Use of fibrin glue in preventing pseudorecurrence after laparoscopic total extraperitoneal repair of large indirect inguinal hernia

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Large Symptomatic Inguinoscrotal Seroma Occurred Early after Laparoscopic Total Extraperitoneal Hernia Repair (TEP): a Case Report and Literature Review

Inguinoscrotal hernia (ISH) is an entity for which treatment is under debate. Open surgery is the standard approach, but the laparoscopic technique has a great outcome when used by experienced surgeons. Seroma is one of the complications following laparoscopic hernia repair for these scrotal hernias, which is due to the large hernia sac, usually transected, leaving in place a remnant of the sac. Conservative measures can be applied for the treatment of seroma; however, in symptomatic cases, puncture and aspiration of fluid are recommended. Sometimes, these seromas can reach a large size and require surgery to remove the remnant sac. Herein, we report the case of a 49-year-old male with a large seroma that occurred four days after the laparoscopic approach - total extraperitoneal repair (TEP) for inguinoscrotal hernia. Conservative measures failed, and because the symptoms were not alleviated, reintervention was opted for. The distal sac was excised and the patient recovered uneventfully. The six-month follow-up did not show any recurrence of the hernia or seroma. We emphasize the importance of sac management in large ISH cases and discuss seromas after laparoscopic hernia repair in such instances.

Large Symptomatic Inguinoscrotal Seroma Occurred Early after Laparoscopic Total Extraperitoneal Hernia Repair (TEP): a Case Report and Literature Review

Inguinoscrotal hernia (ISH) is an entity for which treatment is under debate. Open surgery is the standard approach, but the laparoscopic technique has a great outcome when used by experienced surgeons. Seroma is one of the complications following laparoscopic hernia repair for these scrotal hernias, which is due to the large hernia sac, usually transected, leaving in place a remnant of the sac. Conservative measures can be applied for the treatment of seroma; however, in symptomatic cases, puncture and aspiration of fluid are recommended. Sometimes, these seromas can reach a large size and require surgery to remove the remnant sac. Herein, we report the case of a 49-year-old male with a large seroma that occurred four days after the laparoscopic approach - total extraperitoneal repair (TEP) for inguinoscrotal hernia. Conservative measures failed, and because the symptoms were not alleviated, reintervention was opted for. The distal sac was excised and the patient recovered uneventfully. The six-month follow-up did not show any recurrence of the hernia or seroma. We emphasize the importance of sac management in large ISH cases and discuss seromas after laparoscopic hernia repair in such instances.

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

INTRODUCTION AND IMPORTANCE

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

CASE PRESENTATION

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

CLINICAL DISCUSSION

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

CONCLUSION

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

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

Background

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

Patients and Methods

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

Results

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

Conclusion

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

Effects of intraoperative fixation of residual hernia sac on postoperative seroma in laparoscopic transabdominal preperitoneal inguinal hernia repair: a prospective randomized controlled trial

The study was aimed to evaluate a prospective randomized controlled trial (RCT) In laparoscopic transabdominal preperitoneal inguinal hernia repair (TAPP), whether fixation of the residual sac after transecting the hernia sac can reduce the severity of postoperative seroma. A total of 252 male patients with a primary unilateral indirect inguinal hernia who underwent TAPP from September 2018 to November 2022 were recruited. Patients were randomized to the control group (CG)and the experimental group (EG). In the experimental group, after the hernia sac was transected, the residual sac was fixed to the lower edge of the rectus abdominis, while it was left in the preperitoneal space in the control group. Close follow-up was arranged to observe the incidence of seroma and other postoperative complications. All 214 patients were discharged successfully. 106 patients were randomly assigned to the control group, and 108 patients were assigned to the experimental group. There was no significant difference in the incidence of postoperative fluid extraction between the experimental group and the control group (11.1% VS.10.4%, p = 0.862), but the patients with seroma after the operation had fewer repeated extraction (0% VS. 45.5%, P = 0.033). The incidences of other postoperative complications were comparable in the two groups. In the treatment of indirect inguinal hernia with TAPP, after transecting the hernia sac, suturing and fixing the residual sac to the inferior edge of the rectus abdominis can reduce the incidence of repeated aspiration.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Robotic hernia surgery I. English version : Robotic inguinal hernia repair (r‑TAPP). Video report and results of a series of 302 hernia operations

The treatment of inguinal hernias with open and minimally invasive procedures has reached a high standard in terms of outcome over the past 30 years. However, there is still need for further improvement, mainly in terms of reduction of postoperative seroma, chronic pain, and recurrence. This video article presents the endoscopic anatomy of the groin with regard to robotic transabdominal preperitoneal patch plasty (r‑TAPP) and illustrates the surgical steps of r‑TAPP with respective video sequences. The results of a cohort study of 302 consecutive hernias operated by r‑TAPP are presented and discussed in light of the added value of the robotic technique, including advantages for surgical training. r‑TAPP is the natural evolution of conventional TAPP and has the potential to become a new standard as equipment availability increases and material costs decrease. Future studies will also have to refine the multifaceted added value of r‑TAPP with new parameters.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Robotic hernia surgery : Part I: Robotic inguinal hernia repair (r‑TAPP). Video report and results of a series of 302 hernia operations]

The treatment of inguinal hernias with open and minimally invasive procedures has reached a high standard in terms of outcome over the past 30 years. However, there is still need for further improvement, mainly in terms of reduction of postoperative seroma, chronic pain, and recurrence. This video article presents the endoscopic anatomy of the groin with regard to robotic transabdominal preperitoneal patch plasty (r‑TAPP) and illustrates the surgical steps of r‑TAPP with respective video sequences. The results of a cohort study of 302 consecutive hernias operated by r‑TAPP are presented and discussed in light of the added value of the robotic technique, including advantages for surgical training. r‑TAPP is the natural evolution of conventional TAPP and has the potential to become a new standard as equipment availability increases and material costs decrease. Future studies will also have to refine the multifaceted added value of r‑TAPP with new parameters.

Suture and Fixation of the Transversalis Fascia during Robotic-Assisted Transabdominal Preperitoneal Hernia Repair to Prevent Seroma Formation after Direct Inguinal Hernia Repair

Background. Seroma formation after videoendoscopic repair of inguinal hernias, known as "pseudorecurrence", may vary from an asymptomatic, self-limiting occurrence to a painful, chronic problem. The aim of this study was to investigate the incidence of postoperative seroma in robotic-assisted transabdominal preperitoneal hernia repair (R-TAPP), modified by suturing and fixating the transversalis fascia to the Cooper ligament. Methods. The study was approved by the local ethics committee (2019-01132 CE-3495). Patients undergoing R-TAPP for direct inguinal hernia from October 2017 to December 2019 were included. In all patients, a barbed running suture of the transversalis fascia was performed to close the cavity resulting from the direct hernia reduction and to fix it to the Cooper ligament, then a lightweight mesh was placed. Demographic and clinical data were collected and analysed. Results. Over the study period, 67 R-TAPP in 51 patients were identified. All patients were male, with a mean age of 63.1 ± 12.7 years. There was 1 case of conversion to open surgery due to adhesions of the caecum to the groin as a result of perforated appendicitis. The mean length of the hospital stay was 1.8 ± .6 days. After discharge, no cases of seroma or recurrence at 30 days nor chronic pain at a mean follow-up of 10.3 ± 6.8 months was detected. Conclusions. In the treatment of direct inguinal hernia with R-TAPP, suturing and anchoring the transversalis fascia to the Cooper ligament are safe, feasible and recommendable in order to prevent postoperative seromas.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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