Open mesh removal combined with laparoscopic totally extraperitoneal inguinal hernia repair: A case report of a novel surgical technique for chronic postoperative inguinal pain

A 74-year-old man presented for surgical treatment to alleviate chronic post-herniorrhaphy inguinal pain. Physical and imaging examinations suggested that his pain was due to his ilioinguinal nerve being entrapped by a meshoma composed of bilayer mesh and plug mesh. The patient strongly desired mesh removal, although it appeared challenging because of adhesion of the meshes from the previous herniorrhaphies. Anticipating technical difficulty, we performed laparoscopic totally extraperitoneal repair followed by open mesh removal. Thus, the risk of damaging the peritoneum and visceral organs during open mesh removal was eliminated because the peritoneum had already been separated from the pathogenic mesh during the laparoscopic repair. The patient's chronic pain was drastically relieved. Combination surgery may therefore be a safe and useful technique in select patients with chronic postoperative inguinal pain. This approach could also prevent hernia recurrence.     

Chronic pain after open inguinal hernia repair

Following the widespread use of mesh repairs, recurrence rates after inguinal hernia surgery have become acceptable and focus has shifted from recurrence to chronic pain. Although pain can be controlled with analgesics, chronic postsurgical pain is a major clinical problem, which can significantly influence the patient’s quality of life. The rate of chronic pain after inguinal hernia mesh repair can reach 51.6%. The reasons for posthernioplasty chronic pain are often unclear. It has been linked to nerve injury and nerve entrapment, but there is also association between the rate of chronic pain and the type of mesh used for hernia repair. As there are >160 meshes available in the market, it is difficult to choose a mesh whose usage would result in the best outcome. Different mesh characteristics have been studied, among them weight of mesh has probably gained the most attention. The choice of adequate therapy for chronic groin pain after inguinal hernia repair is controversial. The European Hernia Society recommends that a multidisciplinary approach at a pain clinic should be considered for the treatment of chronic postoperative pain. Although surgical treatment of chronic posthernioplasty pain is limited because of the lack of relevant research data, resection of entrapped nerves, mesh removal in the case of mesh related pain or removal of fixation sutures can be beneficial for the patient with severe pain after inguinal hernia surgery. One drawback of published studies is the lack of consensus over definition of chronic pain, which makes it complicated to compare the results of different studies and to conduct meta-analyses and systematic reviews. Therefore, a uniform definition of chronic pain and its best assessment methods should be developed in order to conduct top quality multicenter randomized trials. Further research to develop meshes with optimal parameters is of vital importance and should be encouraged.     

腹腔镜经腹腔腹膜前网片疝修补术和开放疝修补术的随机对照研究

目的 通过一项随机临床试验对腹腔镜经腹腔腹膜前网片疝修补术（TAPP）和开放式疝修补术进行比较.方法 将101例腹股沟疝病人随机分成腹腔镜组（n=51）及开放手术组（n=50）,分别行TAPP和开放无张力疝修补术（Lichtenstein修补）,术后对病人进行随访,比较2组病人的相关参数.结果 腹腔镜组病人的手术时间比开放组长（P＜0.05）.2组术中并发症率无差异.术后1周的腹腔镜组的并发症率较开放组高（P＜0.05）.腹腔镜组病人的住院时间、恢复工作的时间比开放组短（P＜0.05）.术后1年,腹腔镜组病人发生慢性疼痛的比率与开放组相比差异无显著性（P＞0.05）.结论 TAPP治疗腹股沟疝是可行的、安全的,且在术后恢复方面较开放无张力修补更有优势.     

全腹膜外腹股沟疝网片固定和不固定修补法的临床效果对比研究

目的比较全腹膜外腹股沟疝网片固定和不固定修补法的临床效果。方法选择韩城市人民医院2016年6月至2019年6月收治的184例腹股沟疝患者,根据随机数字表法,将所有患者分为固定组和未固定组,各92例。固定组患者行全腹膜外腹股沟疝修补法(TEP)网片固定手术进行治疗,未固定组行TEP网片不固定手术治疗,对比两组患者的手术效果、并发症发生率以及慢性疼痛发生情况。结果两组患者手术时间和术后恢复正常活动时间比较,差异无统计学意义(P>0.05),未固定组患者住院时间短于固定组,手术费用明显少于固定组(P<0.05)。术后固定组患者感觉异常、阴囊血肿、血清肿、术区感染、睾丸鞘膜积液、大出血、左下肺炎等并发症发生率为17.4%,明显高于未固定组的7.6%,差异有统计学意义(P<0.05)。固定组患者术后慢性疼痛发生率为8.70%(8/92),明显高于未固定组的1.09%(1/92),慢性疼痛持续时间也明显长于未固定组,差异均有统计学意义(P<0.05)。结论使用较大的网片行TEP时可不固定网片,既可缩短住院时间、减少治疗费用,也能减少并发症和慢性疼痛发生率,效果显著,可推广使用。     

Case of chronic pain after laparoscopic percutaneous extraperitoneal closure in an adolescent girl with inguinal hernia in which open repair was effective

Chronic pain after laparoscopic percutaneous extraperitoneal closure is very rare. Here, we report a case of chronic pain after laparoscopic percutaneous extraperitoneal closure in an adolescent patient with inguinal hernia who underwent open repair. A 15‐year‐old girl was diagnosed with a left indirect inguinal hernia, and laparoscopic percutaneous extraperitoneal closure was performed. However, 6 months later, after strenuous exercise, she developed localized pain around the hernia site. Her pain was well controlled by internal treatment but failed to completely resolve. The pain type was somatic, Tinel's sign was negative, and there was no recurrence of the inguinal hernia. Because she strongly wished to undergo surgery, the Potts procedure with removal of the ligature and excision of the round ligament was performed. Her pain improved after surgery, and further medical treatment was not required. The Potts procedure may be an effective treatment for chronic pain such as in this case.     

Recurrent abdominal pain due to small bowel volvulus after transabdominal preperitoneal hernioplasty: A case report and review of literature

BACKGROUNDCompared with open mesh repair, transabdominal preperitoneal (TAPP) hernioplasty results in less chronic postoperative inguinal pain and faster postoperative recovery. However, it may still lead to rare but serious complications. Here we report a case of intestinal volvulus with recurrent abdominal pain as the only clinical symptom, which occurred 3 mo after TAPP repair for bilateral inguinal hernia.CASE SUMMARYA 50-year-old male patient underwent laparoscopic TAPP for bilateral inguinal hernias. After the operation, he experienced recurring pain in his lower right abdomen around the surgical area, which was relieved after symptomatic treatment. Three months after the surgery, the abdominal pain became severe and was aggravated over time. The whirlpool sign of the mesentery was seen on contrast-enhanced computed tomography (CT). Laparoscopic exploration confirmed that a barb of the V-Loc™ suture penetrated the peritoneum, which caused the adhesion of the small intestinal wall to the site of peritoneal injury, forming intestinal volvulus. Since there was no closed-loop obstruction or intestinal ischemia, recurrent abdominal pain became the only clinical manifestation in this case. After laparoscopic lysis of adhesions and reduction of intestinal volvulus, the patient recovered and was discharged.CONCLUSIONThe possibility of intestinal volvulus should be considered in patients who experience recurrent abdominal pain following TAPP surgery during which barbed V-Loc sutures are used for closing the peritoneum. Contrast-enhanced CT and active laparoscopic exploration can confirm the diagnosis and prevent serious complications.     

TAPP和Kugel疝修补术临床效果比较分析

目的比较TAPP和Kugel手术方式在治疗成人腹股沟疝中的效果。方法将152例患者随机分成两组,一组接受TAPP手术,另一组接受Kugel手术,比较两组短期并发症,手术时间及住院时间等方面的指标。结果 TAPP组术后1周并发症明显少于Kugel组(χ2=0.83,P<0.05);手术时间、术后住院时间较Kugel组缩短(t分别=1.99、2.36,P均<0.05);TAPP组术后疼痛程度较轻,使用止痛药物次数较少(χ2=1.72,P<0.05)。结论 TAPP术是一种更为简单、微创、安全,恢复快的手术方式。     

疝环充填式无张力疝修补术治疗腹股沟疝

目的探讨聚丙烯网塞及补片在腹股沟疝修补术中的优点、并总结经验教训。方法采用美国巴德公司的聚丙烯锥形填充物及成型补片对216例腹股沟疝病人施行疝环填式无张力疝修补术,观察手术时间,伤口疼痛,术后自主能力恢复,并发症及复发率。结果手术时间平均为45min;术后3～8h病人能下床活动;伤口疼痛时间2～3d。术后排尿困难3例,切口血肿1例,无一例切口感染。腹股沟异物感10例,睾丸炎1例。术后随访6～96月206例,仅1例复发,复发率0．45％。结论锥形填充物及成型补片组织兼容性好,无排异反应,具有一定的抗感染能力,是理想的疝修补材料。疝环填充式无张力修补术,手术操作简便,损伤轻,恢复快,并发症少和复发率低,手术指征可适当放宽,是较先进的疝修补术式。     

Laparoscopic repair of inguinal hernia in a patient with a ventriculoperitoneal shunt: A case report

Laparoscopic surgery in patients with a ventriculoperitoneal (VP) shunt is reportedly associated with increased intracranial pressure secondary to high intraperitoneal pressure and retrograde infection due to intraperitoneal infection. We herein report the first case of transabdominal preperitoneal (TAPP) inguinal hernia repair without catheter manipulation for a patient with a VP shunt. A 69-year-old man with a VP shunt was suspected to have an inguinal hernia based on symptoms and examination findings. With a pneumoperitoneum pressure of 10 mm Hg, the VP shunt was not clamped and mesh was placed while confirming cerebrospinal fluid outflow from the tip of the catheter. The patient developed no shunt-associated complications and was discharged 3 days postoperatively. TAPP inguinal hernia repair without catheter manipulation is a potential surgical option for patients with a VP shunt.     

Laparoscopic repair via the transabdominal preperitoneal procedure for bilateral lumbar hernia: Three cases report and review of literature

A lumbar hernia is a rare entity, and a bilateral lumbar hernia is much rarer. From May 2015 to October 2017, we treated only three patients with bilateral lumbar hernias. One patient came to the hospital presenting with right-sided abdominal pain, and the other two patients presented with bilateral lumbar masses. The previous bilateral lumbar hernia reported in the literature was repaired by open surgery. The laparoscopic approach via the transabdominal preperitoneal (TAPP) procedure with the self-gripping Parietex ProGrip™ mesh was performed at our center. The laparoscopic repair was conducted by a skilled hernia surgeon, and was successfully performed in the three patients. The patients resumed a semi-liquid diet and had no activity restriction after six hours following the operation. No antibiotics were used after the surgery. The operative times of the three patients were 120 min, 85 min, and 130 min. The blood loss volumes of the three patients were 20 mL, 5 mL, and 5 mL. The visual analogue scale pain scores of the three patients were 1, 2, and 2 on postoperative day 1, and were 1, 2, and 1 on postoperative day 3. No perioperative complications, such as bulge, wound infection and hematoma, occurred after the surgery. All of the patients were discharged on the third day after the operation. There was no chronic pain and no hernia recurrence during the follow-up. This study showed that the laparoscopic TAPP approach with the self-gripping mesh is safe and feasible, and can be considered an alternative method for the treatment of bilateral lumbar hernias.     

腹腔镜经腹腹膜前和全腹膜外腹腔镜疝修补术的临床应用对比研究

目的：比较腹腔镜经腹腹膜前疝修补术（TAPP）与完全腹膜外腹腔镜疝修补术（TEP）治疗成人腹股沟疝的效果。方法回顾分析2007年10月～2013年02月收治的214例（235侧）腹股沟疝患者的临床资料,根据手术方式分为TAPP组58例和TEP组156例,将2组的临床资料进行比较分析。结果TEP组手术时间较短（P＜0.01）、住院费用较低（P＜0.01）。术后下床活动时间、住院时间、术后不适感方面,TAPP组与TEP组差异无统计学意义;TAPP组术中发现隐匿疝4例;术后并发症、复发率,TAPP组和TEP差异无统计学意义。结论TAPP与TEP各具优点,TAPP较TEP更利于发现隐匿疝。但是TEP较TAPP手术时间更短,住院费用更低。     

疝环充填式无张力疝修补术治疗腹股沟疝569例

目的：总结疝环充填式无张力疝修补术治疗腹股沟疝的临床疗效。方法：对我院1999年4月至2008年8月采用疝环充填式无张力疝修补术治疗569例腹股沟疝患者的临床资料进行回顾性分析,对手术时间、伤口疼痛、术后自主能力的恢复、住院时间、并发症及复发率等进行观察。结果：与传统疝修补手术相比,具有方法简便,术后疼痛轻,恢复快,住院时间短,并发症少,复发率低和更宽的手术指征等优点。结论：疝环充填式无张力疝修补术是一种治疗腹股沟疝的理想手术方法。     

Laparoscopic hernia repair: A prospective study off 409 cases

Inguinal hernia is a common operation which until recently has required a groin incision with the attendant morbidity and discomfort. A trans-abdominal pre-peritoneal mesh repair of inguinal hernias was prospectively studied with the aim of minimizing wound problems whilst achieving recurrence rates comparable to open techniques utilizing mesh repair. A total of 359 patients with 409 hernias (309 unilateral, 50 bilateral) including 41 recurrent hernias were repaired. Ages ranged from 17 to 83 years (median 54). Thirteen per cent were aged 70 years or older. A total of 337 patients (94%) were discharged from hospital within 24 h. Fifty-four patients (15%) had complications, mostly minor. These included fluid collections [23], spontaneously resolving pain in the testicle [9] and the pubic tubercle [5], and meralgia para-esthetica [6]. Major complications occurred in seven patients (1.9%): urinary retention in five (two requiring prostatectomy and another a small bowel obstruction), one small bowel obstruction from a port site hernia and a single mesh infection. There was no complication from laparoscopy. Convalescent time is short with a median return to normal activities of 3 days (range 0–30) and median return to work of 12 days (range 2–95). Three recurrences have been noted at a maximum 13 months (median 7) follow-up. We conclude that the laparascopic technique described is acceptable for the repair of inguinal hernias.     

腹腔镜经腹膜前修补术治疗腹股沟嵌顿疝

目的探讨腹腔镜经腹膜前修补术（TAPP）治疗腹股沟嵌顿疝的临床价值。方法回顾性分析2015年1月~2016年12月收治的44例急性腹股沟嵌顿疝的临床资料,按手术方式的不同分为观察组（n=19）和对照组（n=25）,观察组采用TAPP术,对照组采用开放腹膜前修补术,比较两组患者的临床疗效。结果两组均成功完成手术。观察组的手术时间、术中出血量分别是60.13±9.52 min和6.00±2.27 mL,对照组分别是60.25±10.71 min和7.25±3.92 mL,两组差异无统计学意义（P>0.05）。观察组术后疼痛VAS评分、术后肠道恢复时间、住院时间分别是2.63±1.06分,18.88±7.83 h和3.19±0.60 d,对照组分别是5.75±1.67分,41.63±7.13 h和5.38±1.13 d,两组差异有统计学意义（P<0.05）。术后观察组并发症发生率为16%（3例血清肿）,对照组为28%（3例血清肿,2例切口脂肪液化,1例术后慢性疼痛和1例复发）,两组差异无统计学意义（P>0.05）。结论正确掌握适应症,TAPP可以安全有效治疗急性腹股沟嵌顿疝,且具有创伤小、疼痛轻、恢复快等优点。     

Management of Postherniorrhaphy Chronic Neuropathic Groin Pain: A Role for Dorsal Root Ganglion Stimulation

Chronic neuropathic groin pain is a sequela of hernia surgery that occurs at unacceptably high rates, causing widespread impacts on quality of life. Although the medical community is beginning to recognize the role of surgical technique in the initiation and maintenance of postherniorrhaphy neuropathic pain, little information exists regarding pain management strategies for this condition. This review presents a summary of the pain condition state, its treatment options, and treatment recommendations. Both literature review and clinical experience were used to develop a proposed a treatment algorithm for the treatment of postherniorrhaphy pain. The development of chronic pain may be prevented via a number of perioperative measures. For pain that is already established, some surgical approaches including inguinal neurectomy can be effective, in addition to standard pharmacological treatments and local infiltrations. An unmet need may still exist with these options, however, leaving a role for neuromodulation for the treatment of intractable cases. A pain management algorithm for iterative interventions including stimulation of the dorsal root ganglion (DRG) is described. It is expected that cross‐disciplinary awareness of surgeons for nonsurgical pain management options in the treatment of chronic neuropathic postherniorrhaphy pain will contribute to better clinical outcomes.     

Indocyanine green fluorescence-guided laparoscopic removal of infected mesh with chronic sinus formation after inguinal mesh plug repair

Chronic mesh infection with sinus formation is usually amenable to open method with dye. Recently, intraoperative real-time fluorescent imaging has been applied to various organs but not to mesh infection. A 72-year-old man with the history of two times removal of infected mesh was referred for groin bulge with purulent discharge. Laparoscopy assisted infected mesh removal was undertaken using intraoperative real-time fluorescent imaging with indocyanine green injection via the sinus orifice. We experienced the first case of the infected mesh with chronic sinus formation treated by the help of intraoperative indocyanine green fluorescent. This method is simple and easy to apply for laparoscopic assisted removal of chronic mesh infection with sinus.     

疝环充填式无张力疝修补手术切口疼痛的原因分析及防治

目的探讨疝环充填式无张力疝修补手术切口疼痛的原因及防治方法。方法回顾分析了2010年10月~2011年12月本院68例行疝环充填式无张力修补腹股沟疝患者,采用材料为美国Bard公司锥形充填物和成型补片。结果 68例患者近期内均无复发,无切口感染,无皮下血肿。术后切口慢性疼痛和切口异物感各2例。结论疝环充填式无张力疝修补术具有损伤小、复发率低、术后恢复快等特点,但仍然存在着一定的切口并发症。     

Adductor-related groin pain in the athlete

Background:

Owing to a multifactorial etiology, the differential diagnosis of groin pain in the athlete is often complex, with a diagnosis being clinically elusive in up to 30% of individuals. It has been suggested in the literature that the adductor musculature is a viable and prevalent source of groin pain. Thus, recognition of the elements related to effective management of these individuals is essential for the clinician.

Objectives:

To review the current literature related to prevalence, risk factors, clinical testing, conservative, and surgical interventions for adductor-related groin pain.

Major findings:

Adductor-related groin injuries may occur in isolation or combination. Athletes participating in multi-directional sports, with prior groin injury, weakness of adductors compared to abductors, and higher level of play are at greatest risk. Clinical testing using the adductor squeeze test at varying angles offers high specificity in the absence of imaging modalities. Evidence for preventative programs exists among soccer and ice hockey players. Interventions focusing on progressively improving adductor muscle performance and lower extremity impairments have been found effective, as have multi-modal interventions. Surgical interventions, recommended for those recalcitrant (>2 months) to conservative care appear effective, with adductor repair or tenotomy procedures being primarily described in case series designs.

Conclusion:

A paucity of research exists to determine the diagnostic utility of clinical tests as well as the efficacy of interventions. Clinicians should be aware of adductor-related groin pain as a clinical entity and recognize the potential merits and limitations of both preventive and adductor-focused interventions.     

Current Understandings on Complex Regional Pain Syndrome

The mechanisms underlying complex regional pain syndrome (CRPS) have been increasingly studied over the past decade. Classically, this painful and disabling disorder was considered to emerge from pathology of the central nervous system. However, the involvement of additional peripheral disease mechanisms is likely, and recently these mechanisms have also attracted scientific attention. The present article provides an overview of the current understandings regarding pathology of the autonomic and somatic nervous system in CRPS, as well as the roles of neurogenic inflammation, hypoxia, and the contribution of psychological factors. Potential connections between the separate disease mechanisms will be discussed. Additionally, currently known risk factors for CRPS will be addressed. Insight into risk factors is of relevance as it facilitates early diagnosis and tailored treatment. Moreover, it may provide clues for further unraveling of the pathogenesis and etiology of CRPS.     

Lichtenstein无张力疝修补术的临床应用

目的探讨用聚丙烯网片,采用Lichtenstein术式在成年人腹股沟无张力疝修补术中的优点、并总结经验教训。方法采用德国蛇牌集团公司的聚丙烯网片对312例腹股沟疝病人施行Lichtenstein无张力疝修补术,观察手术时间,伤口疼痛,术后自主能力恢复,并发症及复发率。结果手术时间平均为50min;术后3—4h病人能下床活动;伤口疼痛时间2～3d。术后切口血肿3例,无一例切13＇感染。腹股沟异物感10例。术后随访238例6个月至4年。无一例复发。结论Lichtenstein无张力疝修补术操作简单,术后恢复迅速,并发症极少,复发率低,疗效肯定,手术指征可适当放宽,是近年较先进的一种无张力疝修补术式。