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.     

Surgical management of massive ventral hernias in children.

The management of 7 children with massive abdominal wall hernias is reviewed, utilizing a technique of stabilizing the defect by insertion of a Teflon mesh prosthesis followed by pneumoperitoneum and staged reduction. Teflon mesh has proven ideally suited for this purpose because of its flexibility, elasticity, and relative nonreactivity, allowing it to be applied directly over the surface of exposed bowel without inducing fistula formation. Although the mesh is securely incorporated into the fascial perimeter of the abdominal wall, a pseudomembrane is formed at the point of contact with the bowel surface which allows subsequent dissection and removal of the prosthesis with relative ease. Having limited the size of the defect by insertion of the mesh, an ideal situation is created for use of pneumoperitoneum to expand the peritoneal cavity and stretch the normal tissues of the abdominal wall, thus facilitating subsequent operative reduction of the ventral hernia. Utilizing this approach, excellent cosmetic and functional results have been achieved in all 7 patients.     

Recurrent inguinal hernias in infants and children

The objective of this study was to analyze the etiologic factors possibly associated with the development of recurrent groin hernias in infants and children. For this purpose we analyzed the records of 2754 pediatric patients operated on for primary hernias between 1966 and 1990 at our department who have not had recurrences. They were compared with 28 boys and 4 girls we treated for recurrent hernias during the same period. We found an indirect hernia in 29 cases, a direct hernia in 4 patients, and a femoral hernia in 1 child at the time of reoperation. A significantly high recurrence rate was found to be associated with incarceration (21.9% versus 7.6%) postoperative complications (9.4% versus 1.8%), concomitant diseases (31.2% versus 5.7%), and premature birth. Day case treatment was closely related to concomitant diseases. No impact on the development of recurrences was seen for the surgeons' educational level and the time of day the surgery was performed. Knowledge of the factors contributing to hernia recurrence and perfect surgical technique with reduction of incarcerated hernias and early elective operation may result in fewer recurrences in infants and children.     

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     

Acute management of a unilateral incarcerated spigelian hernia in a patient with bilateral spigelian hernias

Spigelian hernias were first described by Joseph Klinkosch in the 18th century, and have since posed a diagnostic and surgical problem owing to their non-specific presentation and rarity. While the management of unilateral hernias is fairly well described in today’s literature, bilateral Spigelian hernias are very rare. We describe the emergency management of a patient with bilateral Spigelian hernias, diagnosed on computed tomography.     

Autodermal plasty in postoperative ventral hernias

The method of autodermal plasty was used in 299 patients with postoperative ventral hernias. Among them great and giant hernias made up 62,8%. The autodermal method of plasty results in less amount of complications in the wound which can be explained by an increased concentrations of humoral non-specific defense factors in the operation field due to the effect of the skin flap. Remote results were followed in 84% of the patients during 2-6 years. Recurrences were detected in 3,2%.     

Transumbilical endoscopic surgery for incarcerated inguinal hernias in infants and children

Purpose

To describe transumbilical laparoscopic herniorrhaphy after unsuccessful attempted manual reduction of incarcerated inguinal hernias in infants and children.

Methods

In our two hospitals, two-trocar transumbilical endoscopic surgery (TUES) is the standard technique used to repair incarcerated inguinal hernias in infants and children. Seventeen patients (aged 8 months to 2.5 years; median, 15 months; 15 boys, 2 girls) with incarcerated inguinal hernias underwent urgent laparoscopy after unsuccessful attempted manual reduction. Two 3- or 5-mm trocars were inserted into the abdomen through two intraumbilical incisions, under laparoscopic guidance. The hernia was reduced by combined external manual pressure and internal pulling with bowel forceps. After inspection of the bowel, a round needle with a 2-0 nonabsorbable suture was introduced into the peritoneal cavity through the anterior abdominal wall near the internal inguinal ring. The hernial orifice was closed with an extraperitoneal purse-string suture around the internal inguinal ring, and tied with an intraperitoneal knot. A similar procedure was performed on the contralateral side if the processus vaginalis was patent.

Results

The TUES procedure was successful in all patients. No conversions to open surgery were required. The mean operating time was 30 min (range, 25–40 min). All patients were discharged on the second postoperative day. No complications such as postoperative bleeding, hydrocele, or scrotal edema were observed. The mean follow-up period was 15 months. No cases of testicular atrophy, hypotrophy, or hernia recurrence were reported.

Conclusions

Our preliminary experience with using TUES for the treatment of incarcerated inguinal hernias in infants and children had satisfactory outcomes. This technique appeared to be safe, effective, and reliable, and had excellent cosmetic results.     

Survey on ventral hernias: surgeon indications, contraindications, and management of large ventral hernias

Repair of ventral hernias constitutes one of the most common surgical procedures. Although an abundance of data exists on objective outcome measures, very little information exists on subjective measures of surgeon preference and patient satisfaction in surgical management of ventral hernias. Moreover, there are minimal data on indications for elective repair of ventral hernias. Two questionnaires were sent to a population of general and plastic surgeons active in hernia surgery. The first of these aimed at gathering information from surgeons about their indications and contraindications for repair of ventral hernias. The second survey was aimed at determining surgeons' perception of patient satisfaction with repair of large ventral hernias (greater than 15 cm width). Five hundred sixty-eight surgeons responded to the first survey and 336 responded to the second survey. The most common indications for elective repair of abdominal wall hernias were generalized pain (68.7%) and cosmesis (54.6%), whereas the most common contraindications were morbid obesity (43.3%), American Society of Anesthesiologists Class III or IV (35.4%), and enterocutaneous fistula (33.1%). The majority of surgeons do not routinely repair large abdominal wall hernias in asymptomatic patients, but 31.6 per cent do repair asymptomatic large hernias. Most surgeons reported that the majority of patients had resolution of pain and subjective impression of improved cosmesis after surgery. This study demonstrates uniform indications and contraindications for surgical repair of ventral hernias among surgeons as well as surgeons' perception of improvements in satisfaction of most patients after surgery. Future studies will focus on comparing surgeon and patient satisfaction.