostic algorithm, all patients underwent a dynamic ultrasound examination for signs of groin herniation and tendinopathy of the proximal insertion of the adductors.

RESULTS

Evidence of groin herniation was found in 34 hips (41%). There were 27 inguinal (6 female, 21 male) and 10 femoral (9 female, 1 male) hernias. In 3 cases, inguinal and femoral herniation was coexistent. Overall, 5 patients underwent subsequent hernia repair. Patients with groin herniation were significantly older than those without (33 vs 27 years, respectively; P = .01). There were no significant differences for any of the radiographic or clinical parameters. Tendinopathy of the proximal adductor insertion was detected in 19 cases (23%; 11 female, 8 male). Tendinopathy was coexistent with groin herniation in 8 of the 19 cases. There were no significant differences for any of the radiographic or clinical parameters between patients with or without tendinopathy. Patients with a negative diagnostic hip injection result were more likely to have a concomitant groin hernia than those with a positive injection result (80% vs 27%, respectively). Overall, 38 hips underwent FAI surgery with satisfactory outcomes in terms of score values and subjective improvement.

CONCLUSION

The results demonstrate that groin herniation and adductor insertion tendinopathy coexist frequently in patients with FAI. Although the clinical effect is yet unclear, 5 patients underwent hernia repair. Dynamic ultrasound is a useful tool to detect such pathological abnormalities. Diagnostic hip injections can be helpful to differentiate between the sources of pain.

An Incarcerated Colon Inguinal Hernia That Perforated into the Scrotum and Exhibited an Air-Fluid Level

There are few reports of a transverse colon inguinal hernia; furthermore, an inguinal hernia perforating the scrotum is rare. Here we report the case of a 79-year-old man who died after developing an incarcerated colon inguinal hernia that perforated the scrotum and exhibited an air-fluid level. The patient was referred to our hospital in November 2011 with a complaint of inability to move. Physical examination revealed an abnormally enlarged left scrotum and cold extremities. He reported a history of gastric cancer that was surgically treated more than 30 years ago. His white blood cell count and C-reactive protein level were elevated. Abdominal and inguinal computed tomography revealed that his transverse colon was incarcerated in the left inguinal canal. Free air and air-fluid level were observed around the transverse colon, suggestive of a perforation. The patient and his family refused any surgical intervention; therefore, he was treated with sultamicillin tosilate hydrate and cefotiam hydrochloride. However, he succumbed to panperitonitis 19 days after admission. The findings from this case indicate that the transverse colon can perforate into an inguinal hernia sac.

Indirect inguinal hernia containing a fallopian tube and ovary in a reproductive aged woman

An indirect inguinal hernia containing an incarcerated fallopian tube and ovary is extremely rare in adult females. The current report describes a woman of reproductive years presenting with an irreducible indirect hernia which required the surgical intervention of a general surgeon as well as counseling regarding future fertility by a gynecologist. The diagnosis was made by physical and sonographic examination and was confirmed by CT scan and surgical intervention. We suggest a multimodel and multidisciplinary approach in order to safely and efficiently preserve ovarian and fertility function in young women who present with an inguinal hernia containing reproductive organs.

Inguinal hernia as a presentation of testicular feminization

We present a case of a 20-year-old female who was admitted to our department for an elective inguinal hernia repair. An oval-shaped mass was found in the hernia sac during the surgery that was suspected to be an ovary. Histological examination revealed testicular tissue. Further evaluation confirmed testicular feminization. She underwent laparoscopic orchiectomy and hernia repair from the contralateral side 3 months later.

Hernia emergencies

Hernia emergencies are commonly encountered by the acute care surgeon. Although the location and contents may vary, the basic principles are constant: address the life-threatening problem first, then perform the safest and most durable hernia repair possible. Mesh reinforcement provides the most durable long-term results. Underlay positioning is associated with the best outcomes. Components separation is a useful technique to achieve tension-free primary fascial reapproximation. The choice of mesh is dictated by the degree of contamination. Internal herniation is rare, and preoperative diagnosis remains difficult. In all hernia emergencies, morbidity is high, and postoperative wound complications should be anticipated.

Inguinal hernia repair in women: is the laparoscopic approach superior?

PURPOSE

Laparoscopic inguinal hernia repair is associated with reduced post-operative pain and earlier return to work in men. However, the role of laparoscopic hernia repair in women is not well reported. The aim of this study was to review the outcomes of the laparoscopic versus open repair of inguinal hernias in women and to discuss patients' considerations when choosing the approach.

METHODS

A retrospective chart review of all consecutive patients undergoing inguinal hernia repair from January 2005 to December 2009 at a single institution was conducted. Presentation characteristics and outcome measures including recurrence rates, post-operative pain and complications were compared in women undergoing laparoscopic versus open hernia repair.

RESULTS

A total of 1,133 patients had an inguinal herniorrhaphy. Of these, 101 patients were female (9 %), with a total of 111 hernias. A laparoscopic approach was chosen in 44 % of patients. The majority of women (56 %) presented with groin pain as the primary symptom. Neither the mode of presentation nor the presenting symptoms significantly influenced the surgical approach. There were no statistically significant differences in hernia recurrence, post-operative neuralgia, seroma/hematoma formation or urinary retention between the two approaches (p < 0.05). A greater proportion of patients with bilateral hernias had a laparoscopic approach rather than an open technique (12 vs. 2 %, p = 0.042).

CONCLUSIONS

Laparoscopic herniorrhaphy is as safe and efficacious as open repair in women, and should be considered when the diagnosis is in question, for management of bilateral hernias or when concomitant abdominal pathology is being addressed.

Laparoscopic diagnosis and management of a novel inguino-pelvic hernia

Inguinal hernias can typically be diagnosed with a proper history and thorough physical exam. However, patients with chronic groin pain, normal physical exam and no radiologic findings present a diagnostic/therapeutic dilemma [1]. We present a case of a female patient with obscure chronic groin pain. Upon laparoscopic exploration, she was found to have a hernia in a previously non-described location. Reduction of a chronically incarcerated preperitoneal fat and subsequent repair using traditional transabdominal preperitoneal repair resulted in a complete resolution of her pain.

Groin pain in women: use of sonography to detect occult hernias

OBJECTIVES

Symptomatic groin hernias in women may be difficult to assess clinically and commonly mimic pathologic musculoskeletal and gynecologic conditions. The objective of our study was to investigate the accuracy of sonography in women with groin pain and normal physical examination findings.

METHODS

A consecutive group of 87 women (median age, 44.6 years; range, 19-82 years) with groin pain and normal physical examination findings were included in the study. All patients had a standardized sonographic examination of the groin performed by an experienced radiologist or a sonographer. If a groin hernia was identified, it was classified as indirect, direct, or femoral. Normal examination findings and alternate pathologic groin conditions were also recorded. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated for the sonographic findings and compared to the findings for patients sent for surgery.

RESULTS

Of the 87 women with groin pain, 37 groin hernias were diagnosed in 35 patients. Surgery was performed in 26 patients (27 groins). Sonography correctly depicted and classified groin hernias in 18 of the 21 groins that had surgical confirmation. Six women without groin hernias also had surgical exploration of the affected side. The sensitivity, specificity, positive predictive value, and negative predictive value for the patients with surgical confirmation were 95%, 75%, 95%, and 75%, respectively. Groin pain in 26 patients was attributed to other causes. The remainder of the patients had normal examination findings or were lost to follow-up.

CONCLUSIONS

Groin hernias in women can be occult and confound the clinical diagnosis. In a woman with groin pain and normal or indeterminate physical examination findings, we have found that sonography can accurately depict and classify groin hernias and other pathologic processes.

Risk factors related with unfavorable outcomes in groin hernia repairs

PURPOSE

Hernia repairs are a common surgical procedure, and are associated with a significant cost. Despite the acceptance of the advantages of early elective hernia repairs, the incidence of emergency admissions with complicated presentations remains high, and the natural history of an untreated hernia is not obvious. This study aimed to define risk factors related with unfavorable outcomes in groin hernia repairs.

METHODS

We analyzed the records of 685 elective or emergency repairs of groin hernias between December 2005 and June 2009. Patient age ranged from 17 to 85 years, with 240 (35%) of patients being older than 60 years of age. Indirect inguinal hernias were the most common hernia type in both sexes of patients. Coexisting cardiopulmonary problems were noted in 294 male and 33 female patients. American Society of Anaesthesiologists (ASA) grades 3 and 4 were encountered in 61 (9%) patients. Data were analyzed by chi-square test.

RESULTS

Significantly high incarceration and strangulation rates were found in females and femoral hernia type. The overall morbidity rate was 7%, major complications 3%. No mortality was observed in the series and postoperative complications were significantly more common in patients with high ASA score and severe coexisting cardiopulmonary problems. Advanced age, delayed admission, femoral type hernia and female sex were also linked with unfavorable outcomes.

CONCLUSIONS

The risk of complicated presentation and unfavorable outcome in patients with groin hernia is significant in the presence of factors such as advanced age, femoral hernia, female sex, delayed admission, severe coexisting cardiopulmonary problems and high ASA score. Although it is difficult to estimate the natural history of untreated hernia, hernia repairs of patients with the above-mentioned risk factors should be timely and elective.