To repair or not to repair incidental defects found on laparoscopic repair of groin hernia

Background: During laparoscpic transabdominal preperitoneal (TAPP) repair of unilateral groin hernias, a significant proportion of patients are found to have unsuspected hernias (incidental defects) on the contralateral side without any clinically demonstrable signs. The reported incidence is 10% to 25%, and controversy exists about the routine repair of these hernias. We present the early results of a prospective randomized study designed to follow the clinical behavior of incidental defects. Methods: For this study, 32 consecutive men found to have incidental defects on the contralateral side during laparoscopic TAPP repair of groin hernias were prospectively randomized into two categories. In 16 patients (control group), the defects were repaired simultaneously, and in another 16 patients (trial group), surgical repair was not performed. Subsequently, five consecutive patients found to have incidental defects were included in the trial group. Hence, the total number of patients with unrepaired defects was 21. All the patients subsequently were followed up in the clinic and examined by an independent clinician to detect any clinically demonstrable hernias. Results: The median follow-up was 15 months for the control patients and 12 months for the trial patients. During this time, demonstrable hernias developed in 6 patients of the trial group (28.6%). Conclusions: This study demonstrated that despite a short follow-up period, a significant proportion of incidental defects will progress to a symptomatic hernia if left untreated. Hence, their simultaneous repair is justifiable on the grounds that it reduces the number of operations and hospital visits, and thus the cost to the National Health Service. It also is of major benefit to the patient.     

成人腹股沟疝患病情况的多中心研究

目的：了解上海地区的腹股沟疝的患病及相关情况。方法：对上海市的三家医院20734例体检者进行了专项的腹股沟疝情况的调查。结果：腹股沟疝的患病率约为3．6‰，其中男性为4．8‰，女性为1．3‰。60岁以下的患病率约为1.7‰，60岁以上的患病率约为11．5‰，腹股沟疝的发病似与职业，肥胖，吸烟等因素无关，但有较明显的家族性倾向。结论：腹股沟疝的发病男性多于女性；60岁以上者明显多于60岁以下者；有家族倾向，发病与职业，肥胖，吸烟等因素的关系不明确。     

腹股沟疝术后顽固性疼痛的处理

目的：探讨疝修补术后顽固性疼痛的原因和手术治疗方式。方法：分析1998－2001年我院收治的8例腹股沟疝修补术后疼痛病人的临床资料，结合文献进行讨论。结果：1例病人经神经阻滞治疗后缓解；2例行单纯神经松解，2例行痛点局部疤痕切除，1例行翻转无张力补片部分修剪，2例行髂前上棘内侧髂腹股沟，髂腹下神经部分切除，术后疼痛均缓解。结论：疝修补术后出现顽固性疼痛的常见原因为神经被缝扎或补片移位压迫或被纤维粘连牵扯等；手术方式应个体化，结合术前疼痛特点及术中探查情况，合理选择神经松解，疤痕切除，翻转补片部分修剪及神经切除等方式，可避免盲目切除神经带来的严重后果和疝的复发。     

Current Practices in Adult Groin Hernias: A Survey of Japanese General Surgeons

The tendency to perform abdominal wall reinforcement using various types of mesh (tension-free repair) is increasing. A questionnaire to poll Japanese surgeons on their current surgical modalities for groin hernias was sent to 105 hospitals and was returned by 83 hospitals. The majority (83%) of responders to this survey supported the tension-free repair as a standard operation for adult groin hernias. Of these 69 tension-free repairs, the mesh-plug repair was the most frequent standard operation (n = 53, 64%) and was performed by all responders. Ten (12%) opted for the prolene hernia system (PHS) repair as a standard operation and 52% of responders had experience of the PHS repair. Laparoscopic repair was performed as a standard operation by only one responder and was performed by only 34% of responders. Received: January 18, 2002 / Accepted: July 2, 2002 Reprint requests to: A. Onitsuka     

Primary Malignant Peritoneal Mesothelioma in an Incarcerated Groin Hernia: Report of a Case

Malignant peritoneal mesothelioma arising from the inguinal hernia sac is rare. We report the case of a 71-year-old man examined in our emergency department for a bilateral inguinoscrotal hernia, which was recurrent in the right groin, and primary and incarcerated in the left groin. An emergency exploratory operation revealed a firm mass, 10cm in diameter, in the left inguinal hernia sac. The remaining peritoneal surface appeared macroscopically normal. Therefore, we resected the mass and performed a Rutkow hernioplasty. The patient was discharged after a short, uneventful recovery, and was referred to the oncology department for adjuvant therapy. He is now well and asymptomatic with no evidence of ascites, 26 months after his operation. A mesothelioma of the hernial sac peritoneum was the final histological diagnosis.     

Minimally Invasive Spigelian Hernia Repair

Introduction:

Spigelian hernia is an uncommon ventral hernia characterized by a defect in the linea semilunaris. Repair of spigelian hernia has traditionally been accomplished via an open transverse incision and primary repair. The purpose of this article is to present 2 case reports of incarcerated spigelian hernia that were successfully repaired laparoscopically using Gortex mesh and to present a review of the literature regarding laparoscopic repair of spigelian hernias.

Methods:

Retrospective chart review and Medline literature search.

Results:

Two patients underwent laparoscopic mesh repair of incarcerated spigelian hernias. Both were started on a regular diet on postoperative day 1 and discharged on postoperative days 2 and 3. One patient developed a seroma that resolved without intervention. There was complete resolution of preoperative symptoms at the 12-month follow-up.

Conclusion:

Minimally invasive repair of spigelian hernias is an alternative to the traditional open surgical technique. Further studies are needed to directly compare the open and the laparoscopic repair.     

完全腹膜外腹腔镜免气囊免钉合疝修补术112例

目的探讨腹股沟疝完全腹膜外腹腔镜疝修补术（total extraperitoneal hernia repair,TEP）的效果。方法 2007年10月～2011年12月112例行TEP,术中充分游离腹膜前间隙,精索或子宫圆韧带骨骼化,平铺补片免钉合。结果手术时间40～162 min,平均83 min。术后住院时间2～7 d,平均4 d。腹股沟区血肿4例,其中3例保守治疗治愈,1例手术清除后治愈;阴囊气肿2例,术后第2天自愈。105例随访1～44个月,平均23个月,其中76例随访〉24个月：2例复发,其中1例右侧斜疝术后半年同侧直疝复发,另1例左侧直疝术后3个月复发;术后无腹股沟区慢性疼痛,无粘连性肠梗阻。结论 TEP治疗腹股沟疝安全有效,规范操作并正确把握手术指征对顺利开展TEP具有重要意义。     

A Literature Review on the Role of Totally Extraperitoneal Repairs for Groin Pain in Athletes

A literature review was made on the role of totally extraperitoneal (TEP) hernia repairs for groin pain in athletes. Electronic databases were searched for literature published from January 1993 to November 2011. There were 10 articles incorporating 196 patients included in this review. Thirty percent of patients were reported to have direct inguinal hernias, 22% had indirect inguinal hernias, and 41% had dilated internal rings. Of note, 30% of cases had no macroscopic abnormality. Four studies reported on an early follow-up ranging between 3 and 6 weeks. Only minimal or mild symptoms were reported. Up to 33% of patients had impaired ability to perform at peak levels. Up to 53% of patients had persistence of symptoms at the early follow-up. Total follow-up time ranged from 3 to 80 months, and most patients were active (90%–100%). At long-term follow-up, 3% to 10% were unable to play, and 5% were reported as being unable to train. Two studies from the same center reported on TEP surgery for osteitis pubis, and most patients returned to sporting activity after 4 to 8 weeks. TEP repair is a good operative intervention in athletes with chronic groin pain not relieved by conservative measures. Athletes recover quickly and return to sport early.     

Parastomal Hernia Repair: a Single Center Experience

Background/Objectives:

Despite multiple options for operative repair of parastomal hernia, results are frequently disappointing. We review our experience with parastomal hernia repair.

Methods:

A retrospective chart review was performed on all patients with parastomal hernia who underwent LAP or open repair at our institution between 1999 and 2006. Information collected included demographics, indication for stoma creation, operative time, length of stay, postoperative complications, and recurrence.

Results:

Twenty-five patients who underwent laparoscopic or open parastomal hernia repair were identified. Laparoscopic repair was attempted on 12 patients and successfully completed on 11. Thirteen patients underwent open repair. Operative time was 172±10.0 minutes for laparoscopic and 137±19.1 minutes for open cases (P=0.14). Lengths of stay were 3.1±0.4 days (laparoscopic) and 5.1±0.8 days (open), P=0.05. Immediate postoperative complications occurred in 4 laparoscopic patients (33.3%) and 2 open patients (15.4%), P=0.38. Parastomal hernia recurred in 4 laparoscopic patients (33.3%) and 7 open patients (53.8%) after 13.9±4.5 months and 21.4±4.3 months, respectively, P=0.43.

Conclusion:

Laparoscopic modified Sugarbaker technique in the repair of parastomal hernia affords an alternative to open repair for treating parastomal hernia.     

腹腔镜在先天性食管裂孔疝修补术中的应用

目的探讨腹腔镜手术治疗小儿食管裂孔疝的安全性和疗效。方法2001年9月～2008年12月对7例小儿食管裂孔疝施行腹腔镜食管裂孔疝修补术联合胃底折叠术（Nissen法）。1例因术前上消化道造影发现合并胃排空延迟,联合实施了腹腔镜幽门成形术。1例合并右腹股沟斜疝同时行腹腔镜疝囊高位结扎术。1例术中发现合并副脾,未给予处理。结果7例患儿均在腹腔镜下完成食管裂孔疝修补联合胃底折叠术（Nissen法）,无中转开腹者。手术时间平均94.2min（75～150min）;术中出血量平均5ml（2～10ml）,无术中术后输血者。术后24～48h进奶或进食。术后住院3～7d,平均4.5d。7例患儿术后随访6～20个月,平均12.6月。1例术后第10天出现呕吐,给予食管扩张和胃动力药物治疗后好转;1例术后1年复发,再次行腹腔镜食管裂孔疝修补联合Nissen胃底折叠术治愈;其余5例术后恢复顺利,无并发症发生。结论腹腔镜治疗食管裂孔疝创伤小,安全性好,疗效确切,可以联合治疗其他疾病,应注意适应证的选择。     

Groin hernias: features of recurrences

Summary In 2390 groin hernias operated on by the same surgeon there were 2327 inguinal hernias (97.4%) and 63 femoral (2.6%); 261 (11.2%) were recurrent hernias. The aim of this study was to define the different features of recurrences in a series of 206 recurrences operated on by an inguinal approach. The median time of recurrence was 3 years (< 1–58). It was < 1 year in 67 cases (40%) and 50% of all recurrences had occurred in 2.4 years. The time of recurrence after operation performed in childhood was 31 years (15–58). All recurrences were located in the area of the myo-pectineal and femoral orifices. There was only one site of recurrence in 125 cases (61%); the recurrence was direct in 73 cases (58%), indirect in 44 cases (35%) and femoral in 8 cases (7%). There were 2 sites of recurrence in 81 cases (39%), 76 mixed (94%) and 6 inguinal associated with a femoral hernia (6%). Altogether there were 288 sites of recurrence. There were 44 direct diverticular recurrences and 26 of these were located near the pubic tubercle. The rate of recurrence in current practice is much higher than that in specialized centers. The long delay of recurrence after simple resection of the sac in childhood constitutes an indirect argument for the Marcy procedure in adolescents and young men with type I or II hernias. The preeminence of direct recurrences and the existence of direct diverticular suprapubic recurrences are arguments for mesh procedures. The fact that all recurrences are located in the area of myo-pectineal and femoral orifices must be considered for the choice of a mesh procedure.     

Laparoscopic Repair of Left Lumbar Hernia After Laparoscopic Left Nephrectomy

Lumbar hernias, rarely seen in clinical practice, can be acquired after open or laparoscopic flank surgery. We describe a successful laparoscopic preperitoneal mesh repair of multiple trocar-site hernias after extraperitoneal nephrectomy. All the key steps including creating a peritoneal flap, reducing the hernia contents, and fixation of the mesh are described. A review of the literature on this infrequent operation is presented. Laparoscopic repair of lumbar hernias has all the advantages of laparoscopic ventral hernia repair.     

Evaluation of the Rebound Hernia Repair Device for Laparoscopic Hernia Repair

Background:

The characteristics of the ideal type of mesh are still being debated. Mesh shrinkage and fixation have been associated with complications. Avoiding shrinkage and fixation would improve hernia recurrence rates and complications. To our knowledge, this is the first study of a device with a self-expanding frame for laparoscopic hernia repair.

Methods:

Six Rebound Hernia Repair Devices were placed laparoscopically in pigs. This device is a condensed polypropylene, super-thin, lightweight, macro-porous mesh with a self-expanding Nitinol frame. The devices were assessed for adhesions, shrinkage, and histological examination. Laboratory and radiologic evaluations were also performed.

Results:

The handling properties of the devices facilitated their laparoscopic placement. They were easily identified with simple x-rays. The mesh was firmly integrated within the surrounding tissue. One device was associated with 3 small adhesions. The other 5 HRDs had no adhesions. We noted no shrinkage or folding. All devices preserved their original size and shape.

Conclusions:

At this evaluation stage, we found that the Rebound Hernia Repair Device may serve for laparoscopic hernia repair and has favorable handling properties. It prevents folding and shrinkage of the mesh. It may eliminate the need for fixation, thus preventing chronic pain. The Nitinol frame also allowed radiologic evaluation for gross movement. Further studies will be needed to evaluate its clinical application.     

The Use of Needlescopic Instruments in Laparoscopic Ventral Hernia Repair

A successful laparoscopic hernia repair requires complete covering of the hernia defect, adequate tension of the prosthesis, and secure stapling with a stapler. We describe herein our technique of performing laparoscopic hernia repair using a needlescopic instrument which results in minimal damage to the abdominal wall and has significant cosmetic benefits. Our technique is easy to perform and useful for achieving initial anchoring of the prosthesis before fixation to the abdominal wall with a laparoscopic stapler. Received: October 18, 2000 / Accepted: May 15, 2001     

腹腔镜技术在急性腹股沟嵌顿疝中的应用价值(附11例报道)

目的探讨腹腔镜技术在腹股沟嵌顿疝复位及修补中的价值。方法回顾性分析我院2007年3月至2008年2月期间利用腹腔镜治疗11例急性腹股沟嵌顿疝患者（腹股沟直疝3例，腹股沟斜疝8例）的临床资料。结果7例患者在全身麻醉后嵌顿疝自动复位，4例在腹腔镜下行松解、复位；11例患者在腹腔镜下观察或采取促进嵌顿肠管血液循环恢复的措施后，均行经腹腹膜前补片植入术（TAPP）。术后所有患者均恢复良好，平均随访6．6个月（2～12个月），无复发。结论腹腔镜下腹股沟嵌顿疝复位及修补是一种安全并具有一定优势的手术方式，值得在临床推广。     

Virgin and Recurrent Groin Hernia: A Comparison of Patient Recovery Following Endoscopic Preperitoneal Herniorrhaphy

Introduction:

The advantage of minimally invasive hernia repair techniques remains controversial. One of the more established indications for this technique''s use is the presence of a recurrent hernia. No prior study has compared the recovery following endoscopic repair of virgin and recurrent hernias.

Patients and Methods:

Between July 15, 1994 through August 16, 1996, one primary surgeon supervised the performance of 373 hernia repairs on 250 patients. Twenty-two patients underwent endoscopic preperitoneal herniorrhaphy for unilateral recurrent groin hernia (RH), while 105 patients underwent repair of a virgin unilateral hernia (VH) in the absence of prior contralateral open hernia repair. No significant differences were seen for age (VH: 54, RH: 64), male:female ratio (VH: 92:13, RH: 22:0), operative time (VH: 58 min, RH: 59 min), anesthetic used, IV fluid requirements or blood loss (p > 0.05 for all comparisons). At the time of discharge, all patients were given a postoperative survey and asked to record their level of pain, narcotic use, and level of activity on the day of surgery and postoperative days 1, 2, 3, 7, 14, and 28.

Results:

Patients undergoing repair of virgin hernias had statistically significant increased levels of pain and/or narcotic use on the day of surgery and postoperative days 1, 2 and 3. Despite these differences, level of activity and return to work/normal activity (VH: 6.35+/- 3.44 days, RH: 6.40 +/- 2.67 days) were the same for the two groups.

Conclusion:

Despite the differences in pain perception and narcotic use in the early postoperative period, overall patient recovery appears similar for the two groups. Differences seen are likely due to a lack of any prior surgical pain to serve as a benchmark for comparison.