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.     

Classification of primary and incisional abdominal wall hernias

Purpose  A classification for primary and incisional abdominal wall hernias is needed to allow comparison of publications and future studies on these hernias. It is important to know whether the populations described in different studies are comparable. Methods  Several members of the EHS board and some invitees gathered for 2 days to discuss the development of an EHS classification for primary and incisional abdominal wall hernias. Results  To distinguish primary and incisional abdominal wall hernias, a separate classification based on localisation and size as the major risk factors was proposed. Further data are needed to define the optimal size variable for classification of incisional hernias in order to distinguish subgroups with differences in outcome. Conclusions  A classification for primary abdominal wall hernias and a division into subgroups for incisional abdominal wall hernias, concerning the localisation of the hernia, was formulated.

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目的评价腹腔镜腹股沟疝修补术(LIHR)的临床疗效。方法回顾性分析2001年1月至2011年12月上海交通大学医学院附属瑞金医院普外科2056例(2473侧)行LIHR的临床资料,其中经腹腹膜前修补术(TAPP)874例(1005侧),全腹膜外修补术(TEP)1175例(1458侧),腹腔内修补术(IPOM)7例(10侧)。2473侧疝中,斜疝1481侧(59.9%),直疝525侧(21.2%),复发疝225侧(9.1%),复合疝206侧(8.3%),股疝36侧(1.5%)。疝分型:Ⅰ型疝95侧(3.8%),Ⅱ型疝995侧(40.2%),Ⅲ型疝1157侧(46.8%),Ⅳ型疝226侧(9.1%)。手术由同组医师完成,术式选择由术者决定,随访时间3～60个月(中位时间35个月)。结果 1例TAPP因腹腔广泛粘连中转为Lichtenstein术。病人术后无需应用镇痛剂。2周和4周内恢复非限制性活动率为99.0%和99.9%。共6例复发,复发率为0.24%。TAPP和TEP各3例复发。发生3例严重并发症,分别为戳孔疝、肠管损伤和机械性肠梗阻,其他并发症依次为血清肿129例(5.2%)、尿潴留34例(1.4%)、暂时性神经感觉异常26例(1.1%)、麻痹性肠梗阻3例(0.12%)。结论 LIHR是安全有效的手术,合理选择手术适应证和规范化操作可以获得良好的临床效果。     

Clinically diagnosed groin hernias without a peritoneal sac at laparoscopy—what to do?

Background

Groin or femoral hernias may be concealed behind intact peritonea when the laparoscopic transabdominal preperitoneal (TAPP) mesh technique is used. The aim of this study was to determine the causes, frequency, and surgical procedures in cases of clinically diagnosed hernias without peritoneal defects.

Methods

A prospective controlled study comprising 1795 consecutive patients undergoing 2190 laparoscopic TAPP herniorraphies was conducted. All hernias were first subjected to clinical investigations by the surgeons. Intraoperatively, all suspicious hernias were examined with regard to the presence of peritoneal hernial sacs.

Results

Of 2190 hernias, no hernia was seen transperitoneally in the laparoscopic procedures in 136 cases (6.2%). Forty-one femoral hernias (30.1%) were concealed behind intact peritonea. Forty-six lateral (33.8%) and 31 medial (22.8%) defects were sacless sliding fatty inguinal hernias.

Conclusions

When using the TAPP technique, in addition to femoral hernias, especially sacless sliding fatty inguinal hernias may be overlooked because of intact peritonea. Therefore, in cases of clinically diagnosed inguinal hernias, the preperitoneal space should be inspected intraoperatively to avoid unsatisfactory results.     

Adult groin hernias

Inguinal hernias are common, affecting one in four men in their lifetime. They are much less common in women with a lifetime risk of about 3%. Consequently, inguinal hernia repair is one of the commonest operations with more than 20 million operations performed annually worldwide. Africans have a much higher incidence of hernias than Caucasians and this is thought to be because of the anatomical configuration of the African pelvis. Many hernias in poorer countries are not repaired, so that presentation as an emergency and indeed mortality due to complications are much more often seen than in more affluent societies.     

Laparoscopic Repair of Left Lumbar Hernia After Laparoscopic Left Nephrectomy

Lumbar hernias, rarely seen in clinical practice, can be acquired after open or laparoscopic flank surgery. We describe a successful laparoscopic preperitoneal mesh repair of multiple trocar-site hernias after extraperitoneal nephrectomy. All the key steps including creating a peritoneal flap, reducing the hernia contents, and fixation of the mesh are described. A review of the literature on this infrequent operation is presented. Laparoscopic repair of lumbar hernias has all the advantages of laparoscopic ventral hernia repair.     

青年腹股沟疝临床特点及腹腔镜手术治疗疗效分析

目的分析青年腹股沟疝病人的临床特点,探讨腹腔镜手术治疗策略及疗效。方法对2001年1月至2018年12月间在上海交通大学医学院附属瑞金医院普外科行腹腔镜腹股沟疝修补术(LIHR)6220例(7415侧)病人进行回顾性同期非随机对照研究。其中,青年组(18～44岁)804例(860侧),中年组(45～64岁)1976例(2323侧),老年组(≥65岁)3440例(4232侧)。结果与中老年组相比,青年组病人的病程时间长、女性比例高、单侧疝比例高、腹部手术史少、体重指数低(P=0.000)。青年组的斜疝比例高,直疝、复合疝、复发疝、IV型疝比例低(P=0.000)。青年组的经腹腹膜前修补术(TAPP)和轻量大网孔补片比例高(P=0.000)。青年组的手术时间长(P=0.000),术后住院时间短(P=0.000)。青年组和中老年组在术后第1天疼痛分数、术后2周恢复非限制性活动方面差异无统计学意义(P>0.05)。青年组有1例复发,中老年组有13例复发,差异无统计学意义(P>0.05)。青年组无严重并发症(需要手术干预)发生,尿潴留发生率低(P=0.000),其他普通并发症(如血清...     

A strangulated Spigelian hernia mimicking diverticulitis

Summary Spigelian hernias are true interparietal hernias that are frequently not associated with a palpable mass and, as such, are not frequently diagnosed before surgery. Reported herein, is the serendipitous discovery of an incarcerated Spigelian hernia that was discovered on a CT scan being performed for presumed diverticulitis.     

Left paraduodenal hernia causing small bowel obstruction in an adolescent patient

Internal hernias are an uncommon cause of bowel obstruction, accounting for less than 1% of cases. Paraduodenal hernias, the most common type of internal hernias, are believed to be congenital in origin. They can be asymptomatic, cause chronic abdominal pain, or present with acute intestinal obstruction with strangulation and ischemia. We describe a case of left paraduodenal hernia found in a patient who presented with acute intestinal obstruction.     

Surgical technique and complications during laparoscopic repair of diaphragmatic hernias

Diaphragmatic hernias can present as retrocostoxiphoid hernias (RCXH) or diaphragmatic dome hernias. The RCXH include the Larrey hernia (LH), the Morgagni hernia (MH), and the Larrey–Morgagni hernia (LMH). These congenital hernias are usually asymptomatic, and the diagnosis is simplified by two exams: chest X-ray, and thoraco-abdominal computed tomography (CT) scan. The potential risk in this condition is small-bowel incarceration in the hernia defect and subsequent obstruction. We report two cases of LH and one case of LMH treated by laparoscopy between February 2004 and October 2005, with a review of the surgical techniques. Two different laparoscopic techniques were used: the tension-free technique, and resection of the hernia sac with closure of the defect and reinforcement by prosthesis. One patient presented a postoperative cardiac tamponade due to a clip-induced bleeding of an epicardial artery at the inferior surface of the heart. Treatment by laparoscopy is feasible, but a consensus regarding the best laparoscopic repair is needed.     

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.     

Groin hernias: features of recurrences

Summary In 2390 groin hernias operated on by the same surgeon there were 2327 inguinal hernias (97.4%) and 63 femoral (2.6%); 261 (11.2%) were recurrent hernias. The aim of this study was to define the different features of recurrences in a series of 206 recurrences operated on by an inguinal approach. The median time of recurrence was 3 years (< 1–58). It was < 1 year in 67 cases (40%) and 50% of all recurrences had occurred in 2.4 years. The time of recurrence after operation performed in childhood was 31 years (15–58). All recurrences were located in the area of the myo-pectineal and femoral orifices. There was only one site of recurrence in 125 cases (61%); the recurrence was direct in 73 cases (58%), indirect in 44 cases (35%) and femoral in 8 cases (7%). There were 2 sites of recurrence in 81 cases (39%), 76 mixed (94%) and 6 inguinal associated with a femoral hernia (6%). Altogether there were 288 sites of recurrence. There were 44 direct diverticular recurrences and 26 of these were located near the pubic tubercle. The rate of recurrence in current practice is much higher than that in specialized centers. The long delay of recurrence after simple resection of the sac in childhood constitutes an indirect argument for the Marcy procedure in adolescents and young men with type I or II hernias. The preeminence of direct recurrences and the existence of direct diverticular suprapubic recurrences are arguments for mesh procedures. The fact that all recurrences are located in the area of myo-pectineal and femoral orifices must be considered for the choice of a mesh procedure.     

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.     

Internal Hernias: Surgeons Dilemma-Unravelled by Imaging

Internal hernias may present as intestinal obstruction and account for 0.5 to 4.1 % of all cases. Clinical diagnosis of internal hernias is often difficult and thus imaging studies plays an important role in the early diagnosis. It is vital for the radiologist to be familiar with the various types of internal hernias and their radiological features so that prompt diagnosis and early intervention can be made.     

Aetiology of femoral hernias revisited: bilateral femoral hernia in a young male (two cases)

Bilateral femoral hernias are less common in men than in women and rare in young adults. Only one case of a bilateral femoral hernia in a young man has been reported in the literature before. Three main theories have been postulated for femoral hernias. The theory that they are an acquired disease is the most accepted due to the common occurrence of such hernias in multiparous women but the theory lacks enough evidence. We report two cases in young men. Anatomical variations in the femoral canal could be the primary aetiological factor in these patients. A unilateral femoral hernia in young men with acquired aetiological factors requires a clinical examination of the opposite side.     

腹腔镜手术治疗老年腹股沟疝2771例分析

目的 分析老年腹股沟疝病人的临床特点,探讨腹腔镜治疗的合理性、安全性和有效性。方法 回顾性分析2001年1月至2016年12月在上海交通大学医学院附属瑞金医院接受腹腔镜腹股沟疝修补术（LIHR）的5050例病人（6047侧）的临床资料。其中＜65岁组2279例（2622侧）,65～80岁组2332例（2883侧）,＞80岁组439例（542侧）。结果 老年病人（65~80岁组和>80岁组,下同）的男/女比、手术史、双侧疝、直疝、复合疝、Ⅲ型疝、Ⅳ型疝（复发疝）比例高于中青年病人（<65岁组,下同）（P=0.000）。＞80岁组的经腹腔腹膜前疝修补术（TAPP）比例最高,65～80岁组的TEP比例最高。重量型补片（HWM）的使用和机械性固定的比例在＞80岁组最高,＜65岁组最低,三组差异有统计学意义（P=0.000）。随访时间18～60个月（中位时间36个月）。三组在单侧手术时间、术后第1天疼痛视觉模拟评分（VAS）评分、术后2周和4周恢复非限制性活动病例数等方面差异无统计学意义（P>0.05）。老年病人双侧手术时间长于中青年病人（P=0.001）,三组病人术后住院时间比较,＞80岁组最长,＜65岁组最短,差异有统计学意义（P=0.000）。共有13例复发（0.021%）病例,老年病人的复发率高于中青年病人（P=0.006）。并发症依次为血清肿、尿潴留、暂时性神经感觉异常和肠麻痹,其中,病人的尿潴留发生率＞80岁组最高,＜65岁组最低,三组差异有统计学意义（P=0.000）。结论 对于术前评估合格的老年腹股沟疝病人,LIHR是安全、有效、合理的术式。     

Laparoscopic cure of small ventral hernias with composite mesh

BACKGROUND: The use of mesh is recommended to reduce the rate of recurrence after the curing of ventral hernias. METHODS: A multicentre prospective trial was conducted to assess the laparoscopic cure of small ventral hernias with a composite mesh. RESULTS: Around 222 patients entered the trial and received laparoscopic repair for ventral hernias of less than 5 cm. There was one conversion. The mean length of post-operative hospitalisation was 2.5 days. At 1 year, the recurrence rate was 2%. Two meshes were removed due to infection, 3% of the patients were using analgesics and 86.1% of the patients described no pain on EVA scoring. CONCLUSION: The laparoscopic cure of small ventral hernias with composite mesh is efficient. Further technical progress is warranted to reduce the rate of seroma formation.     

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.     

Pregnancy and ventral hernia repair

Summary Reluctance to repair anterior abdominal wall hernias in women of childbearing age is probably unjustified. A unique series is described of 27 women who gave birth to 41 full-term babies following repair of an anterior abdominal wall hernia with no recurrence of the hernia. Nineteen had primary and recurrent umbilical hernias and an incisional hernia in a low transverse incision repaired by the onlay darn technique and have produced 29 babies. Eight had umbilical hernias, gross diastasis of the recti and post-cesarean section vertical incisional hernias repaired by the Shoelace technique followed by 12 full-term pregnancies. Little is written about the fate of the abdominal wall subjected to pregnancies following repair of ventral hernias, since the majority of women having these hernias repaired are past the child-bearing age or are warned off further pregnancies by their doctors or undergo tubal ligation with the hernia repair. The Shoelace repair is described, stressing its advantages over mesh hernioplasties in women who wish to have further pregnancies. There is apparently no reason to refuse to repair these hernias. There are even positive indications in view of serious complications associated with pregnancy in the presence of an anterior wall hernia. Prosthetic mesh tends to contract and harden and may seriously interfere with abdominal expansion in pregnancies so these hernias are probably best repaired by the Shoelace technique.     

Traumatic flank hernias: acute and chronic management

BACKGROUND: Traumatic flank hernias are increasingly recognized as occurring after severe blunt injury. To clarify the role and timing of operative therapy, we review here our recent experience. METHODS: A prospectively maintained database at Oklahoma's only level I trauma center was reviewed to identify all patients presenting with traumatic flank hernias. RESULTS: During the period from July 2001 through February 2007, 25 patients (.2% of all blunt trauma patients) had traumatic flank hernias. The average age was 36.4 years (range 13 to 66), and all cases but 1 were related to motor vehicle crashes. All patients had at least 1 associated injury. Repairs were done by standardized approach. Eleven patients underwent immediate surgery; 8 underwent delayed repair; and 3 underwent late repair (range 4.5 to 10 years after injury). The other 3 patients were managed expectantly. There was 1 mortality and 3 recurrences. Length of stay for acute trauma ranged from 5 to 49 days and was dependent on the severity of associated injuries. Follow-up of 21 patients ranged from 7 to 710 days. CONCLUSIONS: Traumatic flank hernias are rare but more common than previously recognized. Prompt recognition, proper timing, and technique are key to successful outcomes.