Direct Hernia Research Articles

A Review of the Incidence, Manifestation, Predisposing Factors, and Management of Recurrent Pediatric Inguinal Hernia.

AbstractRecurrent pediatric inguinal hernia is relatively rare. In a large series, the recurrence rates vary from 0.3 to 1.2%. In a university hospital with surgical service for a wide spectrum of sick pediatric patients, the real recurrence rate may be 3 to 6%. Recurrence manifests typically 6 months after first repair. Current evidence indicates that recurrence rates in open and laparoscopic repair are similar. Laparoscopic repairs are, however, still performed by a minority of skilled pediatric surgeons, whereas the majority of pediatric surgeons rely on open repair not least because of the assumed lower risk of recurrence. After repair of an indirect hernia, the majority of recurrences (97%) are indirect, whereas in rare cases the recurrence turns out to be a formerly undiagnosed direct or femoral hernia. In Children's Hospital of Helsinki, Finland, recurrence rate from 2012 to 2016 was 2.8% and operations for recurrent hernias comprised 3.3% of the total. From 1991 to 2017, a total of 130 operations for recurrent hernias were performed with open inguinal approach (n = 75, 58%), laparoscopy (n = 49, 38%), and laparotomy (n = 4, 4%). One teenage patient underwent a Lichtenstein Prolene net repair. A recurrent inguinal hernia can be repaired either with an open or laparoscopic approach. In laparoscopy, the nature of the recurrent hernia can be clarified and an immediate repair performed either by laparoscopic or open technique. In expert hands new laparoscopic techniques using muscular arch, lateral umbilical ligament, iliopubic tract, and division of the sac may be an alternative to a simple purse-string closure.

Inappropriate Use of Direct Access Hernia Pathway Costs the CCG, The Trust and Patients

Inappropriate Use of Direct Access Hernia Pathway Costs the CCG, The Trust and Patients

Clinical study of prolene hernia system in inguinal hernia repair

Background: Lichtenstein was first to coin the term "tension-free hernioplasty" in his book "Hernia repair without disability". All direct, indirect and recurrent adult hernias can be repaired by this procedure. The objective of this study was to determine the feasibility of using the prolene (polypropylene) hernia system for open tension-free repair on inguinal hernias.Methods: During period of 2 years, 42 patients were subjected to prolene hernia. Of these 42 patients, 3 patients underwent bilateral repair. Thus, in all 45 inguinal hernias were repaired. The median age of patients in our study was 57 years. In our study majority hernias were indirect inguinal hernias (47.61%). Nineteen (45.23%) hernias were of direct type while 2 (4.76%) pantaloon and 1 recurrent inguinal hernias. Out of the 42 patients, 16 were operated under local anesthesia while 17 patients operated under spinal anesthesia. Maximum hernias were Gilbert’s type III hernias.Results: The duration of surgery averaged 35 min (range 20-90 min). There were no postoperative deaths. Two out of 42 patients developed local infection at wound site. Wound seroma was found in 3 patients but subsided by giving antibiotics and patients were discharged as per routine protocol. 2 patients (4.76%) developed mild pain in testicular region which subsided with non-steroidal anti-inflammatory drugs. One patient (2.38%) in our series had pain in operative region that lasted for more than one month, only non-steroidal analgesics sufficed to deal with this problem and no patient complained of pain after 2 months of surgery. No patient in our series developed late infection or testicular atrophy. No recurrence was noted during the period of follow-up. This was consistent with the result of other series performed worldwide. Most of the patients in our study (18 patients i.e. 42.87%) were discharged on 3rd postoperative day. One patient had mild neuralgia up to maximum of 2 months in the follow up period which subsided with analgesics. No recurrence was seen in the follow up period.Conclusions: The prolene hernia system is a novel approach in the management of inguinal hernias, with encouraging initial results. Its long-term efficacy needs to be studied with larger, prospective double-blind randomized trials, with longer follow-up.

Clinical efficacy of laparoscopic transabdominal preperitoneal hernia repair and risk analysis affecting postoperative complications

Objective To explore the clinical efficacy of laparoscopic transabdominal preperitoneal (TAPP)hernia repair and risk factors affecting postoperative complications. Methods The retrospective case-control study was conducted. The clinical data of 595 patients who received laparoscopic TAPP hernia repair in the First Affiliated Hospital of Soochow University from February 2008 to August 2016 was collected. Operations were performed by the same doctors′ team. Observation indicators: (1) surgical situations; (2) postoperative situations; (3) follow-up situations; (4) risk factors affecting complications after laparoscopic TAPP hernia repair. Follow-up using outpatient examination and telephone interview was performed to detect the recovery time of non-restricted activity, postoperative complications and hernia recurrence up to February 2017. Measurement data with normal distribution were represented as ±s. The univariate analysis and multivariate analysis were done using the chi-square test and Logistic regression model. Results (1) Surgical situations: 595 patients underwent laparoscopic TAPP hernia repair using the heavy meshes. Overall operation time and overall volume of blood loss were (55±25) minutes and (7±5)mL, including operation time of (50±20)minutes in 502 unilateral hernias and operation time of (81±29)minutes in 93 bilateral hernias. Of 595 patients, 34 had incarcerated hernia, the contents of hernia: greater omentum, small intestine and sigmoid colon were detected in 21, 11 and 2 patients, respectively, with an incarcerated time of 2-21 hours; 4 with incarcerated hernia induced small intestinal necrosis received laparoscopy-assisted small intestinal resection + anastomosis, 1 with sigmoid colon necrosis received necrotic sigmoid canal resection + sigmoidostomy and 29 received repair after the contents restoration of hernia. Operation time and volume of intraoperative blood loss in 34 patients with incarcerated hernia were (84±39)minutes and (12±6)mL. Thirteen of 595 patients (10 with indirect hernia and 3 with direct hernia) had recurrent hernia, and operation time and volume of intraoperative blood loss were (75±26)minutes and (10±5)mL. (2) Postoperative situations: time to initial exsufflation of 595 patients was (19±12)hours. Of 595 patients, 590 took fluid diet at 6 hours postoperatively and 5 undergoing enterectomy took fluid diet at 24 hours postoperatively. The pain score at 1 day postoperatively and duration of hospital stay were respectively 2.5±1.4 and (2.1±1.9)days. (3) Follow-up situations: of 595 patients, 593 recovered non-restricted activity at 2 weeks postoperatively and 2 didn′t recover non-restricted activity at 2 weeks postoperatively. Of 595 patients, 542 were followed up for 6-60 months, with a median time of 31 months. Fifty-seven, 25, 13 and 1 patients were respectively complicated with seroma, surgical pain, urinary retention and enteroparalysis, they were improved by symptomatic treatment, and the same patient can have multiple complications. There were no severe complications which needed surgical intervention, such as vascular injury, damnify of intestinal canal and poke hole hernia. Of 2 patients with recurrence of hernia, 1 with right indirect hernia had recurrence of direct hernia and then received Lichtenstein tension-free hernia repair, and 1 received treatment in other hospital. (4) Risk factors affecting complications after laparoscopic TAPP hernia repair: results of univariate analysis showed that age, diameter of hernia sac, incarcerated hernia, recurrent hernia, operation time and volume of intraoperative blood loss were related factors affecting complications after laparoscopic TAPP hernia repair (χ2=6.657, 55.296, 44.305, 5.253, 117.461, 100.722, P<0.05). Results of multivariate analysis showed that diameter of hernia sac ≥4 cm, incarcerated hernia, operation time ≥100 minutes and volume of intraoperative blood loss ≥10 mL were independent risk factors affecting complications after laparoscopic TAPP hernia repair (OR=3.610, 11.315, 12.401, 7.346, 95% confidence interval: 2.009-6.486, 3.579-35.772, 5.408-28.437, 3.739-14.434, P<0.05). Conclusion Laparoscopic TAPP approach for inguinal hernia is safe and effective, and diameter of hernia sac ≥4 cm, incarcerated hernia, operation time ≥100 minutes and volume of intraoperative blood loss ≥10 mL are independent risk factors affecting complications after laparoscopic TAPP hernia repair. Key words: Hernia, inguinal; Transabdominal preperitoneal hernia repair; Risk factor; Laparoscopy

Closure of a direct inguinal hernia defect in laparoscopic repair with barbed suture: a simple method to prevent seroma formation?

Seroma is a frequent postoperative complication after laparoscopic direct inguinal hernia repair (both in TAPP and TEP). There are several methods to address this problem; however, these techniques are not without problems. The purpose of this study was to introduce and evaluate a new technique to address this problem. This is a prospective study of consecutive patients. All patients diagnosed with direct inguinal hernias eligible for laparoscopic repair were included. A single surgeon performed all the included operations. During laparoscopic inguinal hernia repair (TAPP or TEP), we closed the direct hernia defect with barbed sutures around the transversalis fascia, inverted the apex of the attenuated transversalis fascia, and sutured it at the base to completely eradicate the defect cavity. Prosthetic mesh was not additionally fixed in all patients. The primary postoperative outcome parameter was seroma formation, and secondary outcome parameters included groin pain, surgical complications, and hernia recurrence. Twenty-five male patients with 36 sides of direct hernias were included in this study, and all procedures were carried out laparoscopically and successfully. Only one patient developed significant seroma, which resolved 1month later. The early postoperative pain was minimal, and no recurrence and chronic pain occurred during the follow-up period (4-13months). The present direct inguinal hernia defect closing technique with barbed suture is a simple, easily reproducible, and effective method for the prevention of seroma formation.

A study of open inguinal hernioplasy with horizontal incision at tertiary care hospital

Background: Transverse incision may be truly horizontal or may curve to varying degrees. Transverse incisions mostly follow LANGER lines and give better cosmetic results. The present study was planned with an objective to study open inguinal hernioplasty with transverse crease (Langer’s line) incisions.Methods: The present cross-sectional study was conducted on patients operated for inguinal hernia in single surgical unit between March 2013 to October 2015. After admission in a surgical ward, thorough history and clinical examination of all patients done. A transverse skin incision was used (follow the Langer’s line) in all cases.Results: The mean age of the cases in the present study was 45.21±14.2 years. It was noted that among Indirect inguinal hernias (IIH), 85% of the cases were below 50 years of age while among direct inguinal hernias (DIH), 66% cases were above 50 years of age. It was seen that 42.6% of the direct hernia was right-sided while 70.0% of the indirect hernias were right sided. All the patient had a very good cosmetic outcome.Conclusions: It was concluded from the present study that right sided indirect inguinal hernia was the most common type of Hernia. The use of transverse incision through Langer lines is aesthetical, no folding of scar is seen, all the layers are not on same level so preventing ridge effect, repair become sounder, bigger lower flap of external oblique aponeurosis and even wound is infected, no scar widening.

Two mesh technique in lieu of single mesh in giant prosthetic reinforcement of the visceral sac for bilateral inguinal hernias

Background: Posterior wall strengthening is the essential aim of Bilateral Inguinal hernia repair. The two methods for it are tissue repair and tension free repair. Tension free repair have become the gold standard. The preperitoneal repair for Bilateral Inguinal hernia is performed by wrapping the lower part of the parietal peritoneum with a large chevron shape polypropylene mesh.Methods: This study presents a modification of stoppas repair using a polypropylene mesh of size 15×9 cm to cover the myopectineal ostium of fruchaud on each side. The direct hernia sac was inverted with a purse string suture. Indirect hernia was opened and margins approximated with a 2-0 polyglycolic acid suture. No drainage was used.Results: Post-operative period was uneventful in all the patients. This new technique uses less post-operative time and the cost of surgery is reduced. There was one post-operative recurrence on one side only on follow up at one week, three weeks and three months.Conclusions: The use of two small size mesh covering both Fruchaud’s myopectineal orifices for bilateral inguinal hernia repair instead of a large size mesh is a promising technique. It saves the operative time and shortens the hospitalization time.

Clinical Characteristics and Laparoscopic Treatment of Supravesical Hernia.

Inguinal hernias may be direct or indirect, and supravesical hernias, a subtype of inguinal hernias, are often mistaken as direct hernias as their symptoms are similar. The purpose of this study was to describe the characteristics of supravesical hernias and to introduce a minimally invasive surgical method as a treatment for supravesical hernias. Thirty-seven patients with supravesical hernias were treated using laparoscopic herniorrhaphy and wall defect suture with a mesh implant from September 2012 to December 2016 at Damsoyu hospital, Seoul, Korea. Patient characteristics and surgical outcomes were retrospectively evaluated. All 37 patients were men with external supravesical hernias. The mean age was 55.3 (range 32-79) years; 23 patients had right-sided, 12 had left-sided, and 2 had bilateral hernias. Comorbidities included lipoma (7/37), contralateral indirect hernia (1/37), and contralateral direct hernia (14/37). No recurrences were reported at the end of the study period. Laparoscopic transabdominal defect closure with a mesh implant herniorrhaphy seems to be an effective, minimally invasive treatment option for supravesical hernia.

Clinical study of patients with inguinal hernia at a tertiary care hospital

Background: The history of hernia is the history of surgery. Historically hernia causative was attributed to a mechanical disparity between visceral pressure and the resistance of the musculature.Methods: 100 cases of inguinal hernia admitted in Medical College Teaching Hospitals were selected on the basis of the nonprobability (purposive) sampling method. All patients with uncomplicated direct and indirect hernias treated by open approach surgeries were included. The age/sex incidence, mode of presentation, precipitating factors, surgical treatment, postoperative complications were all evaluated and compared with standard published literature. A predesigned proforma was used to collect this information for individual case.Results: The incidence of hernia was common in younger,18-40-year age group (33%), people engaged in agriculture (42%), labourers (33%). 52% patients presented with swelling and 48% with pain and swelling. Right indirect hernia was the most common (41%), right direct hernia (23%), pantaloon (7%) and bilateral in 8%. 32% patients had strenuous work as a precipitating factor, 35 % had smoking as associated factors. Abdominal tone was poor in 8% cases.Conclusions: Strenuous work is often responsible for development of hernia. Heavy work, especially lifting weights, puts a great strain on the abdominal muscles. If there is an underlying weakness already present, hernia may develop. The patient relates the onset of the hernia to a particular event.

Laparoscopic inguinal hernia repair in elderly patients: single center experience in 12 years

Background: To evaluate the clinical outcome of laparoscopic inguinal hernia repair (LIHR) in elderly patients. Methods: The clinical data of 3,203 cases (3,847 hernias) un-derwent LIHR from January 2001 to December 2013 were analyzed retrospectively. There were 1,677 transabdominal preperitoneal (TAPPs) in 1,475 cases, 2,154 total extraperito-neal (TEPs) in 1,718 cases and 16 intra-peritoneal onlay mesh (IPOMs) in 10 cases. All procedures were performed by the same surgical team and the choice of techniques was made by the surgeons. The follow-up period ranged from 23 to 60 months (median 43 months). Results: The hernias in elderly patients aged over 60 years ac-counted for 69.4%. These patients had more bilateral hernia, direct hernia and complex hernia than patients younger than 60 years (P=0.000, 0.000), more grade III hernia and grade IV hernia (P=0.000). There were more TEP and IPOM procedures in elderly patients (P=0.000), of which IPOMs were all used in recurrent hernias. There were more heavy-weight meshes used in elderly patients (P=0.000). No significant differences were found in operation time, visual analogue scales (VAS), postoperative hospital stay, cases returned to normal activities in 2 and 4 weeks between the two groups (P>0.05). There were no significant differences in recurrence rate and overall complication rate between the two arms (P>0.05), of which, there were more urinary retention in elder cases (P=0.008). No significant differences were found in seroma, transient paresthesia and ileus between two groups (P>0.05). Conclusions: LIHR is a safe and efficient technique in elderly patients. With reasonable application, LIHR can achieve good clinical outcome.

Inguinal pain syndrome. The influence of intraoperative local administration of 0.5% bupivacaine on postoperative pain control following Lichtenstein hernioplasty. A prospective case-control study.

During the period between December 2015 and May 2016, 133 patients with preoperative diagnosis of an inguinal (81.95%, n=109), scrotal (13.53%, n=18) or recurrent hernia (4.51%, n=6) underwent an elective intervention and were randomly allocated to the group, which intraoperatively received 20 mL of 0.5% bupivacaine locally in selected anatomical points of the inguinal canal. In the group with preoperative diagnosis of an inguinal hernia, this intervention was applied in 56.88% of cases (n=62). In the case of scrotal or recurrent hernia, a similar intervention was applied in 41.67% (n=10) of patients. During the hospital stay, pain was assessed four times a day using the NRS numeric scale. All patients received preoperative antibiotic prophylaxis, and, during observation, analgesics and low-molecular-weight heparin were used. In the studied group, risk factor were identified, which affect the pain level associated with surgical treatment of an inguinal hernia. Mean pain level score according to the NRS scale (0-10) for an inguinal hernia was 4.17 on day 0 (standard deviation 2.22; minimum 0; maximum 10). On day 1 - 2.86 (standard deviation 1.86; minimum 0; maximum 8). On day 2 - 0.84 (standard deviation 1.21; minimum 0; maximum 5). The values of those parameters for a scrotal and recurrent hernia were as follows: on day 0 - 3.67 (standard deviation 1.76; minimum 0; maximum 7). On day 1 - 3.79 (standard deviation 1.67; minimum 0; maximum 7). On day 2 - 2.25 (standard deviation 1.54; minimum 0; maximum 4). Intraoperative application of 20 mL 0.5% bupivacaine did not reduce the postoperative pain on the postoperative day 0, 1, 2. Among independent risk factors exacerbating pain, the following variables were identified: local complications of the operated site including edema, ecchymosis and hematoma of the inguinal region. More frequent dressing changes were directly correlated with an increased pain sensation. Postoperative urethral catheterization due to urinary retention was associated with an increased pain immediately after surgery. In the case of intraoperative diagnosis of concurrent direct and indirect hernia (so-called pantaloon hernia), less intense pain was observed on postoperative day 0. Other parameters such as age, sex, duration of operation, duration of hospitalization and wound drainage did not influence the pain sensation. Local injection of an analgesic into the operated site was not associated with the reduction of pain assessed on postoperative day 0, 1 and 2 after an isolated inguinal, scrotal or recurrent hernia repair. Pathologies of the operated site such as edema, ecchymosis or hematoma were associated with an increased pain sensations on observation. Also, postoperative urinary retention and urethral catheterization increased the pain sensation after an inguinal hernia repair. A lack of wound complications significantly decreased the pain sensation during the immediate postoperative period after hernia repair.

The Novel Technique of Transabdominal Preperitoneal Hernioplasty Herniorrhaphy for Direct Inguinal Hernia: Suture Repair of Hernia Defect Wall

Conventional laparoscopic surgeries of direct inguinal hernia include two methods, transabdominal preperitoneal hernioplasty (TAPP) and totally extraperitoneal hernioplasty. Both methods are performed using synthetic mesh without suturing the hernia defect and require extensive mesh coverage for not only Hesselbach's triangle but also indirect ring. For minimally invasive operation, suture of direct hernia defect was devised and performed. The purpose of this study is to evaluate the efficacy of defect wall suture of laparoscopic herniorrhaphy for direct inguinal hernia patients. We evaluated 210 direct inguinal hernia patients who received TAPP in Damsoyu Hospital, Seoul, Republic of Korea from September 2012 to December 2015. The patients were categorized into two groups according to TAPP techniques; cTAPP group had conventional TAPP without defect wall suture, and rTAPP group had defect wall suture TAPP. There were 99 patients in a cTAPP group and 111 patients in rTAPP group. Operation time and postoperative hospital stay showed no difference between two groups. The postoperative pain score within the first week was significantly lower in rTAPP group than in cTAPP group (P < .001). The mean timing of a return to normal activities for rTAPP group was 3.8 days, which was shorter than 4.6 days of cTAPP group (P < .001). There was no difference in complication and recurrence rates between two groups. Defect wall suture for direct inguinal hernia had shorter operation time, faster recovery time, reduced pain, and an acceptable rate of recurrence and complication. This TAPP surgery with hernia defect wall suture that requires smaller dissection area is an effective method for treating direct inguinal hernia.

Surgical Repair of Inguinal Direct Hernia without Cremaster Resection

Surgical Repair of Inguinal Direct Hernia without Cremaster Resection

Intraoperative Inguinal Measurements to Estimate a Single Optimal Mesh Size for Lichtenstein Inguinal Hernioplasty: an Observational Study

In inguinal hernia surgery, use of optimal mesh size during Lichtenstein hernioplasty technique is essential in preventing recurrence. This study was an attempt to determine a single optimal mesh size which can be adapted in vast majority of cases based on intraoperative inguinal measurements. This observational study was done for 1 year in the Department of Surgery, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, India. A total of 60 patients aged above 18 years who were scheduled for elective inguinal hernioplasty using the Lichtenstein technique for direct or indirect inguinal hernia were subjected to intraoperative measurements. All the patients were male with mean age of 52.75 ± 15.39 years. Mean body mass index (BMI) was 24.51 ± 3.10 kg/m2. With regard to hernia characteristics, most of the patients had right-sided hernia (61.7%), indirect (51.67%), and incomplete hernia (81.67%). The mean width of mesh required was 6.65 ± 0.24 cm and mean length was 13.75 ± 0.25 cm. The mesh size was comparable with respect to demographic characteristics, anthropometry, BMI, and type and extent of hernia (p > 0.050) but age and length of mesh size varied significantly in patients with direct and indirect type of hernia (p < 0.050). The present study made an attempt to determine a single optimal mesh size in cases who underwent inguinal hernia repair based on the principles of Lichtenstein hernioplasty, which being 6.7 cm × 13.8 cm. Another significant finding was varying in mesh length size between direct and indirect hernias.

Direct bladder hernia after indirect hernia repair in extremely low birth weight babies: two case reports and a review of the literature

BackgroundInguinal hernia repair is the most common surgical procedure in babies. Despite a meticulous technique, relapses may occur. The occurrence of a direct bladder wall hernia in relapses has never before been reported in the literature.Case presentationHere, we report two cases of direct bladder herniation: a white baby boy born after 25 weeks of gestation and a white baby boy born after 26 weeks of gestation. Both of the formerly extremely low birth weight babies were affected after open bilateral hernia repair. Recurrent hernias developed on the right side, and direct bladder herniation was identified intraoperatively. In one case, laparoscopy was applied to identify a supravesical type of hernia. Immaturity and a difficult postnatal course might have contributed to hernia relapse in these cases.ConclusionsMisinterpretation of bladder herniation might have disastrous consequences. Laparoscopy is a helpful tool in comparable cases.

Metalloproteinases and Their Inhibitors in Patients with Inguinal Hernia.

The aim of this prospective study is to investigate if there is a relationship between inguinal hernia, matrix metalloproteinases (MMPs), and tissue inhibitors of metalloproteinases (TIMPs). This case control study was performed on patients admitted to the general surgery department of Erzincan University Hospital. Four groups were created: control, indirect hernia, direct hernia, and bilateral hernia. All groups were comprised of 11 patients. Serum and tissue levels of MMP-1, MMP-2, MMP-9, MMP-13, TIMP-1, TIMP-2, TIMP-3, and hydroxyproline were evaluated. MMPs values were significantly high at hernia groups, especially at bilateral hernia group (p<0.05), whereas TIMPs values were significantly low at bilateral hernia group (p<0.05). MMPs values were increasing at hernia groups in an order as control, indirect, direct, and bilateral. TIMPs values were decreasing at hernia groups in an order as control, indirect, direct, and bilateral. Increased levels of MMP-1-2-9-13 and decreased levels of TIMP-1-2-3 may have played role in the formation of inguinal hernia. Hernia is not only a local defect, but a reflection of systemic disease. This is even more significant for bilateral hernias.

A clinical study of inguinal hernia with special reference to laparoscopic trans-abdominal pre peritoneal repair

Background:Hernia may be generally defined as the protrusion of an abdominal viscus outside the abdominal cavity through a natural or acquired defect. Latin meaning of the word “hernia” is tear or rupture. A Clinical study on inguinal hernia is undertaken to assess the incidence of inguinal hernia in relation to age, gender and occupation, the different types and modes of clinical presentation of patients, the management of patients with special consideration to laparoscopic (TAPP) repair, to evaluate the operating time, pre-operative and post-operative complications, duration of hospital stay, time taken for recovery, recurrence rate and limitations with respect to laparoscopic TAPP repair.Methods: This is a prospective study of 54 cases of inguinal hernia admitted and underwent surgery for inguinal hernia in Department of General Surgery in Guwahati Medical College and Hospital during the study period of August 2014 to July 2015.Results:The highest number of cases presenting with inguinal hernia were over 45 years and it was more common in males which constituted 96.3 percent of cases. It is more common on right side and indirect hernia is more common than direct hernia. The major possible risk factors are smoking and strenuous work. The commonest presenting mode was swelling followed by swelling with pain. The mean time taken for TAPP was 91.85±15.85 minutes and the median time was 87.50 minutes. There were no intra operative (neurovascular, visceral) complications in any of the patient and there was no conversion to open surgery. There was no mortality in present study and none of the patient had any testicular complication.Conclusions:Laparoscopic hernia repair is associated with steep learning curve for surgeons and is more costly both to patients and health care system in the present scenario. Laparoscopic TAPP hernia repair is found to have encouraging results which is a safe and viable option for repair of inguinal hernia with less postoperative pain and discomfort, improved cosmesis, less post-operative complications and early return to work.

Dissection of a large direct hernia sac (chief surgeon: Liu Jialin, MD)

Dissection of a large direct hernia sac (chief surgeon: Liu Jialin, MD)

Twenty-year experience with laparoscopic inguinal hernia repair in infants and children: considerations and results on 1833 hernia repairs.

The role of laparoscopy in pediatric inguinal hernia (IH) is still controversial. The authors reported their twenty-year experience in laparoscopic IH repair in children. In a twenty-year period (1995-2015), we operated 1300 infants and children (935 boys-365 girls) with IH using laparoscopy. The average age at surgery was 18months (range 7days-14years). Body weight ranged between 1.9 and 50kg (average 9.3). Preoperatively all patients presented a monolateral IH, right-sided in 781 cases (60.1%) and left-sided in 519 (39.9%). We excluded patients with bilateral IH and unstable patients in which laparoscopy was contraindicated. If the inguinal orifice diameter was ≥10mm, we performed a modified purse string suture on peri-orificial peritoneum, in orifices ≤5mm, we performed a N-shaped suture. No conversion to open surgery was reported. In 533 cases (41%), we found a contralateral patency of internal inguinal ring that was always closed in laparoscopy. In 1273 cases (97.9%), we found an oblique external hernia; in 21 cases (1.6%), a direct hernia; and in 6 cases (0.5%), a double hernia on the same side (hernia en pantaloon). We found an incarcerated hernia in 27 patients (2%). Average operative time was 18min (range 7-65). We recorded 5/1300 recurrences (0.3%), but in the last 950 patients, we had no recurrence (0%). We recorded 20 complications (1.5%): 18 umbilical granulomas and two trocars scar infections, treated in outpatient setting. On the basis of our twenty-year experience, we prefer to perform IH repair in children using laparoscopy rather than inguinal approach. Laparoscopy is as fast as inguinal approach, and it has the advantage to treat during the same anesthesia a contralateral patency occured in about 40% of our cases and to treat also rare hernias in about 3% of cases.

Current concepts in the management of inguinal hernia and hydrocele in pediatric patients in laparoscopic era

The surgical repair of inguinal hernia and hydrocele is one of the most common operations performed in pediatric surgery practice. This article reviews current concepts in the management of inguinal hernia and hydrocele based on the recent literature and the authors׳ experience. We describe the principles of clinical assessment and anesthetic management of children undergoing repair of inguinal hernia, underlining the differences between an inguinal approach and minimally invasive surgery (MIS). Other points discussed include the current management of particular aspects of these pathologies such as bilateral hernias; contralateral patency of the peritoneal processus vaginalis; hernias in premature infants; direct, femoral, and other rare hernias; and the management of incarcerated or recurrent hernias. In addition, the authors discuss the role of laparoscopy in the surgical treatment of an inguinal hernia and hydrocele, emphasizing that the current use of MIS in pediatric patients has completely changed the management of pediatric inguinal hernias.