Dissection Of Sac Research Articles

PHASIX™ ST MESH FOR CRURAL REINFORCEMENT DURING GIANT HIATAL HERNIA REPAIR: PRESENTATION OF SURGICAL TECHNIQUE

Abstract Aim Crural mesh reinforcement during large hiatal hernia repair has been advocated to defend against early recurrences. However, the optimal mesh material and configuration remain in question. This study presents the rationale and surgical technique for crural repair augmentation using Phasix™ ST Mesh. Methods We present a case of a giant hiatal hernia and outline the rationale and surgical technique for using Phasix™ ST Mesh in the repair. Results A 72-year-old man presented with a giant type IV hiatal hernia. A massive mediastinal protrusion of intra-abdominal fat and viscera, and an associated crucial cardiorespiratory compromise were noted. A preoperative CT scan revealed a widened hiatus measuring 9.2 × 7.6 cm. The patient underwent laparoscopic hiatal hernia repair and Nissen fundoplication. During the procedure, following visceral reduction and hernia sac dissection and excision, a widened round hiatus and significantly thinned crura were found. To reinforce the primary crural suturing, two strips of Phasix™ ST Mesh, each measuring 1.5 × 4 cm, were used, and a U-shaped mesh was placed onlay to augment the repair. The procedure lasted 214 minutes, and the patient was discharged on the 3rd postoperative day without complications. Conclusions The application of Phasix™ ST Mesh in the repair of giant hiatal hernias offers the dual benefits of reconstructing the original anatomy and reinforcing the hiatus, while avoiding the implantation of permanent foreign material around the esophagus.

Evidence mapping on how to perform an optimal surgical repair of large hiatal hernias

BackgroundSymptomatic and large hiatal hernia (HH) is a common disorder requiring surgical management. However, there is a lack of systematic, evidence-based recommendations summarizing recent reviews on surgical treatment of symptomatic HH. Therefore, this systematic review aimed to create evidence mapping on the key technical issues of HH repair based on the highest available evidence.MethodsA systematic review identified studies on eight key issues of large symptomatic HH repair. The literature was screened for the highest level of evidence (LE from level 1 to 5) according to the Oxford Center for evidence-based medicine’s scale. For each topic, only studies of the highest available level of evidence were considered.ResultsOut of the 28.783 studies matching the keyword algorithm, 47 were considered. The following recommendations could be deduced: minimally invasive surgery is the recommended approach (LE 1a); a complete hernia sac dissection should be considered (LE 3b); extensive division of short gastric vessels cannot be recommended; however, limited dissection of the most upper vessels may be helpful for a floppy fundoplication (LE 1a); vagus nerve should be preserved (LE 3b); a dorso-ventral cruroplasty is recommended (LE 1b); routine fundoplication should be considered to prevent postoperative gastroesophageal reflux (LE 2b); posterior partial fundoplication should be favored over other forms of fundoplication (LE 1a); mesh augmentation is indicated in large HH with paraesophageal involvement (LE 1a).ConclusionThe current evidence mapping is a reasonable instrument based on the best evidence available to guide surgeons in determining optimal symptomatic and large HH repair.

Robotic-Assisted Splenectomy by a Modified Lateral Approach: Technique and Outcomes.

Introduction The utilization of robot-assisted technique for splenectomy has recently gained popularity especially in patients undergoing splenectomy for hematological indications owing to its magnification of and easy manipulation of internal abdominal organs. Moreover, robotic splenectomy emerged as an essential teaching module before approaching more complex robotic procedures. Methods A total of 43 elective splenectomies were performed for hematological indications in Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) between January 2018 to July 2023 of which 14 patients underwent robotic splenectomy. All patients underwent lateral approach of robotic splenectomy with a modification of avoiding the lesser sac dissection. Prospectively maintained data were retrospectively analyzed and results were recorded in terms of intra-operative time taken, blood loss, need for blood and blood product transfusion and postoperative morbidity and mortality. Results The indications for patients who underwent robotic splenectomy include idiopathic thrombocytopenic purpura in eight patients, autoimmune hemolytic anemia in three patients, Evans syndrome in one patient and hereditary spherocytosis in two patients. The median splenic diameter was 14.8cm and the median platelet count before the operation was 10,800 cells/cubic millimeter (7000-3,20,000). The mean operative time was 92 minutes and blood loss was 40ml. The median duration of hospital stay was 2.4 days. All 14 patients had therapeutic success and there was no procedure-related mortality or morbidity. Conclusion Robotic splenectomy using the modified lateral approach can safely be performed with comparable operative time, blood loss and overall morbidity. However further studies are mandatory to confirm the advantage of this modified technique of lateral approach of robotic splenectomy.

Can the Hydrocele Sac Dissection Technique Affect the Surgical and Cosmetic Satisfaction Results of Conventional Hydrocelectomy?

Aim: In this study, we applied the classical technique and modified open pull-through procedure (OPtP) for hydrocele sac dissection in excisional Winkelmann hydrocelectomy procedure (WHP) to retrospectively compare the surgical and cosmetic satisfaction results of the two techniques. Material and Methods: Sixty-two patients underwent excisional WHP from 2017 to 2020. The modified OPtP and classical technique groups included 30 and 32 patients, respectively. The intraoperative and postoperative parameters of the patients in both groups were evaluated statistically until the postoperative second month. Cosmetic satisfaction was evaluated statistically at the postoperative sixth month. Results: Postoperative infection and recurrence were not observed in either group. The patients in both groups had large hydrocele sacs. There was no statistically significant difference between the groups in terms of the hydrocele sac volume, operation time, length of hospitalization, postoperative scrotal edema, and postoperative scrotal pain scores (p>0.05). The postoperative hematoma rate was 15.6% in the classical technique group. The statistical difference in incision length and cosmetic satisfaction was significant in favor of the modified OPtP group (p<0.05). Conclusion: Excisional WHP was determined to be safe in the treatment of large hydroceles. In the modified OPtP group, shorter scrotal incision length and low risk of postoperative scrotal hematoma were achieved, and cosmetic satisfaction was also increased.

Nasolacrimal Duct Coronary Stent Recanalization (NCR): First Cadaver Experience and Its Potential as an Alternative to DCR.

To investigate the feasibility of implanting a drug-eluting cobalt-chromium alloy coronary stent in the nasolacrimal ducts (NLDs) of human cadavers. The pilot study was carried out in 5 NLDs of 4 adult human cadavers. Sirolimus-eluting coronary stents of 2 mm in width and lengths of 8 and 12 mm, which were mounted on balloon catheters, were used. Following dilatation of the NLDs, the balloon catheters were introduced into the NLDs under direct endoscopy guidance. The stents were delivered following dilatation of the balloon to 12 ATMs and secured in a locked (spring out) position. The balloon is then deflated and securely extubated. The dacryoendoscopy confirmed the stent position. The lacrimal system was then dissected to assess several key parameters like the uniformity of the NLD expansion, anatomical interactions of the NLD mucosa with the stent rings and struts, integrity of the soft and bony NLD, stent movement on mechanical push and pull, and ease of manual removal. The cobalt-chromium alloy coronary stents could be delivered with ease and secured in the cadaveric NLDs. Its position was confirmed by a dacryoendoscopy and later by the direct NLD dissection. The NLD was uniformly dilated 360° with a wide and uniform lumen. NLD mucosa was noted to be uniformly distributed in spaces between the stent rings without influencing the expanded lumen. Following the lacrimal sac's dissection, the NLD stent showed significant resistance to downward movement but could be easily retrieved with forceps. The 12-mm stents could reach the near total length of the NLD with good luminal expansion. The integrity of the bony and soft-tissue NLD was maintained. The learning curve is shallow if the surgeon is adept with the techniques of balloon dacryoplasty. Drug-eluting cobalt-chromium alloy coronary stents can be precisely deployed and secured within the human NLDs. The study is the first of its kind to demonstrate the technique of NLD coronary stent recanalization in human cadavers. It is a step forward in the journey to evaluate their use in patients with primary acquired NLD obstructions and other NLD disorders.

Management of paraesophageal hiatus hernia: recommendations following a European expert Delphi consensus

AimsThere is considerable controversy regarding optimal management of patients with paraesophageal hiatus hernia (pHH). This survey aims at identifying recommended strategies for work-up, surgical therapy, and postoperative follow-up using Delphi methodology.MethodsWe conducted a 2-round, 33-question, web-based Delphi survey on perioperative management (preoperative work-up, surgical procedure and follow-up) of non-revisional, elective pHH among European surgeons with expertise in upper-GI. Responses were graded on a 5-point Likert scale and analyzed using descriptive statistics. Items from the questionnaire were defined as “recommended” or “discouraged” if positive or negative concordance among participants was > 75%. Items with lower concordance levels were labelled “acceptable” (neither recommended nor discouraged).ResultsSeventy-two surgeons with a median (IQR) experience of 23 (14–30) years from 17 European countries participated (response rate 60%). The annual median (IQR) individual and institutional caseload was 25 (15–36) and 40 (28–60) pHH-surgeries, respectively. After Delphi round 2, “recommended” strategies were defined for preoperative work-up (endoscopy), indication for surgery (typical symptoms and/or chronic anemia), surgical dissection (hernia sac dissection and resection, preservation of the vagal nerves, crural fascia and pleura, resection of retrocardial lipoma) and reconstruction (posterior crurorrhaphy with single stitches, lower esophageal sphincter augmentation (Nissen or Toupet), and postoperative follow-up (contrast radiography). In addition, we identified “discouraged” strategies for preoperative work-up (endosonography), and surgical reconstruction (crurorrhaphy with running sutures, tension-free hiatus repair with mesh only). In contrast, many items from the questionnaire including most details of mesh augmentation (indication, material, shape, placement, and fixation technique) were “acceptable”.ConclusionsThis multinational European Delphi survey represents the first expert-led process to identify recommended strategies for the management of pHH. Our work may be useful in clinical practice to guide the diagnostic process, increase procedural consistency and standardization, and to foster collaborative research.

Symptomatic reponible umbilical hernia in the rabbit

A case of umbilical hernia in a 7-month-old female rabbit was presented to the Surgery Clinic of the Veterinary Faculty, University of Sarajevo. The owner noticed inappetence and lethargy four days before arrival at the clinic. Clinical parameters on physical examination were within the physiological range. Bruxism and lethargy were noted as signs of discomfort due to gas accumulation in colon. A reponible, nonpainful mass in the umbilical scar area was palpated but intestinal peristalsis was not altered. General anesthesia was induced by intramuscular administration of ketamine with medetomidine and maintained with isoflurane. Surgical treatment of hernia included the peritoneal sac dissection and amputation, repositioning of small intestines, and correction of abdominal wall defect. Intraoperative multimodal analgesia approach was used to reduce inhalant anesthesia requirements and to prevent pain-related and stress-related complications. In this case report we described a surgical and veterinary treatment of the reponible umbilical hernia in a rabbit.

Sutureless versus purse string with complete sac dissection in laparoscopic inguinal hernia repair in children: a randomized clinical trial

IntroductionPediatric inguinal hernia is a common surgical condition with a cumulative incidence of 4.2%. Minimal invasive surgery is playing a growing role in the treatment of this condition. We compared the outcomes of laparoscopic sutureless herniotomy and purse string with sac dissection repair with regards to complications and operative time.MethodsOne hundred fifty-two patients were operated on in two centers with two different techniques: sac dissection and purse-string suture, and sutureless repair. Operative time and recurrence were the main outcomes for comparison.ResultsSutureless repair has a shorter operative time (29 ± 10 min) compared to purse string repair (38 ± 13 min). The recurrence rate showed no statistical significance difference. However, the recurrence rate of sutureless repair was three times higher than that of purse string repair, and all recurrences were in large defects of 10–15 mm.ConclusionsSutureless repair is safe for defects up to 10 mm with excellent operative time. However, it had an unfavorable outcome in larger defects.

V-029 TOTALLY ENDOSCOPIC SUBLAY (TES) REPAIR FOR L2-L3 INCISIONAL HERNIA

Abstract Aim Endoscopic lateral incisional hernia (IH) repair provides advantages in terms of low infection rates and hospital stay when compared with open repair. Material and Methods 62 years old men with a history of HTA and an open radical right nephrectomy for a renal tumor, developed a symptomatic iliac IH. L2–3 W2 according to the European Hernia Society (EHS) classification was clinically diagnosed and confirmed with a CT scan. Full endoscopic abdominal wall repair with defect closure was proposed. 3 trocars in right retrorectus space were placed. Once the lateral edge of the rectus sheath is reached, the posterior rectus sheath is incised, access to the preperitoneal lateral plane. During hernia sac dissection, an opening of the hernia sac occurs. The posterior layer is closed by a barbed suture, an accessory trocar placement was necessary for the closure. Subsequently, the internal oblique and transversus abdominis muscles that formed the defect were approximated with a barbed suture. During dissection, a right inguinal hernia was identified and repaired. A trimmed 20 x15 cm polipropilene mesh is placed in the preperitoneal space without fixation. Results The patient was discharged on the 3rd postoperative day without complications. Follow-up in the outpatient clinic at 6 months did not show any signs of recurrence. Conclusion Endoscopic abdominal wall reconstruction with posterior component separation is an alternative to the open procedure for lateral IH, providing a complete abdominal wall repair. The mesh is placed extraperitoneal with the advantages in terms of less adhesions and postoperative pain.

Transgastric Pancreaticogastrostomy

Pancreatico-enteric stenosis (PES) is a long-term complication following pancreaticoduodenectomy (PD). The incidence of clinically relevant PES is likely to improve with better outcomes following PD for benign and neoplasms with favorable prognosis. Endoscopy and surgical techniques have been described addressing PES with revision of pancreatico-enteric anastomosis (PEA) being the most common performed surgery. Dense adhesions in the lesser sac especially after postoperative pancreatic fistula can be prohibitive to access the PEA. We describe a technique for postPD PES, transgastric pancreaticogastrostomy, that avoids lesser sac dissection and enables performing a wide anastomosis. Thus, it has the potential to reduce postoperative morbidity.

Zig Maneuver in Total Extraperitoneal Inguinal Hernia Repair.

The difficulties in the hernia sac dissection in repairing large inguinal hernias with the endoscopic total extraperitoneal (TEP) technique prolong the operation and increase the risk of injury. This study investigates the effectiveness of the Zig maneuver (ligation of the hernia sac at the deep inguinal ring) in TEP in male patients with L3 inguinal hernia by European Hernia Society classification. A total of 224 male patients with L3 inguinal hernia who underwent laparoscopic TEP surgery in 2018 and 2019 were retrospectively screened and included in the study. The patients were divided into 2 groups as Zig group (n=99) and the non-Zig group (n=125), depending on whether the Zig maneuver was performed during TEP application. The mean patient age was 45.49 for the non-Zig group and 47.12 for the Zig group. The median operative time was 50 minutes in the non-Zig group and 43 minutes in the Zig group (P<0.005). The median value of the postoperative first 24 hours pain score was 3 in the non-Zig group and 2 in the Zig group (P=0.033). Scrotal edema was 7.2% in the non-Zig group and 1% in the Zig group (P=0.023). According to logistic regression analysis, the Zig maneuver reduced the probability of scrotal edema by 87% in almost the entire population (odds ratio=0.130, 95% confidence interval: 0.016-1.047). There was no statistically significant difference between the groups in terms of early and late recurrence. Zig maneuver shortened the operative time and significantly reduced the feeling of pain in the first 24 hours postoperatively in male patients with indirect L3 hernia who underwent endoscopic TEP. It also significantly reduced the likelihood of scrotal edema in almost the entire population. As a result, the Zig maneuver is an effective method that could be applied during endoscopic TEP.

Presence of testicle in indirect hernia sac during laparoscopic inguinoscrotal hernia repair

During the laparoscopic right inguinoscrotal hernia repair in an adult male patient, the right testicle was clearly viewed in the inguinal hernia sac. The presence of testicle in indirect hernia sac is not uncommon, especially in congenital hernia types, surgeons should be aware of this condition, and avoid injury during hernia sac dissection.

English

BACKGROUND Incisional hernias are a common occurrence following midline laparotomy. Numerous techniques have been employed in the management of this common condition. Randomized trials and evidence based medicine help us in deciding what the optimal treatment is in a particular condition. This is often not possible in case of hernia due to the heterogeneity of population. Laparoscopy is gaining popularity in the management of this condition as results are comparable to open surgery with lesser post-operative pain. The placement of mesh intraperitoneally as in laparoscopic intraperitoneal onlay mesh repair has its own disadvantage such as mesh erosion into viscera. Placement of mesh endoscopically as an onlay repair seems to be a good option, more so in the developing world, considering the prohibitive cost of composite mesh. The purpose of this study was to analyze the technical ease, reproducibility, outcome, postoperative pain and complications of laparoendoscopic hybrid technique in the management of abdominal wall hernia. METHODS This technique combines the benefits of minimal invasive surgery and ease of onlay mesh repair, while reducing wound related problems associated with open surgery. It involves first a laparoscopic approach in entry, reducing the contents, visualizing the sac followed by endoscopic dissection using the same trocar anterior to abdominal wall in the subcutaneous plane. This is followed by sac dissection, suturing the abdominal wall and placing an onlay mesh RESULTS Fifteen patients have been operated; no subcutaneous drains were placed. A polypropylene onlay mesh was used and fixation done with suturing. No major complications were seen. There was no subcutaneous emphysema. CONCLUSIONS The laparoendoscopic hybrid technique offers advantage of being minimally invasive and having lower wound related complications, with early ambulation and decreased hospital stay. It is also technically easier to suture the defect and allow complete excision of the sac. However a randomized trial is necessary and larger series are required to compare the results with other established techniques. KEY WORDS Incisional Hernia, Laparo - Endoscopic - Onlay Mesh, Surgical Techniques, SCOLA

Application of membrane anatomy theory in totally extraperitoneal inguinal hernia repair

Trocar placement and camera-dissection in the midline is the most commonly applied method for total extraperitoneal inguinal hernia repair (TEP), for which the theory of membrane anatomy has guiding significance. We hereby applies the theories and concepts, such as "fascia lining", "multi-layer", "inter-fascial planes", "combined inter-fascial plane" and "plane transition", to elucidate the key steps of TEP, for instance, space creation, hernia sac dissection, mesh flattening. Camera-dissection is performed along the posterior sheath of the rectus abdominis. Firstly, the camera enters retro-rectus space locating between the rectus abdominis and the transversalis fascia (TF). There are inferior epigastric vessels and their branches in the retro-rectus space, thus over-dissection should be avoided. Secondly, the camera goes downward through the TF into the pre-peritoneal space. The pre-peritoneal space is divided into the parietal plane and visceral plane by pre-peritoneal fascia (PPF). Both bladder and spermatic cord components locate on the visceral plane. Dissection of the median area should be implemented on the parietal plane, namely "surgical space", to protect the bladder. The parietal plane is the "holy plane" of TEP. Dissection of the indirect hernia area should be implemented on the visceral plane, namely "anatomical space", to protect the spermatic cord components. The reduction of direct hernia could be understood as the easy separation of TF and PPF. The reduction of indirect hernia is relatively difficult separation of peritoneum and spermatic cord components. During the transition of parietal and visceral planes, PPF (especially the pre-peritoneal loop) should be dissected for complete parietalization, in order to flatten the mesh.

FEMORAL HERNIA: UNCOMMON, BUT ASSOCIATED WITH POTENTIALLY SEVERE COMPLICATIONS.

ABSTRACT Background: Although the laparoscopic access is becoming the preferable treatment for femoral hernia, there are only few studies on this important subject. Aim: To assess the outcomes of the totally extraperitoneal laparoscopic (TEP) access in the treatment of femoral hernia. Methods: Data of 62 patients with femoral hernia who underwent herniorrhaphy were retrospectively reviewed. The diagnosis of femoral hernia was established by clinical and/or imaging exams in 55 patients and by laparoscopic findings in seven. Results: There were 55 (88.7%) females and 7 (11.3%) males, with female to male ratio of 8:1. The mean age was of 58.9±15.9 years, ranging from 22 to 92 years. Most patients (n=53; 85.5%) had single hernia and the remaining (n=9; 14.5%) bilateral, making a total of 71 hernias operated. Prior lower abdominal operations were recorded in 21 (33.9%) patients. Conversion to laparoscopic transabdominal preperitoneal procedure was performed in four (6.5%). Open herniorrhaphy was needed in two (3.2%), one with spontaneous enterocutaneous fistula in the groin region (Richter’s hernia) and the another with incidental perforation of the adjacent small bowel that occurred during dissection of hernia sac. There was no mortality. Conclusion:Femoral hernia is uncommon, and it may be associated with potentially severe complications. Most femoral hernias may be successfully treated with totally extraperitoneal laparoscopic access, with low conversion and complication rates.

Safety and feasibility of single-incision laparoscopic totally extraperitoneal inguinal hernia repair: a retrospective comparative analysis of 163 patients

To analyze the benefit and feasibility of single-incisional laparoscopic totally extraperitoneal (SIL TEP) repair compared with those of conventional laparoscopic TEP (CL TEP). The procedure of laparoscopic herniorrhaphy includes medial, lateral, and sac dissection with mesh positioning. The actual procedure performed during SIL TEP is the same as those of CL TEP, except for the number of incisions. We performed SIL TEP in 23 patients with an inguinal hernia. The operative and short-term outcomes, including postoperative complications and recurrence, were analyzed and compared with 140 cases of CL TEP. Age, gender, BMI, comorbidity, ASA score, and types of hernia were similar in both groups. Also, operation time, open or transabdominal preperitoneal conversion rate, length of hospital stay, postoperative complication rate, and recurrence were not significantly different between the two groups. SIL TEP is as feasible and safe a procedure as laparoscopic herniorrhaphy. Surgeons familiar with single-incision laparoscopic surgeries like appendectomy or cholecystectomy can begin to perform SIL TEP for hernia repair.

Laparoscopic assisted percutaneous internal ring suturing for inguinal hernia repair in pediatrics

Several laparoscopic techniques used in treatment of pediatric inguinal hernia differ in their approach to the internal inguinal ring, suturing and knotting techniques, number of ports, endoscopic instruments used and hernia sac dissection technique. The aim of this study was to evaluate efficacy and safety of laparoscopic assisted percutaneous internal ring suturing for inguinal hernia repair in pediatrics. Laparoscopic assisted percutaneous internal ring suturing was performed under general endotracheal anesthesia on 54 children with 64 hernias during the period from July 2018 to June 2019. Under laparoscopic-guided vision a 2-0 Prolene® thread inside an 18-gauge epidural needle was placed through the abdominal wall into the peritoneal cavity, then the thread passed under the peritoneum around the internal ring. The knot was tightened from outside and placed in the subcutaneous space. The mean operative time was 14.18 min for unilateral and 21.2 min for bilateral hernias. Cosmetic results are excellent with almost invisible scars. There were no intraoperative and six postoperative complications (recurrence in three cases, transient hydroceles in two boys and one patient had stitch sinus). Laparoscopic assisted percutaneous needle repair of congenital inguinal hernia seems to be a simple minimally invasive procedure in small ring diameter with excellent cosmetic results. But I do not recommend this technique due to high rate of complications and recurrence, also simplicity of the technique can be regarded as a hindrance to the surgeons in training from challenging their skills to be ready for the more complex scenarios.

A prospective study on effects of treatment of hernia sac stump in laparoscopic transabdominal preperitoneal inguinal hernia repair on postoperative seroma

Objective To investigate the effects of treatment of hernia sac stump in laparoscopic transabdominal preperitoneal inguinal hernia repair (TAPP) on postoperative seroma. Methods The prospective study was conducted. The clinical data of 128 male patients with primary indirect inguinal hernia who were admitted to Fujian Medical University Union Hospital from October 2017 to March 2019 were selected. Patients were divided into two groups by random number method. Patients in experimental group had hernia sac stump sutured and fixed at the lower margin of rectus abdominis after transection of hernia sac in TAPP, and patients in control group had hernia sac stump free in the abdominal cavity after dissection and transection of hernia sac in TAPP. Observation indicators: (1) surgical situations; (2) follow-up. Follow-up using outpatient examination and telephone interview was conducted to detect the incidence of postoperative seroma, incision infection, chronic pain, and hernia recurrence up to June 2019. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was done using the t test. Measurement data with skewed distribution were represented as M (range), and comparison between groups was done using the Mann-Whitney U test. Count data were described as absolute numbers and percentages, and comparison between groups was analyzed using the chi-square test. Results A total of 128 male patients were screened for eligibility, including 60 patients in the experimental group and 68 patients in the control group. The 128 patients were aged from 47 to 74 years, with an average age of 61 years. (1) Surgical situations: operation time and hospital expenses were (102±34)minutes and (12 813±2 390)yuan for the experimental group, and (97±30)minutes and (12 125±2 205)yuan for the control group, respectively, showing no significant difference between the two groups (t=0.907, 1.685, P>0.05). (2) Follow-up: all the 128 patients received follow-up. There were 8 cases of seroma in both the experimental group and the control group, with no significant difference between the two groups (χ2=0.072, P>0.05). The extraction volume of patients with seroma was 20 mL (range, 4-31 mL) in the experimental group, and 43 mL (range, 23-98 mL) in the control group, showing a significant difference between the two groups (Z=-2.013, P<0.05). There was no incision infection, chronic pain or hernia recurrence in 3 months after operation in patients with seroma of either experimental group or control group. Conclusions During TAPP, suture and fixation of the hernia sac stump to the lower edge of rectus abdominis and free hernia sac stump in the abdominal cavity after dissection and transection of hernia sac can effectively repair indirect inguinal hernia. The former method can reduce the extraction volume of seroma after operation. Key words: Hernia; Indirect inguinal hernia; Transabdominal preperitoneal inguinal hernia repair; Seroma; Laparoscopy; Prospective study

Laparoscopic Posterolateral Suture Rectopexy for Recurrent Rectal Prolapse in Children.

Introduction: Laparoscopic rectopexy for recurrent rectal prolapse (RP) is more widely used nowadays. Strict indications are needed to get proper outcomes. The advantages rely on the careful dissection of peritoneal sac and fixation of rectum. One of the theories of recurrent RP is hernia-like physiology in front of the rectum. Purpose: The aim of this study is to present our experience of posterolateral laparoscopic suture rectopexy (LSR) in indicated children of recurrent RP. Patients and Methods: Sixteen patients were included with recurrent RP wherein all were subjected to LSR procedure after exclusion of other probable causes. Dissection of peritoneal sac anterior to the rectum was carried out followed by closure of the deep pouch by nonabsorbable sutures then fixation of the right side of rectum and sigmoid to the lateral wall of areolar tissue. Fixation to sacral promontory is done by Ethibond or Prolene sutures when redundancy is obvious. Results: The study included 11 girls and 5 boys with age ranging between 3 and 12 years in the past 5 years. Ten cases were treated earlier with injection therapy and 6 following Thiersh procedure after failure of conservative treatment for 6 months. Operative time ranged between 40 and 100 minutes. Follow-up period ranged between 6 and 36 months with mean of 19.5 months. Postoperative mucosal prolapse reported in 1 case 6 months postsurgery with no full thickness recurrence. Conclusions: LSR is an efficient technique in well-selected children of recurrent RP and could reverse this underlying pathology. Longer follow-up and evidence are needed to standardize the technique.

Triangle Trocar Configuration in Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair: A Prospective Randomized Controlled Study

BackgroundIn totally extraperitoneal (TEP) operation, when trocars are arranged with midline configuration, operative instruments can easily interfere with each other because of the small operative angle. The triangle trocar configuration, which creates a large operative angle, may minimize interference. Therefore, we evaluated the use of triangle trocar configuration in TEP inguinal hernia repair. MethodsA prospective randomized controlled study was conducted in 113 patients of laparoscopic TEP inguinal hernia repair in the Department of Hernia and Abdominal Wall Surgery, Shanghai East Hospital, between July 2016 and June 2017. Patients were randomly assigned to TEP laparoscopic inguinal hernioplasty with triangle trocar configuration (study group, n = 59) or midline trocar configuration (control group, n = 54). Perioperative outcomes (operative time, operative complications, postoperative pain, hospital stay, and costs), early postoperative complications (seroma/hematoma and uroschesis), and mid-term outcomes (late postoperative complications and recurrence) were observed and compared. ResultsAfter a mean follow-up of 10.21 ± 2.32 mo, there was no significant difference in operative time, operative complications, postoperative pain, postoperative hospital stay, costs, postoperative complications, and recurrence rate between the two groups. The indirect hernia sac dissection time was shorter in the study group than in the control group. ConclusionsTriangle trocar configuration in TEP laparoscopic hernia repair is safe and reliable and is an option for hernia surgeons. The technique creates a large operative angle and avoids interference between endo-instruments, which facilitates TEP and decreases the indirect hernia sac dissection time.