Endoscopic totally extraperitoneal repair for occult bilateral obturator hernias and multiple groin hernias

INTRODUCTION: An obturator hernia is a rare hernia that is bilateral in about 6% of patients. Most patients present with chronic pelvic pain although a few patients may present with features of intestinal obstruction. Only about 10% of obturator hernias are diagnosed preoperatively. METHODS: A 65-year-old female patient with chronic obstructive pulmonary disease presented with bilateral groin swellings associated with local pain and heaviness. She also suffered from recurrent episodes of abdominal distension. She was diagnosed to have bilateral direct inguinal hernias and a left femoral hernia. At endoscopy under epidural anesthesia she was found to have a direct inguinal, an indirect inguinal, and a femoral hernia on the left side and an indirect inguinal hernia on the right side. Additionally, the endoscopic totally extraperitoneal approach to inguinal hernias identified hitherto undiagnosed bilateral obturator hernias. The hernias were reduced and polypropylene mesh was placed bilaterally covering the myopectineal orifice and pelvic floor bilaterally. RESULTS: The patient was discharged the next day and is symptom-free on followup at eight months. CONCLUSION: Endoscopic repair of groin hernias allows the surgeon not only to diagnose and treat unsuspected groin hernias but also allows identification, dissection, and repair of coincidental occult pelvic hernias like obturator hernias at the same time.     

Laparoscopic or open preperitoneal repair in the management of recurrent groin hernias

Laparoscopic repair is considered by many to be the operation of choice for a recurrent hernia. The aim of this study was to compare long-term outcome of laparoscopic and open preperitoneal repair of recurrent groin hernias. All patients operated on by one surgeon for recurrent groin hernia between January 1994 and December 2001 were reviewed. Forty-five percent had their data collected prospectively, while in 55% the data was collected retrospectively. Over the study period 128 patients underwent repair of a recurrent groin hernia of whom 99 had either a laparoscopic or open preperitoneal repair. The mean age was 60 years (range 15–88), 93 were men while 6 were women. Forty-five had their hernia repaired laparoscopically while 54 had an open preperitoneal repair. Patients have been followed for a median of 5 years (range 2–9 years). There has been no recurrence in either group of patients. Two patients in the laparoscopic group and four in the open group suffered from chronic groin pain. One patient in either group developed a Hydrocele that was dealt with surgically. Laparoscopic and open preperitoneal repair of a recurrent groin hernia are associated with similar long-term outcomes.     

Anterior preperitoneal repair of extremely large inguinal hernias: An alternative technique

INTRODUCTIONStandard open anterior inguinal hernia repair is nowadays performed using a soft mesh to prevent recurrence and to minimalize postoperative chronic pain. To further reduce postoperative chronic pain, the use of a preperitoneal placed mesh has been suggested. In extremely large hernias, the lateral side of the mesh can be insufficient to fully embrace the hernial sac. We describe the use of two preperitoneal placed meshes to repair extremely large hernias. This ‘Butterfly Technique’ has proven to be useful. Hernias were classified according to hernia classification of the European Hernia Society (EHS) during operation. Extremely large indirect hernias were repaired by using two inverted meshes to cover the deep inguinal ring both medial and lateral. Follow up was at least 6 months. VAS pain score was assessed in all patients during follow up. Outcomes of these Butterfly repairs were evaluated. Medical drawings were made to illustrate this technique. A Total of 689 patients underwent anterior hernia repair 2006–2008.PRESENTATION OF CASESeven male patients (1%) presented with extremely large hernial sacs. All these patients were men. Mean age 69.9 years (range: 63–76), EHS classifications of hernias were all unilateral. Follow up was at least 6 months. Recurrence did not occur after repair. Chronic pain was not reported.DiscussionOpen preperitoneal hernia repair of extremely large hernias has not been described. The seven patients were trated with this technique uneventfully. No chronic pain occurred.CONCLUSIONThe Butterfly Technique is an easy and safe alternative in anterior preperitoneal repair of extremely large inguinal hernias.     

Adult groin hernias

A groin hernia is a common presenting complaint for adults and surgical repair is usually recommended. Patients may present with swelling or pain in the groin and one should be cognisant of the surgical emergency of a strangulating or obstructing hernia. A careful history and examination will help determine differential diagnoses and with planning the potential approach for repair. Surgical techniques have developed in recent years with a swing towards favouring laparoscopy in the elective patient. For both open and laparoscopic approaches, there are recognized techniques to consider. It is crucial to have a clear understanding of the anatomy in order to develop the skills required for accurate dissection, reduction and repair. Complications, although rare, can lead to severe morbidity. Laparoscopy has the advantage of reducing postoperative chronic pain but requires greater skill and experience to perform successfully. This chapter outlines the key considerations and surgical techniques for groin hernia repair and should be used in conjunction with practical training.     

Crucial anatomy and technical cues for laparoscopic transabdominal preperitoneal repair: Advanced manipulation for groin hernias in adults

Groin hernias include indirect inguinal, direct inguinal, and femoral hernias. Obturator and supravesical hernias appear very close to the groin. High-quality repairs are required for groin hernias. The concept of "tension-free repair" is generally accepted, and surgical repairs with mesh are categorized as "hernioplasties". Surgeons should have good knowledge of the relevant anatomy. Physicians generally focus on the preperitoneal space, myopectineal orifice, topographic nerves, and regional vessels. Currently, laparoscopic surgery has therapeutic potential in the surgical setting for hernioplasty, with laparoscopic transabdominal preperitoneal(TAPP) repair appearing to be a powerful tool for use in adult hernia patients. TAPP offers the advantages of accurate diagnoses, repair of bilateral and recurrent hernias, less postoperative pain, early recovery allowing work and activities, tension-free repair of the preperitoneal(posterior) space, ability to cover obturator hernias, and avoidance of potential injury to the spermatic cord. The disadvantages of TAPP are the need for general anesthesia, adhering to a learning curve, higher cost, unexpected complications related to abdominal organs, adhesion to the mesh, unexpected injuries to vessels, prolonged operative time, and as-yet-unknown long-term outcomes. Both technical skill and anatomical familiarity are important for safe, reliable surgery. With increasing awareness of the importance of anatomy during TAPP repair, we address the skills and pitfalls during laparoscopic TAPP repair in adult patients using illustrations and schemas. We also address debatable points on this subject.     

Stab anterior preperitoneal hernioplasty in groin hernias: a new technique

With laparoscopic hernia repair still not qualifying as the ideal method, the search is still on for the optimal method of intervention combining the advantages of both open mesh repair and laparoscopic repair for groin hernias. Eighty-five patients with uncomplicated inguinal hernias classified as Nyhus type 2 or higher were operated on by the modified anterior preperitoneal (APP) repair. The peroperative parameters were studied and compared with those of totally extraperitoneal (TEP) repair to determine the efficacy of the modified approach. Eighty-eight anterior preperitoneal repairs were carried out on these 85 patients. Twenty-one patients were Nyhus type 2, 17 were type 3a (direct), 41 were type 3b (indirect), and nine were type 4 (recurrent). The results were compared with TEP parameters done by the same surgeon. The incision size was 2.8 cm (2.3-4.5 cm). The operating time was 15.7 min (11-26 min) compared with 31.2 min for the TEP repair. Discharge time was 2.3 days (range 2-4 days) compared with 2.2 days in TEP repair. Complications included seroma in eight patients, pain radiating to the scrotum even at 6 months in one patient, and superficial wound infection in one patient. Return to work in patients with stab APP was 12.6 days ( 7-15 days ), whereas it was 10.4 days in TEP repair. The overall recurrence rate was 1.66% at the end of 2 years. The results with stab APP repair were comparable with those with TEP repair. The stab APP in addition had the advantage of being easier to learn and can be done faster.     

Laparoscopic repair of recurrent groin hernia: results of a prospective study

Background  Recurrences continue to be seen after repair of inguinal hernias. The repair of these recurrent hernias is a more complex and demanding procedure, with a high re-recurrence rate. Definite advantage has been demonstrated with endoscopic repair of these hernias. Methods  The results for this prospective study from January 2003 to December 2006 were evaluated after laparoscopic repair of 65 recurrent hernias in 61 patients. The patients were followed up for 1 year. Longer follow-up evaluation was performed for the patients who underwent surgery in the initial 3 years. Results  In this study, 37 recurrent hernias were managed using the transabdominal preperitoneal technique (TAPP) technique and 28 using the totally extraperitoneal (TEP) technique. There was no conversion and no cases of postoperative wound infection. Of the 12 metachronous hernias repaired simultaneously, 3 were occult. Seroma developed in five patients. At a follow-up assessment after 1 year, one patient had groin pain, and there was one re-recurrence. A longer follow-up period with a mean of 35.11 months failed to show any new re-recurrence. Conclusions  Laparoscopic repair of recurrent inguinal hernia is safe and effective. The morbidity and recurrence rates for the procedure are as low as for laparoscopic repair of primary hernias. Laparoscopic repair should be the gold standard for these hernias.     

老年（高龄）女性腹股沟疝诊断及治疗方案选择

老年腹股沟疝（包括股疝）中的女性比例高于成人各年龄段腹股沟疝总体中的女性比例。老年女性腹股沟疝的急诊手术比例、疝手术的病死率均高于男性。老年女性腹股沟疝仅以腹股沟区疼痛或盆腔疼痛为表现的并不少见,对于隐匿疝的诊断须结合超声检查等影像学检查方法,甚至可以腹腔镜探查。因此,对于老年女性腹股沟疝,建议尽早选择择期手术,降低高龄急诊手术并发症发生率以及可能死亡的风险。老年女性腹股沟疝手术推荐腹膜前疝修补术,包括完全腹膜外疝修补术（TEP）、经腹腔腹膜前疝修补术（TAPP）等,在病情特殊或手术技术有限的情况下,网塞或网塞平片疝修补术也是一种很好的选择。     

改良腹腔镜经腹腔腹膜前腹股沟疝修补术

目的探讨改良后的腹腔镜经腹腔腹膜前腹股沟在成人疝修补中的应用价值。方法2006年5月至2008年4月，对腹股沟疝403例、股疝22例行改良TAPP术。剪开脐外侧韧带，斜疝患者以缝合小儿疝的方法关闭内环口，直疝疝囊、股环疝囊予以剥离、置补片，游离的脐外侧韧带腹膜全部覆盖网片，钉合及可吸收线以针织的方法固定。结果手术无中转，每侧手术时间20～30min，出血量约4～5ml，随访时间2～22个月，无复发，无腹部牵拉不适，也无腹痛、腹胀、恶心等肠梗阻及尿频、尿痛等膀胱刺激症状。结论改良经腹腹膜前（TAPP）腹腔镜腹股沟疝修补术方法简单、效果确切、创伤小、并发症少、费用低，值得临床推广应用。     

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.     

Joint mobility in adult patients with groin hernias

The basic mechanisms of hernia formation remain mostly unknown, but several studies suggest that a connective-tissue pathology, affecting mainly the collagen metabolism, could play a role in the genesis of groin hernias. It would be interesting to know if this pathology can express some clinical signs other than the hernia. Our study focused on the joint mobility and the diagnostic criteria for benign joint hypermobility syndrome. Sixty male adult patients with inguinal hernias and 62 control subjects without hernias, age-matched, were compared, taking into account anamnestic criteria (family history of groin hernia, joint sprain, joint dislocation, skin striae, major arthralgia) and joint mobility. This was assessed by using Beighton criteria and measuring the range of movement of five joints (extension of the fifth finger, thumb, wrist, elbow, and knee). The frequency of the positive anamnestic criteria was not statistically different between the two groups. Nevertheless, a family history of groin hernia was observed in 25% of the hernia patients, against 16% in the control subjects ( P =0.23). The mean Beighton score was 0.30 in the hernia patients and 0.29 in the control population. The movement range of the five examined joints was similar in the two groups. In conclusion, patients with a groin hernia presented neither joint hypermobility nor clinical evidence of a benign joint hypermobility syndrome. Although abnormal collagen metabolism is likely implicated in hernia formation, this pathology does not seem to have clinical repercussion on joint mobility. Electronic Publication     

疝环充填式无张力修补术治疗腹股沟疝体会

目的 探讨疝环充填式无张力修补术治疗腹股沟疝的特点。方法 采用美国Bard公司生产的Bard mesh，Perfix p1ug治疗89例腹股疝癌，观察手术时间、切口疼痛、活动能力恢复、并发症和复发率。结果 手术平均时间为29min切口无明显疼痛，无紧绷感；术后6—8h下床活动，2周恢复日常工作；术后切口血肿l例，腹股沟区局部肿胀l例，尿潴留l例；无切口感染；随访2—34个月，无一例复发。结论 疝环充填式无张力修补手术操作方便，损伤少，恢复快，复发率低，适用范围广，是理想有效的疝修补术。     

Successful endoscopic treatment of chronic groin pain in athletes

Background Chronic groin pain, especially in professional sportsmen, is a difficult clinical problem. Methods From January 1999 to August 2005, 55 professional and semiprofessional sportsmen (53 males; mean age, 25 ± 4.5 years; range, 17–36 years) with undiagnosed chronic groin pain were followed prospectively. All the patients underwent an endoscopic total extraperitoneal (TEP) mesh placement. Results Incipient hernia was diagnosed in the study athletes: 15 on the right side (27%), 12 on the left side (22%), and 9 bilaterally (16%). In 20 patients (36%), an inguinal hernia was found: 3 direct inguinal hernias (5%) and 17 indirect hernias (31%). All the athletes returned to their normal sports level within 3 months after the operation. Conclusions A TEP repair must be proposed to patients with prolonged groin pain unresponsive to conservative treatment. If no clear pathology is identified, reinforcement of the wall using a mesh offers good clinical results for athletes with idiopathic groin pain.     

Prolene hernia system compared with mesh plug technique: a prospective study of short- to mid-term outcomes in primary groin hernia repair

Two types of anterior tension-free hernioplasty, prolene hernia system (PHS) repair and mesh plug technique (MPT), were introduced to Taiwan in 2001. This study compared the short- to mid-term outcomes following primary groin hernia repair with PHS and MPT. From January 2001 to December 2003, 393 patients with 426 primary groin hernias were operated on by a single surgeon using MPT (n=192) and PHS (n=234). Baseline perioperative details and follow-up information were compared. Demographic characteristics of both groups were similar. The laterality, types of anesthesia, postoperative stay, postoperative wound pain scores, wound complications and days to return to activities of daily life were equally distributed between the two groups. However, the distribution of Gilbert types in the PHS group was shifted a little to the right compared with that of the MPT group. PHS repair had longer operative time (34±17 vs 25±9 minutes, p<0.01). No recurrence was noted in both groups during the follow-up from 5 to 41 months. Chronic non-disabling groin pains were noted in 2.8% (6/218) of patients in the PHS group and 8.9% (14/175) in the MPT group (p=0.01). Our results show that both PHS and MPT repairs can be performed with short operation time, minor wound pain and quick return to activities of daily life without short- to mid-term recurrences, but postoperatively the MPT group had higher incidence of chronic non-disabling groin pain. Although the MPT is less invasive, the additional protective patch in the preperitoneal space of the PHS may provide a further safeguard against recurrences, especially for those patients with attenuated inguinal floor. Long-term follow-up is needed.     

Adult groin hernias: acute and elective

Groin hernias are a common general surgical condition and inguinal hernias will affect over a quarter of the male population in their lifetime. As a consequence, inguinal hernia repair remains one of the most frequently performed general surgical procedures carried out in the UK, at a cost of £100 million to the National Health Service per annum. Although hernia-related complications are relatively rare, they may be catastrophic and repair is recommended because of the potential functional consequences for the patient and the impact on quality of life. These issues need thorough consideration when deciding upon treatment, particularly in reference to the suitability of the patient, the nature of the hernia to be repaired and the type of surgical approach to be utilized. As with many other areas in medicine, improved outcomes in hernia surgery are achieved by experienced high-volume operators with a specialist interest in the condition. This is particularly the case with laparoscopic hernia surgery, which when introduced was associated with significant complications, and continues to have a steep learning curve. In light of the prevalence of the condition and the potential morbidity associated with hernia treatment, these factors have important global socio-economic implications.     

Laparoscopic diagnosis and management of a novel inguino-pelvic hernia

Inguinal hernias can typically be diagnosed with a proper history and thorough physical exam. However, patients with chronic groin pain, normal physical exam and no radiologic findings present a diagnostic/therapeutic dilemma [1]. We present a case of a female patient with obscure chronic groin pain. Upon laparoscopic exploration, she was found to have a hernia in a previously non-described location. Reduction of a chronically incarcerated preperitoneal fat and subsequent repair using traditional transabdominal preperitoneal repair resulted in a complete resolution of her pain.     

Planned reduction of incarcerated groin hernias with hernia sac laparoscopy

Background: Laparoscopic techniques have been described as adjuncts in the management of acutely incarcerated groin hernias, with the intention of reducing operative morbidity and patients discomfort. However, the use of laparoscopy in acute incarcerations, as well as its appropriateness, remains to be elucidated. Herein we discuss the use of hernia sac laparoscopy in the algorithm of managing incarcerated groin hernias. Methods: Five patients presenting with small bowel obstruction secondary to incarcerated groin hernias underwent surgical reduction of the hernia followed by hernia sac laparoscopy. The purpose of hernia sac laparoscopy was to determine the viability of the incarcerated bowel segment based on color, peristalsis, and venous congestion. When bowel resection was required, a separate incision was made after repair of the hernia. Results: Bowel viability was assessed accurately with this method. Although hemorrhagic fluid in the hernia sac was noted in three patients, only one patient required a limited exploration through a separate incision for nonviable bowel. Postoperative recovery was standard, with no morbidity or mortality. Patients were discharged in 2–5 days. Conclusions: Hernia sac laparoscopy, without additional trocar placements, is a safe adjunct for determining the viability of the incarcerated bowel segment. This method reduces the need for laparotomy so long as the reduced incarcerated segment meets the criteria for viability. Videoscopic inspection potentially offers additional information, such as the existence of ascites and peritoneal tumors.     

Laparoscopic repair of strangulated hernias

Background Although laparoscopic transabdominal preperitoneal polypropylene (TAPP) hernia repair is now a recognized procedure for groin hernia repair in patients undergoing elective surgery, there is a scarcity of data on TAPP repair in emergency situations such as those involving strangulated hernias. Methods Unless contraindicated, the authors’ department considers laparoscopic TAPP repair the procedure of choice for all strangulated hernias. A prospective database of 1,532 consecutive hernia repairs performed between May 1998 and April 2004 was reviewed. Results A total of 28 irreducible strangulated hernias were observed and repaired through laparoscopic TAPP. There were three conversions (10.7%): one because of extensive adhesions and two because of bowel distention. Resection became necessary in 9 (36%) of the 25 cases involving effective TAPP repair of strangulated hernias. The mean operation time, with and without resection, was 103 and 55 min, respectively. The rate of postoperative morbidity was 4% because of one inguinal hematoma case. During a mean follow-up period of 340 days, there were no recurrences after TAPP repair. Conclusions For selected patients, the TAPP approach appears to be a good therapeutic option for strangulated hernias.     

Tisseel versus tack staples as mesh fixation in totally extraperitoneal laparoscopic repair of groin hernias

Background The laparoscopic repair of groin hernias generally involves mesh fixation to avoid displacement and recurrence. Fixation usually uses staples that can lead to nerve injury and chronic postoperative pain. Laparoscopic repairs are associated with a risk of chronic pain of up to 22.5%. The use of fibrin glue (Tisseel) may represent an alternative method of mesh fixation preventing the risk of nerve injury.Methods Sixty-six patients had groin hernia repair using a totally extraperitoneal (TEP) laparoscopic procedure. Mesh fixation was achieved using 2 ml of fibrin glue. Comparison was made with an earlier series of 102 patients operated on according to the same procedure in which mesh fixation used tack staples. Complications, length of stay, recurrence, and postoperative chronic pain were assessed.Results No difference was found between the two series, except there was a significantly higher rate of postoperative chronic pain in the staples series (14.7 vs 4.5%, p = 0.037) and there was one recurrence (1.5%) in the fibrin glue group of patients.Conclusions Fibrin glue achieved an adequate mesh fixation with a lower incidence of chronic postoperative pain. Although a prospective randomized study is needed, Tisseel appears to be an alternative to staples for mesh fixation and may help reduce the postoperative pain problems after hernia repair.     

Complications and recurrences associated with laparoscopic repair of groin hernias

Although the laparoscopic technique is a new approach to groin hernia, it is becoming more widely accepted as an alternative to traditional open techniques. This study is a preliminary review of complications and recurrences.A questionnaire specific for complications was sent to each investigator. From 12/89 to 4/93, 1,514 hernias were repaired; 119 (7.8%) were bilateral and 192 (12.7%) recurrent. There were 860 indirect, 560 direct, 43 pantaloon, 37 femoral, and 6 obturator hernias, and 8 were not specified; 553 were repaired using a transabdominal preperitoneal mesh technique (TAPP), 457 with a total extraperitoneal technique (TEP), 320 with intraperitoneal onlay mesh (IPOM), 102 by ring closure, and 82 involved plug and patch technique.Eighteen intraoperative and 188 postoperative complications were seen. The total complication rate was 13.6%, of which 1.2% were intraoperative. Of the intraoperative complications, 12 were related to the laparoscopic technique, three were related to the hernia repair, and one was related to anesthesia. The rate of conversion to open was 0.8%. Of the postoperative complications, there were 95 local, 25 neurologic, 23 testicular, 23 urinary, 10 mesh, and 12 miscellaneous. There were 34 recurrences after the 1,514 hernia repairs (2.2%). The follow-up was reported in 828 patients for an average of 13 months. The recurrence rate varied drastically with the technique: A 22% recurrence rate after the plug and patch vs 3%, 2.2%, 0.7%, and 0.4% with the ring closure, IPOM, TAPP, and TEP, respectively.Laparoscopic repair of groin hernia can be safely performed. Complications, mostly minor, diminish with experience. The recurrence rate is less with large mesh which is anchored.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA, 18–19 April 1994