Management of congenital giant inguinal scrotal hernias in the newborn

Giant inguinoscrotal hernias are a rare entity seen largely in the adult population. Presentation in the child is more unusual, with only one case previously documented. As there is scant literature regarding these hernias in children, their management may be challenging. Here, we present the case of a newborn born with giant bilateral inguinal hernias complicated by in utero perforation and meconium peritonitis managed by laparoscopy and then laparotomy for repair. The case illustrates several points that may be useful for pediatric surgeons who may encounter this condition.     

Congenital spigelian hernias and cryptorchidism

Purpose

Spigelian hernias in childhood are rare. Only 24 infants in the English literature have been identified to have spigelian hernias, and 12 of these have been associated with cryptorchidism. Spigelian hernias are more commonly seen in the adult population and are considered to be acquired because they are typically associated with trauma or other etiologies of increased intraabdominal pressure. In the infant however, the etiology remains unclear, but a congenital defect in abdominal wall development is suspected.

Methods

We discuss the presentation and treatment of 4 additional patients with spigelian hernias (2 siblings included) associated with cryptorchidism.

Results

The hernias occurred within the well-described spigelian hernia belt in the semilunar line at the level of the semicircular fold of Douglas. Of the 6 repaired spigelian hernias, 5 were closed primarily with absorbable suture similar to previously reported cases; the sixth hernia required a patch closure because of its large size. All cryptorchid testes (7) were repaired in single-stage orchiopexies.

Conclusions

Spigelian hernias are rare entities in infants. We present 4 new cases of spigelian hernias associated with cryptorchidism and, with previously reported cases, discuss the probability of a congenital origin of these hernias in infants.     

Diaphragmatic hernias complicating pregnancy

BACKGROUND: Diaphragmatic hernias complicating pregnancy are not a common problem but they can have catastrophic consequences. They can present to the surgeon as a life-threatening emergency or pose a management dilemma when detected incidentally. In this paper, recommendations for the management of non-hiatal maternal diaphragmatic hernias are made based on our experience and the available published reports. METHODS: The presentation, management and outcomes of a series of three recent cases are described. A review of all other reported cases of diaphragmatic hernias complicating pregnancy was also carried out. RESULTS: All three cases were emergency presentations in the third trimester of pregnancy, resulting from compression of thoracic contents. All cases required emergency laparotomy and one also required thoracotomy. Delivery was by Caesarean section at the time of emergency surgery in two cases and was delayed in the third case. There was one fetal and no maternal deaths. One mother suffered persistent pleural infection. One baby also had a diaphragmatic hernia requiring postnatal repair. Published reports showed only 36 previously reported cases of diaphragmatic hernias identified in pregnancy. There is a consensus that hernias presenting with evidence of strangulation represent a surgical emergency and mandate operative management, irrespective of fetal maturity. Elective management of asymptomatic hernias is more controversial and both conservative and operative approaches have been suggested. CONCLUSION: Diaphragmatic hernias can cause life-threatening complications in pregnancy. Consideration should be given to operative repair in the second trimester if asymptomatic hernias are identified during pregnancy. If vaginal delivery is attempted in the presence of a hernia, this should only be carried out under closely monitored conditions.     

EuraHS: the development of an international online platform for registration and outcome measurement of ventral abdominal wall hernia repair

Background

Although the repair of ventral abdominal wall hernias is one of the most commonly performed operations, many aspects of their treatment are still under debate or poorly studied. In addition, there is a lack of good definitions and classifications that make the evaluation of studies and meta-analyses in this field of surgery difficult.

Materials and methods

Under the auspices of the board of the European Hernia Society and following the previously published classifications on inguinal and on ventral hernias, a working group was formed to create an online platform for registration and outcome measurement of operations for ventral abdominal wall hernias. Development of such a registry involved reaching agreement about clear definitions and classifications on patient variables, surgical procedures and mesh materials used, as well as outcome parameters. The EuraHS working group (European registry for abdominal wall hernias) comprised of a multinational European expert panel with specific interest in abdominal wall hernias. Over five working group meetings, consensus was reached on definitions for the data to be recorded in the registry.

Results

A set of well-described definitions was made. The previously reported EHS classifications of hernias will be used. Risk factors for recurrences and co-morbidities of patients were listed. A new severity of comorbidity score was defined. Post-operative complications were classified according to existing classifications as described for other fields of surgery. A new 3-dimensional numerical quality-of-life score, EuraHS-QoL score, was defined. An online platform is created based on the definitions and classifications, which can be used by individual surgeons, surgical teams or for multicentre studies. A EuraHS website is constructed with easy access to all the definitions, classifications and results from the database.

Conclusion

An online platform for registration and outcome measurement of abdominal wall hernia repairs with clear definitions and classifications is offered to the surgical community. It is hoped that this registry could lead to better evidence-based guidelines for treatment of abdominal wall hernias based on hernia variables, patient variables, available hernia repair materials and techniques.     

Small Bowel Obstruction Caused by an Unusual Variant of Paraduodenal Hernia. The “Middle Congenital Mesocolic Hernia”: Case Report

Internal hernias account for 0.2–0.9 % of all small bowel obstructions and are associated with a mortality rate of 50 % when strangulation is present. Congenital mesocolic hernias, traditionally called paraduodenal hernias, caused by an abnormal rotation of the primitive midgut, are the most common type of internal hernia. They can be divided into three types: the right and the left congenital mesocolic hernias, accounting for the 25 and 75 % of all cases, respectively, and the extremely rare transverse congenital mesocolic hernia. A high preoperative misdiagnosis rate has been reported and a surgical exploration is recommended to identify strangulation. The present case report describes a case of small bowel obstruction due to an unusual variant of congenital mesocolic hernia never previously reported in the literature. We discuss the clinical appearance, pathogenesis, diagnosis, and treatment of the case, with a brief review of the literature focused on the pathogenesis and management of mesocolic congenital hernias.     

Inguinal hernias in pediatrics: initial experience with laparoscopic inguinal exploration of the asymptomatic contralateral side.

Laparoscopic inguinal "exploration" was undertaken in 22 consecutive pediatric patients to assess the value of this technique in detecting the presence or absence of occult inguinal hernias on the asymptomatic side of patients with unilateral disease. After a CO2 pneumoperitoneum was established using a Veress needle, a 2 mm 0 degree laparoscope was passed via a 3 mm cannula and both inguinal rings were inspected. Eleven cases (50%) had previously unsuspected bilateral disease diagnosed at laparoscopy and had bilateral inguinal hernias confirmed at exploration. Nine cases, in which the asymptomatic side was assessed as being negative at laparoscopy, were confirmed negative by open exploration. In one misdiagnosed case of bilateral hernias, no hernias were found at laparoscopy and one side had a non-communicating hydrocele at exploration. There was one failure, an infant less than 2 months of age, in whom the inguinal anatomy could not be adequately visualized at laparoscopy and a hernia was found at exploration. There were no complications. Thus, laparoscopic inguinal "exploration" was 96% accurate in this initial evaluation. The adoption of this approach to the assessment of the asymptomatic contralateral side in infants with unilateral hernias would eliminate many inguinal operations and the complications associated with unnecessarily manipulating the delicate cord structures.     

Endoscopic total extraperitoneal repair of primary and recurrent inguinal hernias

Background: In most reports different techniques have been described for combinations of primary and recurrent hernias. The aim of this study was to investigate and compare the results of endoscopic total extraperitoneal repair (TEP) of primary and recurrent inguinal hernias. Methods: From January 1993 to July 1995, 221 patients with an unilateral inguinal hernia (186 primary and 35 recurrent) underwent TEP repair. Follow-up, including physical examination, was performed at regular 3-month intervals. Results: The mean operation time was 37.6 min. Minor perioperative complications occurred in 23 cases. Conversion was required for 16 patients (7.2%). Postoperative complications were reported for 11.7% of the patients. Hospital stay was short. Mean follow-up was 40.4 months. The recurrence rate was 3.2% for primary hernias and 20% for recurrent hernias. Conclusions: This study confirms the preliminary success of TEP for primary inguinal hernia repair, as previously reported. The high recurrence rate after endoscopic repair of recurrent hernias needs to be studied further. Received: 3 December 1997/Accepted: 7 May 1998     

Management of primary and recurrent inguinal hernia by surgeons from the South West of England

BACKGROUND: The National Institute of Clinical Excellence (NICE) has advocated open mesh repair for primary hernia but suggested laparoscopic repair may be considered for recurrent hernias. AIM: To establish current surgical practice by surgeons from the South West of England. METHODS: A postal survey was distributed to 121 consultant surgeons and a response rate of 75% was achieved. RESULTS: The majority (86%) of the surgeons surveyed performed hernia repairs, and most (95%) of these used open mesh repair as standard for primary inguinal hernia. Only 8% used laparoscopic repair routinely for primary hernias. Few consultants (only 28%) were able to quote formally audited hernia recurrence rates. A total of 90% of respondents still employed open mesh repair routinely for recurrent hernias; however, if mesh had been used for the primary repair, this figure fell to 55%. Some 7% of respondents recommended laparoscopic repair for recurrent hernia, but this increased to 17% if the primary repair was done with mesh. All laparoscopic surgeons in the South West employed the totally extraperitoneal approach (TEP). There was a range of opinion on the technical demands of repair of a recurrent hernia previously mended with mesh; the commonest cause of mesh failure was thought to be a medial direct recurrence (insufficient mesh medially). CONCLUSIONS: Current surgical practice for primary hernias in the South West England reflects NICE guidelines although many surgeons continue to manage recurrent hernias by further open repair. In this survey, there was anecdotal evidence to suggest that hernia recurrence can be managed effectively by open repair.     

Laparoscopic repair of bilateral spigelian and inguinal hernias

Spigelian hernias are rare and difficult to diagnose. Treatment has previously been limited to open surgical repair. We report the successful laparoscopic repair of bilateral spigelian and inguinal hernias using mesh. Received: 14 January 1997/Accepted: 11 April 1997     

Spigelian Hernia: a Diagnostic Dilemma and Laparoscopic Management

Spigelian hernias, also called as lateral ventral hernias, are rare hernias to present themselves in clinical practice. The significance of these hernias lies in the fact that they are commonly intraparietal hernias and are, hence, difficult to diagnose clinically. Moreover, the neck of these hernias is usually small, posing a fair risk of strangulation. With the advancement in laparoscopic hernia repair, there is evidence that Spigelian hernias too can be repaired laparoscopically, thereby causing less morbidity and shorter hospital stay. Here, we present a rare case of large Spigelian hernia that posed to us as a diagnostic dilemma. The symptoms, clinical findings, and ultrasound of the patient were not specific, and a CT scan had to be used as the measure to confirm the diagnosis. The patient was then managed successfully with laparoscopic intraperitoneal onlay mesh repair. The details of the case and a brief discussion are included.     

Laparoscopic repair of iatrogenic diaphragmatic hernias after sternectomy and pedicled omentoplasty

Purpose

During sternectomy and pedicled omental flap transposition for the treatment of deep sternal wound infections, an ectopic diaphragmatic aperture is created. This may be the site of an iatrogenic diaphragmatic hernia, which may result in the herniation of intra-abdominal organs, and is difficult to repair. Although this complication was described as early as 1991, no effective treatment for this condition has been described previously.

Methods

The defect in poststernectomy diaphragmatic hernias has features similar to other incisional abdominal wall hernias, as well as to parastomal hernias and hiatal diaphragmatic hernias. We describe our laparoscopic approach developed from experience with these other types of hernias. We use an intraperitoneal flat mesh without keyhole. Fixation of the mesh to the anterior abdominal wall and to the diaphragm is done with a combination of sutures and spiral tackers. The omental pedicle is lateralised, fixed to the diaphragm and covered with the mesh. Special caution is needed when spiral tackers are applied to the diaphragm, because fatal complications of pericardial and cardiac injury have been described in laparoscopic hiatal diaphragmatic hernia repair.

Results

We used this technique in four patients who presented with a symptomatic poststernectomy diaphragmatic hernia. No procedure-related intra-operative or postoperative complications occurred. With a follow up of at least 12 months, no clinical or radiographic recurrence of diaphragmatic herniation has been encountered.

Conclusion

We describe a laparoscopic technique to repair this difficult diaphragmatic hernia used in four patients, with a good clinical and computed tomographic outcome at 12 months.     

Massive inguinal scrotal bladder hernias: a review of the literature with 2 new cases

The bladder frequently is a component of inguinal hernias. However, massive bladder hernias into the scrotum are rare, with 73 cases having been reported previously in the literature. We report 2 additional successfully treated cases. From our experience, we believe that simple reduction of the hernia followed by inguinal herniorrhaphy is the treatment of choice.     

Atraumatic lung hernia.

Lung hernia is a distinctly rare event, regardless of its location and cause. Most lung hernias are acquired traumatic thoracic hernias. All previously reported cases of acquired spontaneous lung hernia involve some aspect of trauma, most commonly caused by vigorous coughing with a subsequent rib fracture. We report a case of totally atraumatic, acquired spontaneous lung hernia.     

Combined laparoscopic and open extraperitoneal approach to scrotal hernias

Background

Laparoscopic repair of scrotal hernias is often a difficult endeavor to successfully complete. The longstanding nature of these hernias often results in significant adhesions and anatomic distortion of the inguinal floor. These two issues make reduction of the hernia arduous and subsequent reinforcement of the parietal sac difficult. We have previously described techniques to increase the chances of success when attempting laparoscopic repair of scrotal hernias. Here, we describe some of those techniques as well as a combined laparoscopic and open approach to achieve a robust preperitoneal repair of incarcerated scrotal hernias when the usual totally extraperitoneal approach does not work.

Patients and methods

We performed a retrospective review of 1890 TEP hernia repairs we performed from 1990 to 2010. Rate of conversion to an open approach or a combined laparoscopic and open approach was examined. Incidence of complications or recurrences was assessed over a 12-month follow-up period.

Results

Among the 1890 TEP repairs, 94 large scrotal hernias were identified. Of these, nine cases (9.5 %) required conversion to an open procedure due to an incarcerated and indurated omentum. Three were completed with a conventional open preperitoneal whereas six patients (6.4 %) underwent repair with the combined approach. In this group, no recurrences or complications were found over a 12-month period.

Conclusion

In cases where a large scrotal hernia may be difficult or dangerous to reduce laparoscopically, immediate conversion to an open repair may not be necessary. A combined laparoscopic and open approach can greatly assist in the visualization and dissection of the preperitoneal space, thereby facilitating reduction of the hernia and placement of the mesh.     

Anatomical repair of large incisional hernias.

We present a method of repair for large incisional hernias using lateral relieving incisions of the anterior rectus sheath. This is a modification of the methods previously described by Young (1), Hunter (2) and Maguire and Young (3). There were no recurrences in the 13 patients reviewed. Other methods of repair for large incisional hernias are discussed.     

Adhesion formation after laparoscopic ventral incisional hernia repair with polypropylene mesh: a study using abdominal ultrasound.

OBJECTIVE: Laparoscopic repair of ventral incisional hernias is feasible and safe. Polypropylene mesh is often preferred because of its ease of handling and lower cost. Complications like adhesion and fistula formation can occur. The goal of this study was to determine whether bowel adhesions and their attendant complications could be prevented by interposition of omentum. METHODS: Thirty patients underwent laparoscopic ventral incisional hernias repair with polypropylene mesh. Omentum was always positioned over the loops of bowel for protection. At a mean follow-up of 14 months, 20 patients underwent ultrasonic examination using the previously described visceral slide technique to detect adhesions. RESULTS: The mean size of the hernias in the study was 50.3 cm2, and the mean size of the mesh applied was 275 cm2. Thirteen patents (65%) had no sonographically detectable adhesions. Five patients demonstrated adhesions between the mesh and omentum, 1 patient developed adhesions between the left lobe of the liver and the mesh, and only 1 case of bowel adhesion to the edge of the mesh was found. CONCLUSION: Laparoscopic ventral incisional hernias repair with polypropylene mesh and omental interposition is not associated with visceral adhesions in the majority of patients. Polypropylene mesh can be used safely when adequate omental coverage is available.     

The late-presenting pediatric Bochdalek hernia: a 20-year review

A 20-year retrospective study was made of children with congenital posterolateral (Bochdalek) hernias presenting more than 8 weeks after birth. The records of 26 patients (16 boys and 10 girls) were evaluated. Sixteen infants and children (62%) were originally misdiagnosed clinically and radiologically as having either infective lung changes, congenital lung cysts, or pneumothoraces; inappropriate thoracentesis occurred in four patients misdiagnosed as having a pneumothorax. Five patients had previously normal chest radiographs. The most useful investigation was a plain radiograph following passage of a nasogastric tube. Coexisting abnormalities (in particular, gut malfixation and malrotation) were common. All patients except one were operated on within days of presentation, and as emergencies if symptoms were acute. More than one third of our patients were left with a smaller than normal ipsilateral lung after their diaphragmatic hernia repair, and these lungs must be considered hypoplastic to some degree. Chest tubes made no difference in the lung's eventual expansion. Two deaths occurred as a result of acute cardiorespiratory arrest in previously well children. Therefore, the symptoms, signs, and radiologic findings of patients with diaphragmatic hernias presenting after the neonatal period may be difficult to interpret, and may result in diagnostic delay, misguided therapy, and a potentially fatal outcome.     

Treatment of the abdominal wall defects in an ambulatory surgical setting: our experience

Introduction: The creation of Outpatient Surgery (OPS) units has allowed to reduce the costs and the waiting lists in an efficient fashion. We describe our series of patients operated on for abdominal wall defects, a pathology suitable for ambulatory surgery. Patients and methods: Between May 1994 and March 1998, 206 inguinal hernias, 23 femoral hernias, 47 umbilical-epigastric hernias and nine incisional hernias were operated on in an ambulatory surgical setting. The patients were selected following the selection criteria previously established (related to the patient, the environment and the surgical procedure). The average age was 45 years, and the distribution by sex, 210 men and 75 women. Spinal anesthesia was preferently performed. The surgical techniques employed were Lichtenstein's hernioplasty and Shouldice and Bassini procedures for inguinal hernias; Lichtenstein's plug technique for femoral hernias and simple closure or preperitoneal mesh for the middle line defects. Results: 44 patients needed readmitttance to hospital (failure of OPS), the most important causes being excessive pain, urinary retention and nausea/vomiting. There was no severe morbidity nor mortality. Conclusion: Surgery for abdominal wall defects constitutes a group of procedures suitable for efficient and low risk OPS programs.     

Primary and unusual abdominal wall hernias

Primary ventral hernias can be congenital or acquired, but are not associated with a fascial scar or related to a trauma. Some ventral hernias such as Spigelian, lumbar, or obturator hernias represent a diagnostic challenge, given their relative rarity and their unusual anatomic locations. The article presents the etiology, clinical presentation, and diagnosis of these hernias, and briefly describes the various surgical approaches, including open and laparoscopic.     

Diagnosis and treatment of epigastric hernia. Analysis of our experience

BACKGROUND: Epigastric hernias are 0.35-1.5% of abdominal hernias and 8% of midline ones. They are often of small dimensions (15-25 mm) but voluminous epigastric hernias (5-10 cm) may occur. In these cases the sac may contain epiploic appendages or viscera (ileum loops, stomach). 20% of epigastric hernias are multiple: for this reason we must consider the integrity of the whole linea alba. Ultrasound scan, showing a 100% sensibility towards this pathology, is extremely effective to achieve this aim. METHODS: We have reviewed our experience since 1989 analysing the clinical, diagnostical and therapeutical aspects and pointing out the not too distinct symptomatology of epigastric hernias, including those complicated by incarceration. We always carry out surgical correction of epigastric hernias in general anaesthesia and open the peritoneal sac in order to loosen possible adhesions. We have employed a properitoneal MESH (polypropylene) only in voluminous hernias. RESULTS: In a two years follow-up in 79% of patients, no recurrences have been observed. CONCLUSIONS: The surgical correction of epigastric hernias does not always need a prosthesis, but it may be a simple direct reconstruction as long as the suture is carried out in the correct direction depending on the dimensions of the hernial porta. On the other hand, recurring epigastric hernias and voluminous hernias, multiple or isolated, can be corrected with a polypropylene MESH placed in the properitoneal area.