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.     

Inguinal hernia repair with the mesh plug method is safe after radical retropubic prostatectomy

Purpose

We evaluated the safety and efficiency of using the mesh plug method (MP) to repair inguinal hernias in patients with a history of radical retropubic prostatectomy (RRP). We also investigated how RRP influences the development of inguinal hernias and impacts their repair.

Methods

Among 488 adult male patients who underwent inguinal hernia repair during a recent 5-year period, 37 had a history of RRP. We compared the characteristics and surgical outcomes of the patients who had undergone RRP (post-RRP group) with those who had not (non-RRP group).

Results

All post-RRP hernias were treated by MP. The 37 post-RRP patients had a collective 41 hernias, 40 of which were of the indirect type. The side affected by the hernia did not differ significantly between the groups. We compared the short-term surgical outcomes of the indirect post-RRP hernias vs. the indirect non-RPP hernias without recurrence and incarceration. The operation times, postoperative hospital stay, and mobility rates did not differ significantly between the two groups. The blood loss was almost equal in both groups.

Conclusion

Inguinal hernia repair after RRP may be difficult because of inflammatory changes in the preperitoneal cavity, but the surgical outcomes of MP were equivalent in patients with or without a history of RPP in this study. MP is a safe and effective method for post-RPP hernia repair.     

Retromuscular Preperitoneal Repair of Flank Hernias

Introduction

Flank hernias represent a challenging problem to reconstructive surgeons. Their anatomic proximity to the bony prominence and major neurovascular structures limits fixation options and restricts mesh overlap. We present our technique and outcomes of a preperitoneal repair with wide mesh overlap.

Methods

This study is a retrospective analysis of patients undergoing open flank hernia repair with a retromuscular preperitoneal approach.

Results

Between September 2007 and April 2011, 16 patients, mean age 55?years (range 34?C80) and BMI 33?kg/m² (range 26?C46), underwent open flank hernia repair. Eight were recurrent hernias; six previously had mesh placed; nine were incarcerated. Mean hernia defect size was 232?cm² (range 25?C800). Mean operative time was 178?min (range 105?C245). One intraoperative complication, ureteral injury in a transplant recipient, occurred and was primarily repaired without sequela. Two patients developed wound complications, one requiring superficial debridement and another requiring partial excision (<5?%) of the mesh with secondary healing. With a mean follow-up of 16.8?months (range 2?C49), no recurrent hernias were noted.

Conclusion

Open retromuscular preperitoneal repair of flank hernias with iliac bone fixation is technically feasible, allowing wide mesh overlap for a durable repair. This approach may offer advantages of treating abdominal wall laxity and repair of larger defects when compared to laparoscopic approaches.     

Laparoscopic totally extraperitoneal versus open preperitoneal mesh repair for inguinal hernia recurrence: a decision analysis based on net health benefits

Background

The aim of this study is to evaluate the most cost-effective treatment strategy using preperitoneal mesh for patients with recurrent inguinal hernia. Currently, the issue of cost-effectiveness is entirely unresolved.

Methods

A decision analysis was carried out based on the results of a systematic literature review of articles concerning recurrent inguinal hernia repair that were published between 1979 and 2011. A virtual cohort was programmed to undergo three different treatment procedures: (1) laparoscopic totally extraperitoneal hernia repair (TEP), (2) open preperitoneal mesh repair according to Stoppa, and (3) open preperitoneal mesh repair according to Nyhus. We carried out a base-case analysis and varied all variables over a broad range of reasonable hypotheses in multiple one-way and two-way sensitivity analyses.

Results

The average cost-effectiveness ratio of Nyhus, Stoppa, and TEP per quality-adjusted life year was US $ ($)1,942, $1,948, and $2,011, respectively. In terms of the incremental cost-effectiveness ratio (ICER), Stoppa was dominated. The choice between TEP or Nyhus procedure depends on the combination of a specific center’s rates of recurrence and morbidity as disclosed by three-way sensitivity analysis.

Conclusions

Nyhus and TEP repairs are possible optimal choices depending primarily on the institution’s rates of recurrence and morbidity. Based on our net benefit-related decision analysis, a hypothetical “fixed budget trade-off” suggests potential annual incremental health system cost savings of $200,000 attained by shifting care for 1,000 patients from TEP to Nyhus repair (depending on clinical end-points, which is a decisive factor).     

Laparoscopic transabdominal preperitoneal inguinal hernia repair using needlescopic instruments: a 15-year, single-center experience in 317 patients

Background

Laparoscopic inguinal hernia repair is associated with a decrease in postoperative pain, shortened hospital stay, earlier return to normal activity, and decrease in chronic pain. Moreover, laparoscopic surgery performed with needlescopic instruments has more advantages than conventional laparoscopic surgery. However, there are few reports of large-scale laparoscopic transabdominal preperitoneal inguinal hernia repair using needlescopic instruments (nTAPP). This report reviews our experiences with 352 nTAPP in 317 patients during the 15-year period from April 1996 to April 2011.

Methods

We performed nTAPP as the method of choice in 88.5% of all patients presenting with inguinal hernia. To perform the nTAPP, 3-mm instruments were used. A 5-mm laparoscope was inserted from the umbilicus, and surgical instruments were inserted through 5- and 3-mm trocars. After reduction of the hernia sac and dissection of the preperitoneal space, we placed polyester mesh or polypropylene soft mesh with staple fixation. The peritoneum was closed with 3–0 silk interrupted sutures.

Results

The mean operative time was 102.9?min for unilateral hernias and 155.8?min for bilateral hernias. There was no conversion to open repair. Forty-three patients (13.6%) used postoperative analgesics, and the mean frequency of use was 0.5 times. Regarding intraoperative complications, we observed one bladder injury, but no bowel injuries or major vessel injuries. Postoperative complications occurred in 32 patients (10.1%). One patient with a retained lipoma required reoperation. There was no incidence of chronic pain or mesh infection. The operative time for experienced surgeons (≥20 repairs) was significantly shorter than that of inexperienced surgeons (<20 repairs; P?Conclusions The nTAPP was a safe and useful technique for inguinal hernia repair. Large prospective, randomized controlled trials will be required to establish the benefit of nTAPP.     

Lower Reoperation Rate for Recurrence after Mesh versus Sutured Elective Repair in Small Umbilical and Epigastric Hernias. A Nationwide Register Study

Background

Repair for a small (≤2 cm) umbilical and epigastric hernia is a minor surgical procedure. The most common surgical repair techniques are a sutured repair or a repair with mesh reinforcement. However, the optimal repair technique with regard to risk of reoperation for recurrence is not well documented. The aim of the present study was in a nationwide setup to investigate the reoperation rate for recurrence after small open umbilical and epigastric hernia repairs using either sutured or mesh repair.

Materials and methods

This was a prospective cohort study based on intraoperative registrations from the Danish Ventral Hernia Database (DVHD) of patients undergoing elective open mesh and sutured repair for small (≤2 cm) umbilical and epigastric hernias. Patients were included during a 4-year study period. A complete follow-up was obtained by combining intraoperative data from the DVHD with data from the Danish National Patient Register. The cumulative reoperation rates were obtained using cumulative incidence plot and compared with the log rank test.

Results and conclusions

In total, 4,786 small (≤2 cm) elective open umbilical and epigastric hernia repairs were included. Age was median 48 years (range 18–95 years). Follow-up was 21 months (range 0–47 months). The cumulated reoperation rates for recurrence were 2.2 % for mesh reinforcement and 5.6 % for sutured repair (P = 0.001). The overall cumulated reoperation rate for sutured and mesh repairs was 4.8 %. In conclusion, reoperation rate for recurrence for small umbilical and epigastric hernias was significantly lower after mesh repair compared with sutured repair. Mesh reinforcement should be routine in even small umbilical or epigastric hernias to lower the risk of reoperation for recurrence avoid recurrence.     

Female ‘groin’ hernia: totally extraperitoneal (TEP) endoscopic repair seems the most appropriate treatment modality

Background

About 30% of all female ‘groin’ hernias are femoral hernias, although often only diagnosed during surgery. A Lichtenstein repair though, as preferred treatment modality according to guidelines, would not diagnose and treat femoral hernias. Totally extraperitoneal (TEP) hernia repair, however, offers the advantage of being an appropriate modality for the diagnosis and subsequent treatment of both inguinal and femoral hernias. TEP therefore seems an appealing surgical technique for women with groin hernias.

Methods

This study included all female patients ≥18?years operated for a groin hernia between 2005 and 2009.

Results

A total of 183 groin hernias were repaired in 164 women. TEP was performed in 85% of women; the other 24 women underwent an open anterior (mesh) repair. Peroperatively, femoral hernias were observed in 23% of patients with primary hernias and 35% of patients with recurrent hernias. There were 30 cases (18.3%) of an incorrect preoperative diagnosis. Peroperatively, femoral hernias were observed in 17.3% of women who were diagnosed with an inguinal hernia before surgery. In addition, inguinal hernias were found in 24.0% of women who were diagnosed with a femoral hernia preoperatively. After a follow-up of 25?months, moderate to severe (VAS 4-10) postoperative pain was reported by 8 of 125 patients (6.4%) after TEP and 5 of 23 patients (21.7%) after open hernia repair (P?=?0.03). Five patients had a recurrent hernia, two following TEP (1.4%) and three following open anterior repair (12.5%, P?=?0.02). Two of these three patients presented with a femoral recurrence after a previous repair of an inguinal hernia.

Conclusion

Femoral hernias are common in women with groin hernias, but not always detected preoperatively; this argues for the use of a preperitoneal approach. TEP hernia repair combines the advantage of a peroperative diagnosis and subsequent appropriate treatment with the known good clinical outcomes.     

Unsuspected femoral hernia in patients with a preoperative diagnosis of recurrent inguinal hernia

Purpose

Small femoral hernias may be difficult to diagnose by physical examination and are sometimes identified unexpectedly by laparoscopy. The aim of this study was to examine the incidence of unsuspected femoral hernia discovered during laparoscopic inguinal hernia repair in two well-defined patient groups.

Methods

Patients undergoing laparoscopic transabdominal preperitoneal inguinal hernia repair from April 2000 until December 2009 (n?=?561) were prospectively registered including data on previous hernia operations and identified type of hernia during surgery. We included patients whose preoperative diagnosis was either bilateral primary inguinal hernia (Primary Group) or recurrent inguinal hernia (Recurrent Group).

Results

Four hundred and sixty-one (82.2?%) patients were included in the study, of whom 211 (45.8?%) was in the Primary Group and 250 (54.2?%) in the Recurrent Group. The incidence of unsuspected femoral hernia in the Recurrent Group [23/250, 9.2?% (95?% CI 5.9–13.5?%)] was significantly higher than in the Primary Group [8/211, 3.8?% (95?% CI 1.7–7.3?%)], p?=?0.02. Furthermore, 38.1?% of women operated on for a recurrent inguinal hernia, presented with an unsuspected femoral hernia at surgery as opposed to 6.6?% of the men, p?=?0.003.

Conclusion

Unsuspected femoral hernias are more prevalent in patients with recurrent hernia than in patients with primary hernia in the inguinal region. Femoral hernias may be unrecognized at the primary inguinal hernia operation, or the previous inguinal hernia operation may facilitate the formation of a femoral hernia. Unsuspected femoral hernias are especially frequent in women with recurrent inguinal hernia. In women with a groin hernia, a femoral hernia should always be excluded by laparoscopy or by open exploration of the preperitoneal space.     

A comparison of outcomes between open and laparoscopic surgical repair of recurrent inguinal hernias

Background

Inguinal hernia recurrence after surgical repair is a major concern. The authors report their experience with open and laparoscopic repair of recurrent inguinal hernias.

Methods

After institutional review board approval, a retrospective review was performed with the charts of 197 patients who had undergone surgical repair of recurrent inguinal hernias from January 2000 through August 2009, and the data for 172 patients who met the inclusion criteria were analyzed. Surgical variables and clinical outcomes were compared using Student??s t test, the Mann?CWhitney U test, chi-square, and Fisher??s exact test as appropriate.

Results

The review showed that 172 patients had undergone either open mesh repair (n?=?61) or laparoscopic mesh repair (n?=?111) for recurrent inguinal hernias. Postoperative complications were experienced by 8 patients in the open group and 17 patients in laparoscopic group (p?=?0.70). Five patients (8.2%) in the open group and four patients (3.6%) in the laparoscopic group had re-recurrent inguinal hernias (p?=?0.28). Four patients in the open group (9.5%) and no patients in the laparoscopic group had recurrence during long-term follow-up evaluation (p?=?0.046). In the laparoscopic group, 76 patients (68.5%) underwent total extraperitoneal (TEP) repair, and 35 patients (31.5%) had transabdominal preperitoneal (TAPP) repair. Postoperative complications were experienced by 13 patients in the TEP group and 4 patients in the TAPP group (p?=?0.44). Two patients (2.6%) in the TEP group and two patients (5.7%) in the TAPP group had re-recurrent inguinal hernias (p?=?0.59).

Conclusions

This retrospective review showed no statistical difference in the re-recurrence rate between the two techniques during short-term follow-up evaluation. However, the laparoscopic technique had a significantly lower re-recurrence rate than the open technique during long-term follow-up evaluation. Both procedures were comparable in terms of intra- and postoperative complications. Among laparoscopic techniques, TEP and TAPP repair are acceptable methods for the repair of recurrent inguinal hernia. A multicenter prospective randomized control trial is needed to confirm the findings of this study.     

Long-term complaints after elective repair for small umbilical or epigastric hernias

Purpose

Elective repair for umbilical or epigastric hernia is a frequent minor surgical procedure. Several studies have demonstrated chronic pain after groin hernia repair but long-term complaints have been only scarcely studied. This study was undertaken to investigate long-term pain and discomfort after open repair for small umbilical or epigastric hernias.

Methods

This is a retrospective study with prospective long-term follow-up. Only elective primary umbilical or epigastric hernias with an open mesh or sutured repair were included. A structured follow-up questionnaire was sent to all patients regarding verbal rating scores (VRS) of pain and discomfort (no, little, moderate, or severe) and recurrence. Patients with suspected recurrence were clinically examined.

Results

There were 139 eligible patients, and 132 patients answered the questionnaire (95 % response rate). The median follow-up time was 36 months (range 15–85), and defect size was 1.0 cm (0.2–8.0). Sixteen patients reported moderate or severe pain and/or discomfort (12 %, 95 % confidence interval (CI): 6–18). The cumulated risk of recurrence was 11.5 %. Of the 15 patients with clinical recurrence or reoperation for recurrence, 5 patients reported moderate/severe complaints (31 %) whereas 11 of the remaining 116 patients with no recurrence (10 %) reported moderate/severe complaints (P = 0.014).

Conclusion

Surprisingly, many patients complained about pain and discomfort 3 years after elective repair for a small umbilical or epigastric hernia.     

Low recurrence rate and low chronic pain associated with inguinal hernia repair by laparoscopic placement of Parietex ProGrip™ mesh: clinical outcomes of 220 hernias with mean follow-up at 23 months

Introduction

The aim of this study was to demonstrate the safety and the efficacy of the self-gripping Parietex ProGrip? mesh (Sofradim Production, Trévoux, France) used with the laparoscopic approach for inguinal hernia repair. The incidence of chronic pain, post-operative complications, patient satisfaction and hernia recurrence at follow-up after 12 months was evaluated.

Methods

Data were collected retrospectively from patient files and were analyzed for 169 male and female patients with 220 primary inguinal hernias. All patients included had undergone surgical repair for inguinal hernia by the laparoscopic transabdominal preperitoneal approach using Parietex ProGrip? meshes performed in the same clinical center in Germany. Pre-, per- and post-operative data were collected, and a follow-up after 12 months was performed prospectively. Complications, pain scored on a 0–10 numeric rating scale (NRS), patient satisfaction and hernia recurrence were assessed.

Results

The only complications were minor and were post-operative: hematoma/seroma (3 cases), secondary hemorrhage through the trocar’s site (2 cases), hematuria, emphysema in the inguinal regions (both sides) and swelling above the genital organs (1 case for each). At mean follow-up at 22.8 months, there were only 3 reports of hernia recurrence: 1.4 % of the hernias. Most patients (95.9 %) were satisfied or very satisfied with their hernia repair with only 1.2 % reporting severe pain (NRS score 7–10) and 3.6 % reported mild pain.

Conclusion

This study demonstrates that in experienced hands, inguinal hernia repair surgery performed by laparoscopic transabdominal preperitoneal hernioplasty using Parietex ProGrip? self-gripping meshes is rapid, efficient and safe with low pain and low hernia recurrence rate.     

Chronic pain and discomfort after inguinal hernia repair

Purpose

The purpose of this study was to estimate the incidence and degree of persistent chronic pain after inguinal hernia repair performed in our hospitals.

Methods

We mailed a questionnaire on the frequency and intensity of postoperative inguinal pain and discomfort to 219 adult patients who had undergone inguinal hernia repair in one of our hospitals more than 3?months previously.

Results

There were 191 (87.2%) respondents, 28 (14.7%) of whom reported pain and 33 (17.3%) reported discomfort. The frequency of pain was “rare” in more than half of the patients who reported pain. No patient reported “continuous” pain. The intensity of the pain was “mild” in most of the patients, and none reported “pain that required a painkiller”. The answers on the face scale questionnaire (score “0” to “10”) were “0” or “1” for most of the patients. The incidence of chronic pain and/or discomfort was significantly higher in women than in men, and tended to be higher in patients who had undergone repair using onlay mesh.

Conclusions

The frequency and intensity of persistent chronic pain or discomfort after inguinal hernia repair was not high or severe. These data will be useful for further studies to determine the best treatment for adult inguinal hernia.     

Repeated laparoscopic treatment of recurrent inguinal hernias after previous posterior repair

Background

The reported recurrence rates after laparoscopic inguinal hernia repair are 0–4 %. It is unclear which technique could best be offered to a patient with a recurrent hernia after a previous posterior repair. The purpose of this retrospective study was to determine the safety, feasibility, and reliability of a repeated laparoscopic repair (TAPP) for a recurrent hernia after a previous posterior inguinal hernia repair.

Methods

The study group contains 2,594 consecutive transabdominal inguinal hernia repairs (TAPP). Of these, 53 repairs were attempted in 51 patients for recurrent hernias after a previous posterior repair. During the follow-up period, patients were examined for recurrences and for presence of a port-site hernia. Pain was scored by the visual analogue pain scale (VAS).

Results

Fifty-one patients underwent a TAPP repair for a recurrent inguinal hernia after previous posterior hernia repair. Two patients presented a bilateral recurrent inguinal hernia. In two thirds of the patients, the recurrence was located caudally or medially from the previously placed mesh. Two attempted repairs had to be converted to an open technique due to severe adhesions. One intraoperative complication was encountered when the vas deferens was ligated during surgery due to adhesions of the previous placed mesh. Nine patients encountered an adverse event postoperatively, but none of them were serious events. No mesh infections were reported. The mean follow-up was 70 (range, 1–198) months. At follow-up, no recurrences were found at physical examination. Four patients developed a port-site hernia. Four patients had complaints of postoperative pain and were restricted in daily activities due to groin pain. The mean VAS score (scale 0–100), including the four patients with persistent pain, was 5.7 (range, 0–61).

Conclusions

It is concluded that repeated laparoscopic hernia repair (TAPP) is a definite repair for recurrent inguinal hernias. The procedure is feasible, safe, and reliable.     

Open preperitoneal mesh repair of inguinal hernias using a mesh with nitinol memory frame

Purpose

To prospectively evaluate the use of a continuous Nitinol containing memory frame patch during a TIPP-technique in the open repair of inguinal and femoral hernias.

Methods

Over a 3-year period all consecutive adult patients that needed treatment for an inguinal or femoral hernia were treated by the TIPP repair using the Rebound Shield mesh. Intra-operatively the type and size of the hernia were evaluated according to the EHS classification, as well as the size of the mesh used. Baseline characteristics for all patients were evaluated considering age, gender, BMI and American society of Anesthesiologists score. Standard X-ray was performed to evaluate mesh position. All patients were evaluated for post-operative pain using the visual analogue scale (VAS 0–10 scale).

Results

In total 289 groin hernias were operated using a nitinol containing patch in 235 patients. The mean operating time was 38 min for unilateral hernias and 59 min for bilateral hernias. The median follow-up is 21.2 months (14–33 months) during which three patients died, unrelated to the groin hernia repair. At the time of re-evaluation 12 patients (5.0 %) complained of chronic pain, with a VAS score higher than 3 after 3 months (range 3–10). Two of these patients already had severe pain pre-operatively. A total of 3 recurrences (2.9 %) were noted with strong correlation with X-ray findings.

Conclusion

A nitinol memory frame containing mesh is a valuable tool to achieve complete deployment of a large pore mesh in a TIPP repair for inguinal hernias with acceptable morbidity and a low recurrence rate.     

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.     

Two-stage laparoscopic treatment for strangulated inguinal,femoral and obturator hernias: totally extraperitoneal repair followed by intestinal resection assisted by intraperitoneal laparoscopic exploration

Purpose

Total extraperitoneal preperitoneal (TEP) repair is widely used for inguinal, femoral, or obturator hernia treatment. However, mesh repair is not often used for strangulated hernia treatment if intestinal resection is required because of the risk of postoperative mesh infection. Complete mesh repair is required for hernia treatment to prevent postoperative recurrence, particularly in patients with femoral or obturator hernia.

Cases

We treated four patients with inguinocrural and obturator hernias (a 72-year-old male with a right indirect inguinal hernia; an 83-year-old female with a right obturator hernia; and 86- and 82-year-old females with femoral hernias) via a two-stage laparoscopic surgery. All patients were diagnosed with intestinal obstruction due to strangulated hernia. First, the incarcerated small intestine was released and then laparoscopically resected. Further, 8–24 days after the first surgery, bilateral TEP repairs were performed in all patients; the postoperative course was uneventful in all patients, and they were discharged 5–10 days after TEP repair. At present, no hernia recurrence has been reported in any patient.

Conclusion

The two-stage laparoscopic treatment is safe for treatment of strangulated inguinal, femoral, and obturator hernias, and complete mesh repair via the TEP method can be performed in elderly patients to minimize the occurrence of mesh infection.

     

Use of fibrin sealant (Tisseel/Tissucol) in hernia repair: a systematic review

Background

Abdominal wall and inguinal hernia repair are the most frequently performed surgical procedures in the United States and Europe. However, traditional methods of mesh fixation are associated with a number of problems including substantial risks of recurrence and of postoperative and chronic pain. The aim of this systematic review is to summarize the clinical safety and efficacy of Tisseel/Tissucol fibrin sealant for hernia mesh fixation.

Methods

A PubMed title/abstract search was conducted using the following terms: (fibrin glue OR fibrin sealant OR Tisseel OR Tissucol) AND hernia repair. The bibliographies of the publications identified in the search were reviewed for additional references.

Results

There were 36 Tisseel/Tissucol studies included in this review involving 5,993 patients undergoing surgery for hernia. In open repair of inguinal hernias, Tisseel compared favorably with traditional methods of mesh fixation, being associated with shorter operative times and hospital stays and a lower incidence of chronic pain. Similarly, after laparoscopic/endoscopic inguinal hernia repair, Tisseel/Tissucol was associated with less use of postoperative analgesics and less acute and chronic postoperative pain than tissue-penetrating mesh-fixation methods. Other end points of concern to surgeons and patients are the risks of inguinal hernia recurrence and of complications such as hematoma formation and intraoperative bleeding. Comparative studies show that Tisseel/Tissucol does not increase the risk of these outcomes and may, in fact, decrease the risk compared with tissue-penetrating fixation methods. When used in the repair of incisional hernias, Tisseel/Tissucol significantly decreased both postoperative morbidity and duration of hospital stay.

Conclusions

Clinical evidence published to date supports the use of Tisseel/Tissucol as an option for mesh fixation in open and laparoscopic/endoscopic repair of inguinal and incisional hernias. Guidelines of the International Endohernia Society recommend fibrin sealant mesh fixation, especially in inguinal hernia repair. Nonfixation is reserved for selected cases.     

Minimal incision transinguinal repair for incarcerated obturator hernia

Background

Patients with incarcerated obturator hernia are usually elderly, frail, and physically inactive women with serious comorbidities. Although a laparotomy is standard surgical intervention for emergency incarcerated or strangulated obturator hernia, it is invasive particularly for these high-risk patients. The aim of this study is to show the feasibility of minimum open inguinal approach to reduce surgical risk for preoperatively diagnosed incarcerated obturator hernia.

Methods

Between April 2008 and July 2012, 3 consecutive incarcerated obturator hernia patients at Kamitsuga General Hospital who were diagnosed preoperatively by computed tomography underwent the following procedure. First a 4 cm inguinal hernia incision and preperitoneal dissection through the opening of the deep inguinal ring are made. The obturator hernia can be easily found 2 cm dorsally from the Cooper’s ligament extraperitoneally. A small incision is made at medial sharp edge of the hernia defect. The hernia sac and its content can then be reduced. If the incarcerated bowel is viable, a prosthetic mesh is placed as a patch. If the bowel is necrotic, the damaged bowel loop is withdrawn through the wound and easily reconstructed extra-abdominally.

Results

All operations were successfully completed with this procedure. All patients recovered without incident.

Conclusions

Minimal incision transinguinal repair for diagnosed incarcerated obturator hernia is feasible and provides an improved option to more invasive procedures.     

Proposed technique for open repair of a small umbilical hernia and rectus divarication with self-gripping mesh

Introduction

There are a group of patients in which umbilical or epigastric hernias co-exist with rectus divarication. These patients have weak abdominal musculature and are likely to pose a higher risk of recurrence following umbilical hernia repair. We would like to describe a technique for open repair of small (<4 cm) midline hernias in patients with co-existing rectus divarication using self-adhesive synthetic mesh. The use of a self-adhesive mesh avoids the need for suture fixation of the mesh in the superior portion of the abdomen, allowing for a smaller skin incision.

Results

In 173 patients, preperitoneal self-fixating mesh has been used for the repair of midline hernias <4 cm in diameter. In 58 of these patients, the mesh was extended superiorly to reinforce a concurrent divarication.

Discussion

The described technique offers a simple option for open repair of small midline hernias in patients with co-existing rectus divarication, to decrease the risk of upper midline recurrence in an at-risk patient group. This initial case series is able to demonstrate a suitably low rate of recurrence and complications.