Complicated Inguinal Hernia Research Articles

Complicated Inguinal Hernia Incidentally Detected on a Radiolabelled Autologous White Blood Cell Scan.

A 73-year-old male with left hip prosthesis infection performed a 99mTc HMPAO-labelled autologous WBC (WBC) scan to evaluate the response to antibiotic therapy. Since the early planar scan, an area of increased activity was visible extending from the left groin region to the ipsilateral flank. At late planar images, the area progressively focused in the left groin, site of a painful inguinal hernia. The contextual tomographic acquisition showed increased activity partly referable to non-specific intestinal contents and partly localized at the parietal wall of the herniated intestinal loop. Our case suggests that the incidental detection of increased accumulation of WBC in correspondence of the intestinal wall of an inguinal hernia may indicate inflammatory involvement and subsequent further complications.

Acute Small-bowel Obstruction: An Appraisal of Common Etiology and Management at the Federal Medical Centre, Keffi, North-central Nigeria.

Acute small intestinal obstruction is a common surgical emergency in the sub-Saharan region. Over the decades, complicated inguinal hernias have been identified as a leading cause. However, we observed from our clinical practice that complicated inguinal hernias were not the most common etiology. This study aimed to evaluate the common etiology of acute small bowel obstruction in the study center and compare our findings with that from other centers and existing literature. This was a retrospective, cross sectional study carried out over a period of five years (January 2017 to December 2021). This study looked at the patients presenting with acute, mechanical, small bowel obstruction that did not respond to conservative treatment in our hospital facility. Relevant information were extracted from patients' clinical details and entered into the proforma prepared for this study. A total of 147 patients were recruited into this study out of which 85(57.8%) were males and 62 (42.2%) were females (M:F=1.44:1). Majority (80.3%) of the patients that presented with post-operative bowel adhesion had previous appendectomy. Simple bowel obstruction was seen in 93 (63.3%) patients while strangulated obstruction and gangrenous bowel were seen in 26 (17.7%) patients and 22 (15.0%) patients respectively. Majority (47.6%) of the patients had adhesiolysis done while others had bowel resection. The common cause of acute small bowel obstruction as observed in this study is post-operative adhesions arising from previous appendectomy and laparotomies.

Outcomes from a new modified single needle laparoscopic percutaneous extraperitoneal closure and cut off for pediatric inguinal hernia

Inguinal hernia is a prevalent surgical condition in pediatric patients. Despite the efficacy of current treatment modalities, a certain recurrence rate still persists. Hence, our objective in this study is to introduce an innovative surgical technique designed to minimize surgical complications. We conducted a retrospective analysis on 809 pediatric cases that underwent laparoscopic repair with our innovative technique for inguinal hernia from June 2020 to June 2022. Demographic information, perioperative details, and postoperative follow-up outcomes were thoroughly assessed. All surgeries were conducted laparoscopically under general anesthesia. The procedure commenced by encircling the hernia sac with two sutures under laparoscopic guidance. Subsequently, the sac was exteriorized from the body using the two sutures, followed by ligation and excision of the hernia sac. The research findings demonstrate that the duration of unilateral and bilateral procedures was recorded as 15.9 ± 4.8 and 21.7 ± 3.9 min, respectively. Incision infection occurred in 7 patients (0.87%), and Male Complicated Inguinal Hernia (MCIH) was observed in 2 patients (0.23%). Notably, there were no occurrences of iatrogenic cryptorchidism, testicular atrophy, or recurrence (0%) during the follow-up period. In conclusion, our novel modification shows a notable reduction in postoperative recurrence rates and alleviates the impact of the procedure on the positioning of the testis or uterus. This modified technique is both safe and valuable, thus warranting broader adoption and promotion.

Modified multilayer alloplasty of complicated inguinal hernias.

Aim. To enhance the treatment outcomes of complicated inguinal hernias (characterized by a high inguinal gap, a large hernia orifice, a weakened posterior wall of the inguinal canal, or recurrence) through the implementation of a developed technique involving multilayer alloplasty.Materials and Methods. Within the overall cohort of 396 patients who underwent inguinal hernia surgeries between 2019 and 2023, the prevalence of complicated hernias was investigated. The main study group comprised 28 patients with complicated inguinal hernias who underwent surgery following the proposed method utilizing a two-layer prosthesis.Results. Complicated inguinal hernias, necessitating additional reinforcement of the posterior wall of the inguinal canal, predominantly manifest in patients with a large hernia orifice size (W3 — 6.57 ± 1.25 %), a significant inguinal gap (13.13 ± 1.70 %), and a history of relapses (8.59 ± 1.41 %). An associated condition complicating hernioplasty and elevating the risk of recurrence (0.618) is obesity (61.76 ± 8.33 % in the recurrent hernia group). The application of the developed hernioplasty method shows no significant difference in terms of complication risk and subjective sensations compared to the Lichtenstein method. Notably, no hernia recurrences were observed with the utilization of the duplication plasty technique.Conclusion. The suggested duplication design of the prosthesis proves effective in providing ex- tensive reinforcement for the inguinal gap in cases of problematic hernias. It is easy to position and is associated with minimal discomfort, as reported by the subjective sensations of patients.

Comparison of Perioperative Complication Rates of Total Extraperitoneal and Transabdominal Preperitoneal Repairs in Primary Inguinal Hernia.

Hernia may be defined as a protrusion of viscus through layers anatomically designed to contain that viscus. Most abdominal hernias occur at well-described sites of potential weakness. Repair of inguinal hernia is one of the most common operations in general surgery. Objectives: To compare the perioperative complication rates of total extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) repairs of primary inguinal hernias. It is a randomised comparative study, conducted at the department of general surgery. A total of 50 patients were included and divided into two groups with 25 in each. Group A represents the laparoscopic TEP repair and group B represents the laparoscopic TAPP repair. Patients above 18 years with primary unilateral inguinal hernia were included. Patients having complicated inguinal hernia and history of previous abdominal surgery were excluded. We observed that hernia occurrence is more common in the 31-50 years of age group and right-sided hernia is more common. Scrotal oedema and conversion to open surgery chances are similar in both TEP and TAPP groups. The duration of surgery in TEP is significantly higher as compared to TAPP. Patients who underwent TEP experienced less pain as compared to TAPP as per visual analogue scale. Postoperative hospital stay and time taken to resume the routine activity were significantly less in case of TEP. TEP is preferred over TAPP for laparoscopic hernia repair because it preserves the peritoneal integrity and has lesser postoperative pain. The early recovery and return to the routine work were seen with the patient treated with the TEP and also showed better visual analogue score than the TAPP repair group.

Traversing Boundaries: An Analysis of the Unremitting Psychic Unity in The Waste Land

Known as ‘Pope of Russel Square’ in the history of English literature from the 20th century, T. S. Eliot’s, literary ingenuity augmented the modernist writings. ‘The Waste Land’ is one such eventuality that, retrospectively from the publication, permuted worldwide, giving boundless definitions and ceaseless critical appraisals. Contriving the idiom of modern poetry, his career as a part never went over the hill since it was chiselled out of the emotional and intellectual retaliation to a gest which was his life itself. The close-grained, fragmented study of his works, has seemingly been immense and comprehensive. Being portrayed as the literary arbiter, his personal life was lucid and full of drama. The oeuvre hence hollers the zeitgeist of his era. As a philosopher, his happy hunting ground was both religion and the emphasis on conforming to the basic moral values of life. His ethical involvement with life emanates from the underlying desolation and devastation regarding his personal life. When he assiduously carried his position in poetry, politics, and literature, he was tagged as heedless in his personal life. The childhood limitations sprouted out from the complications of inguinal hernia, later when he was at Harvard while studying Sanskrit and Indian philosophy, the commencement of WWI and the escape from Oxford after witnessing a society which was wartorn, a love affair with Emily Hale which closed out in two shakes of a lamb’s tail and the hasty entry into wedlock with Vivienne Haigh-Wood whose alleged adultery with Bertrand Russel and her ailment that followed took a toll on his burgeoning literary career. The shuffling was wilfully implemented, as alluded to by many critics. But for a feeler who, exasperated by the atrocities of war, could not necessarily keep the word restrained to the end and the overscrupulous side of Eliot could not have missed the slightest of the change either.

EGS P15 Perforated Stomach within an Inguinal Hernia: A Rare Case Report and Surgical Management

Abstract Background Inguinal hernias are a common surgical condition requiring urgent medical attention. While complications of inguinal hernias are frequently encountered, the presence of a stomach herniation within this anatomical site is an exceptionally rare occurrence. This rare phenomenon presents diagnostic challenges and necessitates prompt surgical intervention. This case report aims to provide a detailed account of a patient with a perforated stomach within an inguinal hernia, emphasizing the unique clinical presentation, diagnostic dilemmas, and the subsequent surgical management required for such a complex condition. Methods We report the case of an 83-year-old male who presented with severe abdominal pain and a tender mass in the left groin. Clinical examination revealed an irreducible inguinal hernia with signs of peritonitis. CT scan confirmed a giant incarcerated inguinal hernia containing part of the stomach with associated gas and fluid collection. An emergency open hernia repair was attempted but swiftly converted to an exploratory laparotomy. The hernia content was reduced intraabdominally, surprisingly revealing a posterior stomach wall perforation. Damage-control suture repair, washout, and laparostomy were performed. Tragically, he succumbed to multiorgan failure soon after in ITU. Results The occurrence of a perforated stomach within an inguinal hernia is an exceptionally rare and diagnostically challenging entity. Timely diagnosis and intervention are vital to prevent life-threatening complications. Imaging, particularly CT scan, aids in diagnosis and surgical planning. Prompt surgical management, involving hernia reduction and gastric repair, is crucial for optimal outcomes. play a critical role in identifying the gastric perforation and guiding the surgical approach. Conclusions This case underscores the importance of recognizing rare complications, such as stomach herniation in inguinal hernias. Heightened awareness and appropriate use of imaging facilitate accurate diagnosis and guide surgical interventions. Timely surgical intervention is essential in reducing morbidity and mortality associated with this rare presentation.

Desarda’s Repair as an Alternative Procedure: A Physiological Approach to Complicated Inguinal hernia

Background: Complicated inguinal hernia is one of the most common conditions encountered in a surgical emergency. Of arious surgical procedures available we are comparing Desarda’s and Modified Bassini’s repair in our study. Aims & Objectives: To compare Desarda’s repair with Modified Bassini’s repair in complicated inguinal hernia concerning the duration of the procedure and various post-operative complications. Methods: We have included 52 patients with complicated inguinal hernias presenting to the emergency department after taking informed consent and ethical committee clearance. Patients were randomly divided into two groups using computer software Group A and Group B. Group A: Consists of 26 patients and underwent Modified Bassini’s repair. Group B: Consists of 26 patients and underwent Desarda’s repair. Various intraoperative and post-operative complications were studied. The patient was followed up for a 3 years period for recurrence of an inguinal hernia. Results: Desarda’s repair had less post-operative pain score. Complications such as seroma formation and recurrence in the follow-up period were less compared to Modified Bassini’s repair. Conclusion: Desarda’s repair was found to be a better alternative for a complicated inguinal hernia when compared to Modified Bassini’s repair.

Bilateral Obstructed Inguinal Hernia with Left Amyand’S Hernia: A Rare Case Report

Obstruction and strangulation are the most vicious complications of inguinal hernia that require prompt intervention in the form of surgical exploration. Presence of appendix in the inguinal hernia sac is a rare condition seen in less than 1% of all inguinal hernia cases. Usually this appendix is on right side, but its presence on the left side is extremely rare.
 Case Report: A 70 year male patient with scrotal swelling and inability to pass stool and flatus presented to JNMCH emergency. Upon examination and evaluation a diagnosis of intestinal obstruction secondary of obstructed inguinal hernia was made. Further, upon exploration, a healthy appendix and caecum was seen in left sac whereas right sac contained small bowel, which was unhealthy.

Laparoscopic treatment of complicated obturator hernia: A case series of 6 patients

Abstract Obturator hernia (OH) is a rare type of abdominal hernia. Preoperative diagnosis of OH is often challenging because of nonspecific signs and symptoms, leading to late diagnosis and increased mortality. Laparoscopic repair has been suggested as one of the alternative options for complicated inguinal hernias. We describe a case series of 6 consecutive patients diagnosed with complicated OH and treated by laparoscopic repair. All patients were females, aged 81 to 90 years. Most of them were underweight (body mass index, <18.5 kg/m2). All cases presented with acute small bowel obstruction. All cases were unilateral OH. Concomitant femoral hernia existed in 3 cases (50%). Bowel resection was required in 2 cases because of bowel ischemia and perforation. Four of 6 cases were repaired using synthetic mesh, and the 2 remaining patients were treated with peritoneal closure and medial umbilical fold flap reinforcement. There were no postoperative deaths. Laparoscopic repair seems to be a safe and effective option for the treatment of complicated OH.

Single-incision laparoscopic transabdominal preperitoneal hernioplasty: 1,054 procedures and experience

PurposeAlthough there have been numerous studies on single-incision laparoscopic inguinal hernia repair (SIL-IHR), the short- and long-term outcomes in patients from a large single institution who underwent single-incision laparoscopic transabdominal preperitoneal hernioplasty (SIL-TAPP) have rarely been reported. The purpose of this study is to evaluate the short- and long-term outcomes of SIL-TAPP and its safety and feasibility in patients from a large single institution.MethodsThe details of 1,054 procedures in 966 patients who underwent SIL-TAPP at the Affiliated Hospital of Nantong University from January 2015 to October 2022 were retrospectively analysed. SIL-TAPP was performed completely through the umbilicus using conventional laparoscopic instruments. Short-term and long-term outcomes of SIL-TAPP were collected by outpatient and telephone follow-ups. In addition, we further compared the operation time, length of postoperative hospital stay, and postoperative complications of patients with simple and complicated unilateral inguinal hernias.ResultsA total of 1,054 procedures were performed for 878 unilateral inguinal hernias and 88 bilateral inguinal hernias. In total, there were 803 (76.2%) indirect inguinal hernias, 192 (18.2%) direct inguinal hernias, 51 (4.8%) femoral hernias and 8 (0.8%) combined hernias. The mean operative time was 35.5 ± 17.0 min for unilateral inguinal hernias and 51.9 ± 25.5 min for bilateral inguinal hernias. There was one (0.1%) conversion to two-incision laparoscopic transabdominal preperitoneal hernioplasty. No intraoperative haemorrhages, inferior epigastric vessel injury or nerve damage occurred. Postoperative complications were minor and could be resolved without surgical intervention. The mean length of hospital stay was 1.3 ± 0.8 days. The median follow-up was 44 months, no trocar hernia occurred, and there was one (0.1%) recurrence. The operation time in the complicated inguinal hernia group was significantly higher than that in the simple inguinal hernia group (38.9 ± 22.3 vs. 35.0 ± 15.6, p = 0.025). The length of postoperative hospital stay and complication rate of the complicated inguinal hernia group were slightly higher than those of the simple inguinal hernia group, but the difference was not statistically significant.ConclusionSIL-TAPP is safe and technically feasible, and both short- and long-term outcomes are acceptable.

P-075 CHRONIC INGUINAL SEROMA AFTER LAPAROSCOPIC SURGERY

Abstract Aim Chronic inguinal seroma is rare, with 80% being totally reabsorbed 3 months after surgery. Inguinal seroma after laparoscopic indirect hernia repair is presented in 3,7–70% of cases. Material and Methods Description of a clinical case. Results Male, 74 years-old. Prior bilateral inguinal herniorrhaphy. Diagnosed with recurrent right inguinal hernia, ultrasound confirmed. The patient underwent TAPP and a L2R right inguinal hernia was observed (EHS classification). The patient was discharged on day 1. One month after, the patient presented an irreducible tumefaction on right inguinal zone. Ultrasound describes a hydric collection measuring 5.8×5.4×4.1cm, suggesting a seroma, and excluded hernia relapse. 50mL of pure serous fluid was aspirated with clear reduction of the mass. Negative microbiology. Five months post-operatively, the tumefaction was present and 35mL of a fluid, with the same characteristics, was aspirated again. One month later, seroma was still found, and 35mL of a fluid was aspirated. After that, 100mg of Doxycycline was injected. Two years after surgery, tumefaction was present. He was proposed for surgical intervention and underwent unroofing and scarification of the seroma. Three-month follow-up without complications. Conclusions Chronic seroma that needs intervention is extremely rare. It is estimated that only 0,24% need percutaneous drainage and 0,2% reoperation. Therefore, this case is relevant and should inform us for this infrequent form of presentation of a common complication of inguinal hernia.

COMPLICATED INGUINAL HERNIA OR INGUINAL DERMOID: A DIAGNOSTIC DILEMMA

Simple or complicated inguinal hernias are the common inguinal lumps of any surgical emergency or outpatient settings. However, inguinal hematoma, abscess, enlarged inguinal lymph node, undescended testis, lipoma, or encysted hydrocele of the spermatic cord are few relatively less common entities seen in inguinal region whereas inguinal supernumerary pectineus bursa, preperitoneal lipoma, pedunculated uterine fibromyoma, angioma of uterine ligament, inguinal endometriosis, aneurysm of femoral artery, saphena varix, and thrombophlebitis are extremely uncommon entities of the groin region. We present an interesting case in which patient presented with painful firm lump in inguinal region and the history and clinical examination was consistent with the diagnosis of an incarcerated inguinal hernia but intraoperative findings amazed us and subsequently histopathological analysis labeled it a dermoid cyst.

US for Evaluation of Acute Abdominal Conditions in Neonates

US is the imaging modality of choice for evaluation of a variety of abdominal conditions, and in recent years it has also become useful and promising as a bedside technique for assessment of acute abdominal conditions in neonates. Bedside US can help, complement, and sometimes replace radiographic or contrast-enhanced studies in critically ill and labile neonates who are difficult to transport to the fluoroscopy suite. Some of the features of bedside US can be applied as point-of-care US (POCUS) of the sick neonate. Some of the abdominal conditions in neonates that can be assessed and monitored with bedside US are necrotizing enterocolitis and its complications, malrotation with a midgut volvulus, segmental volvulus, meconium peritonitis, and complicated inguinal hernia. High-resolution US with the use of 15-MHz and higher-frequency probes allows characterization of the bowel anatomy and features of intestinal abnormalities in neonates in fine detail. Color Doppler US and microvascular imaging improve accuracy in the detection and characterization of bowel vascularity, which is important in the treatment and follow-up of patients with intestinal conditions. © RSNA, 2023 Quiz questions for this article are available through the Online Learning Center. The slide presentation from the RSNA Annual Meeting is available for this article.

The Prevalence of Inguinal Hernia Among Athletes in Saudi Arabia: A Cross-Sectional Study.

Introduction An inguinal hernia is the most common type of hernia. It might manifest as a groin bulge, lump, or enlarged scrotum. Swelling may be uncomfortable and painful and even cause intestinal obstruction. This study aimed to measure the prevalence of inguinal hernia among athletes in Saudi Arabia. Subject and methods This is a cross-sectional study conducted among Saudi Arabian athletes. A self-administered questionnaire was distributed among athletes using an online survey through different Saudi Olympic Training and Fitness Centers throughout the kingdom. The questionnaire includes sociodemographic characteristics (i.e. age, gender, etc.), risk factors, and complications of inguinal hernia. Results Of the 594 athletes, 55.6% were females and 57.6% were aged between 18 and 24 years. The most common type of sport was running (31%). The most common risk factor for inguinal hernia was previous abdominal surgery (57.5%). The prevalence of inguinal hernia among Saudi athletes was 12.3%. Being older in age and being male were the independent significant predictors associated with increased risk for inguinal hernia, whereas weightlifting was the independent significant factor of decreased risk for inguinal hernia. Conclusion The prevalence of inguinal hernia among athletes was 12.3%. Older male athletes were most likely at a greater risk to suffer from inguinal hernia as compared to the rest of the athletes. Further research is needed to extract more data about the prevalence of inguinal hernia among Saudi Arabian athletes and determine its risk factors.

A comparative analysis of trans-abdominal pre-peritoneal repair in uncomplicated vs complicated inguinal hernia repair.

Trans-abdominal pre-peritoneal (TAPP) repair is one of the standard techniques for laparoscopic repair of groin hernias. Literature has shown that both total extraperitoneal (TEP) and TAPP are equally effective with similar outcomes but TAPP has an advantage over TEP as there is more working space, and it provides access to the opposite side for repair of occult hernias. We reviewed our experience of TAPP repair in complicated groin hernias and compared the outcomes with uncomplicated groin hernia. Patients undergoing TAPP repair from January 2004 to December 2019 were analyzed, and divided into two groups-I uncomplicated and II complicated groin hernia. TAPP repair was performed in 820 patients, of which 70.3% had uncomplicated and 29.7% patients had complicated hernias. Occult hernia was detected in 61 patients. The intra-operative complications (16.8% vs 1.3%) and conversions (2.4%) were higher in complicated hernias. Laparoscopic assisted repair was used in 16.8% patients with complicated hernias. The incidence of post-operative complications (62.1% vs 17.3%; P value <.01) were significantly higher in complicated groin hernia patients. The median follow-up was 15 months; only three patients in the uncomplicated hernia group developed recurrence, and chronic groin pain was higher in the complicated hernia repair patients (P > .05) at 6months. Although operative time, incidence of intra-operative and post-operative complications (albeit minor in nature), and conversions to open are higher after TAPP repair for complicated groin hernias, the short-term outcomes (hematoma, mesh infection) as well as long-term outcomes (chronic groin pain, port site hernia and recurrence) are not different when compared with uncomplicated hernias. TAPP repair can be used in both complicated and uncomplicated groin hernias with similar short-term and long-term outcomes, albeit with a slightly higher incidence of minor complications in complicated hernias. This can be taken into consideration while operating on patients with complicated hernias and taking informed consent.

Feasibility and outcome of tension-free Desarda repair for treatment of complicated inguinal hernia

Feasibility and outcome of tension-free Desarda repair for treatment of complicated inguinal hernia

Robot-assisted repair of complicated inguinal hernia: Advantages in comparison with conventional repair

Abstract The adoption rate of robot-assisted surgery has skyrocketed in recent years, despite limited evidence, an unclear clinical benefit, and an increase in cost. The laparoscopic approach to inguinal hernia repair by either transabdominal or extraperitoneal approach has gradually gained traction owing to distinct advantages over traditional open repairs. Although robotic inguinal hernia repair has been established as a safe alternative to conventional laparoscopy, as of yet no superiority has been proven. We aim to give an overview of certain clinical situations, in which the robot might be advantageous. Specifically, we discuss inguinoscrotal hernia repair, inguinal hernia repair after prostatectomy, and mesh explantation. In our opinion, robotic systems are an invaluable tool in the case of mesh resection or recurrence after previous anterior and posterior repairs. With the increased expansion of the surgical tools and techniques to repair abdominal wall problems, a definitive and clear rule as to which cases should be handled robotically and which should not will be difficult and probably unattainable. We are very much proponents of a tailored approach, where every individual case deserves its surgical plan, bearing in mind all aspects of a patient, with the aim of the best surgical outcome.

Enterocutaneous fistula from a perforated incarcerated Littre inguinal hernia in an infant

Inguinal hernia is a common surgical condition encountered of pediatric age group. Inguinal hernia may get incarcerated and if strangulated, it requires prompt intervention. Rarely incarcerated bowel can perforate leading to formation of entero-cutaneous fistula. Littre's hernia is the protrusion of a Meckel diverticulum through a potential abdominal opening. A one and half months old infant presented with an irreducible right inguino-scrotal swelling and faecal discharge from the scrotum for a month. Patient was passing stools from normal anal opening as well. Patient underwent exploratory laparotomy which revealed an incarcerated right inguinal hernia containing long ruptured Meckel's diverticulum of size 8 cm passing from deep inguinal ring to right hemiscrotum. Diverticulectomy with ileo-ileal end to end anastomosis with right herniotomy was done. The main complication of inguinal hernia is incarceration, which may result in bowel obstruction. Spontaneous intestinal-cutaneous fistula from incarcerated inguinal hernia with Meckel's diverticulum as content in neonates and infants is a rare occurrence and hitherto only one such case has been reported in the world literature. Prompt and early seeking of medical facility of patients with incarcerated inguinal hernias is necessary to reduce their morbidity and mortality.

An analytical study of acute surgical emergencies in groin hernia

Aim and Objectives: This is a analytical study about various presentations, etiopathogenesis, complications and management in acute surgical emergencies in groin hernia presented in Trichy SRM medical college Hospital from May 2019 to October 2021. Observation and Conclusions: Incidence of highest in age group of 60yrs to 70yrs and Complication of inguinal hernia was more common in males than females and it was observed hernia is commoner on the right side than on the left side. The most common symptom was groin swelling with pain followed by vomiting and most common content found in the sac was small bowel followed by omentum with the most common site of obstruction. The most common procedure followed in my study was only herniorraphy. It was followed by omentectomy.