Incidental Non-Inguinals Hernias in Totally Extra-Peritoneal Hernia Repair

Introduction

Totally extra-peritoneal (TEP) inguinal hernia repair allows identification and repair of incidental non-inguinal groin hernias. We assessed the prevalence of incidental hernias during TEP inguinal hernia repair and identified the risk factors for incidental hernias.

Materials and Methods

Consecutive patients undergoing TEP repair from May 2005 to November 2012 were the study cohort. Inspection for ipsilateral femoral, obturator and rarer varieties of hernia was undertaken during TEP repair. Patient characteristics and operative findings were recorded on a prospectively collected database.

Results

A total of 1,532 TEP repairs were undertaken in 1,196 patients. Ninety-three patients were excluded due to incomplete data, leaving 1,103 patients and 1,404 hernias for analyses (1,380 male; 802 unilateral and 301 bilateral repairs; median age, 59 years). Among the 37 incidental hernias identified (2.6% of cases), the most common type of incidental hernia was femoral (n=32, 2.3%) followed by obturator (n=2, 0.1%). Increasing age was associated with an increased risk of incidental hernia, with a significant linear trend (p<0.01). The risk for patients >60 years of age was 4.0% vs 1.4% for those aged <60 years (p<0.01). Incidental hernias were found in 29.2% of females vs 2.2% of males, (p<0.0001). Risk of incidental hernia in those with a recurrent inguinal hernia was 3.0% vs 2.6% for primary repair (p=0.79).

Conclusions

Incidental hernias during TEP inguinal hernia repair were found in 2.6% of cases and, though infrequent, could cause complications if left untreated. The risk of incidental hernia increased with age and was significantly higher in patients aged >60 years and in females.     

Hospital Costs Associated With Laparoscopic and Open Inguinal Herniorrhaphy

Purpose:

The purpose of this study was to compare the total hospital costs associated with elective laparoscopic and open inguinal herniorrhaphy.

Methods:

A prospectively maintained database was used to identify patients who underwent elective inguinal herniorrhaphy from April 2009 to March 2011. A retrospective review of electronic patient records was performed along with a standardized case-costing analysis using data from the Ontario Case Costing Initiative. The main outcomes were operating room (OR) and total hospital costs.

Results:

Two hundred eleven patients underwent elective unilateral inguinal herniorrhaphy (117 open and 94 laparoscopic), and 33 patients underwent elective bilateral inguinal herniorrhaphy (9 open and 24 laparoscopic). OR and total hospital costs for open unilateral inguinal hernia repair were significantly lower than for the laparoscopic approach (median total cost, $3207.15 vs $3723.66; P < .001). OR and total hospital costs for repair of elective bilateral inguinal hernias were similar between the open and laparoscopic approaches (median total cost, $4574.02 vs $4662.89; P = .827).

Conclusions:

In the setting of a Canadian academic hospital, when considering the repair of an elective unilateral inguinal hernia, the OR and total hospital costs of open surgery were significantly lower than for the laparoscopic techniques. There was no statistical difference between OR and total hospital costs when comparing open surgery and laparoscopic techniques for the repair of bilateral inguinal hernias. Given the perioperative benefits of laparoscopy, further studies incorporating hernia-specific outcomes are necessary to determine the cost-effectiveness of each approach and to define the optimal treatment strategy.     

Conversion to Stoppa Procedure in Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair

Background and Objectives:

Conversion to open surgery is an important problem, especially during the learning curve of laparoscopic totally extraperitoneal (TEP) inguinal hernia repair.

Methods:

Here, we discuss conversion to the Stoppa procedure during laparoscopic TEP inguinal hernia repair. Outcomes of patients who underwent conversion to an open approach during laparoscopic TEP inguinal hernia repair between September 2004 and May 2010 were evaluated.

Results:

In total, 259 consecutive patients with 281 inguinal hernias underwent laparoscopic TEP inguinal hernia repair. Thirty-one hernia repairs (11%) were converted to open conventional surgical procedures. Twenty-eight of 31 laparoscopic TEP hernia repairs were converted to modified Stoppa procedures, because of technical difficulties. Three of these patients underwent Lichtenstein hernia repairs, because they had undergone previous surgeries.

Conclusion:

Stoppa is an easy and successful procedure used to solve problems during TEP hernia repair. The Lichtenstein procedure may be a suitable option in patients who have undergone previous operations, such as a radical prostatectomy.     

Bulging of the Mesh After Laparoscopic Repair of Ventral and Incisional Hernias

Background and Objectives:

To investigate the prevalence, diagnosis, clinical significance, and treatment strategies for bulging in the area of laparoscopic repair of ventral hernia that is caused by mesh protrusion through the hernia opening, but with intact peripheral fixation of the mesh and actually a still sufficient repair.

Methods:

Medical records of all 765 patients who underwent laparoscopic ventral hernia repair were reviewed, and all patients with a swelling in the repaired area were identified and analyzed.

Results:

Twenty-nine patients were identified. They all underwent a computed tomography assessment. Seventeen patients (2.2% of the total group) had a hernia recurrence; in an additional 12 patients (1.6%), radiologic examinations indicated only bulging of the mesh but no recurrence. Bulging was associated with pain in 4 patients who underwent relaparoscopy and got a new, larger mesh tightly stretched over the entire previous repair. Eight asymptomatic patients decided on “watchful waiting.” All patients remained symptom free during a median follow-up of 22 months.

Conclusion:

Symptomatic bulging, though not a recurrence, requires a new repair and must be considered as an important negative outcome of laparoscopic ventral hernia repair. In asymptomatic patients, “watchful waiting” seems justified.     

Direct inguinal hernia containing bladder carcinoma: A case report and review of the literature

INTRODUCTION

Inguinal hernia containing bladder carcinoma is a very rare occurrence.

PRESENTATION OF CASE

We report a case of a male patient who presented with a left groin hernia containing an irregular mass. The hernia was repaired without the use of mesh and a partial cystectomy was done.

DISCUSSION

Only 1–3% of all inguinal hernias involve the bladder, with very few reports containing a carcinoma.

CONCLUSION

Treatment consists of removing the tumor and repairing the hernia.     

NiTiNol hernia device stability in inguinal hernioplasty without fixation

Background and Objective:

To determine whether the NiTiNol frame of a novel hernia repair device utilizing polypropylene mesh for inguinal hernioplasty remains stable and intransient without fixation after a minimum of 6 months.

Methods:

Twenty patients had 27 inguinal hernias repaired using a novel hernia repair device that has a NiTiNol frame without any fixation. Initial single-view, postoperative X-rays were compared with a second X-ray obtained at least 6 months later. The NiTiNol frame, which can be easily visualized on a plain X-ray, was measured in 2 dimensions, as were anatomic landmarks. The measurements obtained and the appearances of the 2 X-rays were compared to determine the percentage of change in device size and device stability with regard to device location and shape.

Results:

There were minimal changes noted between the 2 sets of measurements obtained with an overall trend towards a slight increase in the size of the hernia repair device. The devices demonstrated intransience of position and stability of shape.

Conclusions:

The NiTiNol frame of a novel hernia repair device utilizing polypropylene mesh exhibits radiographic evidence of size and shape stability and intransience of position without fixation when used in inguinal hernioplasty after a minimum follow-up of 6 months.     

Laparoscopic Hernia: Umbilical-Pubis Length Versus Technical Difficulty

Laparoscopic hernia repair is more difficult than open hernia repair. The totally extraperitoneal procedure with 3 trocars on the midline is more comfortable for the surgeon. We studied the impact of the length between the umbilicus and the pubis on the totally extraperitoneal procedure (95 hernias operated on in 70 patients). This length did not influence the totally extraperitoneal procedure in this study.

Background:

The laparoscopic repair of hernias is considered to be difficult especially for the totally extra-peritoneal technique (TEP) due to a limited working space and different appreciation of the usual anatomical landmarks seen through an anterior approach. The aim of our study has been to answer a question: does the umbilical-pubic distance, which influences the size of the mesh, affect the TEP technique used in the treatment of inguinal hernias?

Methods:

From January 2001 to May 2011, the umbilical-pubic (UP) distance was measured with a sterile ruler graduated in centimeters in all patients who underwent a symptomatic inguinal hernia by the TEP technique in two hernia surgery centers. The sex, age, BMI, hernia type, UP distance, operation time, hospital stay and complications were prospectively examined based on the medical records.

Results:

Seventy patients underwent 95 inguinal hernia repairs by the TEP technique. The umbilical-pubic distance average was 14 cm (10 to 22) and a 25 kg/m2 (16–30) average concerning the body mass index (BMI). Seventy percent of patients were treated on an outpatient basis. The postoperative course was very simple. There was no recurrence of hernia within this early postoperative period.

Conclusion:

The umbilical-pubic distance had no influence on the production of TEP with 3 trocars on the midline in this study.     

Prevalence of abdominal aortic aneurysms in over 65-year-old men with inguinal hernias

INTRODUCTION

The aim of this study was to determine the prevalence of abdominal aortic aneurysms (AAAs) in over 65-year-old men who have inguinal hernias and discuss if pre-operative selective screening of this population is appropriate.

PATIENTS AND METHODS

A prospective study on 70 consecutive male patients with an age range of 65–88 years (mean, 74 years) who were referred to a single vascular consultant''s out-patient clinic with an inguinal hernia were screened for the presence of an AAA with an ultrasound scan before hernia repair over a period of 3 years.

RESULTS

Two patients were found to have an AAA measuring 3.8 cm and 6.0 cm giving an AAA prevalence of 3% (exact 95% confidence interval = 0–10%).

CONCLUSIONS

This study does not demonstrate an increased AAA prevalence in over 65-year-old male patients with inguinal hernias, scanned pre-operatively when compared to screening programmes. Selective screening of this cohort cannot be justified on this evidence.     

Swelling of the right thigh for over 30 years—The rare finding of a De Garengeot hernia

INTRODUCTION

Femoral hernias may – in some rare cases – contain the appendix, a phenomenon called de Garengeot hernia. It is usually an incidental finding in hernia repair. We found our case to be of interest because of the long standing femoral swelling before peracute appendicitis led to its removal.

PRESENTATION OF CASE

We present the case of a 71-year-old woman with a swelling of the right medial thigh for over more than 30 years. When the swelling suddenly grew in size and became tender, she was referred to our emergency department. Sonographically as well as clinically a femoral hernia was diagnosed. Intraoperatively, the appendix was found and open appendectomy as well as a hernioplasty was performed.

DISCUSSION

Open appendectomy is an elegant and safe procedure to repair a long standing de Garengeot hernia. Most case reports call for extensive diagnostics such as CT scan etc. We found a sonography of the femoral region to be conclusive.

CONCLUSION

Apart from the inherent risk of sudden incarceration in hernias, De Garengeot hernias can also develop peracute appendicitis years after their formation. This differential diagnosis needs to be taken into consideration in patients presenting with the clinical signs of a femoral hernia.     

Female Gender and Diabetes Mellitus Increase the Risk of Recurrence after Laparoscopic Incisional Hernia Repair

Background

Laparoscopic hernia repair is used widely for the repair of incisional hernias. Few case studies have focussed on purely ‘incisional’ hernias. This multicentre series represents a collaborative effort and employed statistical analyses to provide insight into the factors predisposing to recurrence of incisional hernia after laparoscopic repair. A specific hypothesis (ie, laterality of hernias as well as proximity to the xyphoid process and pubic symphysis predisposes to recurrence) was also tested.

Methods

This was a retrospective study of all laparoscopic incisional hernias undertaken in six centres from 1 January 2004 to 31 December 2010. It comprised a comprehensive review of case notes and a follow-up using a structured telephone questionnaire. Patient demographics, previous medical/surgical history, surgical procedure, postoperative recovery, and perceived effect on quality of life were recorded. Repairs undertaken for primary ventral hernias were excluded. A logistic regression analysis was then fitted with recurrence as the primary outcome.

Results

A total of 186 cases (91 females) were identified. Median follow-up was 42 months. Telephone interviews were answered by 115/186 (62%) of subjects. Logistic regression analyses suggested that only female sex (odds ratio (OR) 3.53; 95% confidence interval (CI) 1.39–8.97) and diabetes mellitus (3.54; 1–12.56) significantly increased the risk of recurrence. Position of the defect had no statistical effect.

Conclusions

These data suggest an increased risk of recurrence after laparoscopic incisional hernia repair in females and subjects with diabetes mellitus. These data will help inform surgeons and patients when considering laparoscopic management of incisional hernias. We recommend a centrally hosted, prospectively maintained national/international database to carry out additional research.     

Laparoscopic repair of complicated umbilical hernia with Strattice Laparoscopic™ reconstructive tissue matrix

INTRODUCTION

Complex hernias continue to present a challenge. Surgical techniques for repair are carefully considered to reduce risk for complications. Laparoscopic repairs improve postoperative infection rates, and placement of biologic mesh decreases mesh infection rates. However, laparoscopic repairs using biologic mesh is generally challenging due to difficulty with maneuverability.

PRESENTATION OF CASE

We present a case of a complex ventral hernia that was laparoscopically repaired using a new FDA cleared laparoscopic biologic graft. The patient had multiple comorbidities, including obesity, hepatitis C, endocarditis secondary to IV drug use, tobacco smoking, bilateral inguinal hernia, and recurrent umbilical hernia. The recurrent hernia was larger, irreducible, and discolored compared to original defect. The patient underwent laparoscopic repair with primary closure and reinforcement with Strattice™ Tissue Matrix Laparoscopic (LifeCell Corporation, Branchburg, NJ). At nine months postoperative, the patient had no evidence of recurrence, infection, or chronic pain, demonstrating early success from the surgical management.

DISCUSSION

Presence of multiple comorbidities and incarcerated recurrent hernia increase risk for complications during and/or after hernia repair. Considering these factors, laparoscopic repair with Strattice Laparoscopic and defect closure was a reasonable technique for repair.

CONCLUSION

Laparoscopic suture repair reinforced with biologic dermal tissue matrix was successfully performed during a complex hernia repair.     

A pseudo-TEP repair of an incarcerated obturator hernia

Introduction

Obturator hernia (OH) is a rare condition and difficult to diagnose. While they account for as few as 0.073% of all hernias, mortality can be as high as 70%. The typical clinical presentation for OH is small bowel obstruction. Computed tomography is the diagnostic tool of choice. Surgical repair is mandatory in virtually all cases of OH and traditionally consists of performing an exploratory laparotomy.

Presentation of case

A 90-year-old female was admitted to our surgical service with signs of small bowel obstruction and a CT scan revealing incarcerated fatty tissue and small bowel within a left OH.

Discussion

The role of laparoscopic surgery in the management of OH has been limited to elective repairs; most reports detail that the OH was found serendipitously during laparoscopic inguinal hernia operations or other pelvic procedures. A few reports describe the use of laparoscopy to treat OH associated with bowel obstruction in an emergency setting using a TAPP approach. A strict TEP hernia repair is not indicated for all patients with OH, and should rarely be performed in emergency situations given its limitation to assess or resect bowel if necessary. In selected cases, a formal exploratory laparoscopy that is negative for compromised bowel can be safely followed by a TEP repair using the same umbilical access as shown in our patient.

Conclusion

A 90-year-old female with a small bowel obstruction related to an incarcerated OH was treated effectively with an extraperitoneal laparoscopic approach.     

Over a thousand ambulatory hernia repairs in a primary care setting

INTRODUCTION

This paper outlines the development and feasibility of a dedicated ambulatory primary care hernia service and examines the outcomes achieved during the period 1 March 2005 to 31 December 2008.

PATIENTS AND METHODS

A prospective analysis of 1164 patients who underwent abdominal wall hernia repair at Probus Surgical Centre during the study period. The operations were carried out by two GPs with a special interest (GPwSI) and one retired surgeon. The techniques used were a Lichtenstein mesh repair or modified Shouldice repair for inguinal hernias and a primary sutured repair for ventral hernias. All procedures were performed as day-cases under local anaesthesia without sedation. All patients were reviewed routinely at 6 weeks. The primary outcomes of the study were recurrence and patient satisfaction levels, and complications such as infection, haematoma and chronic pain.

RESULTS

No patient required conversion to general anaesthesia. There were three (0.3%) recurrences. Complication rates were low and similar to those obtained in other specialist hernia units. More than 90% of patients were satisfied with the service and would recommend it to a friend.

CONCLUSIONS

Routine elective abdominal wall hernia repairs can be performed in a primary care setting, safely and with excellent outcomes.     

Intrasaccular caecal adenocarcinoma presenting as enlarging right inguinoscrotal hernia

INTRODUCTION

Colorectal cancer and inguinal hernias are both common surgical pathologies in the elderly but rarely co-exist. Where the conditions overlap, there can be difficulties in both diagnosis and treatment.

PRESENTATION OF CASE

A 78 year old man with unexplained iron deficiency anaemia was investigated for gastrointestinal cancer. He was found to have enlarging bilateral inguinoscrotal hernias. CT colonoscopy revealed a herniated caecal carcinoma contained within the scrotum. An open excision was performed.

DISCUSSION

Iron deficiency anaemia without obvious bleeding is associated with colorectal cancer and should be thoroughly investigated. Asymptomatic inguinal hernias are often ignored by patients. However, a change in an existing hernia may be associated with neoplasia.

CONCLUSION

Dual pathology raises new difficulties in assessment, investigation and management of colorectal cancer.     

The Laparoscopic Approach for Repair of Morgagni Hernias

Background and Objectives:

Morgagni hernias are unusual congenital diaphragmatic hernias that are generally asymptomatic and discovered incidentally. Surgical treatment is indicated once the diagnosis is made. These hernias have traditionally been repaired by the open abdominal or thoracic approaches. We report a case of Morgagni hernia repaired successfully via the laparoscopic approach.

Methods and Results:

The patient was noted to have a large anteromedial diaphragmatic hernia by chest radiograph and CT imaging. He underwent laparoscopy, during which the hernia was reduced and the defect repaired with mesh placement. We used intracorporeal suture placement to anchor the mesh. The patient recovered uneventfully after a short hospitalization.

Conclusions:

The laparoscopic approach for repair of Morgagni hernias offers diagnostic advantages as well as the potential for reduced morbidity when compared to laparotomy. We report intracorporeal knot-tying for fixation of the mesh to be a secure and satisfactory means to achieve the laparoscopic repair.     

Inguinal Hernia Repair: Local or General Anaesthesia?

INTRODUCTION

Specialist hernia centres and public hospitals with a dedicated hernia service (Plymouth Hernia Service) have achieved remarkable results for inguinal hernia repair with the use of local anaesthesia and set the standards for groin hernia surgery. There is minimal data in the literature as to whether such results are reproducible in the National Health Service in the UK.

PATIENTS AND METHODS

A retrospective analysis of all inguinal hernia repairs performed in one district general hospital over a 9-year period was performed. The outcome measures were type of anaesthesia used, early and late postoperative complications and recurrence. A postal questionnaire survey was conducted to obtain satisfaction rates. In addition, a postal questionnaire survey of consultant surgeons in Wales was performed to determine the use of local anaesthesia and day-case rates for inguinal hernia repair.

RESULTS

A total of 577 hernia repairs were performed during the study period. Of these, 369 (64%) repairs were performed under local anaesthesia (LA) and 208 (36%) under general anaesthesia (GA). Day-case repair was achieved in 70% (400) of cases. The day-case rates were significantly higher under LA compared to GA (82.6% versus 42.6%; P < 0.05). Patients operated under LA had lower postoperative analgesic requirements and lower incidence of urinary retention compared with the GA group (P < 0.05). There were 7 (1.2%) recurrences at a median follow-up of 5.1 years (range, 10.3–2.5 years). Postal questionnaire revealed higher satisfaction rates with LA compared to GA repair. Only 15% of surgeons in Wales offer the majority of their patients local anaesthetic repair.

CONCLUSIONS

The use of LA results in increased day-case rates, lesser postoperative analgesic requirements and fewer micturition problems. The excellent results obtained by specialist hernia centres can be reproduced by district general hospitals by increasing the use of LA to repair inguinal hernias.     

An irreducible left scrotal hernia containing a sigmoid colon tumor (adenocarcinoma) – Case report

INTRODUCTION

In relation to all inguinal hernias, large irreducible scrotal hernias are quite rare, while such hernias containing colon tumors in the sac have so far been described in fewer than 30 cases.

PRESENTATION OF CASE

A 61-year-old patient was admitted for a planned surgery because of a large irreducible left-sided scrotal hernia. Intraoperatively, a large tumor of the sigmoid colon was found in the hernial sac. In a histopathological examination it was diagnosed as adenocarcinoma. A palliative operation was performed and he was referred to further systemic and palliative treatment (because of numerous coexisting liver metastases).

DISCUSSION

Until now, only about 30 cases of colon tumor in inguinal hernia sac have been reported.

CONCLUSION

It should be remembered that even the most obvious preoperative diagnosis may be verified intraoperatively.     

Allograft AlloDerm® tissue for laparoscopic transabdominal preperitoneal groin hernia repair: A case report

INTRODUCTION

Synthetic mesh is the prosthetic material used for most inguinal hernioplasties. However, when left in contact with intra-abdominal viscera, it often becomes associated with infection and migration, particularly in irradiated tissues, contaminated fields, immunosuppressed individuals, and patients with intestinal obstruction or fistula. AlloDerm^® Regenerative Tissue Matrix (LifeCell Corporation, Branchburg, NJ) is derived from human cadaver skin and may be associated with fewer visceral adhesions and more durability in infected fields than synthetic mesh.

PRESENTATION OF CASE

We report the first case in which AlloDerm was used in a laparoscopic transabdominal preperitoneal repair of a multiple recurrent right inguinal hernia, a left femoral hernia, and an umbilical hernia in the same patient. Use of AlloDerm greatly enhanced the maneuverability during laparoscopic hernia repair due to its pliability and strength and eliminated the need to cover the prosthetic with peritoneum.

DISCUSSION

Previous pelvic radiation and multiple previous groin repairs can render the peritoneum friable, resulting in obstacles to successful closure. AlloDerm is a reasonable choice for groin hernia repairs when such factors are present.

CONCLUSION

The long-term durability of AlloDerm for laparoscopic groin hernia repairs is yet to be determined, but based on current data it seems prudent to use this technique in laparoscopic repair of complex groin hernias where infection is suspected or inadequate prosthetic coverage with peritoneum is anticipated.