Transabdominal preperitoneal laparoscopic approach for incarcerated inguinal hernia repair: A report of 73 cases

Transabdominal preperitoneal (TAPP) repair for emergency groin hernia: a systematic review

PURPOSE

Laparoscopic groin hernia repair has evolved and gained popularity and laparoscopic transabdominal preperitoneal (TAPP) procedure provides an opportunity to evaluate the peritoneal cavity and both inguinal areas without the need for additional dissection. There is still a paucity of evidence to support TAPP repair in the emergency setting. In this systematic review, we aim to evaluate the feasibility and safety of TAPP repair for incarcerated and strangulated groin hernias.

METHODS

PRISMA guidelines were followed for literature search and established inclusion and exclusion criteria were applied. Data were extracted and analyzed for the outcomes of interest.

RESULTS

Overall, 8 studies were included in the review, comprising 316 patients. Patients characteristics and outcomes were limitedly reported. Only 3 cases of conversion to open approach were reported and 2 recurrences were diagnosed. Postoperative complications are inconsistently reported but mostly refer to minor complications. There were no mortality cases. Visceral resections were performed in 25 cases due to ischemia, mostly extracorporeally.

CONCLUSION

Laparoscopy is a game changer and TAPP approach is a feasible, safe, and effective technique for the emergent repair of groin hernias. Further studies and prospective randomized data are needed to establish its role in the emergent groin hernia management.

Comparison of emergent laparoscopic and open repair of acutely incarcerated and strangulated hernias-short- and long-term results

BACKGROUND

Incarcerated and strangulated hernias are a common clinical presentation encompassing several challenges in acute care surgery. The role of laparoscopy is still controversial and the data is scarce. Laparoscopy enables better evaluation of the incarcerated organ and its viability. The use of mesh repair in these emergent operations is also a major concern. In this series we aimed to evaluate the safety and efficacy of laparoscopic emergent repairs of acutely incarcerated and strangulated hernias, and their long-term results, in comparison to the conventional open repairs.

METHODS

Retrospective review of prospectively collected data of all adult patients, between the ages of 18 and 89, who underwent emergent operation due to an incarcerated and strangulated hernia between November 2017 and December 2020.

RESULTS

During the study period, 89 patients underwent emergent operation due to incarcerated hernias-63 laparoscopic repair and 26 underwent an open repair. In the laparoscopic group (LG) 38 patients had a groin hernia and 25 had a ventral hernia, while in the open group (OG) the distribution was 12 and 14, respectively. When operated laparoscopically, all groin hernias but one were repaired in the TAPP approach and most ventral hernias were repaired using the IPOM + approach. During the peri-operative period there were 3 mortalities (1 in the LG). There were no significant differences between the groups in minor or major complications. Mean follow-up time in the LG was 27.9 months and 29.4 months in the OG. There was no significant difference in recurrence rates. Long-term results showed better outcome in the LG regarding pain at rest, difficulty doing exercise and local discomfort.

CONCLUSION

Laparoscopic emergent repair of incarcerated hernias is a safe and feasible approach, with better short and long-term results compared to the open approach.

Outcomes of laparoscopic repair in complicated groin hernia: A single institutional based cohort study in Nepal

Introduction

Laparoscopic hernia repairs have comparable recurrence rate with less persisting pain and numbness and quicker return to usual activities as compared to open mesh repair. The excellent outcomes of minimally invasive surgery encourage us to extend the laparoscopic technique to complicated groin hernia.

Method

A total of 22 patients with complicated groin hernia who presented to our institute from September 2017 to September 2018 were included in this prospective cohort study. Inclusion criteria were patients with age greater than 18 years and clinically diagnosed as complicated groin hernia. Patients with peritonitis, those with previous abdominal surgery and unfit for general anesthesia were excluded from our study.

Results

The most common age group was 51–60 (31.8%) years.17 cases were repaired with totally laparoscopic approach (12 TEP, 5 TAPP). Laparoscopic repair with additional procedure was needed in 3 cases and 2 cases were converted to open for completion of the procedure. The mean operating time was 154.8 ± 51.6 (range: 90 to 230) minutes. The average length of hospital stay was 3.8 ± 3 (range: 1 to 12) days. Bleeding from the inferior epigastric and testicular vessels were the major intra-operative complication (11.8%). Seroma and surgical site infection were seen in 2 (11.8%) patients.

Conclusion

Laparoscopic approach in cases of complicated groin hernia can achieve desirable patient outcomes without major complications, provided good patient selection and expertise. The evidence for laparoscopic repair as the choice of procedure in complicated groin hernia can be established from further comparative studies.

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Laparoscopic repair in complicated hernia has been attempted more frequently due to availability of expertise and detailed knowledge of anatomy.

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Successful reduction of hernia contents in laparoscopic repair is possible with minimal complications.

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Complications in laparoscopic repair in complicated hernia (intraoperative/postoperative) are comparable to that of laparoscopic repair of uncomplicated hernia or open repair of complicated hernia.

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Mesh can be used in laparoscopic repair of uncomplicated hernia.

Laparoscopic transperitoneal hernia repair (TAPP) in emergency: long-term follow-up in a high volume centre

PURPOSE

Aim of this study was to analyse feasibility, safety and effectiveness of laparoscopic transperitoneal hernia repair (TAPP) approach to inguinal hernias in the emergency setting, with a longer follow-up than the studies present in literature.

METHODS

We retrospectively analysed all patients who underwent emergency TAPP hernia repair in San Marco Hospital (Zingonia, Italy), from September 2010 to June 2020. A prospectively collected database of 685 consecutive TAPP hernia repair was reviewed. Feasibility and safety were evaluated through operative time, conversion rate, perioperative mortality, morbidity and prosthesis infection rate. Effectiveness was assessed by recurrence and complication rate, acute (during admission) and chronic (during follow-up) pain by Visual Analogic Scale (VAS), and recovery to normal activity in a long-term follow-up (mean period 1718 days).

RESULTS

The final study group included 47 patients. The mean age was 59.6 years (range 22-89), 29 patients were male and 18 were female. The mean operation time was 64 min. Two cases were converted to open approach (4%). In four cases bowel resection became necessary (8.5%). Appendicectomy and omentectomy occurred once and twice, respectively (2% and 4%), and orchiectomy was required in two patients (4%). Seroma was the only postoperative complication that we registered in four patients. During a mean follow-up period of 1718 days, there was no recurrence of the hernia or other complications. Five patients referred mild occasional groin pain (VAS < 3), with quick relief without taking any pain killers.

CONCLUSION

TAPP approach is a safe, feasible and effective therapeutic option for groin hernias in emergency setting. No recurrence or severe complications were reported in over 4 years of follow-up.

Robotic Inguinal Hernia Repair for Incarcerated Hernias

Purpose: This is the first study to investigate clinical outcomes after robotic emergent inguinal hernia repair (rEIHR). Methods: Data were retrospectively analyzed from patients who underwent rEIHR from 2013 to 2020. Any patients who underwent concomitant nonabdominal wall procedures were excluded. Complications were assessed with the Clavien-Dindo (CD) and Comprehensive Complication Index (CCI^®) scoring systems. Results: Out of 616 patients who underwent inguinal herniorrhaphy throughout the study period, 23 rEIHRs were identified among 19 patients. The median Acute Physiology and Chronic Health Evaluation-II score was 6, and the average skin-to-skin time was 75.9 minutes. The average length of stay (LOS) was 1.4 days. During the mean follow-up period of 31.7 months, a total of three complications (CD-grades I, II, and IVa) in two patients were observed. The median CCI score was 0 (max = 43.3). Conclusion: rEIHR is a feasible option for surgeons to utilize, with a short LOS and low complication rate, given the sufficient experience and support as well as the appropriate patient selection.

Incarcerated Appendix Epiploica in Inguinal Hernia Sac: Treatment with Laparoscopic TAPP Approach-Report of a Rare Case

Appendix epiploica (AE) in an incarcerated inguinal hernia sac is very rare. We herein report the case of a 57-year-old man admitted to the emergency department with complaints of nausea, swelling, and pain in the left inguinal area. He was diagnosed with left incarcerated inguinal hernia and treated laparoscopically with transabdominal preperitoneal (TAPP) mesh hernioplasty. During the operation, AE, lodged in the direct hernia sac, was seen to originate from the sigmoid colon. The narrow internal inguinal ring was incised at the 2 o'clock position using a monopolar hook, and the hypertrophic AE was reduced to the abdomen and resected. The patient was discharged uneventfully on the second postoperative day.

Tension-Free Mesh Repair for Incarcerated Groin Hernia: A Comparative Study

Background. Management of emergent groin hernias remains challenging, due to limited consensus in surgical approach and repair options (eg, mesh vs nonmesh, biological mesh, and polypropylene [PP] mesh). Methods. A 5-year retrospective study was conducted on 118 patients who received emergency incarcerated groin hernia repair in Beijing Chaoyang Hospital. The incidence of surgical site infection (SSI), preoperative mortality, sepsis, and ileus was noted. In the follow-up, postoperative foreign body sensation, chronic pain, seroma/hematoma, and recurrence were recorded. The outcomes of different surgical procedures (with mesh/without mesh, biological mesh/PP mesh, transabdominal preperitoneal (TAPP)/Lichtenstein repair) were compared and analyzed. Results. Out of the 118 patients, 14 cases received suture repair (as group A); 104 cases had TAPP repair (n = 44) or Lichtenstein repair (n = 60) with meshes, including 23 cases of biological mesh (as group B); and 81 cases had repair with PP mesh (group C). There were no significant differences between the 3 groups regarding SSI, mortality, sepsis, and ileus. After 20.5 months of follow-up (range from 6 to 65 months), 21.4% of group A developed recurrence, a rate significantly higher than that of group B (4.3%) and group C (0). The incidence of seroma/hematoma in group B was higher than that in group A (7.1%) and group C (7.4%). The results between TAPP group and Lichtenstein group were comparable. Conclusion. Tension-free mesh repair in the treatment of emergency incarcerated groin hernia is safe and effective, which can reduce hernia recurrence without increasing infection risk. The results of biological mesh and PP mesh were comparable.

Resection of mesothelial cyst of uterine round ligament by laparoscopic transabdominal preperitoneal procedure alone or combined with open surgery

Objective

Surgical treatment of a mesothelial cyst of the uterine round ligament (MCURL), an uncommon entity, has been rarely documented. In this article, we present our experience with excision of MCURLs.

Methods

The records of all female patients undergoing surgical removal of a groin mass in our department from March 2013 to November 2018 were retrospectively reviewed. Demographic information, clinical data, and follow-up outcomes were collected and analyzed.

Results

Among 298 women who underwent groin hernia repair, 17 (5.7%) had MCURLs. Of these 17 patients, 13 were aged 30 to 45 years and 15 had a normal body mass index (18.5–23.9 kg/m²). MCURLs occurred predominantly on the right side (11/17). Approximately half of the patients (9/17) were preoperatively misdiagnosed with inguinal hernias. Approximately 70% (12/17) of the lesions were localized medially to the inner ring of the inguinal canal and excised by a laparoscopic transabdominal preperitoneal (TAPP) procedure alone. Five patients required open surgery following the TAPP procedure because the cyst extended distally beyond the inner ring. No recurrence was noted during the entire follow-up period.

Conclusion

Most MCURLs were localized medially to the inner ring of the inguinal canal and could be excised by a TAPP procedure.

Case of reduction en masse who presented with no symptoms

The early and accurate diagnosis of reduction en masse followed by proper treatment is important but has been difficult. Here, we report the case of a 58-year-old Japanese man who presented with abdominal pain and vomiting at a nearby clinic. He was referred to our hospital on suspicion of small bowel obstruction. Despite the total disappearance of his symptoms, the abdominal X-ray examination showed distended loops of small bowel. The preoperative diagnosis of small bowel strangulation due to an internal hernia was made by CT, and we therefore performed emergency exploratory laparoscopy. We intraoperatively diagnosed the patient with the reduction en masse of a right inguinal hernia, and we conducted a transabdominal preperitoneal hernioplasty. This patient's case demonstrates that even when a patient is asymptomatic after the reduction of an inguinal hernia, the possibility of a reduction en masse remains.

The Use of Prosthetic Mesh in the Emergency Management of Acute Incarcerated Inguinal Hernias

INTRODUCTION

Tension-free hernia repair has been regarded as a gold standard treatment for selected inguinal hernias, but the use of prosthetic mesh in acute incarcerated inguinal hernias is controversial. Our study focused on evaluating the safety and efficacy of the prosthetic mesh repair for emergency cases.

METHODS

Patients with acute incarcerated inguinal hernias who underwent emergency prosthetic mesh repair during 2009 to 2014 at our department were included. Patient characteristics, operative approaches and results, and complications were retrospectively analyzed.

RESULTS

A total of 167 patients were included in our study. One hundred and twenty-two patients underwent open surgery while the remaining 45 patients underwent transabdominal preperitoneal laparoscopic approach. The hernia was indirect inguinal in 133 patients (79.6%), direct inguinal in 15 patients (9.0%), and femoral in 19 patients (11.4%). The overall wound infection rate of these patients was 3%. Nonviable intestinal resection was performed in 25 patients (8.4%), only 2 of whom underwent wound infection. Another 3 patients who developed wound infection had viable hernia content. There was no mesh-related infection. There was no statistically significant difference in wound infection rates between patients with viable hernia contents and those with nonviable contents ( P < .05).

CONCLUSION

The use of the prosthetic mesh in the treatment of acute incarcerated inguinal hernia is safe and effective. Nonviable intestinal resection cannot be regarded as a contradiction of the mesh repair.

Laparoscopic transabdominal preperitoneal technique versus open surgery with the ULTRAPRO Hernia System for the repair of female primary femoral hernias-an observational retrospective study

Femoral hernias (FHs), predominantly seen in females, require surgery for cure. To date, surgical repair of primary FHs in female patients with either open surgery or laparoscopic operation has been poorly documented. We retrospectively investigated the treatment of female primary FHs with open surgery using the ULTRAPRO Hernia System (UHS procedure) or the laparoscopic procedure, namely, the transabdominal preperitoneal (TAPP) technique. A total of 41 female patients with primary FHs who had undergone UHS or TAPP were included in this study. The procedural parameters, post-surgical complications, treatment expense, and follow-up results were analyzed. The vast majority of patients (39/41) underwent elective operations: 15 received UHS (including 2 emergency cases) and 26 had TAPP (P = .08). The UHS group had a greater average age, due to the fact that FHs occur often in people with advanced age who tend to have systemic disease, limiting the use of general anesthesia required for TAPP. Compared with UHS, TAPP took a significantly shorter time to complete and patients undergoing TAPP had a dramatically shorter hospital stay. While no recurrence was observed in both groups, post-procedure pain and foreign body sensation were reported by significantly more patients in UHS group. The cost was greater with TAPP. Taken together, we concluded that both UHS and TAPP are effective in the management of female FHs. In view of the advantages and disadvantages between the open and the laparoscopic operation, surgeons can select a procedure according to their skills and patients' situation.

Risk factors of postoperative complications after emergency repair of incarcerated groin hernia for adult patients: a retrospective cohort study

Purpose

This study aimed to explore risk factors of postoperative complications for adult patients with incarcerated groin hernia (IGH).

Methods

From January 2010 to December 2017, consecutive patients undergoing emergency hernia repair for IGH in our center were retrospectively reviewed. Postoperative complications, such as surgical site infection, seroma, hernia recurrence and mortality, were investigated, with risk factors for such complications analyzed using univariate and multivariate regressions.

Results

Sixty-four patients were included, with 51 males and 13 females (mean age 65.1, range 25–98 years). Ten patients (15.6%) underwent resection of necrotic bowel and anastomosis. 43 patients (67.2%) received open tension-free herniorrhaphy with polypropylene mesh, whereas the rest (32.8%) received herniorrhaphy without mesh. The overall postoperative complication rate was 40.6% (26/64), with an incisional complication rate of 31.2% (20/64) and an infection rate of 6.2% (4/64). At a median follow-up of 32 months, hernia recurrence and mortality were recorded in five cases each (7.8%). Mesh repair was associated with decreased recurrence rate compared with non-mesh repair (2.3% vs. 19.0%, p = 0.019). Diabetes mellitus (OR 8.611, 95%CI 1.292–57.405; p = 0.026) was an independent risk factor of postoperative complications, together with chronic obstructive pulmonary disease (COPD; OR 14.365, 95%CI 1.652–127.767, p = 0.016), intestinal necrosis (OR 14.260, 95%CI 1.079–188.460, p = 0.044), and general anesthesia (OR 14.543, 95%CI 1.682–125.711, p = 0.015) as risk for incisional complications after surgery.

Conclusions

Diabetes mellitus was an independent risk factor of postoperative complications for IGH, along with COPD, intestinal necrosis and general anesthesia associated with incisional complications. The use of polypropylene mesh did not increase infection or recurrence rate in this cohort.

Minimally invasive approach to incarcerated or strangulated groin hernias: A 2018 EAST Master Class Video Presentation

Groin hernia repair is one of the most common general surgical procedures performed worldwide. Although only a small percentage will become incarcerated or strangulated, this is an indication for repair. Minimally invasive surgery is becoming the standard of care for most procedures, and we believe this to be a safe and feasible approach for incarcerated or strangulated groin hernias. We present a description of our recommended approach with technical details and accompanying video clips to highlight these techniques.