Inguinal Defect Research Articles

A Keystone Flap as A Reconstructive Option for Anterior Abdominal and Inguinal Defect

The keystone flap is an effective solution to this by utilizing local tissue similar to a keystone to close the defect without the need for tissue transfer from other locations in the body. This makes it a highly effective option in reconstructing complex defects of the anterior abdomen and inguinal region, supporting complete patient recovery. This study aims to determine the effectiveness of using keystone flaps in covering large defects in the abdominal and inguinal walls after tumor removal. This study used a descriptive method with a retrospective approach. Data collection techniques in this study were literature study, observation and patient medical records. The data that has been collected is then analyzed in three stages, namely data reduction, data presentation and conclusion drawing. The results showed that the keystone flap can be used to cover extensive damage to the abdominal and inguinal walls after tumor removal with success. The keystone flap is a reasonably easy defect reconstruction, is very reliable, and has low morbidity and complications

IS MESH TERROR ENDEMICAL? A GEOGRAPHICAL ANALYSIS OF TRENDS

Abstract Introduction Mesh reinforcement for hernia repair has demonstrated to reduce recurrence rates for many scenarios of ventral and inguinal defects. In recent years, many hernia surgeons from specific geographies have encountered patients who feel strongly against the use of mesh, while physicians from other areas of the world have not reported this situation. This study aims to explore the regional trends associated with this phenomenon. Methods A global Google Trends search using the query “hernia”, “mesh complications” and “hernia mesh lawsuit” was used for data analysis. Search results are normalized to the time and location of a query by the following process: each data point is divided by the total searches of the geography, language, and time range it represents to compare relative popularity. The popularity index is represented as a percentile. Results An increase in popularity of hernia-related topics has been consistent for the past 15 years and this phenomenon has been consistent almost worldwide. The search term “mesh complications” also showed an increase in popularity mainly among English-speaking countries: the average popularity index since 2004 for this term has been 12% for the United States, 8% for the United Kingdom and <1% for Australia. “Hernia mesh lawsuit” has shown a significant increase in its popularity within the United States with an average popularity index score of 4% since 2004 and growing to 10% after 2016; while remaining relatively low (1–2%) for the rest of English-speaking countries. Even after adjusting for proportionality, non-English (Spanish, Mandarin, Portuguese and Hindi) mentions of “mesh complications” and “hernia mesh lawsuit” were significantly less frequent and were, in fact, very often advertising translations of legal firms within the United States. Conclusion Parallel to a global increase in the interest in hernia knowledge, there has been an escalation in the search for mesh complications information especially within the United States. This increase appears to be related to a surge in law firm advertising for hernia related issues. Further studies should focus on improving understanding of the general public perception and refining education mechanisms to assist patients and surgeons.

CYSTIC INGUINAL LYNFHANGIOMA IN ADULT FEMALE

Abstract Background To present a clinical case of cystic inguinal lymphangioma in an adult female, an atypical site and age of presentation. Method A 42-year-old woman was referred for consultation due to persistent pain and swelling in the right inguinal region, with initial suspicion of inguinal hernia. A mobile, irreducible mass without protrusion during the Valsalva maneuver was identified. Faced with diagnostic uncertainty, inguinal ultrasound and magnetic resonance imaging were requested, revealing a cystic lesion indicative of cystic inguinal lymphangioma. Results Elective surgery was decided. A right inguinal incision revealed a cystic tumor extending along the inguinal canal from the labium majus to the preperitoneal space. Complete excision was performed, requiring section of the round ligament. Subsequently, closure of the deep inguinal ring was conducted, with the conjoint tendon approximated to the inguinal ligament using a continuous suture of slowly absorbable monofilament. Hernioplasty with self-adhesive polypropylene mesh was employed to repair the inguinal defect. The procedure was carried out in the ambulatory major surgery program. At the one-month post-surgery follow-up, the patient exhibited satisfactory recovery with no signs of clinical recurrence. Histopathological examination of the surgical specimen confirmed the diagnosis of cystic inguinal lymphangioma, with no additional pathological findings. Conclusion Cystic lymphangioma is a benign and uncommon malformation of the lymphatic system. It should be considered in cases of inguinal masses with progressive growth whose examination is not consistent with an inguinal hernia. Ultrasound is the imaging test of choice, with definitive diagnosis confirmed by histopathology. Surgery with complete resection is recommended due to the risk of recurrence.

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.

V-044 ABDOMINAL WALL RECONSTRUCTION OF A POST-HEMIPELVECTOMY INCISIONAL HERNIA: AT THE LIMITS OF WHAT IS POSSIBLE

Abstract Incisional hernias in patients with bone defects are a real challenge. There is very little evidence of how to repairing them. Clinical Case 56-year-old patient. He underwent a left external hemipelvectomy for osteosarcoma of the iliac bone in 2012 and a left nephrectomy in 2013. The patient presents an inguinal and right thigh root bulge of progressive growth with severe pain and limited mobility. In the past month, he was unable to walk. Physical examination: inguinal defect, defect in the right thigh root and a large lateral bulge. Preoperative CT scan: atrophy of the left abdominal musculature, absence of the left hemipelvis, left hip prosthesis with a pseudocapsule, a large lumbar defect, and a large defect in the inguinal area. Surgery Dissection of hernia sacs and retroperitoneal/preperitoneal dissection was performed, cranially to the retrodiaphragmatic area, medially to the linea alba, posteriorly to the spine and caudally to the pelvis. The abdominal wall is reconstructed with a polyglycolic acid and trimethylene carbonate mesh to reinforce the abdominal wall and a large polypropylene mesh that envelops the visceral sac and is fixed to the right pubis and the pseudocapsule of the hip prosthesis. In the postoperative period, the patient presented pulmonary thromboembolism and surgical wound infection. He was discharged on the 17th postoperative day. One year after surgery, the patient is asymptomatic, and has a continent wall with discrete lateral bulging. Preperitoneal dissection makes it possible to solve very complex wall defects, even with very large bone defects.

Laparoscopic versus open inguinal hernia repair in infants: an initial experience.

Inguinal hernia repair is a common operation performed in children. In Australia, open repair (OR) continues to be the preferred method of treatment in infants, despite laparoscopic repair (LR) gaining popularity amongst some international centres. Our aim was to analyse initial outcomes with LR at our paediatric centre. We conducted a retrospective review of all patients <1year of age who received LR or OR between January 2017 and July 2021 at our institution. Data were retrieved from both electronic and scanned medical records. Data were analysed using an unpaired t-test, Mann-Whitney test, Fisher's exact test or simple linear regression. A P-value <0.05 was considered significant. A total of 376 patients were identified: LR was performed in 73 patients, and OR in 303 patients. Bilateral repair was more common amongst patients receiving LR: 56.2% versus 21.5%, P= 0.0001, treating either a symptomatic hernia or an intra-operative contralateral inguinal defect (70%). All LR patients received general anaesthetic, compared to 82.8% of patients in the OR group, P= 0.0001. There were no recurrences following LR and 3 with OR (P= 1.0). The metachronous contralateral inguinal hernia rate following OR was 10% (21/206). There was no significant difference in other complications, including wound infection, haematoma, testicular atrophy, and hydrocele formation. In our population OR was performed more often than LR. Operative complication rates were equivalent between OR and LR groups. However, infants that underwent OR were significantly more likely to develop a MCIH.

Lymphatic flow through (LyFT) ALT flap: an original solution to reconstruct soft tissue loss with lymphatic leakage or lower limb lymphedema

Introduction The lympho-venous shunt using the distal vein of ALT flap pedicle allowed at the same time the coverage of the inguinal defects and to perform lymphovenous shunt into a run-in vein of the descending branch of the lateral circumflex femoral pedicle, draining the lymph through the flap pedicle. Surgical technique, complications and final outcomes (both clinical and lymphoscintigraphic) are reported. Methods Five patients (45.8 y.o.[22–70]) with groin soft tissue loss with lymphatic leakage or lower limb lymphedema, benefited of the described technique. The ALT flap was used to cover the defect and, at the same time, we could perform a lymphovenous shunt between afferent lymphatics to the thigh and the descending branch of the lateral circumflex femoral pedicle, distal to the perforator nourishing the flap. Clinical and lymphoscintigraphic assessment of the limbs, cease of lymphorrhea or cellulitis/lymphangitis episodes, eventual downstaging of physiologic/physical therapy were recorded. LYMphatic Quality Of Life in leg (LYMQoLLeg) and patient satisfaction were evaluated. Results Average flap size was 88.8cm2 (range 84–126). The mean number of multi-lymphovenous anastomosis (MLVA) performed was 1.8 (range 1–3) per patient with 1–3 lymphatics shunted into each vein. Only one hemato-seroma requiring surgical revision. Mean improvement of perometer values was 48.2% (range 27.7–67.7) with an average follow-up of 13.6 months (range 12–17). Lymphoscintigraphy showed disappearing of the lymphatic leak and lymphedema with a high satisfaction of LYMQoL score. Discussion The combination of pedicle flap with lympho-venous bypass as lymphatic derivation concept, improving the chronic morbidity scenarios of lymphatic complications.

P038 MINIMALLY INVASIVE SURGERY &amp; INCARCERATED INGUINAL HERNIA. CAN WE COMBINE THEM?

Abstract Aim After a long experience of more than 20 years in TEP hernioplasty we explore if it can also be suitable for emergency patients. Material and Methods We present different laparoendoscopic schemes that we have used in our Hospital to treat strangulated inguinal hernia according to clinical and radiological findings. Results TEP in now assumed to be one of the best options in scheduled surgery to treat inguinal hernia. Is now the time to change the paradigm by using it also in emergency surgery? Incarcerated inguinal hernia presents two problems: first of all the clinical emergency, an irreducible inguinal bulge that causes pain, obstruction and bowel ischemia; and second, the need to repair inguinal wall. While treating both problems, we have explored different minimally invasive surgery approaches according to each patient´s characteristics and the preoperative risk of intestinal resection based on CT findings. To reduce the incarcerated bulge, we use a laparoendoscopic methods. After a preperitoneal dissection, and with the help of external maneuvers, we try to reduce the content. If we are not successful, a quelotomy becomes necessary. To treat the inguinal defect we use TEP or TAPP approaches. Conclusions We seek to show that endoscopic preperitoneal approach in an incarcerated inguinal hernia is safe and possible, allowing us to maintain minimal invasive techniques. Laparoscopy allows us to explore and to treat possible complications of intestinal ischemia with no need of laparotomy. Multiple treatment schemes are possible for inguinal incarcerated hernia. The choice must be made according to the surgeońs experience, patient´s characteristic and the risk of intestinal ischemia.

Robotic Direct Inguinal Hernia Repair: To Plicate or Not to Plicate?

Closure of the direct inguinal defect with plication in minimally invasive direct inguinal hernia repair may have potential benefits in terms of reducing postoperative surgical site events (SSEs) and recurrences. However, these advantages remain unclear, particularly in the robotic literature. This is the first comparative study to investigate the outcomes after robotic direct inguinal hernia repair (RDIHR) with defect plication. Among patients who underwent RIHR between 2013 and 2020, those who underwent RDIHR were selected. Patients were then stratified into 2 groups based on defect plication status, and univariate analyses were used to compare variables across preoperative, intraoperative, and postoperative timeframes. A total of 225 RDIHRs were performed in 176 patients, where 74 were assigned to the Plication (+) group and 102 patients were assigned to the Plication (-) group. There was a significantly higher proportion of females in the Plication (-) group (10.8% vs. 1.4%, P=0.015), which accounts for the higher incidence of accompanying femoral hernias in this group. While most M1 hernia defects were left patent, most M2 and M3 hernias were plicated. Larger mesh sizes were used in the Plication (+) group (P<0.001). Three SSEs were observed in the Plication (-) group versus 2 SSEs in the Plication (+) group. No significant differences in postoperative outcomes were found between the 2 groups. Postoperative seroma incidence, pain scores, and recurrence rates were similar between the 2 study groups. Multicenter studies with larger populations and higher complication counts are needed to establish the role of defect plication in RDIHR.

Abdominal-based adipocutaneous advancement flap for reconstructing inguinal defects with contraindications to standard reconstructive approaches: a simple and safe salvage reconstructive option.

BackgroundGroin wounds occurring after vascular surgical site infection, oncologic resection, or occasionally orthopedic surgery and trauma may represent a surgical challenge. Reconstruction of these defects by the usual workhorse flaps may be contraindicated following previous surgery and in patients with lower limb lymphedema or extreme morbidity.MethodsThis study included 15 consecutive patients presenting with inguinal wounds after vascular or general surgery that required debridement and soft tissue coverage. All cases had absolute or relative contraindications to conventional reconstructive techniques, including a compromised deep femoral artery network, limb lymphedema, scarring of potential flap harvesting sites, or poor overall condition. Abdominal adipocutaneous excess enabled the performance of adipocutaneous advancement flaps in an abdominoplasty-like fashion. Immediate and long-term outcomes were analyzed.ResultsSoft tissue coverage was effective in all cases. Two patients required re-intervention due to flap-related complications (venous congestion and partial flap necrosis). All patients fully recovered over a mean±standard deviation follow-up of 2.4±1.5 years.ConclusionsAbdominal flaps can be an effective and simple alternative technique for inguinal coverage with reproducible outcomes. In our experience, the main indications are a compromised deep femoral artery network and poor thigh tissue quality. Relative contraindications, such as previous open abdominal surgery, should be considered.

Enhanced-view totally extraperitoneal (eTEP) approach for the treatment of abdominal wall hernias: mid-term results.

Multiple minimally invasive techniques have been described for ventral hernia repair. The recently described enhanced view totally extraperitoneal (eTEP) ventral hernia repair seems an appealing option since it allows to address midline and lateral hernias, placing the mesh in the retromuscular position without the use of traumatic fixation. To report on the mid-term result of a series of patients with ventral hernias repaired by the eTEP approach. A retrospective analysis of our case series between June 2017 and December 2019. Demographic and clinical data were gathered. Hernia characteristics, surgical details, hernia recurrences, and complications are reported. 66 patients were included in the study. Median follow-up was 22months (interquartile range 12-26). 60% of patients were male. Mean age, BMI, % of Type-2 diabetes and % of smoking were 59 ± 12years, 30kg/m2, 24% and 23%, respectively. Mean hernia defect size was 5.5 ± 2.9cm. Forty-three eTEP Rives-stoppa and 23 eTEP-Transversus abdominis release (14 unilateral, 9 bilateral) were performed. 22 inguinal hernias and 15 lateral defects were simultaneously repaired. We report 1 recurrence (1.5%) and 10 surgical site occurrences (15%; 6 seromas, 2 hematomas and 2 surgical site infections). Four patients required reinterventions (6%). eTEP is a promising approach to treat midline hernias and allows the simultaneous treatment of lateral and inguinal defects, keeping the mesh in the retromuscular position. However, comparative studies must be performed to know its real benefit in laparoscopic ventral hernia repair.

Littre's hernia in a Tunisian emergency department: a rare image.

Meckel diverticulum is known as the most common congenital anomaly of the gastrointestinal tract. It can also be part of the contents of Littre´s hernia which was described for the first time in 1700 by Alexis Littre. We report in this work a very rare case of Littre hernia which presented with an irreducible mass in the left inguinal site, diagnosed preoperatively as incarcerated inguinal hernia. A 33 years old male, without any past medical history attended the emergency department of our hospital for acute abdominal pain in relation with an incarcerated inguinal hernia. He had fever, nausea and vomiting. The patient had no history of previous abdominal surgeries. Abdominal examination revealed a visible, soft and painful mass in the right groin. It was non-pulsatile and not reducible. A diagnosis of an incarcerated inguinal hernia was made in the emergency room and the patient was admitted immediately in the surgery department. Laboratory tests were normal. No imaging examinations were required. A large indirect hernia sac was dissected revealing a Meckel´s diverticulum approximately 12 cm in length. A small amount of necrotic adipose tissue and purulent material was present. A simple diverticulectomy was performed and a Lichtenstein tension-free mesh repair was used to close the inguinal defect. The patient recovered without complication and was discharged from the hospital after three days of management. He was seen in follow up ten days later and remained well.

Effectiveness of the Surgical Techniques in Acute Inguinal Hernia

The weakness in the abdominal wallmay be a birth defect or it may be developed later in life when muscles are loosened with age, but also in various intense physical activities. Men are the most affected section of population, 8 times more prone to inguinal hernia than women. In certain moments, when the intestinal tissue descends towards the scrotum, bulging areas occur, accompanied by pain around testes. Appreciation of the degree of dystrophia and anatomic dislocation of the inguinal region made possible to adequately choose the tactics of the surgical treatment of inguinal hernias. Presenting a case of incarcerated right inguinal-scrotal hernia. epiploectomy, followed by treatment of hernia, an alloplastic technique. The choice of the technique to repair an inguinal parietal defect depends on the surgeon.

Open mesh versus laparoscopic mesh repair of inguinal hernia

Introduction Inguinal hernia repair is the most frequently performed operation in general surgery. The standard method for inguinal hernia repair had changed little over a hundred years until the introduction of synthetic mesh which can be placed by either using an open or a laparoscopic approach. The cause of groin hernia is probably multifactorial, with one or more factors applying in any particular case. Among the factors predisposing to groin hernia are persistence of the processus vaginalis, weakness of the shutter mechanism of the inguinal canal, raised intraabdominal pressure, heavy physical exertion, loss of integrity of the fascia transversalis, metabolic factors leading to the production of abnormal collagen fibers, cigarette smoking, genetic influences, spontaneous or iatrogenic abdominal wall trauma, aging, and general factors causing weakness of the abdominal wall muscles and fascia. Aim To compare the merits and potential risks between cases subjected to open mesh repair versus cases subjected to laparoscopic mesh repair of inguinal hernia. Patients and methods The patients were selected from those attending the surgical outpatient clinics of Al-Azhar University Hospitals (El-Hussein and El Sayed Galal), during the period from January 2017 till January 2019. Results This study includes 100 patients with inguinal hernias, where 50 of them were repaired laparoscopically by the transabdominal preperitoneal technique whereas the other 50 were repaired through the Lichtenstein tension-free repair. Patients were followed up by routine clinical examination for 6–18 months (with mean 12 months of follow-up) to calculate the incidence of postoperative complications and recurrence rate during the relatively short period of follow-up. Conclusion The Lichtenstein tension-free hernioplasty is the gold standard of groin hernia repair owing to the simplicity of the technique, the short learning curve, the low incidence of recurrence, and the low incidence of easily controllable postoperative complications as well as the relative low price and less expensive instruments required. However, transabdominal preperitoneal repair should be reserved for bilateral and recurrent inguinal hernias as long as the case is fit for general anesthesia or it is best suited to the younger patients in good general health who cannot afford an extended time away from work or who are suspected for a contralateral inguinal defect, and that it should be performed by an experienced surgeon to decrease the risk of complications and the operative time as well as the recurrence rates.

Reconstructive Surgery of Inguinal Defects: A Systematic Literature Review of Surgical Etiology and Reconstructive Technique.

This study aimed to evaluate the literature regarding surgical etiology demanding inguinal reconstructive surgery, associated reconstructive techniques and outcomes. A systematic literature search was performed according to the PRISMA statement between 1996-2016. A total of 64 articles were included, comprising 816 patients. Two main subgroups of patients were identified: Oncological resections (n=255, 31%), and vascular surgery (n=538, 66%). Oncological resection inguinal defects were treated with pedicled myocutaneous flaps (n=166, 65%), fasciocutaneous flaps (77, 31%), muscle flaps (7, 3%) and direct closure (3, 1%). Vascular surgery complications were treated with muscle flaps (n=513, 95%). Complications for the respective subgroup (oncological resections, vascular surgery) were: infection (24%, 14%), seroma (34%, 7.5%), flap dehiscence/delayed healing (20.6%, 40.8%,). The total reintervention rate was 20%. Reconstruction of inguinal defects should be addressed on a case-by-case basis. Myocutaneous flaps were favoured after oncological resections, while muscle flaps were preferred after vascular surgery.

Double-Layered Circular Advancement Flap for Reconstruction of Inguinal Defects

Double-Layered Circular Advancement Flap for Reconstruction of Inguinal Defects

Groin defects seen at extra-peritoneal laparoscopic dissection during surgical treatment of athletic pubalgia.

Recently new disease process, often referred to as athletic pubalgia (AP), has been acknowledged by the medical community. The patients suffering from this ailment present with unilateral or bilateral chronic groin pain associated with physical activity without a clear diagnosis of a groin hernia. Though physical therapy and medical treatments are considered first line remedies, some believe that surgical treatment may have better, quicker, and more durable outcomes and procedures aimed at groin reinforcement seem to relieve most of symptoms in the majority of the patients. Despite many surgeons consistently noting rectus insertion or adductor thinning, multiple hernia defects are often seen during dissections and the clinical significance of these findings is still not known. Between 2007 and 2011, 40 patients underwent an extra-peritoneal laparoscopic reinforcement of rectus abdominals and insertion of adductor muscles for AP. All patients underwent wide and bilateral groin dissection and the findings were cataloged. All of the patients presented with groin defects upon wide dissection. Thirty-four patients (85%) presented with small bilateral indirect inguinal defects and 28 (70%) of these patients did not have any additional defects. Five patients (12.5%) were found to have only unilateral inguinal hernia defects. One patient presented with a small direct defect. In addition to these defects, five patients (12.5%) had additional unilateral femoral hernias, whereas no patient had solitary femoral hernia defects. AP is a new diagnostic entity with poorly understood etiology. It mostly affects young active adults, often involved in competitive sports and surgical methods may be most effective at achieving the cure. In our experience all of the patients presented with groin defects, though not all were the same. It is our belief that these defects, although likely not the only component, play a significant role in the pathophysiology of AP.

Superiorly based perforator plus flap for inguinal defects

Aim: Inguinal block dissections for metastasis to inguinal lymph nodes and occasionally trauma are always associated with soft tissue loss over the groin region. A clinical study was undertaken to demonstrate the ability to utilize a superiorly-based perforator flap with reliable vascularity and less donor site morbidity to cover defects in the inguinal region. Methods: A prospective study was performed on 7 patients with inguinal soft tissue defects managed in our institution from January 2013 to September 2013. During the study period, a superiorly-based perforator plus flap was used for soft tissue coverage over the femoral vessels in the inguinal region. Hyperbaric oxygen therapy was administered postoperatively. The postoperative period, hospital course, and follow-up after radiotherapy was documented in patients with inguinal block dissection. Results: Seven patients presented with soft tissue defects in the inguinal region. Five of the defects were secondary to prior surgery, and 2 were secondary to trauma. A superiorly-based perforator plus flap was performed in all patients. The defect sizes ranged from 9 cm Χ 4 cm to 17 cm Χ 8 cm. The flap dimensions ranged from 12 cm Χ 5 cm to 20 cm Χ 10 cm. No secondary procedures were necessary following surgery. Postoperatively, there was no evidence of partial or total flap loss. No flap revisions were required, and no complications were experienced at either the donor or recipient site following radiotherapy. Patients were followed-up for 10-18 months. Conclusion: Inguinal defects require stable soft tissue coverage to withstand radiotherapy following inguinal block dissection surgery, and are susceptible to wound complications. The superiorly-based perforator plus flap technique is simple, requires little operative time, and is a reliable flap for coverage of the femoral vessels and inguinal region with improved tolerance to postoperative radiotherapy.

Islanded Perforator Flaps in the Reconstruction of Hidradenitis Suppurativa Defects

Hidradenitis suppurativa is a recurrent, chronic, and suppurative cutaneous disease of unknown etiology. Radical excision of all affected skin followed by flap coverage of the defect is the treatment method of choice in severe and recurrent cases. This study discusses the use of local islanded perforator flaps in the reconstruction of defects following excision of hidradenitis suppurativa lesions in axillary, gluteal, and inguinal regions. Eleven male patients (mean age of 39.3 years) underwent reconstruction of hidradenitis suppurativa defects with 13 local islanded perforator flaps. Three patients (one being bilateral) had gluteal, two patients (one being bilateral) had inguinal, and six patients had axillary involvement. The defects in the gluteal region were repaired with superior gluteal artery perforator flaps, inguinal defects were repaired with medial circumflex femoral artery perforator flaps, and the axillary defects were repaired with thoracodorsal artery perforator flaps. There was no total flap loss in the postoperative period, but one marginal necrosis and two wound infections occurred. There was no recurrence of hidradenitis suppurativa or revision requirement during the mean follow-up period of 11.5 months.

A case of giant inguinal hernia with intestinal malrotation

INTRODUCTIONGiant inguinal hernia is uncommon nowadays. PRESENTATION OF CASEA 75-year-old man with schizophrenia presented with complaints of episodic abdomen pain and constipation accompanied by a huge right scrotal mass. Physical examination revealed a large, irreducible, non-tender right inguinoscrotal hernia. The hernial mass was about 30cm and extended to the midpoint of the inner thigh. At laparotomy, the intestine from the proximal transverse colon to the terminal ileum with mesentery was found to have herniated through the right inguinal tract without evidence of ischemia or strangulation. The ascending colon showed no adherence to the retroperitoneum and the third and fourth parts of the duodenum descended vertically without Treitz's ligament. The inguinal defect was closed without complications. Ladd's procedure and appendectomy were performed simultaneously. DISCUSSIONSeveral techniques such as distending the abdominal wall progressively or debulking the abdominal contents have been reported. However, no consensus has been reached on a standard surgical procedure for the management of giant inguinoscrotal hernias. CONCLUSIONThis was the first reported case of giant inguinal hernia containing malrotated intestine.