Bilateral Inguinal Hernia Repair Research Articles

6942 Should there be a consensus statement about managing Inguinal Hernia In females? A Case of Delayed Diagnosis in Complete Androgen Insensitivity Syndrome (CAIS)

Abstract Disclosure: S. Echetebu: None. Introduction: Androgen Insensitivity Syndrome is usually due to a missense mutation that encodes part of the androgen receptor. More than 50% of females with CAIS present with inguinal hernias (4:1 female to male ratio). Previous CAIS studies have estimated the incidence of CAIS to be 0.8% to 2.4% in girls with inguinal hernias. 90% of the girls with CAIS will undergo inguinal hernia repair during childhood. The prevalence of germ cell tumors is estimated as 0.8% therefore, post-pubertal gonadectomy is now the recommended therapy for individuals with CAIS. Clinical Case: We present a case of a 15-year-old patient with primary amenorrhea who underwent bilateral inguinal hernia repair at the age of 5 weeks and was raised as a female. Initial ultrasound imaging at the age of 14 years revealed an absent uterus and complex hemorrhagic cysts of the ovaries. Further laboratory results revealed 46 XY chromosomal analysis, confirming her diagnosis of CAIS. Her laboratory values are: FSH 6.0 mIU/ml (1.0 to 18.6), Prolactin 15.6 ng/mL (<25), 17OHProgesterone 49 ng/dl (<265), Estradiol 30 pg/ml (<47), LH 17 mIU/ml (0.4 -11.7), Anti Mullerian Hormone 368 ng/ml (<13), Testosterone 629 ng/dl (<55 ). Upon our review of her past medical records from a different hospital, the operation note reports that her gonads resembled testes. Gonads were relocated in the abdomen without follow-up or consultation with an endocrinologist. Upon receiving her new diagnosis, the patient experienced significant emotional distress. As a result, both the patient and her family received psychological counseling and were referred to a genetic counselor to assess any potential risks for her younger sister. There is currently no consensus on the management of females with inguinal hernias in the available literature. It is widely accepted to perform gonadectomy. Currently, researchers at NIH are conducting an observational study on the benefits of additional delays in gonadectomy. Although most surgeons are familiar with this condition, it would be beneficial for families and patients to have an early diagnosis and provide appropriate education regarding future sexual encounters and fertility concerns. Conclusion: We propose to initiate a consensus statement for pediatricians, surgeons, and endocrinologists to perform systematic genetic testing in females with inguinal hernia. Such testing may include either a buccal mucosal smear, karyotype, or skin biopsy in all females with inguinal hernias. If the family chooses to delay orchiectomy, it is recommended that during hernioplasty, the testes should be repositioned in a location that allows for easy monitoring using annual imaging. By adopting this methodology, we can increase awareness about the effects of diagnosis and foster discussions among healthcare professionals regarding suitable management options. Presentation: 6/3/2024

TAPP versus lichtenstein techniques for bilateral inguinal hernia repair: A systematic review and meta-analysis.

Inguinal hernia repair is one of the most common surgical procedures performed worldwide. However, very few studies report data on the laparoscopic advantages of bilateral inguinal hernia (BIH) repair over the open approach. Therefore, this meta-analysis was conducted to compare the effectiveness of the laparoscopic trans-abdominal pre-peritoneal (TAPP) technique with the open Lichtenstein repair technique (OLR) for the repair of BIH. A detailed literature search was conducted on PubMed, Google Scholar, and Cochrane Library for comparative studies between TAPP and OLR techniques for repair of BIH. RevMan Version 5.4 was used for data analysis. The Inverse Variance statistical method was used to analyze the primary outcomes and the Mantel-Haenszel statistical method was used to analyze the secondary outcomes. The effect measure was reported as a Risk Ratio. There was no significant difference in recurrence between the two groups. A significant difference was seen in duration of post-operative hospital stay, operative time, pain score on VAS criteria on post-operative Day 1, pain score on VAS criteria on post-operative Day 7, and complications, all in the favor of TAPP except for operative time which was in the favor of OLR. TAPP was found to be superior to OLR in terms of duration of post-operative hospital stay, pain scores on VAS criteria on post-operative days 1 and 7, and complications, whereas OLR was found superior only in terms of operative time. For recurrence, there was no significant difference between the two groups.

Comparison of Clinical Outcomes of Laparoscopic Totally Extraperitoneal (TEP) and Transabdominal Preperitoneal (TAPP) Techniques in Bilateral Inguinal Hernia Repair: A Retrospective Study.

This study compared the clinical outcomes of two commonly used laparoscopic techniques, transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repair, in the treatment of bilateral inguinal hernias. This retrospective cohort study included 250 patients who underwent laparoscopic bilateral inguinal hernia repair using either the TEP or TAPP technique between May 2009 and May 2024. The patients were divided into two groups: 50 patients in the TEP group and 200 in the TAPP group. Data were collected from patient records, including demographics, type of hernia, surgical details, intraoperative and postoperative complications, conversion rates, and early hernia recurrence. Statistical analysis was performed to compare outcomes between the two groups. Among the 250 patients included in the study, the mean age was 51.62 ± 8.79 years, and 94% (n=235) were male. The mean operative time was significantly longer in the TEP group (93.2 ± 13.0 minutes) than in the TAPP group (57.95 ± 7.5 minutes) (p <.001). The mean hospital stay was also longer in the TEP group (1.36 ± 0.48 days) compared to the TAPP group (1.07 ± 0.25 days) (p <.001). The TEP group had a higher rate of conversion to open surgery 18%(n=9) and conversion to TAPP 10% (5) than the TAPP group, which had no conversions (p <.0001). Postoperative complications were more frequent in the TEP group, with urinary retention being significantly higher at 16%(n=8) than in the TAPP group at 2% (n=4) (p <.0004). Additionally, the TAPP group experienced two (1%) notable intraoperative complications that required reoperation: arterial injury and small bowel injury. The findings suggest that, while both TEP and TAPP effectively repair bilateral inguinal hernia, TAPP is associated with shorter operative times, shorter hospital stays, and fewer postoperative complications. However, the TAPP technique also presented notable intraoperative risks, including arterial and bowel injury. The choice between TEP and TAPP should be based on the surgeon's experience, patient characteristics, and the specific clinical context.

Evaluation of Open Rives-Stoppa and Lichtenstein Repair Methods for Bilateral Inguinal Hernias: A Single-Centre Comparative Analysis.

Aim The purpose of the study is to compare the two common open surgical methods for bilateral inguinal hernias: bilateral Lichtenstein repair and Rives-Stoppa repair. It evaluates their benefits, drawbacks, and outcomes to improve the management of bilateral inguinal hernias and enhance patient care and results. Background Abdominal wall hernias are prevalent in the surgical field, and they occur when intra-abdominal organs protrude through weakened or torn regions in the abdominal wall. The Lichtenstein repair, also known as the tension-free mesh repair, is one of the most widely used techniques that involves placing a synthetic mesh over the hernia defect to reinforce the abdominal wall. The Rives-Stoppa technique takes the posterior approach, which involves placing a large mesh in the preperitoneal space, which provides broad coverage of the potential hernia sites. Method This retrospective study included 86 male patients from the Department of General Surgery at Indus Health Network, Karachi, Pakistan. Data were collected up to three months post-operation for all open bilateral inguinal hernia repairs performed between January 2017 and April 2021. The patients were divided into two groups: group A underwent Lichtenstein repair, while group B underwent Rives-Stoppa repair. The procedures were performed by different surgeons and surgical trainees under direct supervision. Results Regarding post-operative complications (scrotal swelling, epididymo-orchitis, seroma formation, ipsilateral testicular swelling, surgical site infection, erectile dysfunction, wound dehiscence, fever, hydrocele, sensory abnormality, hernia recurrence in 3 months, post-operative pain in 14 days), there was no significant difference observed between the two groups. There were two recurrences within three months after Lichtenstein repair and one recurrence after Stoppa repair, but no statistical difference was demonstrated. Conclusion Statistically, both the Lichtenstein repair and the Rives-Stoppa repair demonstrated similar outcomes. However, the Rives-Stoppa repair offers distinct advantages for bilateral inguinal hernia repair, making it a preferable option in many cases as this approach utilises a single midline incision, simultaneously facilitating access to both hernial sites. This method ensures complete coverage of the myopectineal orifices bilaterally, addressing all potential hernia sites in the lower abdomen. These features collectively contribute to the technique's efficacy in managing bilateral hernias.

Analgesic Effect of Bilateral Sonography-Guided Ilioinguinal Iliohypogastric Block and Caudal Block in Children: A Randomized Trial

Background: Herniorrhaphy is the most common inguinal surgery in children. Several methods such as caudal block, ilioinguinal iliohypogastric block, and wound infiltration have been studied for postoperative pain management in these patients. Caudal block is common in pediatrics. However, ilioinguinal iliohypogastric block is effective and less invasive. Previous studies have shown different comparative results regarding these blocks. This study compares the analgesic effect of caudal and bilateral ilioinguinal iliohypogastric block with ropivacaine in children. Methods: This study is a randomized double-blind clinical trial. A total number of 66 patients aged between 1-7 years that volunteered for bilateral inguinal hernia repair were randomly assigned to two groups. After general anesthesia, caudal block with 1cc/kg ropivacaine 0.2% was performed for 33 patients and sonography-guided ilioinguinal iliohypogastric block with 0.1 cc/kg ropivacaine for each side was considered for another group. Hemodynamic parameters (systolic blood pressure, diastolic blood pressure, and heart rate) during anesthesia, pain score (CHEOPS), delirium score (PAED), nurses’ satisfaction score (RN), need for additional narcotic, recovery time, and complications were compared in these two groups. Results: There was no statistically significant difference between the two groups in terms of hemodynamic parameters during the anesthesia process. Furthermore, the two groups had no statistically significant difference in CHEOPS score (6.27 in ilioinguinal block and 5.70 in caudal block, P=0.061), PAED score (5.64 vs 5.30, P=0.144), and RN satisfaction score. However, the need for narcotics, mean recovery time, and block complications were comparable in two groups. Conclusion: Caudal block and ilioinguinal block are equally effective for post herniorrhaphy pain and emergence agitation management in pediatrics. Additionally, no differences were observed in complications. It is recommended that the study be performed with a larger sample size.

Totally extraperitoneal laparoscopy-assisted microsurgical vasovasostomy for the treatment of obstructive azoospermia caused by pediatric bilateral inguinal herniorrhaphy.

Pediatric inguinal hernia repair (IHR) is a common cause of obstructive azoospermia (OA). Yet, the surgical treatment for this kind of OA remains difficult with poor fertility outcome. To evaluate the safety and effectiveness of totally extraperitoneal laparoscopy-assisted microsurgical vasovasostomy (VV) in the treatment of OA caused by pediatric bilateral IHR. Totally, 37 patients with OA caused by pediatric bilateral IHR were enrolled in this study from March 2015 to December 2020 in Shanghai General Hospital. The clinical data and fertility outcomes were collected and analyzed. All patients enrolled had a history of bilateral IHR at the age of 1-10 years old. The mean age of patients was 27±4.31 (range: 18-35) years. Totally extraperitoneal laparoscopy (TEP) was applied in 31 patients for the exploration and retrieval of pelvic vas deferens end, and 30 of them underwent microsurgical VV successfully. Among the six cases where TEP was not applied, five cases underwent microsurgical anastomosis. Intraoperative exploration revealed that the location of vas deferens injuries included scrotum (2.70%, 1/37), inguinal canal (5.41%, 2/37), pelvic cavity (78.37%, 29/37), and multiple sites (13.51%, 5/37). The mean operation time was 339±96.73 min (range: 130-510 min). There were no surgical complications. Thirty-three cases were followed up for 5-48 months with four cases lost to follow-up. The overall patency rate, pregnancy rate, and natural pregnancy rate were 75.86% (22/29), 46.67% (14/30), and 36.84% (7/19, 3 patients without family planning), respectively. And seven couples conceived through the assisted reproductive technique, two of which using fresh sperm in the ejaculate. TEP laparoscopy-assisted microscopic VV is an effective treatment for patients with OA caused by pediatric bilateral IHR.

Outpatient Surgery and Unplanned Overnight Admission in Bilateral Inguinal Hernia Repair: A Population-based Study.

The use of outpatient surgery in inguinal hernia is heterogeneous despite clinical recommendations. This study aimed to analyze the utilization trend of outpatient surgery for bilateral inguinal hernia repair (BHIR) in Spain and identify the factors associated with outpatient surgery choice and unplanned overnight admission. A retrospective observational study of patients undergoing BIHR from 2016 to 2021 was conducted. The clinical-administrative database of the Spanish Ministry of Health RAE-CMBD was used. Patient characteristics undergoing outpatient and inpatient surgery were compared. A multivariable logistic regression analysis was performed to identify factors associated with outpatient surgery choice and unplanned overnight admission. A total of 30,940 RHIBs were performed; 63% were inpatient surgery, and 37% were outpatient surgery. The rate of outpatient surgery increased from 30% in 2016 to 41% in 2021 (p < 0.001). Higher rates of outpatient surgery were observed across hospitals with a higher number of cases per year (p < 0.001). Factors associated with outpatient surgery choice were: age under 65 years (OR: 2.01, 95% CI: 1.92-2.11), hospital volume (OR: 1.59, 95% CI: 1.47-1.72), primary hernia (OR: 1.89, 95% CI: 1.71-2.08), and laparoscopic surgery (OR: 1.47, 95% CI: 1.39-1.56). Comorbidities were negatively associated with outpatient surgery. Open surgery was associated (OR: 1.26, 95% CI: 1.09-1.47) with unplanned overnight admission. Outpatient surgery for BHIR has increased in recent years but is still low. Older age and comorbidities were associated with lower rates of outpatient surgery. However, the laparoscopic repair was associated with increased outpatient surgery and lower unplanned overnight admission.

Ventriculoperitoneal shunt and bilateral herniotomies in mucopolysaccharidosis type I: A surgical challenge

ABSTRACT Mucopolysaccharidosis type I or Hurler syndrome (1 in 100,000) is a rare lysosomal storage disorder caused by a defective IDUA gene which codes for α-L-iduronidase enzyme. Enzyme deficiency results in the accumulation of dermatan and heparan sulfate which leads to characteristic facial features, skeletal abnormalities, hepatosplenomegaly, cardiac and pulmonary disease, and progressive mental retardation. A 1-year-old male child presented with chief complaints of increasing head size and bilateral large inguinoscrotal swellings for 5 months. He had a motor developmental delay with poor speech at 1 year of age. The infant weighed 10 kg with a length of 76.5 cm and large head size with head circumference of 53.5 cm (&gt;97 centiles); the anterior fontanel was wide open. Facial features revealed prominent forehead, bilateral corneal clouding, and coarse facies. Per-abdomen examination revealed hepatosplenomegaly; inguinoscrotal evaluation revealed bilateral large reducible indirect inguinal hernias. Radiographic findings suggested dysostosis multiplex. Serial cranial ultrasonography revealed progressive hydrocephalus. Noncontrast computed tomography brain confirmed communicating type of hydrocephalus with periventricular ooze. Considering the clinical history, clinical examination, and skeletal survey, findings were consistent with mucopolysaccharidoses. Urine spot test for glycosaminoglycans for mucopolysaccharidosis was positive. Enzyme analysis of alpha-L-iduronidase showed deficient levels. A molecular study revealed a homozygous mutation in the IDUA gene confirming the diagnosis of Hurler syndrome. The right ventriculoperitoneal shunt was performed after preoperative optimization. Bilateral inguinal hernia repair was contemplated after a gap of 8 weeks. On 9-month follow-up, there was a gradual reduction in ventricular hemispheric ratio, and the patient is doing well on follow-up. Surgical management of the MPS I patient is challenging, but with timely medical and surgical treatment, the prognosis is improving.

Comparative Analysis of Bilateral Open Inguinal Hernia Repair and Rives-Stoppa Repair: A Comprehensive Review.

Inguinal hernias present a significant healthcare burden globally, necessitating effective surgical management. This comprehensive review evaluates two primary surgical techniques for managing bilateral inguinal hernias: bilateral open inguinal hernia and Rives-Stoppa repair. This review aims to provide insights into optimal surgical approaches through a comparative analysis of these techniques, including examining advantages, disadvantages, outcomes, and factors influencing technique selection. Bilateral open inguinal hernia repair offers simplicity and familiarity, while Rives-Stoppa repair may provide advantages such as reduced recurrence rates and postoperative complications. The findings underscore the importance of considering patient-specific factors, surgeon expertise, and hospital resources when selecting the optimal approach. Further research is warranted to conduct long-term comparative studies and explore innovations in surgical techniques and materials, ultimately enhancing patient outcomes and advancing inguinal hernia repair practices.

Comparison of single absorbable tacker vs. conventional method in fixating the mesh in bilateral inguinal hernia undergoing laparoscopic transabdominal preperitoneal (TAPP): A randomized control trial study

Abstract Background: The current study aims to investigate the superior mesh fixation method, single absorbable tacker versus conventional method, in patients undergoing bilateral inguinal hernia repair through the laparoscopic total abdominal preperitoneal (TAPP) approach. Materials and Methods: The current randomized clinical trial has been conducted on 81 patients undergoing bilateral hernia repair through TAPP. The patients were randomly assigned into one of the mesh fixation groups including single absorbable tacker (Group S) (n = 41) and conventional method (Group C) (n = 40). All patients were assessed during the hospital stay and 1 month postoperatively to assess the surgery-associated complications and days for return to daily activity. Eura-Hs questionnaire was applied to assess the quality of life (QOL) after hernia surgery during 12-month follow-up. Results: The duration of bilateral inguinal hernia operation (P = 0.067), postoperative urinary catheterization (P = 0.813), and hospital stay duration (P = 0.779) did not differ between the groups; whereas Group C significantly required a longer time for returning to daily activity (P &lt; 0.001). Only a patient in Group C represented hematoma (P = 0.494). Seroma incidence was not statistically different between the two groups (P = 0.712). Postoperative pain was statistically less in Group S (P &lt; 0.001 for all the assessments). Postoperative QOL within a year after hernia repair revealed an insignificant difference between the groups in general (P &gt; 0.05); however, a pain subscale was significantly less in Group S (P = 0.002). Conclusion: Based on the findings of this study, a single absorbable tacker was generally superior to the conventional method considering its less pre- and postoperative complications. However, the two methods did not differ regarding 1-year follow-up QOL.

(170) Missed Urinary Leak During an Inflatable Penile Prosthesis Insertion Presenting as a Post-Operative Hydrocoele

Abstract Introduction This is a case of a revision of a three-piece penile prosthesis in a 53-year-old gentleman who had received an infrapubic implantable penile prosthesis (IPP) in Turkey over 12 months ago. He complained of an unsupported floppy shaft when the prosthesis was inflated, as well as a right hemi scrotal bulging which was exacerbated by activity but showed no signs of infection. A hydrocele had occurred 2 months following the IPP insertion and was confirmed on imaging. The MRI showed the pump within the hydrocele. He had previously had a laparoscopy gastric banding and a bilateral inguinal hernia repair with mesh. Objective Video to demonstrate the surgical case Methods This is a video demonstrating the steps of this operation. The procedure started with a transverse penoscrotal incision and dissection through the dartos muscle. The initial corporotomy allowed removal of the first cylinder of the prosthesis. Upon removing the right cylinder, the hydrocele was opened to reveal the presence of turbid fluid, 150ml of fluid was aspirated and sent for microbiology investigations. The next stage involved removal of the left cylinder and 7.5cm of rear-tip extenders (RTE) were subsequently removed intact, with further RTE from the right removed separately using a nasal speculum. Therefore, a 20cm IPP was removed with 7.5cm RTE on each side. An antibiotic salvage wash (Rifampicin/Gentamicin) was performed several times. At this point a 26cm + 1cm (13mm) malleable prosthesis was inserted as a spacer. The previous infrapubic wound was opened to remove the reservoir, 75ml of fluid was aspirated from around the reservoir prior to removal. Attempts are made to identify a possible fistula with flexible cystoscopy, but normal urethra, bladder neck and bladder are seen. Giving no evidence of any fistula into the abdominal cavity or urethral injury to explain fluid in the corporal cavities or around the components of the prosthesis. Methylene blue and distention were also used to attempt to identify a bladder leak, however this was also unremarkable. A suprapubic catheter was inserted to ensure the decompression of the urinary system to allow any small/undetected leaks to heal. This was done under direct vision using a cystoscope prior to being secured. Results The patient had a replacement of the inflatable penile prosthesis to a malleable prosthesis, a suprapubic catheter inserted and a drainage of his hydrocele. The patient recovered well from surgery and on examination the prosthesis tips were seated nicely in the glans. The fluid microbiology culture did not grow any organism. A subsequent cystogram showed no signs of any bladder leak. The patient was happy with the outcome and underwent a trial without catheter. He has a planned review and will be considered for an exchange to an inflatable device at this time. Conclusions This is an unusual presentation of a hydrocele, in the absence of any infective symptoms which is suggestive of a contained urine leak and even a missed bladder injury from the first prosthesis surgery. However, no fistula was found during the surgery or the post-operative cystogram. Disclosure No.

The Night Sweats and Pulmonary Embolism-controversial Presentation and Differentiation

Pulmonary embolism (PE) is a common and potentially fatal condition where early and accurate diagnosis can significantly reduce mortality and morbidity. It typically presents with a range of associated symptoms such as breathlessness at rest or during exertion, coughing, discomfort or swelling in the legs, and wheezing. However, many atypical symptoms are also possible, including epigastric pain, hypotension, and night sweats, with mechanisms not yet understood. The absence of definitive signs and symptoms makes diagnosing pulmonary embolism challenging. We report the case of a 56-year-old male who presented to the ER with right-sided chest pain following laparoscopic umbilical and bilateral inguinal hernia repair 6 days prior. Workup revealed a PE, for which the patient was started on apixaban. Following the initiation of apixaban, the patient developed drenching night sweats, which, after extensive workup, were determined to be a diagnosis of exclusion.

Comparison Between Caudal and Combined Caudal with Spinal Anesthesia in Paediatric Bilateral Inguinal Hernia Surgery

Objective: To compare the analgesic efficacy and adverse effect profile of using caudal anaesthesia versus caudal combined with spinal anaesthesia for paediatric patients undergoing bilateral inguinal hernia surgery. Study Design: Prospective longitudinal study. Place and Duration of Study: Anaesthesia Department of Combined Military Hospital, Rawalpindi Pakistan, from Mar to Aug 2022. Methodology: Eighty paediatric patients between ages 5-10 years requiring bilateral inguinal hernia repair were included in the study. The Caudal Group received 0.25% Bupivacaine per the Armitage regime at a 1 ml/kg volume to reach an effective sensory level of T10. The Combined Group received spinal anaesthesia at a dose of 0.3 mg/kg for &gt;15 kg patients and 0.4 mg/kg for 5-15 kg patients in the L4-L5 epidural space for an effective spinal level of T10. Once the spinal was administered, the same caudal dose as per the caudal Group's Armitage regime. Results: The total duration of block and subsequent reversal to the S1 level was 326.2±12.6 minutes in the Caudal Group versus 441.22±31.8 minutes in the Combined Group (p&lt;0.001). The mean time for the first dose of analgesia for pain was required after 5.27±0.24 hours in the caudal versus 7.03±0.20 hours in the Combined Group. Conclusion: We conclude that the combined caudal spinal approach offers better and superior pain control, resulting in less IV analgesic requirement and less hospital stay, offering a good alternative to general anaesthesia in paediatric surgeries.

Surgical Approach to Bilateral Inguinal Hernia. A Case-Control Study.

Introduction: Bilateral inguinal hernia can be safely repaired simultaneously, open or minimally invasive, in an elective sce-nario. The choice of surgical approach depends on the patient's status, hernia characteristics, surgeons and patient preferences. Whether age criteria should be considered when selecting between the two approaches is still a matter of debate. Considering that there is no consensus regarding the best repair in bilateral inguinal herniorrhaphy, the aim of the study is to perform an analysis regarding elective surgical approach of patients with bilateral inguinal hernias. Material and Methods: To study the relationship between exposure to an open versus laparoscopic approach in patients with bilateral inguinal hernia, we conducted a case-control study. In our retrospective analysis, cases (23 patients) were the open-approach hernia repair, and controls (82 patients) were laparoscopic hernia repair. We analyzed two sets of variables: first, related to patient characteristics (age 65 years, BMI 30 kg/m2, smoking habit, HTA status, COPD status, DM status, use of anticoagulants, presence of neoplastic status) and second, variables related to hernia features (inguinoscrotal hernia, recurrent hernia and complicated hernia). Results: The mean age for cases was 73.26 (Ã+-12.99) years and that of controls, was 56.48 (Ã+-15.15) years. Univariate analysis demonstrated four variables with statistical significance: age 65 years, inguinoscrotal hernia, neo-plastic status, and anticoagulant use. When introduced into the multivariate analysis, we noted that only two variables, age 65 years (OR=4.183, 95% CI [1.289, 13.572], p=0.017) and use of anticoagulants (OR=38.876, 95% CI [1.305, 1158.011], p=0.035) reached statistical significance. Conclusion: This study demonstrates that when we refer to bilateral inguinal hernia repair, patients aged 65 years are at risk of having an open procedure at least fourfold more than patients aged 65 years. In addition, the use of anticoagulants increases the risk of open hernia repair 38 times more than that of minimally invasive repair for the same age group. Interestingly, in our study, hernia characteristics were not found to be associated with open hernia repair and age 65 years. In our study we found that age 65 years is associated with electing open hernia repair over minimally invasive repair, which can be linked to age-related risk factors. Further re-search is needed to investigate the impact of age and age-related risk factors on surgical outcomes of bilateral inguinal hernia repair.

970 A Parisian Pain in the Groin; a Case of De Garengeot’s Hernia

Abstract Introduction 77-year-old gentleman presented with a four-day history of a painful right sided irreducible groin swelling. Background of previous bilateral mesh inguinal hernia repair thirty years prior. Differential diagnosis- recurrent incarcerated inguinal hernia. Description Emergency presentation with a painful right sided groin lump with history of previous inguinal hernia repair. Past medical history of AF on rivaroxaban, HTN and BPH. Patient systemically well with an irreducible lump in the right groin. CTAP showed recurrence of hernia in right inguinal region containing fat stranding and a 2cm-sized fluid-filled structure (suspected appendix). Taken to theatre the following day - oblique incision in right groin. Obvious femoral hernia identified. Haemorrhagic fluid and a necrotic appendix contained in hernia sac. Open appendicectomy performed through groin incision and femoral canal plicated using 2.0 prolene. No mesh used due to risk of contamination. Discharged day 2 post-op. Pathology confirmed acute appendicitis. Discussion Extremely rare case presentation. Femoral hernias account for 3% of all hernias and De Garengeot hernias only 1% of all femoral hernias. Furthermore, De Garengeot hernia with acute appendicitis accounts for only 0.01% of femoral hernias and are much more common in females than males with a 4:1 ratio. Femoral hernias are fifteen times more common in patients who have undergone previous inguinal hernia repair with 33% of men and 4% of women with De Garengeot hernia having undergone previous right inguinal hernia repair. Difficult pre-operative diagnosis given rarity with only 30% of cases diagnosed on pre-operative imaging-initial diagnosis Amyand hernia on CT imaging.

Robotic inguinal hernia repair with the new Hugo RASTM system: first worldwide case series report

Introduction Robotic-assisted surgery has been a part of surgical procedures for more than two decades. Recently new robotic platforms with a different design entered the market. The modular design with independent arms enables increased flexibility of arm docking to increase the range of motion and instrument maneuverability. We herein present the first case series of robotic inguinal hernia repair using the Hugo RAS system (Medtronic, Minneapolis, MN, USA). Material and methods Thirteen inguinal hernia repairs were performed on ten patients. A description of the Hugo RAS system as well as the new concept of modular design is presented along with the description of the operation setup. Results Mean docking time was 9.5 min and mean console time was 50.3 min and 74.7 min for unilateral and bilateral inguinal hernia repair, respectively. No intraoperative or postoperative complications occurred. There was one conversion to laparoscopic surgery due to a technical issue with the robot. Conclusions: The modular design of independent arms seems to enhance maneuverability of the instruments and contribute to fewer arm collisions. Further clinical data and experience with this new surgical system are necessary to understand if this new design has advantages over the standard robotic platforms.

Sigmoido-vesical fistula secondary to hernia mesh migration; a long-term rare complication of laparoscopic transabdominal preperitoneal inguinal hernia repair

A 47-year old male presented with frequent urinary tract infections (UTIs), hematuria and pneumaturia with a past history of laparoscopic bilateral inguinal hernia repair 5 years ago. Ultrasonography (USG) and contrast enhanced computed tomography did not furnish any evidence to arrive at a diagnosis, interestingly, cystoscopy revealed a mesh in the urinary bladder making apparent the diagnosis of Sigmoido-vesical fistula secondary to mesh migration. Later, surgical removal of the mesh from the sigmoid colon and urinary bladder with rent closure of the fistulous opening was done successfully. Our case thus, highlights the long-term rare complication of transabdominal preperitoneal (TAPP) surgery.

Return to Work in Patients With Unilateral Inguinal Hernia Surgery: A Comparative Study Between Laparoscopic Transabdominal Preperitoneal Approach and Lichtenstein Tension-Free Mesh Repair.

Objective The objective of this prospective cohort study was to compare the time to return to work between patients who underwent laparoscopic transabdominal preperitoneal (TAPP) hernia repair and those who underwent Lichtenstein tension-free hernia repair with mesh for unilateral inguinal hernia. Methodology Patients were registered for unilateral inguinal hernia review at Aga Khan University Hospital, Karachi, Pakistan, from May 2016 to April 2017 and followed till April 2020. All patients aged 16-65 planned for unilateral transabdominal preperitoneal hernia repair or Lichtenstein tension-free hernia mesh repair were included. Patients with bilateral inguinal hernia repair, limited activity, or above retirement age were excluded. A non-probability consecutive sampling technique was implemented, and patients were divided into two cohort groups: Group A underwent laparoscopic transabdominal preperitoneal hernia repair, while Group B underwent Lichtenstein tension-free mesh repair. Patients were followed up at one week to inquire about the resumption of activities and then at one and three years for recurrence. Results Sixty-four patients met the inclusion criteria; three patients opted out of research, and 61 patients agreed to participate; one patient was excluded due to the conversion of the procedure. The remaining 30 in Group A and 30 in Group B were followed for the study period. The mean time to return to work in Group A was 5.33 ± 4.46 days; in Group B, it was 6.83 ± 4.58 days, with a p-value of 0.657.One recurrence was observed at three years in Group A. Conclusion Although the time to return to work at our hospital was slightly shorter in laparoscopic hernia repair than in the open technique, the results were not statistically significant. In addition, there was no significant difference in hernia recurrence at the one-year follow-up between laparoscopic transabdominal preperitoneal hernia repair and Lichtenstein tension-free hernia mesh repair for unilateral inguinal hernia.

P-004 APPENDICITIS CAUSING CHRONIC MESH INFECTION: A CASE SERIES OF TWO PATIENTS

Abstract Aim To discuss appendicitis as a cause of chronic mesh infection. Methods This study reports two patients with previous inguinal hernia repair who presented with recurrent groin infections resulting from appendicitis. Results Patient 1 had a history of laparoscopic bilateral inguinal hernia repair, followed by an open repair of a unilateral recurrence. He presented twice with groin pain and discharge. Sinugram demonstrated a superficial tract, but intra-operatively the sinus tract extended to the deep ring where the appendix was adherent and inflamed. There was also a meshoma of the preperitoneal mesh. He underwent appendicectomy and excision of meshoma. Patient 2 presented with perforated appendicitis with a large pelvic collection extending into the anterior abdominal wall. This was treated with percutaneous drainage and antibiotics. Further presentations with recurrent abscesses prompted a laparoscopy where an inflamed appendix was found adherent to the previous mesh through a hole in the peritoneum in a pre-peritoneal abscess cavity. He underwent appendicectomy and washout without mesh removal. Both patients remain symptom free at 10 months and 1 month respectively. Conclusion Literature review found reports of mesh-related appendicitis but no cases of appendicitis causing chronic mesh infection. Whilst rare, appendicitis causing chronic mesh infection should be considered in patients presenting with recurrent groin pain and abscesses having previously undergone inguinal hernia repair. Whilst we do not have long term follow up data, our experience indicates that these patients can be managed with or without mesh removal, providing the appendix is removed and the source of sepsis controlled.

Comparative Analysis of Laparoscopic vs Open Inguinal Hernia Approach for Repair of Recurrent Bilateral Inguinal Hernia

Comparative Analysis of Laparoscopic vs Open Inguinal Hernia Approach for Repair of Recurrent Bilateral Inguinal Hernia