Unexpected adhesions to a previously inserted preperitoneal mesh plug

Adhesion formation is a long-term complication of laparoscopic inguinal hernia surgery-particularly by the transabdominal preperitoneal technique; but it is not thought to occur after open repair. We describe a gentleman presenting with a recurrent hernia who had previously undergone an open mesh plug repair 4 years earlier. At laparoscopy he was found to have considerable adhesions associated with the plug. These were successfully divided before repair. This case illustrates the possibility of intra-abdominal adhesions developing even after open hernia surgery.     

Laparoscopic orchiectomy and simultaneous inguinal herniorrhaphy technique by the transperitoneal route in adult patients

In recent years, laparoscopy has begun to be widely used in many clinics for the diagnosis and repair of nonpalpable testes. Because the technique is noninvasive, it is also used to repair inguinal hernias via the retroperitoneal route. The technique and results of performing laparoscopic orchiectomy and herniorrhaphy simultaneously by the transperitoneal route in patients with abdominal testis and ipsilateral inguinal hernia were addressed in this clinical study. Between 1996 and 2001, laparoscopic intervention was applied in 44 patients ranging in age from 20 to 27 years (average, 23 years) who had both unilateral nonpalpable testis and ipsilateral inguinal hernia. The patients underwent laparoscopic orchiectomy and transperitoneal herniorrhaphy. They were followed for 6 to 24 months postoperatively (average, 16 months). No complications developed during the operation or early postoperative period in any of the patients. No case of recurrent hernia was encountered during the followup period. Efficient laparoscopic transperitoneal hernia repair can be achieved during laparoscopic orchiectomy performed in patients with abdominal testis and ipsilateral inguinal hernia. When this method is used, patients can be discharged on the day after the operation and are able to resume their daily activities within a very short time.     

Assessment of risk for intra-abdominal adhesions at laparoscopy for urological tumors

PURPOSE: Abdominal wall adhesions at laparoscopy may predispose patients to access related injuries and increase the complexity of the procedure. We have observed concern from referring physicians regarding the safety of laparoscopy in patients who previously underwent surgery because of the risk of abdominal adhesions. To assess the risk of adhesions at laparoscopy a retrospective cohort study was performed. MATERIALS AND METHODS: All patients who underwent a transperitoneal urological laparoscopic procedure in a 6-year period at our institution were included in this study. A chart review was performed to obtain demographic/surgical data and identify preoperative risk factors for adhesions, such as previous abdominal or pelvic surgery, radiation and/or intra-abdominal inflammatory disease. Operative videotapes were reviewed to determine the presence and location of adhesions. Standard statistical analyses were performed. RESULTS: During the study period 127 patients underwent transperitoneal laparoscopy and videotapes on 82 (65%) were available for review. A total of 44 patients (54%) were identified with preoperative risk factors for adhesions (group 1), while 38 (46%) had no risk factors (group 2). The relative risk of adhesions was 1.34 (95% CI 0.89 to 2.01, p = 0.18) when risk factors were identified. There were no differences in the groups in patient age, operative time, access technique, conversion to open surgery or complications. Estimated blood loss was significantly higher in group 2, likely due to the preponderance of cytoreductive laparoscopic nephrectomy in this group. CONCLUSIONS: There was no difference in the risk of intra-abdominal adhesions in patients with and without identifiable preoperative risk factors. Preoperative risk factors for adhesions should not contraindicate the transperitoneal laparoscopic approach for urological oncology procedures.     

Totally retroperitoneal laparoscopic aortobifemoral bypass

The classic procedure for aortobifemoral bypass is open surgery. Since the first totally laparoscopic aortobifemoral bypass reported in 1997 by Yves-Marie Dion, laparoscopy has been accepted by several authors as a possible minimally invasive alternative for aorto-iliac occlusive disease. The transperitoneal left retrocolic and retrorenal ways are generally used. The totally retroperitoneal laparoscopic procedure has been described as an alternative to the transperitoneal approach. We report here a totally laparoscopic retroperitoneal approach to performing aortobifemoral bypass. This approach was proposed to a 51-year-old man with aorto-iliac occlusive disease. There was no indication for endovascular revascularization. The patient suffered from 10 metres of bilateral intermittent claudication and lower limb ulcers. During the surgical procedure our patient was placed in a 30-degree right lateral decubitus position. The optical system was first placed in an intra-abdominal position to check the positioning of the trocars in the left retroperitoneal space. The dissection of the retroperitoneal space was performed by CO2 insufflation and by blunt dissection using laparoscopic forceps. The infrarenal aorta was exposed and clamped by laparoscopic clamps. A bifurcated graft was sutured on the left-hand side of the aorta by a running suture. Both prosthetic limbs were tunnelized retroperitoneally to the groin under optical control. The femoral anastomoses were performed by classic open surgery.     

腹腔镜修补成年女性腹股沟疝的临床研究

目的探讨女性腹股沟疝的特殊性及腹腔镜下修补的临床疗效。方法回顾性分析2009年5月至2013年3月苏州大学附属第二医院普外科41例成年女性腹股沟疝腹腔镜下修补的临床资料。结果4l例（46侧）均在腹腔镜下顺利完成腹股沟疝修补术,其中完全腹膜外修补术（totallyextraperitoneal,TEP）28例（32侧）,经腹腹膜前修补术（transabdominalpreperitoneal,TAPP）11例（12侧）,腹腔内修补术（intraperitonealonlaymesh,IPOM）2例（2侧）。术中发现股疝误诊为腹股沟斜疝2例;3例术前诊断为单侧疝,术中发现对侧隐匿疝;2例患者术中发现合并子宫圆韧带囊肿,术后发生血清肿6例（14．6％）;修补区域异物感4例（9．8％）;术后急性疼痛5例（12．2％）,4例3～6周后基本缓解,1例持续疼痛2个月以上,无腹腔脏器损伤、术后出血、感染、术后尿潴留等并发症的发生,所有患者4周内基本恢复非限制性活动,随访期间各修补方式患者均无复发。结论腹腔镜下女性腹股沟疝修补方式覆盖了整个薄弱的耻骨肌孔区域,可以有效的防止女性腹股沟区继发疝的发生,并且具有创伤小、恢复快、美观等优点,术中子宫圆韧带连续性应尽量予以保留,有利于将来女性患者的生活。     

腹腔镜"杂交手术"修补腹壁巨大切口疝合并隐匿性疝临床体会

目的探讨腹腔镜联合腹壁小切口"杂交手术"修复巨大腹壁切口疝合并腹股沟隐匿疝的手术优势及要点。 方法运用腹腔镜联合腹壁小切口"杂交手术"，及防粘连补片修复一例老年男性巨大腹壁切口疝并且合并腹股沟隐匿疝的病例。 结果患者手术时间130 min，术后3 d拔除皮下引流管，术后48 h排气，术后64 h排便，术后5 d出院，术后9 d拆线，未发生明显并发症。 结论"杂交手术"修补巨大型切口疝伴或不伴隐匿疝安全可行，并且具有创伤小、术后疼痛轻、恢复快、住院时间短、复发率低等优点。     

Hernia recurrence through a composite mesh secondary to transfascial suture holes

Laparoscopic ventral hernia repair is an accepted method for incisional hernia repair. Although techniques vary, transfascial suturing of the mesh to the abdominal wall has been proposed as a viable way to fixate the mesh and reduce recurrence rates. We report a 54-year-old woman who had previously undergone a laparoscopic ventral hernia repair following a laparoscopic tubal ligation using a Composix mesh. The patient presented with a symptomatic hernia recurrence. The computed tomography scan showed a periumbilical hernia containing fat. The patient underwent diagnostic laparoscopy and lysis of adhesions. During the lysis of adhesions, a recurrence through the previously placed composite mesh was encountered where holes had been made by the previously placed transfascial sutures. The hernia was reduced, mesh was removed, and an ePTFE mesh was used to repair the hernia. The mechanism of recurrence appeared to be improperly placed transfascial sutures; overly large bites of mesh caused excessive tension and ultimately a hole in the mesh. Hernia recurrence due to mesh or transfascial suture failure is rarely reported and most often caused by inadequate fixation. Our case highlights the need for meticulous placement of transfascial sutures and demonstrates a mechanism of recurrence due to inadequate placement.     

One-Trocar Laparoscopic Transperitoneal Closure of Inguinal Hernia in Children

Background  Laparoscopy is an alternative procedure for pediatric inguinal hernia; however, reported techniques necessitate two or three trocars and excellent intra-abdominal skills. This study was designed to describe and evaluate the preliminary result of one-trocar laparoscopic-assisted transperitoneal closure for inguinal hernia in children. Methods  A total of 33 children with inguinal hernia (body weight range, 2270 g to 58 kg) were included in this study from March to November 2007. Under a 5-mm laparoscopic guidance, the hernia defect was enclosed by a nonabsorbable suture, which was introduced into the abdomen by an 18-gauge vascular access on one side of the hernia defect and withdrawn on the opposite side by a homemade hook-pin through a needle puncture wound. Then, extracorporeal knot tying was performed. Results  A total of 52 procedures were performed, and the mean operating time was 46.2 ± 16.2 (range, 18–87) minutes. No cauterization was used during the operations and there was no serious operative morbidity. The mean follow-up period was 7.6 ± 2.5 (range, 4–12) months. No recurrence was observed during this period. Conclusions  This easy technique provides the benefits of laparoscopic herniorrhaphy and combines the advantages derived from the novel use of a hook-pin and vascular access simplicity, low cost, safety, minimized tissue trauma, and improved cosmetics. In addition, only one umbilical trocar wound and another needle puncture point were made. Therefore, this procedure is recommended for pediatric inguinal hernia.     

Simultaneous laparoscopic prosthetic mesh inguinal herniorrhaphy during transperitoneal laparoscopic radical prostatectomy

Concurrent repair of inguinal hernias during open radical retropubic prostatectomy is well described and commonly practiced. With the advent of the laparoscopic approach to radical prostatectomy, the possibility of concurrent laparoscopic hernia repair merits investigation. We present a case of simultaneous prosthetic mesh onlay hernia repair for bilateral inguinal hernias during laparoscopic transperitoneal radical prostatectomy.     

Mesh erosion into caecum following laparoscopic repair of inguinal hernia (TAPP): a case report and literature review

Repair of inguinal hernia is the most commonly performed surgical procedure. Both open and laparoscopic methods are accepted modalities of surgical treatment. Transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) are the two types of laparoscopic repair of the inguineal hernia. The main advantages of laparoscopic repair, as compared to open repair, are a shorter hospital stay and a quicker recovery to normal activities. However, laparoscopic repairs are associated with a higher incidence of visceral and vascular injuries. One particular complication is the migration and erosion of mesh into the adjacent viscera. Although the total numbers of cases are small, compared to the total numbers of inguinal hernia repairs, they are important, as they often presented with a diagnostic dilemma. Most of the mesh migrations reported in the literature involves the urinary bladder. In this paper, we present a case of erosion of mesh into the caecum. The patient (a 66-year-old male) underwent TAPP repair of a right inguinal hernia in 1996 with polypropelene mesh. He also underwent an open appendicectomy in 1980. During the laparoscopic repair, he was found to have multiple intra-abdominal adhesions. He presented with intermittent diarrhea, for which he was investigated, and a benign caecal lesion was found. He was initially managed conservatively. However, his symptoms persisted and he underwent a right hemicolectomy in February 2006 in our hospital. The offending lesion was found to be the prolene mesh having eroded into the caecum.     

Laparoscopic repair on asymptomatic contralateral patent processus vaginalis in children with unilateral inguinal hernia: A centre experience and review of the literature

Purpose: We investigate the prevalence of contralateral patent processus vaginalis (CPPV) in children presenting with symptomatic unilateral inguinal hernia under diagnostic laparoscopy and its implication on contralateral surgery. Methods: Over a 24‐month period, 79 children (66 boys, 13 girls) aged 1 month to 8 years with symptomatic unilateral inguinal hernia underwent laparoscopic hernia repair. Twenty‐nine patients (36.7%) were under 24 months of age and 45 (57.0%) presented with right inguinal hernia. The contralateral internal inguinal ring was evaluated for CPPV. Bilateral repairs were carried out if CPPV was present. Results: The overall prevalence of asymptomatic CPPV was 39.2% in children who presented with unilateral inguinal hernia. The prevalence of asymptomatic CPPV was 48.3% for children aged under 24 months old and 26.0% in children above 24 months old (P = 0.044). CPPV was present in 52.9% of left‐side hernia under laparoscopy and in 28.9% of right‐side hernia (P = 0.030). Conclusion: The prevalence of asymptomatic CPPV under laparoscopy is nearly twice the reported incidence of symptomatic contralateral hernia development after conventional unilateral herniotomy. Further studies on the natural history of CPPV are necessary to determine the indications for repair of asymptomatic CPPV.     

Cryptorchidism, open processus vaginalis, and associated hernia: laparoscopic approach to the internal inguinal ring

OBJECTIVES: A nonpalpable testis was the first indication for laparoscopy in urology. This primarily diagnostic procedure has evolved to complete laparoscopic orchidopexy. An associated inguinal hernia due to an open processus vaginalis is reported in 26% of cryptorchidism cases. Simultaneous laparoscopic orchidopexy and herniorrhaphy are therefore the next logical step. METHODS: Between 1992 and 1998, 61 children underwent laparoscopy for pathology of the internal inguinal ring. In 48 boys the operation was performed for a nonpalpable testis and in 13 boys laparoscopic transection of the processus vaginalis was performed because of clinical hydrocele. RESULTS: In 25 of the 48 cases an intra-abdominal location was found with 18 existing and 7 vanishing testicles. Laparoscopic orchidopexy was performed either as a two-stage Fowler-Stephens technique (n = 6) or as a direct one-stage repair (n = 12). In 6 boys with cryptorchidism a direct inguinal hernia was associated, which received simultaneous laparoscopic herniorrhaphy. In 23 cases of cryptorchidism with an inguinal location of the testis, 3 vanishing testicles were found. In 20 cases with normal testicular vessels, an inguinal exploration followed. In 4 of the hydrocele cases additional herniorrhaphy had to be performed. In all cases the operation could be performed as planned without complications. After orchidopexy all testicles were in the normal position and well perfused as revealed by flow Doppler sonography. All hydroceles disappeared within several days. There was no inguinal hernia recurrence. CONCLUSIONS: Laparoscopic dissection of the internal inguinal ring allows perfect delineation of the anatomic structures and their relationship. Transection of the processus vaginalis can be performed without disturbance of the inguinal canal. Hernias can be closed with essentially the same technique as used in open surgery. Morbidity was minimal in all patients.     

儿童阑尾炎合并鞘状突未闭行单孔腹腔镜联合手术的临床体会

目的:探讨脐部单孔腹腔镜联合手术治疗儿童急性阑尾炎合并鞘状突未闭的优越性及临床应用价值。方法:在脐部单孔腹腔镜手术治疗儿童腹股沟斜疝、急性阑尾炎的基础上,2003年6月至2012年6月为74例急性阑尾炎合并鞘状突未闭患儿行脐部单孔腹腔镜联合手术。结果:74例手术均获成功,无中转开腹。术后早期1例发生腹腔内感染,抗感染治疗后痊愈。随访6～36个月,早期行腹腔外缝合的患儿中1例于术后1个月缝合线感染,迁延不愈,术后3个月拆除缝线后治愈,随访未发生腹股沟斜疝;中期应用可吸收缝线腹腔内缝合的患儿中1例3个月后同侧发生腹股沟斜疝,再次手术治愈;余者及后期改用医用涤纶缝合线的患儿均无其他并发症及腹股沟斜疝发生。结论:脐部单孔腹腔镜联合手术治疗儿童急性阑尾炎合并鞘状突未闭安全、有效,术后腹壁无明显手术瘢痕,值得临床推广应用。     

Isolated terminal ileum perforation after a kick blow to an inguinal hernia

Small bowel perforation caused by direct blunt trauma to an inguinal hernia has rarely been reported. In this report, we present a patient with terminal ileum perforation after direct blunt trauma to an inguinal hernia region. Both perforation and hernia repair were managed surgically in the same stage. This case demonstrates that leaving an inguinal hernia unrepaired may lead to dangerous outcomes, such as intestinal strangulation and perforation. Inguinal hernias with intestinal perforation need urgent surgical intervention. It is possible to repair the intestinal perforation and inguinal hernia in the same operation.     

腹腔镜切口疝修补术中腹腔粘连的诊断、分型及分离技巧

背景与目的 切口疝是腹部手术的常见并发症之一，而患者在经历了腹部手术后常有不同程度的腹腔内粘连，分离粘连是切口疝修补过程中不可回避且有相对难度的工作。术前人工渐进性气腹是腹腔镜切口疝修补术中的重要环节，笔者前期发现，通过对比气腹前后的影像学资料，可评估切口疝患者腹腔内状态，有利于手术预判，提高手术精准度，减少手术风险。本文旨在进一步探讨人工气腹结合腹部CT在伴腹腔粘连切口疝患者的腹腔镜修补术中的应用价值，并总结腹腔粘连的类型和分离粘连的手术技巧。方法 回顾性收集分析2019年4月—2020年5月在中山大学附属第六医院胃肠、疝和腹壁外科行腹腔镜切口疝修补术患者的临床资料和手术录像。通过术前人工气腹前、后腹部CT对比，判断是否存在腹腔粘连。研究者通过手术录像复盘，观察腹腔粘连的分型，总结粘连分离的技巧，记录术中粘连分离时间和并发症，统计观察孔穿刺时副损伤情况，术后并发症与恢复情况。结果 共收集72例行腹腔镜切口疝修补术病例，其中15例术前未建立人工气腹，7例建立人工气腹后术前未复查腹部CT，15例气腹前或气腹后未行疝囊三维CT重建，均予以排除。最终纳入35例患者，均为II型腹壁缺损；复发疝5例；男16例，女19例；年龄（63.26±11.11）岁；体质量指数25.04（23.03~27.34）kg/m²；既往手术术后有腹腔内感染伴切口感染者4例，切口感染者7例；最多手术次数5次。通过人工气腹前、后腹部CT对比，诊断存在腹腔内容物与腹壁粘连者33例（94.29%），无粘连者2例（5.71%）。其中主要粘连物为肠管20例（60.61%），主要粘连物为网膜组织13例（39.39%）。根据粘连的形态可分为：点状粘连，线状粘连，片状粘连及混合型粘连。根据粘连的质地可分为：膜性粘连，瘢痕性粘连及复合型粘连。粘连分离采取层面变峰面，面转化线和点，钝锐结合分离膜性粘连，锐性分离瘢痕性粘连的程序化方法。全组均成功松解分离粘连，分离时间32（4.50~46.50）min。其中5例发生小肠壁浆肌层损伤，予3-0可吸收缝线行浆肌层缝合。在行观察孔穿刺时，均未发生腹腔内脏器损伤。术后1例出现肺部感染，术后恢复排气时间3（2~4）d。结论 术前人工气腹结合腹部CT有助于判断是否存在腹腔粘连及粘连部位，有利于观察孔布局的选择。根据其形态和性质采取程序化的方法有利于简化腹腔粘连的分离。     

完全腹膜外腹腔镜疝修补术82例临床总结

目的探讨完全腹膜外腹腔镜疝修补术（total extraperitoneal hernia repair，TEP）的临床价值。方法2005～2007年行TEP手术82例97侧。男76例，女6例。年龄21～88岁，平均52岁。单侧腹股沟斜疝50例、直疝9例，双侧腹股沟斜疝9例，双侧腹股沟斜疝合并直疝6例，复发腹股沟斜疝8例。结果5例因下腹部手术史，腹壁严重粘连，腹膜损伤，其中1例无法修补，中转开放手术；4例以5-0可吸收缝线连续缝合，封闭腹膜破13。手术时间30～180min，平均单侧58min，双侧97min。术后无需使用镇痛剂。住院时间4～12d，平均7d。阴囊血清肿9例，局部穿刺抽液及理疗治愈。82例随访13～38个月，平均26个月，术后无复发。结论TEP是一种安全可靠的疝修补术，创伤小，术后疼痛轻，恢复快，特别适用于复发疝、双侧疝。     

单孔腹腔镜治疗小儿腹股沟疝术式改进

目的 改进腹腔镜手术治疗小儿腹股沟疝方式。方法 采用单孔腹腔镜手术治疗小儿腹股沟疝40例,右24例侧,左侧12例,双侧4例,单侧疝中3例有隐性疝。均在腹腔镜下行疝内口缝扎术。结果 手术时间10—30min,平均18min。术中和术后均未发生并发症。本组全部随访4—26个月无复发。结论本法创伤小、恢复快、不需伤口拆线。可同期处理腹股沟隐性疝和双侧腹股沟疝。     

Early strangulated recurrence of incisional hernia after laparoscopic repair: an old complication for a new technique

The introduction of laparoscopy in incisional hernia repair is giving rise to a new class of complications, specific of new techniques and materials. A case of early failure of incisional hernia laparoscopic repair complicated by the strangulation of a jejunal loop four months after surgery is reported. The use of inappropriate material (tacks) to fix the prosthesis to the abdominal wall, a sudden increase of intra-abdominal pressure caused by an episode of haematemesis four hours postoperatively (associated to its consequent endoscopic treatment), and the formation of rectus abdominis muscle hematoma are reported as the main factors determining the slippage of the mesh from the correct position and, ultimately, the early failure of the ventral hernia repair. Furthermore, the aetiology of early failure of laparoscopic incisional hernia repair, reported in literature, is reviewed.     

Laparoscopic management of cryptorchidism in adults

OBJECTIVES: Little is reported on the management of impalpable testis in adults. We present the impact of laparoscopy in this patient group. PATIENTS AND METHODS: Twelve adult patients have been referred to our centre over the last year, with impalpable testis. Pre-operative assessment was by either ultrasound or magnetic resonance imaging (MRI) or both. Quality of life and patient satisfaction were assessed by validated SF8 and client satisfaction (CSQ-8) questionnaires. Patients were also administered a self constructed questionnaire specifically looking at the impact of a laparoscopic service on their condition. RESULTS: The mean age was 29 yrs (range: 19-36). Two patients declined treatment. Of ten patients undergoing transperitoneal laparoscopy, five had intra-abdominal testes treated by laparoscopic orchidectomy (none malignant), two had the vas going into the deep ring and needed inguinal orchidectomy for an impalpable nubbin while in three cases there were blind ending vessels and vas. SF8 scores for physical HRQoL were unchanged but mental scores were significantly improved (p < 0.03). All patients were completely satisfied with a mean CSQ-8 score of 30.6 out of a possible 32. The majority of patients indicated that the availability of a laparoscopic service had prompted them to seek medical advice. CONCLUSIONS: Laparoscopic examination and orchidectomy is a safe and reliable procedure. Excellent patient satisfaction and quality of life are achievable. In particular mental health scores improve as previous uncertainty is removed. The advent of laparoscopy has encouraged adult patients to seek advice regarding a condition that has been present since childhood. We advocate the use of laparoscopy in evaluating and treating adult patients with maldescended testes.