Inguinal Defect Research Articles

The Endoloop technique for the primary closure of direct inguinal hernia defect during the endoscopic totally extraperitoneal approach

Seroma is a frequent complication of endoscopic totally extraperitoneal (TEP) mesh repair of direct inguinal hernia that may cause discomfort and anxiety. Its volume is proportional to the size of the preperitoneal dead space created after the reduction of the hernia. Attempts to reduce its incidence have included tacking the transversalis fascia (TF) to the pubic ramus or closed suction drainage of the preperitoneal space. Both of these techniques are not without problems. The aim of this study was to evaluate the efficiency of a new alternate technique that must be safe and easily reproducible, using a widely available and inexpensive pre-tied suture loop (Endoloop(®) Ligature) for plication of the weakened TF. This is a prospective study of consecutive patients diagnosed with inguinal hernia during a 33-month period and eligible for endoscopic TEP repair. A single surgeon performed all operations. Each of the M2 or M3 direct defects, according to the European Hernia Society (EHS), were systematically closed prior to the introduction of the prosthetic mesh and as follows: grasping and inversion of the attenuated TF at its apex, using a laparoscopic forceps and plication of the TF by placing a tight Endoloop of Polydioxanone (PDS) at its base. All meshes were secured with fibrin sealant only. Patients were reviewed in the clinic 2 and 6 weeks after the operation. Further follow-up was scheduled if it was deemed necessary. The primary post-operative outcome parameter was seroma formation; secondary outcome parameters included groin pain, surgical complications, and recurrence. Two hundred and fifty hernia repairs were prospectively recorded during this period. All procedures were carried out endoscopically. Seventy-nine patients with 94 direct inguinal hernias were selected in a sequential manner. There were 75 males and four females, with a median age of 57 years. Of those, 55 were combined with an indirect inguinal defect. In total, Endoloops of PDS were used to close the weakened TF in 76 cases (30 M3, 44 M2, and two M1). Only one patient (1.3%) complained of a residual seroma formation, which was still clinically present at 3 months post-operatively, but was not symptomatic. There were only two minor post-operative complications, which occurred in the same patient and were not related to the Endoloop technique. Finally, no patient complained of chronic groin pain and there was no hernia recurrence after a median follow-up of 18 months. The primary closure of direct inguinal hernia defects with a pre-tied suture loop during endoscopic TEP repair is safe, efficient, and very reliable for the prevention of post-operative seroma formation, without increasing the risk of developing chronic groin pain or hernia recurrence. This technique should be the preferred method over stapling of the TF or the insertion of a closed suction drainage device in such a situation.

Laparoscopy for perforated Richter hernia with incarcerated foreign body

Children often place nonedible objects into their mouths. Occasionally, these objects are inadvertently swallowed, and fortunately, the majority passes spontaneously without intervention. We present the case of a 10-month-old girl who presented with an incarcerated Richter hernia through an indirect inguinal defect containing a wall of sigmoid colon perforated by a swallowed lollipop stick. Although this is a rare case, we conclude that prompt laparoscopic abdominal exploration is an extremely valuable tool in making an accurate diagnosis in difficult-to-reduce or incarcerated hernia cases.

Quadriceps keystone island flap for radical inguinal lymphadenectomy: a reliable locoregional island flap for large groin defects

Radical inguinal lymphadenectomy (RIL) for bulky metastatic melanoma and non-melanoma skin cancers of the inguinal region, while shown to improve morbidity and survival oncologically, can result in substantial morbidity from wound complications. Skin defects cannot be closed primarily and the substantial dead space predisposes to seroma, wound dehiscence and infection. Despite the clear need for reconstructive options, extended series describing reconstruction of large inguinal defects in this setting have not been reported. A prospectively entered, retrospectively reviewed study of 20 consecutive patients undergoing quadriceps keystone island flaps (QKIF) for the closure of complicated inguinal defects is described. There was 100% flap survival, with no partial or complete flap losses. A reduction in wound breakdown/dehiscence from reported rates was seen, with four patients (20%) having wound breakdown, compared to double that rate in reported series. Other wound complications comprised six patients (30%) with mild wound infections, seven patients (35%) with seromas and two patients (10%) with haematomas. The QKIF is an effective means of reconstructing inguinal defects after RIL, particularly in high-risk patients, and is technically simpler than other reconstructive techniques advocated for this purpose. Furthermore, the QKIF offers patients with advanced disease (where management is primarily palliative) a potentially improved quality of life with reduced operative morbidity.

'The intraabdominal bleeding with an inguinal defect that mimicking a femoral vein aneurysm'. A case report

Inguinal hernia repair is commonly performed operation in surgical practice. Thirty-five years old female patient was operated with the diagnosis of inguinal hernia. The inguinal defect was misdiagnosed as femoral vein aneurysm in surgical exploration. The postoperative diagnostic imaging revealed that the inguinal defect had been confused as femoral vein aneurysm due to intra-abdominal hemorrhogical fluid after an ovarian cyst rupture.

Uncommon Presentation Of Inguinal Hernia: Burst Obstructed Inguinal Hernia With Ileo-Ileal Intussusception

Burst obstructed inguinal hernia with ileo-ileal intussusception as hernia content is an extremely rare condition. We are reporting such a finding in a 60-year-old female patient. This condition requires emergency surgical intervention. We did emergency laparotomy with reduction of the obstructed inguinal hernia, resection of the perforated bowel segment with ileo-ileal intussusception, end to end anastomosis and repair of the inguinal defect.

Prosthetic repair of a perforated Amyand’s hernia: hazardous or feasible?

Dear Sir, We read with interest the article published in your journal by Sharma H et al. [1]. The authors present results from a large group with Amyand’s hernia. They conclude that the inXammatory status of the appendix determines the surgical approach and the type of hernia repair, with or without the use of an alloplastic mesh. As reported in literature [2, 3], use of a synthetic mesh should be avoided because of the high risk of infection. We report a case successfully treated by simultaneous appendectomy and mesh repair. A man of 62 was referred with diagnosis of incarcerated right inguinal hernia. We decided on a surgical open approach. The groin was explored through anterior access. After opening of the external oblique aponeurosis we found an important abscess rising from the internal ring. We drained the purulent material accurately and isolated a sliding hernia. The sac contained the caecum and the perforated gangrenous appendix, both incarcerated in the deep ring. We continued with the appendectomy and irrigation of the peritoneum and the inguinal area with antibiotics. The caecum was freed from adhesion to the sac and reduced into the abdominal cavity. We then resected the previously ligated sac. We decided to repair the inguinal defect, given the presence of intense inXammation and tissutal edema, positioning the PAD complex, a polypropylene Xat mesh that we routinely use to repair primitive inguinal hernias in our department, over the transversalis fascia [4]. Two Redon drainages were left below the aponeurosis, one in direction of the deep ring and the other along the spermatic cord in direction of scrotum; these were removed on seventh postoperative day. We administered postoperative intravenous metronidazole, 500 mg three times a day for 4 days, and piperacillin/tazobactam, 4.5 g three times a day, for 8 days, to the patient. On eighth postoperative day the patient was discharged asymptomatic. One-month and sixmonth follow-ups revealed no problem. In cases of perforated appendicitis in the hernial sac it may seem very hazardous deciding for a mesh repair after appendicectomy [5, 6]. The recommended direct suture using Shouldice’s or Bassini’s procedures could be technically very diYcult in an inXamed and edematous area, however, and could increase the risk of recurrence. We believe use of a synthetic mesh is feasible and safe enough if the inguinal area has previously been accurately irrigated with antibiotics, a drain is placed under the aponeurosis, and the patient is treated postoperatively with intravenous antibiotics. Use of inert materials, for example polypropylene, is, moreover, important, in our opinion, to minimize the risk of infections, as well as plain type protheses are useful to avoid the creation of empty spaces and porousness of the protheses that could make it easy to drain the infection. In our opinion, the presence of pus or perforation of the appendix is not an absolute contraindication to positioning of a mesh for hernia repair, which remains a valid alternative when a direct hernia repair seems diYcult to perform. G. Torino (&) Pediatric Surgery Unit, Policlinico Umberto I, University “La Sapienza”, Viale Del Policlinico 155, 00161 Rome, Italy e-mail: giovannitorino@interfree.it

Bilateral laparoscopic inguinal hernia repair in patients with occult contralateral inguinal defects

A high incidence of bilateral inguinal defects found on laparoscopic evaluation during hernia repair has been reported. However, expectation of bilateral inguinal defects in patients who are diagnosed with pure unilateral hernia might be underestimated. A prospective clinical study was performed to reveal a rate of contralateral occult defects in patients who were diagnosed with unilateral inguinal hernia prior to primary laparoscopic totally extraperitoneal (TEP) repair. One hundred consecutive male patients with primary unilateral inguinal hernias were included in the study. Patients with known bilateral inguinal hernias as well as femoral, giant and combined hernias were excluded. All patients underwent TEP with exploration and evaluation of the contralateral groin. Median follow-up was 24 (4-46) months. Median age was 48 (18-73). Mean operative time was 42.2 (18-167) min. There were 78 (78%) patients with pure unilateral hernias and 22 (22%) patients with bilateral hernias whose contralateral inguinal defect or hernia was revealed only intraoperatively. Of those, 19 (86%) had right and 3 (14%) left occult defects. Minor complications occurred in 17 (17%) patients. There were no major complications. Two patients required a 23-hour stay in the hospital for urinary retention and hypoxia. Median period of returning to normal activity was 7 (5-14) days. There were two (2%) recurrences. Median period of returning to normal activity was 6.2 days after unilateral repair and 8.4 days after bilateral TEP. This study revealed 22% occurrence of bilateral inguinal defects in the patients who are diagnosed with pure inguinal hernia before surgery, with higher incidence for those with left inguinal hernia. It appears that routine contralateral groin exploration and evaluation during TEP is valuable. Patients with occult bilateral hernias are benefit from bilateral TEP.

Vacuum-assisted Closure versus Conventional Wound Care in the Treatment of Wound Failures Following Inguinal Lymphadenectomy for Penile Cancer: A Retrospective Study

ObjectivesImpaired wound healing is a frequent event in inguinal surgery and very common after lymphadenectomy for penile cancer. Although vacuum therapy has been reported to expedite the healing of complex wound failures, vacuum-assisted closure (VAC) has been reported to be contraindicated in malignancy. In the present study we evaluated the use of VAC in the treatment of complex wound failures following inguinal lymphadenectomy for penile cancer in comparison to conventional wound care (CWC) implying debridement and saline-soaked gauze. MethodsWe retrospectively identified six inguinal wounds following inguinal lymphadenectomy for penile cancer and subsequent use of VAC from 2003 to 2006 at our institution. Data on surgical interventions, complications, length of time required for closure, and outcome were compared to 10 inguinal defects treated with CWC between 2000 and 2003. ResultsWound volume was comparable for both groups. Wound breakdown occurred at a median of 7.4 d after inguinal lymphadenectomy and was treated by CWC for a mean of 69.8 d. In the VAC group, the median duration until complete closure was 38.9 d. Thus, VAC was shown to result in complete wound healing in less time (p<0.001). No local recurrence in the VAC group was noted despite positive lymph nodes. ConclusionsVAC therapy is effective in complex inguinal wound failures following lymphadenectomy for penile cancer and appears to be superior to CWC. VAC seems to offer adequate safety concerning local recurrence.

Incarcerated inguinal hernia presenting as spontaneous scrotal fecal fistula

We report a case of neglected, strangulated, inguinal hernia in a middle-aged male, which presented as a scrotal fecal fistula. This is the first such case reported in an adult. The patient was treated by resection and anastamosis of the ileum, local debridement of the scrotum and Shouldice repair for the inguinal defect.

Use of Prolene Mesh in surgical treatment of tissue defects after radical inguinal and pelvic lymph node dissection in vulvar cancer-a brief report

Surgery is still the procedure of choice in treatment of advanced vulvar cancer. Radical vulvar surgery is often associated with severe vulvar and inguinal skin and fat-tissue deficits resulting from wide "butterfly" shape resection. Primary closure of large vulvar and inguinal defects is hampered by lack of tissue. The study presents the case of using prolene mesh in filling up the tissue defects over femoral vein and artery after radical excision of enlarged inguinal superficial, femoral, and pelvic nodes to prevent vessels in hiatus saphenus. It is the first report describing the use of prolene mesh in such a procedure.

The contributions of Usher and others to the elimination of tension from groin herniorrhaphy

Relaxing incisions (Wolfler 1892) were eventually shown (Read and McLeod, 1981) to reduce but not eliminate wound tension after sutured herniorrhaphy of the groin. Reinforcing prosthetics became widely shunned because of morbidity until Usher et al (1958) introduced polyethylene, then polypropylene mesh (1963) for preperitoneal tensionless repair of large defects. Excellent long-term results were obtained, with his technique, by Collier and Griswold (1967). Patt (1967) envisaged its application to primary hernia. Reis (1899) introduced early ambulation. However, it was not until Leithauser (1943), Blodgett (1946), and others showed immediate rising accelerated wound healing and reduced complications that Farquharson (1955) began outpatient hernioplasty (in 1950) under local anesthesia (Cushing 1900). Bellis (1964) followed, performing tensionless repair in 25%. Rodriguez and Phillips (1967) described office herniorrhaphy, 30% undergoing polypropylene mesh coverage without tension. Lichtenstein (1970) reported mesh onlay reinforcement for sutured repair of large defects, discharge was within 24 hours. Martin et al (1982) began (in 1972) to treat all inguinal herniation in adults with polypropylene mesh "to avoid recurrences". Newman did likewise, using tension-free placement (Rodriguez et al) in the subaponeurotic plane. Encountering resistance to publication ("real surgeons don't use mesh") he, in 1980, asked Lichtenstein to publish and popularize the technique. Kelly (1898) introduced plug prosthestic repair of femoral herniation. Drainer and Reid (1972) used polypropylene mesh from below under local anesthesia. Lichtenstein and Shore followed, treating recurrent inguinal defects similarly. Gilbert (1989) applied the technique to indirect herniae. Usher and others deserve recognition for their contributions to the elimination of tension from herniorrhaphy.

The pedicled anterolateral thigh island flap for inguinal defects

The interpolated anterolateral thigh flap islanded on its vascular pedicle, is a durable local flap option for large skin and soft tissue defects caused by inguinal block dissections. So far, this flap has not been described for resurfacing such defects. Two cases are presented to highlight the technique.

Balloon dissection of the space of Bogros via the femoral canal for total extraperitoneal laparoscopic herniorrhaphy

To obviate the need for general anesthesia or dissection of the rectus sheath, we have transferred laparoscopic herniorrhaphy back to the groin by first dissecting the suprainguinal parietoperitoneal space of Bogros via the femoral canal. Cadaver dissections demonstrated that the preperitoneal plane could be routinely fingered and distended with a digitally placed balloon introduced through a 1-cm incision immediately below the inguinal ligament. A 10-mm femoral laparoscopic port was then inserted and pressurized, allowing two standard 5-mm ports to be introduced from above, through the lower quadrant, under vision. The procedure was then carried out in the usual way, the mesh being inserted from below. Ten patients (two women), 23-73 years old, selected because general anesthesia was inadvisable, underwent uncomplicated prosthetic repair of unilateral (eight) or bilateral (two) inguinal defects. Half of the peritoneal sacs were pushed up and out of the inguinal canal; 18 months later there were no recurrences (inguinal or femoral). Preliminary experience with this new technique is promising. It may prove applicable to retroperitoneal exposure of the distal aorta and iliac vessels, allowing laparoscopic bypass for Leriche syndrome.

Pedicled omental flap and skin grafting to cover artificial mesh

Two cases are presented in which a large abdomino-inguinal defect, created during an extended hemipelvectomy, was closed using artificial patch, a pedicled omental flap and skin grafts. In the first case, early postoperative mortality arrested the wound healing process and prevented follow-up. In the second case, the wound was completely covered and there was no evidence of infection at three moths following the initial operation. We propose that pedicled omental flap with skin grafting is a viable means of covering artifical mesh repairs of giant abdominal wall and inguinal region defects.

Prosthetic Inguinal Hernia Repair Using a Laparoscopic Extraperitoneal Approach

The preperitoneal technique offers several advantages over conventional anterior approaches in the surgical repair of inguinal hernias: direct access to the posterior inguinal anatomy, clear visibility of all possible hernial defects, ability to circumvent scar tissue and intra-abdominal adhesions, and ease of effecting difficult repairs. A preperitoneal prosthetic procedure has been successfully used, performed laparoscopically, to repair 163 indirect, 163 direct, and one femoral inguinal defects. In the approach used, a piece of polypropylene mesh, placed extraperitoneally, is used to reinforce or replace the transversalis fascia. In only one of 197 patients (0.5%) was it necessary to convert to an open procedure; this patient had a severely incarcerated hernia. Almost all patients were discharged on the day of surgery, and all returned to normal activities within 7 days. There were few complications, and the recurrence rate in the series of 300 repairs was only 0.3%. One patient required a second procedure because of a retained indirect hernia. Based upon these results and the experience of others using a similar approach, the laparoscopic extraperitoneal prosthetic repair is advocated for patients with recurrent, as well as bilateral and complicated inguinal defects.

Laparoscopic hernia repair

From January 1992 to February 1993 a total of 361 inguinal hernia repairs were performed in our unit. We routinely performed the Shouldice repair. In 60 patients, 46 men and 14 women, 19-82 year old, we closed the inguinal defect with a patch, performing a "tension-free" repair by a laparoscopic technique. In 26 patients we found a left-sided hernia, in 21 patients a right-sided, and in 13 bilateral hernias. We found 29 direct hernias, 26 indirect hernias and 18 combined hernias. There were no intraoperative complications. Postoperatively, 1 patient suffered from epididymitis, and 5 patients reported disturbed sensibility of the skin at the medial proximal thigh for some weeks. One patient had an inguinal seroma postoperatively. In this patient we had not removed the hernia sac. There was no recurrence. Long time results are not available until now.

Localized Genital Edema in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis

Localized genital edema occurred in 8 of 81 patients (10 per cent) undergoing continuous ambulatory peritoneal dialysis. Underlying causes included defects in the inguinal canal and noninguinal peritoneal leaks that were localized with clinical, radiographic and scintigraphic techniques. Management included temporary cessation of continuous ambulatory peritoneal dialysis exchanges in half of the patients, particularly those with recently inserted catheters. Surgical repair was recommended in all cases when inguinal defects were identified. Edema resolved permanently in 6 patients and all patients were able to remain on continuous ambulatory peritoneal dialysis.

THE INTERI{AL INGUINAL RING A COMPARATIVE STUDY

Inguinal hernia is a mammalian lesion due to the presence of the inguinal defect. This defect is present to allow extra-abdminal position of the testis, to attain the temp- ,erature required for the process of spermatogenesis. In birds, the testis is cooled by being situated near the air sae; (Romer and Pfl,rsons, l9?7).'This can explain the intra-abdominal position of the testis in non-mamm- .alian species.As the muscl€s and ttre fascia,e of the anterior abdominal wall differentiate around the gubernaslum, the muscles split around iU (Arey, 1966, Davies, 186?, and Scorcer, and Farrington 1956). The hole through which the testis-and its cord-passes, is present in the lateral psrt of tlte defect, while its medial part is formed by tlre deepest fascialIayer of the abdomen, supported by some fibres from the aponeurosis of the deepest muscle.

LIVING FASCIAL SUTURES IN INGUINAL HERNIORRHAPHY

EFFECTIVE closure of the inguinal defect in the presence of hernia presents a problem which has taxed the ingenuity of surgeons for many years. It is the purpose of this communication to present a technic for herniorrhaphy which includes, among other important details, a broad approximation of the internal oblique muscle to the inguinal ligament by a combination of nonabsorbable and living fascial sutures, the latter from the external oblique aponeurosis. Approximation may be secured lateral as well as medial to the internal inguinal ring, and it is believed that the broad scar so formed presents a firm and relatively nonstretchable barrier to recurrence. A series of two hundred and one hernias treated by this method is presented, with a recurrence rate of 1.74 per cent. ANATOMY AND PHYSIOLOGY OF THE INGUINAL REGION A clear understanding of the anatomy and physiology of the inguinal region is a fundamental requirement for