Extraperitoneal Research Articles

Enhanced-view totally extraperitoneal access for repair of ventral hernias: Advantages and liabilities

The concept of enhanced-view totally extraperitoneal (eTEP) access was developed while exploring ways to facilitate the TEP approach for inguinal hernia repair. Surgeons soon noticed that the surgical space was ideal for repair of other abdominal hernias. The “crossover” maneuver, designed as a technique to cross from one retrorectus space to the other, permitted application of eTEP access to most hernias. eTEP access has the general advantage of working in the extraperitoneal space and the specific advantage of hernia repair allowing implementation of the modern principles of ventral hernia reconstruction and providing flexibility to address different types of hernias in different locations. The technique requires formal training and has inherent complications and limitations. The remarkable widespread acceptance and encouraging early results of this complex technique emphasize the responsibilities of proper training, judicious use, and evaluation of our own and others’ results.

Open Mesh Hernioplasty versus Laparoscopic Total Extraperitoneal Mesh Repair in the Treatment of Inguinal Hernia

Background: There are multiple techniques used worldwide to repair inguinal hernia. The open mesh hernioplasty is easy to carry out, tension free repair and having good long term results but has few complications as well. Recently the laparoscopic repair of inguinal hernia is the best option because of its merits like lower recurrence rate, lesser postoperative pain, fast recovery and lower risk of complications. The results are controversial so there is a need to evaluate that which technique is better in our population so the aim of current study was to compare the outcome of open mesh hernioplasty versus laparoscopic total extra-peritoneal mesh repair in the treatment of inguinal hernia. Methods: A randomized controlled trial was conducted in the department of surgery, Ziauddin hospital, Karachi during May to December 2021. Patients included in the study were divided into two groups, Group A included those who underwent open mesh hernioplasty while Group B contained patients treated with laparoscopic total extra peritoneal mesh repair. The complication including scrotal hematoma was assessed clinically and confirmed by ultrasound then putted on follow up for two weeks. Data was collected on self-designed proforma. Statistical Package for Social Science (SPSS) version 20 was used for analysis of data. Results: The mean age of the study participants was 36.2±5.6 years. In both group A and B, majority of patients were having right sided inguinal hernia. In Group A, majority of patients were presented with direct inguinal hernia while majority of Group B patients were presented with indirect inguinal hernia but the p-value was non-significant. Postoperative scrotal hematoma was found in 19.5% of the study participants among them 7.8% participant were having direct inguinal hernia and 11.7% presented with indirect inguinal hernia. The frequency of scrotal hernia in patients of Group A, having open mesh hernioplasty was 15.6% while in Group B lesser frequency of postoperative scrotal hematoma was noted and the results were highly significant. Conclusion: It can be concluded that laparoscopic total extra-peritoneal mesh repair is the best technique for repairing inguinal hernia because of its minimal postoperative complications in comparison to open mesh hernioplasty. It is recommended to consider laparoscopic total extra-peritoneal mesh repair as the first line treatment option in the case of inguinal hernia. Keywords: Inguinal Hernia, Laparoscopic total extra-peritoneal mesh repair, Open mesh hernioplasty

A case of anterior abdominal wall tuberculosis

A rare case of a middle-aged woman who presented to our emergency department with a huge swelling over lower part of abdomen for 3 years that was associated with continuous purulent foul-smelling discharge from multiple sites over swelling for past 2 years and all her past history was irrelevant except for her significant loss of weight for 6 months and unable to ambulate due to huge swelling for 6 months. She is known diabetes mellitus type 2 for 6 years on oral hypoglycemic drugs. On examination she had stable vital signs, mild pallor, a large globular swelling of about grossly 30×30×20 cm extending from 2 cm below umbilicus superiorly till pubic symphysis inferiorly, bilaterally extending till anterior superior iliac spine, flanks not full, multiple dilated veins over skin. Multiple foul smelling pus discharging sinuses, prominence on leg raise test and absent cough impulse, rest of the abdomen is soft and non-tender with no organomegaly and present bowel sounds. Bilateral inguinal group of lymph nodes were palpable and matted. Swelling was exclusive extra peritoneal on computed tomography (CT) scan. Excision of swelling was done up to anterior rectus raw area open wound with bilateral inguinal lymph node excision was under general anesthesia was done. Histopathology showed granuloma with caseating necrosis from lymph nodes. Anti-tuberculosis therapy intensive phase was started post operative wound was healthy, and after 6 weeks of initiation of anti-tubercular treatment wound was closed with secondary suturing.

Preoperative Subcutaneous Fat is an Useful Indicator for Learning Totally Extraperitoneal Repair.

Totally extraperitoneal (TEP) repair is a recommended procedure for inguinal hernia repair in European hernia guidelines. However, technical challenges have limited its uptake in Japan, where transabdominal preperitoneal (TAPP) repair is more common. We evaluated the association of preoperative subcutaneous fat area (preSFA) with surgical outcomes and identified factors associated with the difficulty of TEP repair. Clinical data from 62 patients undergoing TEP repair were collected retrospectively. Using the median for the preoperative subcutaneous fat index (preSFI; 45.9 cm2/m2), we classified patients as having a high SFI (HSFI) (n=31) and low SFI (LSFI) (n=31). Surgical outcomes and perioperative complications were then compared between these groups. Additionally, TEP repair was divided into five phases (e.g., Phase 1: dissection of the caudal side of the preperitoneal space), and operative time was measured during each phase. Phase 1 was divided into two sub-phases (1A: insertion of the first port, 1B: reaching Cooper's ligament). Operative time was longer (133 min vs 111 min, P = 0.028) and the peritoneal injury rate was higher (35.5% vs 9.7%, P = 0.015) for the HSFI patients. Furthermore, operative time for HSFI patients was significantly longer during Phase 1 (P = 0.014) and Phase 1A (P = 0.022). preSFA was associated with a higher peritoneal injury rate and longer operative time in HSFI patients, suggesting that the presence of abundant subcutaneous fat increases the difficulty of TEP repair.

Early sigmoid perforation involving left inguinal hernia mesh repair: a case report.

Injury to the underlying bowel is a serious potential complication following inguinal hernia mesh repair. Here the authors describe a rare case of a 69-year-old gentleman who initially presented with a deep collection in the retroperitoneum, which extended into the extraperitoneal space on the anterior abdominal wall 3 weeks following left inguinal hernioplasty. Early sigmoid perforation involving the inguinal hernia mesh repair was diagnosed, and he underwent a successful Hartmann's procedure with mesh removal.

Laparoscopic retro muscular lumbar hernia repair using an extended totally extraperitoneal (eTEP) approach: how do we do it?

: Lumbar hernias are infrequent defects of the posterior abdominal wall, located between the 12th rib and the iliac crest. These types of hernias are classified as congenital, spontaneous, traumatic, and incisional. The lumbar hernias generally protrude through two anatomical regions: the superior lumbar triangle of Grynfeltt-Lesshaft and the inferior lumbar triangle of Petit. Although they are usually small defects, they can be very symptomatic and a real surgical challenge even for experienced surgeons. Many techniques have been described for the surgical treatment of these hernias, but there is still no gold standard for multiple reasons. The extended totally extraperitoneal (eTEP) technique consists of a series of maneuvers and operative strategies aimed at enhancing the extraperitoneal space for a minimally invasive repair of ventral, inguinal, and lumbar hernias, in a safe and effective manner. This manuscript describes our technique for a lumbar hernia repair done through an eTEP approach. We have adopted since 2018 the eTEP approach for inguinal and ventral hernia repair and have found these approaches very reproducible and ergonomic, after almost 100 inguinal and 50 ventral cases, this experience helped us extrapolate the skills and competence to tackle down a lumbar hernia defect using an eTEP approach.

Total extra-peritoneal inguinal hernia repair: experience in a tertiary care hospital of Bangladesh

Background: Open hernioplasty, a traditional procedure, is practiced for decades all over the world, for inguinal hernia repair and the newer procedure of total extraperitoneal (TEP) inguinal hernia repair is the current trend. Aim of this study was to share the experience of TEP inguinal hernia repair.
 Methods: This retrospective observational study was done from April, 2012 to March, 2021 at BIRDEM General Hospital, Dhaka, Bangladesh. Patients with inguinal hernia reporting to BIRDEM outpatient department (OPD) were counseled for TEP repair. Those who consented were treated electively with a TEP repair for a unilateral or bilateral hernia defect, either direct or indirect. All procedures were completed with patients under general anaesthesia. Polypropylene mesh was placed in preperitoneal space. Followed up records were noted at one week, one month, one and two years after surgery. Patients’ age, hernia types and locations, complications, length of stay in hospital, return to work and recurrence were noted.
 Results: Total patients were 118 including one female. Patients were between 22 and 72 years. All of them had primary hernias and 72% of them underwent unilateral repairs. One of the cases required conversion to transabdominal preperitoneal procedure. In five patients (4.2%) intraoperative complication occurred and postoperative courses were complicated in 8 patients (6.7%). Patients were able to resume their daily activities after a mean period of 7 days (3 to 10 days). There was no mortality.
 Conclusion: In patients with uncomplicated inguinal hernias, TEP is associated with a very low overall risk of serious complications and recurrence with a very good functional outcome. It is equally applicable with bilateral inguinal hernias without added risk.
 BIRDEM Med J 2023; 13(1): 44-48

Comparison of balloon dissection and telescopic dissection of the preperitoneal space in laparoscopic totally extraperitoneal hernia repair: a systematic review and meta-analysis.

Safety in creating a preperitoneal space is crucial in laparoscopic totally extraperitoneal (TEP) hernia repairs. In this systematic review and meta-analysis, we compared the outcomes of balloon dissection and telescopic dissection in patients with inguinal or femoral hernias who underwent TEP hernia repair. We searched PubMed, Embase, Web of Science, and Cochrane databases for randomized controlled trials (RCTs) and prospective and retrospective studies published from inception to July 2022. Meta-analysis was performed using a random-effects model. The treatment outcome was measured using operation time, incidence of intraoperative hemorrhage, peritoneal laceration, conversion to other approaches, surgical site infection (SSI), hematoma, seroma formation, hernia recurrence, and postoperative pain. Five RCTs, one prospective study, and two retrospective studies (in total, 936 patients) were included. No significant between-group differences were noted in operation time, SSI, hematoma, seroma, recurrence rate, and postoperative pain on days 1 and 7. The conversion rate was significantly lower in the balloon group than in the telescopic group (odds ratio, 0.34; 95% confidence interval, 0.15-0.81). Both balloon dissection and telescopic dissection are viable techniques for creating preperitoneal space in laparoscopic TEP hernia repair and have similar operation time, complication rate, and postoperative pain. Nevertheless, the conversion rate was lower in patients undergoing balloon dissection than in those undergoing telescopic dissection.

SJLA_2024_A16: Unusual Complications of Open Preperitoneal Tension-Free Inguinal Hernia Repair

Background: The purpose of this study is to report two patients referred to our hospital after developing unusual complications attributed to prior open preperitoneal tension-free inguinal hernia repair. Methods: Case # 1 A 75-year-old male developed a left proximal thigh abscess requiring incision and drainage 5 years after open prosthetic, preperitoneal inguinal hernia repair with single-layer mesh. A pelvic computed tomography (CT) scan demonstrated an abscess in the left inguinal preperitoneal space as well as diverticulosis but no diverticulitis. A colonoscopy was negative for any additional findings. The patient underwent groin exploration, debridement of the inguinal canal and sinus tract, and mesh resection followed by JP drain placement. The inguinal defect was repaired utilizing the should ice technique. Intraoperative cultures revealed penicillin-resistant Staphylococcus aureus. The drain was removed on postoperative day nine, and his recovery remains uneventful without hernia recurrence or infectious complications at 11-month follow-up. Case # 2 An 82-year-old man developed progressive left lower extremity edema and disabling claudication 1 month after open prosthetic inguinal hernia repair with a bilayer disc mesh. Venous duplex imaging revealed compression of the left common femoral and external iliac veins. A CT angiogram demonstrated left external iliac and common femoral artery thrombosis and a 5.2 cm fluid collection consistent with hematoma. An inferior vena cava filter was placed. The common femoral artery was controlled after initial exploration revealed a common femoral artery pseudoaneurysm. The mesh was densely adherent to the external iliac vein and was thus not resected. The common femoral artery pseudoaneurysm was repaired and the profunda femoris artery over sewn. An external iliac to superficial femoral artery 8 mm Polytetrafluoroethylene bypass graft was placed. The patient was discharged on systemic anticoagulation without claudication on postoperative day thirteen. Results: Laparoscopic inguinal hernia repair and novel, open techniques and mesh devices have popularized the placement of mesh in the preperitoneal space. Acute, severe vascular complications and latent infectious complications can occur after open, preperitoneal tension-free inguinal hernia repair and may require remedial surgery. CT scans and angiogram pictures are available. Discussion: Laparoscopic inguinal hernia repair and novel, open techniques and mesh devices have popularized the placement of mesh in the preperitoneal space. Acute, severe vascular complications and latent infectious complications can occur after open, preperitoneal tension-free inguinal hernia repair and may require remedial surgery. CT scans and angiogram pictures are available. Conclusion: Laparoscopic inguinal hernia repair and novel, open techniques and mesh devices have popularized the placement of mesh in the preperitoneal space. Acute, severe vascular complications and latent infectious complications can occur after open, preperitoneal tension-free inguinal hernia repair and may require remedial surgery. CT scans and angiogram pictures are available.

Solitary fibrous tumor in the preperitoneal space mimicking an intra-abdominal tumor

Solitary fibrous tumors (SFTs) are uncommon fibroblastic mesenchymal neoplasms that rarely metastasize. They were primarily considered intrathoracic tumors; however, recent studies have reported SFTs in extrathoracic locations. This report describes a rare case of an SFT in the preperitoneal space that mimicked an intra-abdominal tumor radiographically. A 67-year-old woman was diagnosed with an extrahepatic tumor through ultrasonography. Computed tomography revealed a nodule near the liver's left lobe at the upper abdominal midline. Laparoscopic tumor resection was performed to minimize undersampling and tumor seeding. Laparoscopy revealed a well-circumscribed tumor located in the preperitoneal space. The tumor was resected en bloc with a macroscopically negative margin. Histopathological examinations confirmed an SFT using immunohistochemistry. Adjuvant treatment was not administered. No residual lesions were reported at the 6-month and 1-year follow-ups. Although SFT rarely metastasizes, early diagnosis and treatment of SFTs should be emphasized to ensure optimal patient outcomes.

Outcomes of preperitoneal injection of pancreatic auto islet cells

Background: Total pancreatectomy with islet cell auto-transplant is an effective treatment for chronic pancreatitis and avoids the complication of brittle diabetes. The current standard of care for islet auto-transplant is intraportal infusion of processed islets. However, concern for portal vein thrombosis limits islet cell infusion volume. Previously studied alternatives included kidney, omentum, lung, and pancreatic bed. Our group previously suggested the preperitoneal space may be an appropriate location for injection as has been demonstrated in mouse models, although no human studies have been reported. Here we report our initial experience with islet cell auto-transplant into the preperitoneal space during total pancreatectomy for chronic pancreatitis.

Bilateral obturator hernia with incarcerated richter type hernia: A case report

Obturator hernia are a rare type of hernia which can lead to life threatening bowel ischemia. We report a case of a richter type obturator hernia that was repaired primarily followed by contralateral obturator hernia within two weeks. A contralateral obturator hernia causing bowel obstruction was identified and treated laparoscopically with transabdominal preperitoneal mesh placement just two weeks after exploratory laparotomy with primary repair of left sided obturator hernia for a richter type hernia. This case highlights the importance of checking both obturator foramen for defects during repair of obturator hernia. If repaired open, this may only be realized by palpation and would only be visualized by entering the preperitoneal space.

ETEP technique for inguinal and ventral hernias: approach being simplified

Background: Enhanced view totally extra peritoneal (eTEP) approach for inguinal and ventral hernias repair is becoming the preferred technique. Initially the technique was described by Jorge Daes for inguinal hernia repair and later Igor Belyansky applied this technique for ventral and incisional hernia repair. Since it does not penetrate the peritoneal cavity, the major advantage of this approach is in reducing the risk of intestinal and vascular injuries as well as herniation at the trocar sites. This eTEP approach provides scope for flexible port placement and wide coverage by the prosthetic mesh in the retromuscular space with hardly any transfascial fixation. Here we bring forward the technical benefits and avoidable hurdles encountered which might render this as most sought approach. Patients and Methods: 72 patients with mean age of 44 yrs underwent eTEP repair between July 2018 and June 2022. The data was analysed for standardising the surgical steps of eTEP approach, operative time taken, technical advantages in this approach and hurdles encountered Results: All 72 patients underwent laparoscopic repair successfully. There were six conversions to alternate laparoscopic hernia repair techniques. The operative time improved with the subsequent surgeries though initially it was prolonged. Conclusion: Our clinical experience with eTEP approach has been convincing. With improved technical steps, adjunct hybrid manoeuvres & hurdles overcome; eTEP is becoming a favourable approach for laparoscopic inguinal and ventral hernias repair in our practice. We believe this technique makes a striking presence among all the types of surgical approaches for laparoscopic hernia repair.

A retrospective study of short term outcomes of ventral abdominal wall hernia patients operated by extended total extraperitoneal mesh repair at a tertiary care centre

Background: Laparoscopic repair of various abdominal wall hernias are well accepted procedure due to its low post- operative complications, recurrence and long term results. Various procedures have been described like IPOM, MILOS, E-MILOS, SCOLA, TES and E-TEP. Here we present short term outcome of ventral abdominal wall hernia patients operated by extended total extra peritoneal (E-TEP) repair at a tertiary care hospital over a period of two years.Aims and Objectives: To assess the initial outcomes of patients of ventral abdominal hernias operated by extended total extra peritoneal mesh repair (E-Tep).The study was done to find out the effectiveness of E-Tep repair in surgical treatment of ventral abdominal wall hernia patients.Methods: All the patients operated electively for uncomplicated ventral hernias from November 2020 till December 2021 were selected for the study and followed up for one year till December 2022. Results: In our study 35 patients, were operated by E-Tep for ventral hernia repair. There was no incidence of postoperative complications in terms of, haemorrhage, surgical site infection, chronic pain and recurrence. There was 10.5% incidence of seroma in postoperative period which was managed conservatively.Conclusion: In our experience, E-Tep repair is found to be effective as it allows flexibility in placement of ports for better suturing and deployment of an adequate size of polypropylene mesh in a retro muscular space.

The outcome of Transversus Abdominis Release for complex ventral hernia: A one-year of follow-up experience

Introduction: Transversus Abdominis Release is a noble technique for the repair of complex ventral hernia, where the posterior component separation allows a huge pre-peritoneal space advantageous for the placement of large-sized mesh. It has less wound morbidity as compared to anterior component separation due to the preservation of skin perforators. The main objective of this study was to evaluate one-year follow-up results in terms of recurrence, wound morbidity, and various techniques for managing complications of Transversus Abdominis Release. Methods: This is a descriptive crosssectional study that was conducted at the department of surgery, College of Medical Sciences Teaching Hospital. Among 41 patients with complex ventral hernia, 34 patients met the inclusion criteria. Demographic data, intra-operative events like bleeding, operative duration, intraoperative complications, post-operative events like duration of hospital stay, wound morbidity, and follow-up data were analyzed. Results: Posterior rectus sheath closure at midline was possible in 30 (88.2%) patients. In patients, where posterior rectus sheath closure was not possible, the peritoneum of hernia sac was tailored to patch the defect or in some omentum was placed below the raw surface of mesh. The average operative duration and blood losses were 130±12 minutes and 301±133 ml respectively. The semilunar line injury occurred in one case that was diagnosed and repaired at the same time and the TAR plane was re-established. Wound morbidity occurred in three cases that were managed by dressing with commercially available collagen and mupirocin granule. No recurrence was observed in one-year follow-up. Conclusions: Transversus Abdominis Release has a better result with no recurrence in short term follow up and fewer complications which are easily manageable.

Comparative Study on Laparoscopic Hernia Repair: Totally Extra Peritoneal Repair (TEP) and Transabdominal Preperitoneal (TAPP) at a Tertiary Care Centre

Background Minimal invasive surgery (MIS) procedures in the early 90's as laparoscopic transabdominal preperitoneal repair (TAPP) and totally extra peritoneal repair (TEP), have gained popularity worldwide over open hernia mesh repair with low recurrences, complications and early return to work and activities. This retrospective study aims to compare the two laparoscopic procedures regarding various parameters like duration of surgery, postoperative complications and duration of hospital stay in various ages and different sexes as described in the methodology. Methods This is a retrospective study for over 2 years which included patients with unilateral inguinal hernia both direct and indirect using either (TAAP) or (TEP) technique. Results Among sixty patients with an inguinal hernia, 30 patients had undergone (TAPP) and 30 had undergone (TEP). The duration of surgery for (TAPP) was observed 111.03±13.71 minutes which was significantly higher than that of (TEP) (92.80±8.24 minutes) at P<0.001. The pain score at 6 hours for (TEP) was 6.97±1.01 in comparison to 8±0.00 for (TAPP) (P<0.001). The pain score at 24 hours for (TAPP) was 5.18±1.00 in contrast to 4.27±0.70 for (TEP) (P<0.001). Conclusion Both (TAPP) and (TEP) are feasible surgical options to treat an inguinal hernia. (TAPP) had significantly longer operating time and more early post-operative pain as compared to (TEP). However, there was no significant difference in hospital stay, post-operative complications in both the group.

Richter port site hernia as cause of acute bowel obstruction after laparoscopic gastric bypass: A case report

Introduction: Early post-operative small bowel obstruction is challenging. After laparoscopic surgery, port site herniation and herniation through a peritoneal defect into the preperitoneal space should be considered as causes of early post-operative small bowel obstruction. Case Report: A 36-year-old female developed early post-operative small bowel obstruction due to port-site Richter hernia after laparoscopic gastric bypass managed by diagnostic laparoscopy. Conclusion: Early post-operative small bowel obstruction should always be suspected and diagnosed early in certain high risk procedures.

OGBN V07 Laparoscopic repair of rare case of interparietal port-site incisional hernia with mesh in sub-lay; pre-peritoneal space

Abstract Background Interparietal hernias are defined as protrusions of intraabdominal contents within the layers of the abdominal wall. Primary interparietal hernias; like Spigelian's hernia are rare, 0.12% to 2% of all abdominal wall hernias. Recently, interparietal hernias are more encountered as incisional hernias. However, very few cases have been reported in literature of interparietal hernia at port site following laparoscopic surgery, keeping in mind that port site hernias incidence varies between 0.74% to 1.47% after laparoscopic surgical procedures. Here we are presenting a rare case of interparietal port site incisional hernia, its management and summarising the key steps for laparoscopic mesh in sub-lay (pre-peritoneal) plane with defect closure. Methods We present a case of 72-year-old gentleman, who had robotic prostatectomy in January 2020. He presented towards the end of that year with left lower abdominal ache and discomfort. On examination he had bout 2 cm palpable hernia in LLQ at the site of 11 mm port. CT scan confirms the hernia at port site where internal muscles had been damaged, but external oblique muscle remains intact. Hernia MDT discussion advised conservative management, given low probability of incarceration given the current hernia anatomy, and advised surgical intervention if hernia affecting daily activity and lifestyle. Clinical review after one year, patient describes more discomfort as dull pain that increases with his usual activity like gardening, walking or running, necessitating increasing analgesia for 2,3. The patient believes that this hernia is affecting his life. Repeat scan showed muscular defect within the left iliac fossa, between the left rectus abdominis medially and retracted transversus abdominis and internal oblique muscles laterally. The external oblique muscle and facia along with anterior rectus sheath are intact. After further discussion with patient regarding risks vs benefits, patient opted for surgical treatment with laparoscopic approach Results Patient in supine position. Pneumoperitoneum created using Veress needle at Palmer's point, 11mm optical-port in the right lumbar area. Laparoscopy confirmed bulging at the pre marked site of the hernia, another 2×5 mm ports. Bulging identified at hernia site. Anterior parietal peritoneum incised vertically along the midline and dissection carried out laterally to develop the pre-peritoneal space. Defect exposed and assessed. There was a horizontal rupture of the arcuate ligament across the posterior rectus sheath exposing a section of inferior epigastric vessels and rectus muscle. This rupture extends laterally to involve the transverse abdominus and internal obliques muscle total size defect of 6×3 cm. Defect closed with 1.0-Ehtilon that was introduced using Endo Close leaving the free end outside. The defect was closed continuously in two layers then the end was extracted and tied to free end trans-fascially under low abdominal pressure at the end of procedure. 20.3×15.2 Ventralight ST Mesh placed in the pre peritoneal plane after marking the centre with one 2.0-Prolene stitch that was used to anchor the mesh. Mesh was only fixed medially using AbsorbaTack to avoid post operative pain. Then the peritoneum was closed in the midline, covering the mesh using AbsorbaTack. Conclusions Interparietal hernias usually present with discomfort, pain or acutely due to incarceration or strangulation. Very little is reported regarding the presentation of interparietal port site hernia as few are reported in literature. This abstract describes a rare interparietal port site incisional hernia that is presented with pain and discomfort, affecting lifestyle. Furthermore, we describe an approach to repair the hernia without disturbing the intact anterior fascia, utilizing a combination of defect closure and synthetic prothesis placed in the pre peritoneal space, thus minimising the chance of future mesh complication. This case highlights not only the importance of closing port site more than 11 mm but more importantly the need to make sure that all abdominal wall layers are included to avoid interparietal hernia at port site.

Prospective comparative study of mesh fixation in laparoscopic TEP hernia repair using tacker versus cyanoacrylate versus fibrin glue tep mesh fixation with cyanoacrylate

Background: Laparoscopic inguinal hernia repairs done by totally extra peritoneal (TEP) or trans abdominal preperitoneal techniques require mesh fixation which is commonly done by either tackers or fibrin glue. In this study, we discuss about using cyanoacrylate glue for mesh fixation as a more cost effective but equally suitable alternate. Aims and Objectives: The aim of the study was to evaluation of suitability of using highly economical cyanoacrylate ($ 0.13) with tackers ($ 318.52) and fibrin glue ($ 11.94) for mesh fixation during TEP hernia repair. Materials and Methods: A comparative study was done in the Department of Surgery over a period of 3 years (2018–2021). This study included 210 patients who underwent laparoscopic TEP hernia repair. Cases were randomized into three groups of 70 subjects each: Group A - mesh was fixed with tacker, Group B - mesh was fixed using cyanoacrylate, and Group C - mesh was fixed with fibrin glue. Subjects were followed up for 3 months. Type of presentation, diagnosis, and type of mesh fixation were compared to post-operative complications that included pain, seroma, hematoma, and urinary retention findings were recorded and data were statistically analyzed using “SPSS” software. Results: Decreased incidence of post-operative pain (P=0.01) and hematoma was observed in Group B as compared to Groups A and C. Average hospital stay was significantly less in fibrin glue group (P=0.02) and cyanoacrylate group (P=0.02) as compared to tacker group. There was same incidence of postoperative urinary retention (P=0.520) and seroma (P=0.354) formation between all groups. Patients of Group B started daily activities earlier at 15 days follow-up (P=0.032) as compared to Groups A and C. Conclusion: Cyanoacrylate and fibrin glue fixation of mesh in laparoscopic TEP have better outcomes when compared to tackers. Furthermore, as cyanoacrylate is 300 times cheaper than tacker and 10 times cheaper than fibrin glue, this imparts a huge cost advantage to this technique in developing countries. Therefore, use of cyanoacrylate for mesh fixation in laparoscopic TEP can be safely advocated over tackers and fibrin glue.

A Case of Preperitoneal Herniation of the Small Bowel Causing Intestinal Obstruction Following a Totally Extra Peritoneal Hernia Repair

Preperitoneal hernia is a very rare complication following laparoscopic inguinal hernia repair. A 57-yearold male underwent a right inguinal hernia totally extra peritoneal repair on 20/10/2021. Initial recovery was uncomplicated but on post operative day 10, he developed sudden onset of vomiting and abdominal pain. Initial imaging showed small bowel obstruction with a possible transition point. An internal hernia was suspected and he was offered urgent diagnostic laparoscopy following counseling. A preperitoneal defect was noted with distended proximal ileum and collapsed distal ileum and colon. A small bowel runthrough did not reveal any pathological abnormalities. A presumptive diagnosis of a preperitoneal hernia was made, and the defect was closed with a running V lock suture. The patient made an uneventful postoperative recovery. An inadvertent breach in the peritoneum during a totally extra peritoneal repair can lead to preperitoneal herniation of the small bowel and intestinal obstruction postoperatively.