Peritoneal Defect Research Articles

11408 Resolution of Chronic Pelvic Pain With Peritoneal Defect Closure

11408 Resolution of Chronic Pelvic Pain With Peritoneal Defect Closure

Internal hernia through the Treitz fossa after robotic pancreatoduodenectomy: pathogenesis and preventive measures.

Internal hernia through the Treitz fossa following robotic pancreatoduodenectomy is a rare but potentially serious complication. In our review of 328 cases of robotic pancreatoduodenectomies, two patients (0.6%) required repeat surgery due to internal herniation of the entire small bowel through the Treitz fossa. This complication can present as afferent loop syndrome, with symptoms including nausea, vomiting, and abdominal distension, possibly leading to cholangitis and pancreatitis. Timely diagnosis and intervention are paramount, as conservative management often fails. Preventive measures involve closing the peritoneal defect in the Treitz fossa at the end of robotic pancreatoduodenectomy, particularly in lean patients with thin mesentery who are at increased risk of internal hernia due to increased mobility of the small bowel. This technical note elucidates the pathogenesis of Treitz hernia following robotic pancreatoduodenectomy and underscores the importance of closing the peritoneal breach to prevent this rare yet potentially serious complication.

Trans-Abdominal Pre-Peritoneal (TAPP) Approach for Anatomical Repair of Direct Inguinal Hernia in Children, Could it Be the New Standardized Approach?

BackgroundThe incidence of direct inguinal hernia in the pediatric population is relatively low and is usually discovered intraoperatively, rendering it unfamiliar to most pediatric surgeons. The traditional approach involves directly addressing the peritoneal defect, which includes dissecting the sac and repairing the peritoneum, reinforced with the umbilical ligament. In this paper, we present our experience with a novel approach to anatomical repair utilizing a non-mesh transabdominal preperitoneal (TAPP) approach. MethodsThis a retrospective case series of direct inguinal hernia that were operated laparoscopically using the novel approach of repair from January 2018 to January 2024. Data were analyzed for demographics, presentation, type of defect, operative time, complications, and recurrence. The new approach utilizes the pre-peritoneal approach to delineate the exact facial defect then, primary anatomical repair is established using 2/0 non-absorbable braided sutures. Finally, closure of the peritoneum was performed using running 4/0 absorbable sutures.This is a retrospective case series of direct inguinal hernias that were operated on laparoscopically using the novel repair approach from January 2018 to January 2024. Data were analyzed for demographics, presentation, type of defect, operative time, complications, and recurrence. The new approach employs the pre-peritoneal approach to accurately delineate the fascial defect, followed by primary anatomical repair using 2/0 non-absorbable braided sutures. Finally, the peritoneum is closed using running 4/0 absorbable sutures. ResultsData from nine cases were included. Six cases were on right side, and three cases were on left side. Patients were predominantly boys (8 boys and 1 girl). The mean age at operation was 25.1 months (range:11 month to 5 years). Four patients had previous indirect inguinal hernia repair on the same side. The mean operative time was 34 ± 9 min. No intraoperative complications occurred. The median follow up period was 24 months with no recurrence was detected in any of the cases. ConclusionThe non-mesh TAPP approach offers excellent exposure of the fascial structures, facilitating accurate identification and repair of the defect. Despite being technically demanding, it allows for the establishment of a robust anatomical repair. No recurrences occurred in the study group; however, a longer follow up and a larger sample are needed to provide more reliable evaluation. Level of EvidenceIII.

Don't be thrown for a loop: a review of internal hernias for the abdominal imager.

Internal hernias are herniations of abdominal viscera, usually small bowel, through congenital or acquired openings of the peritoneum or mesentery. Congenital hernias may involve anatomic fossae such as the epiploic foramen as well as those related to abnormal peritoneal or mesenteric defects; these include left and right paraduodenal, transomental, transmesenteric, pericecal and broad ligament hernias. Acquired hernias are due to defects in the mesentery or peritoneum, usually resulting from prior surgeries, and include those associated with Roux-en-Y surgery as well as colorectal cancer resections. Internal hernias account for 5.8% of small obstructions. Obstructed internal hernias are considered surgical emergencies due to the high risk of bowel strangulation. This review summarizes the various types of congenital and acquired internal hernias, their relevant anatomy, embryology, associated surgical history and imaging appearance. We will also discuss a location-based approach to identifying internal hernias on CT, as well as complications and relevant signs, of which abdominal imagers should be vigilant.

Selective therapeutic efficacy of tyrosine kinase inhibitor sorafenib on the restoration of methylglyoxal-induced peritoneal fibrosis

Peritoneal fibrosis, a common complication observed in long-term peritoneal dialysis patients, can gradually lead to ultrafiltration failure and the development of encapsulating peritoneal sclerosis. Although mechanisms of peritoneal fibrosis have been proposed, effective therapeutic options are unsatisfactory. Recently, several tyrosine kinase inhibitors have proven to be anti-fibrosis in rodent models. To assess the potential therapeutic effects of tyrosine kinase inhibitors on peritoneal fibrosis in the larger animal model, a novel porcine model of peritoneal fibrosis induced by 40 mM methylglyoxal in 2.5 % dialysate was established, and two different doses (20 mg/kg and 30 mg/kg) of sorafenib were given orally to evaluate their therapeutic efficacy in this study. Our results showed that sorafenib effectively reduced adhesions between peritoneal organs and significantly diminished the thickening of both the parietal and visceral peritoneum. Angiogenesis, vascular endothelial growth factor A production, myofibroblast infiltration, and decreased endothelial glycocalyx resulting from dialysate and methylglyoxal stimulations were also alleviated with sorafenib. However, therapeutic efficacy in ameliorating loss of mesothelial cells, restoring decreased ultrafiltration volume, and improving elevated small solutes transport rates was limited. In conclusion, this study demonstrated that sorafenib could potentially be used for peritoneal fibrosis treatment, but applying sorafenib alone might not be sufficient to fully rescue methylglyoxal-induced peritoneal defects.

AN UNUSUAL CAUSE OF ACUTE SMALL BOWEL OBSTRUCTION

Up to 20% of admissions with severe acute abdomen are due to intestinal obstruction, a common surgical emergency. Paraduodenal hernia is a rare entity of congenital internal hernia which is an unusual cause of small bowel obstruction. This case report describes the case of a 29-year-old woman with acute pain abdomen and vomiting without other significant past history. Radiological investigations revealed mechanical bowel obstruction and gangrenous bowel loops was evident on surgical exploration. Non-viable small bowel loop was resected and peritoneal defect was sutured. Left paraduodenal hernia is a rare cause of acute abdomen and high index of suspicion is required for early diagnosis and management.

Effect of carboxymethyl cellulose, icodextrin and hyaluronic acid solutions on postoperative intraabdominal adhesion formation in rabbits and the role of cytokines in intraabdominal adhesion formation

In this study, the aim was to investigate the effects of 1% CMC, 4% ICO and 0.4% HA solutions in preventing postoperative IAs and their contribution to peritoneal wound healing, as well as the relationship of cytokines with the formation of postoperative IAs in rabbits. The material of the study consisted of 32 healthy rabbits. Rabbits underwent median laparotomy following general anesthesia. Serosal abraded was created at the antimesenteric border of the cecum. Next, a 3 × 2 cm peritoneum was excised on the right abdominal wall and the defect was closed using with a 2/0 silk suture. The rabbits were randomly assigned to either of the following four treatment groups: CNT (0.9% NaCl), ICO (4% icodextrin), HA (0.4% hyaluronic acid) and CMC (1% carboxymethyl cellulose). Both cecum and peritoneal surfaces were treated with 20 ml each of treatment solutions. On the 7th postoperative day, the rabbits were euthanized with a lethal dose of sodium pentobarbital and the degree of adhesion was evaluated. Samples taken from the peritoneal defect were examined histopathologically and tissue hydroxyproline levels were measured. Serum TNF-α, IL-1 and IL-6 levels were measured from blood samples taken before the surgery and at 1, 6, 24 and 48 hours after the surgery. It was observed that the adhesion grade in the HA group (p < 0.05) and CMC group (p < 0.01) was significantly lower than the control group. Although peritoneal tissue hydroxyproline levels were lower in the other groups compared to the control group, they were not statistically significant (p > 0.05). In rabbits with adhesion formation, it was determined that TNF-α levels increased at the 6th postoperative hour (p < 0.05), and IL-6 levels increased at the 6th, 24th and 48th postoperative hours (p < 0.001) compared to preoperative. In this study, treating tissues with 0.4% HA and 1% CMC solutions suppressed peritoneal inflammation, and this resulted in an increase in the levels of proinflammatory cytokines TNF-α and IL-6. It has been determined that the application of these solutions reduces postoperative adhesion formation. It was concluded that TNF-α and especially IL-6, which are proinflammatory cytokines, can be a non-invasive biomarker in determining postoperative IA formation and evaluating the adhesive process.

Bilateral Perineal Reconstruction Using an Oblique V-shaped DIEP Flap

The reconstruction of soft tissue defects in the peritoneal region after malignant tumor resection is challenging. To reconstruct large defects, primary closure or local flaps are inadequate, and they do not provide cosmetically and functionally good results. The gracilis, gluteal, and rectus abdominis flaps are workhorse flaps for reconstructing large peritoneal defects. Surgical procedures should be carefully chosen on the basis of the size and location of the defect. In this report, we describe two cases of bilateral large defect reconstruction after malignant tumor resection using a V-shaped deep inferior epigastric artery perforator flap. Our procedure is useful as it shows that single flaps can be used to reconstruct large and bilateral peritoneal defects.

The Relationship Between Small Peritoneal Flap Defects and Postoperative Seroma in TAPP Repair of Inguinal Hernias.

Total abdominal preperitoneal (TAPP) is one of the most frequently used surgical treatment methods in the treatment of inguinal hernia (IH). One of the most common early postoperative complications after hernia repair is seroma/hematoma. In this study, we aimed to study the role of unclosed peritoneal flap defects on the development of postoperative seroma. The study was performed retrospectively in 2 university hospitals. All patients over the age of 18 years who underwent laparoscopic TAPP surgery in Istanbul Yeni Yüzyıl University Gaziosmanpaşa Hospital General Surgery Clinic and Van Yüzüncü Yıl University Faculty of Medicine General Surgery Clinic between January 1, 2018, and December 31, 2021, were included. Patients were divided into those with peritoneal defects (group 1) and those without (group 2). Whether there was a peritoneal defect or not was compiled from video recordings. In addition, risk factors affecting the development of seroma were determined. A total of 250 patients, 16 (6.4%) women and 234 (93.6%) men, were included in the study. There were bilateral hernias in 35 (14%) patients, and a total of 320 hernias were analyzed in the study. It was determined that an American Society of Anaesthesiologists (ASA) III score increased the risk of seroma 15.97 fold (P<0.001, 95% CI, 4.94 to 51.56), direct hernia type increased risk 7.1 fold (P<0.03, 95% CI, 1.204 to 42.422), hernia descending into scrotum increased risk 22.48 fold (P<0.001, 95% CI, 6.66 to 75.84) and closure of the peritoneal flap completely without leaving any defect increased the risk of seroma 8.67 fold (P<0.001, 95% CI, 3.254 to 23.115). The presence or leaving of small-diameter defects on the peritoneal flap may reduce seroma development without increasing the risk of complications. Prospective randomized studies are required to reach definitive conclusions.

The role of carbondioxide insufflation in preventing postoperative peritoneal adhesions in rats

Aims: Adhesion is the pathological connections that occur during the healing with scar formation of peritoneal surface defects. CO2 is used the most frequently in laparoscopic operations for insufflation. It is believed that it causes to changes in the inflammatory reply of the pneumo-peritoneum, defects in acid-base balance and decrease in peritoneal macrophage functions. CO2 is the only gas whose immunologic effects have been shown. It has been proven in experimental studies that the CO2 insufflation causes to local peritoneal acidosis without affecting the systemic status. Moreover, it has also been shown that it decreases the pneumo-peritoneum TNF-α and IL-6 production; however, increases the IL-10 production which is an anti-inflammatory cytokine. In the literature, the relation between the laparoscopy and the postoperative adhesions has always been explained by taking the suggestion of its causing to less tissue trauma as a basis when compared with the open surgery. The inflammatory reply of the CO2 has been less dealt with. In this study, we wanted to find the answer to the question whether the capno-peritoneum has a role in preventing the postoperative adhesion formation only by using CO2 without a a laparoscopic operation. &#x0D; Methods: 30 female Wistar Albino type rats whose weights varied between 250±20 were used in the study. The rats were divided into 5 groups. Each group had 6 rats. Rats were placed in standard polycarbon cages in groups of 6. The room temperature was kept in 21°C. The rats were fed with standard pellet food during the study and tap water was provided to them. The operational anesthesia was performed by injecting intramuscular Ketamine Hydrochloride (Ketalar, Parke Davis and Eczacıbaşı, İstanbul) 50 mg/kg and Xylazine hydrochloride (Rompun, Bayer HealthCare) 5 mg/kg. &#x0D; Results: A meaningful difference (p

195 Small bowel obstruction through peritoneal defect herniation after a totally extraperitoneal hernia repair- A unusual complication case series

Abstract The rates of major complications associated with totally extraperitoneal (TEP) inguinal hernia repair are reportedly low, and intra-abdominal complications are rare. However, here we present a case series with small bowel obstruction through herniation of the small bowel into the peritoneal defect after a TEP, which is a rare complication. The first case, a 71year old male two weeks post-TEP left inguinal hernia repair, presented with abdomen pain, vomiting, distension, and bowels not opened for three days with elevated inflammatory markers. Computed Tomography of the abdomen and pelvis (CTAP) demonstrated small bowel obstruction secondary to a loop of inflamed small bowel adherent to the anterior abdominal wall in the left inguinal region. During emergency diagnostic laparoscopy found to have a small bowel loop passing through a peritoneal defect just lateral to the medial umbilical ligament, converted to laparotomy, and small bowel resection was performed. In the second case, a 61-year-old male presented with similar complaints and elevated inflammatory markers two days post bilateral TEP. The CTAP showed dilated small bowel with a transition point in the left iliac fossa. Emergency diagnostic laparoscopy found a peritoneal defect on the left groin with small bowel herniation. The bowel-reduced back and the defect was closed with sutures. Small bowel obstruction due to a peritoneal defect after TEP is a rare but potentially fatal complication. Therefore, the clinician should have a low threshold for surgery, as it is unlikely to resolve with conservative treatment like the adhesional bowel obstruction.

194 An uncommon cause of small bowel obstruction with perforation after a caesarean section

Abstract The incidence of small bowel obstruction after any abdominal surgery is 9%, whereas it is only 0.1% after a C-Section. Small bowel obstruction secondary to herniation of a segment of the small bowel beneath the intact rectus sheath and between the rectus muscle is extremely rare. Reviewing the literature revealed that less than five cases were reported. Here we present a 39-year-old female six days post caesarean section presented with abdomen pain, distension, and not opening bowels. The blood investigations showed White blood cells 15.42x109/L and C-reactive protein 286mg/L. She was hypotensive and tachycardic. On clinical examination, the abdomen was distended and peritonitic. The Computed tomography of the abdomen and pelvis with contrast showed there is small bowel obstruction with multiple loops of proximal dilated bowel with a transition point within the pelvis and in midline a small inferior umbilical or incisional hernia containing a knuckle of small bowel with a moderate amount of pneumoperitoneum and free fluid. She underwent an emergency laparotomy and was found to have four quadrants of purulent peritonitis. In addition, a 3cm defect in the midline peritoneum allowed herniation of approximately 30cm of small bowel into preperitoneal space between the recti with ischaemia and perforation at the neck of the hernia. She had small bowel resection anastomosis, and the peritoneal defect was formally closed to prevent re-herniation of bowel loops. The NICE guidelines recommend not closing the peritoneum during the c-section. However, this case is an example of severe postoperative morbidity, which could be avoided by peritoneal closure.

Use of the LigaSure for Closing Peritoneal Defects in an Experimental Rat Model

Background: There has not been an absolute consensus over the routine closure of peritoneal defect (PD) during laparoscopic totally extraperitoneal inguinal hernia repair (TEP). Pretied sutures, endoscopic stapling, and suturing are surgical techniques for closing PDs. Moreover, we observed that we could close small PDs during the TEP procedure by sealing with the LigaSure (LS). Objectives: The present study aimed to evaluate the necessity of closure PDs under a polypropylene mesh and the early intraperitoneal inflammatory, fibrotic, and adhesional effects of sealing PDs with the LS in an experimental rat model. Methods: A total of 35 male rats were assigned to five groups. 1- Control group: mesh was not used, and the peritoneum was left open; 2- Mesh group; mesh was placed directly on the PD without repairing, and three peritoneal repairing methods; 3- Stapling group: PD was repaired with metal clips; 4- Suture group: PD was repaired with Vicryl sutures; and 5- LigaSure group: PD was closed with the LS. Rats were sacrificed on the postoperative 14th day. Adhesion scores, fibrosis, and inflammation scores were compared between all groups. Results: All rats completed the 14 days of follow-up without complication. The Mesh group had significantly higher adhesion scores than the other groups (P&lt;0.001). Nonetheless, no significant difference was observed between peritoneal repairing methods (P=0.696). Fibrosis and inflammatory scores were similar in peritoneal repairing methods (P=0.394 and P=0.112, respectively). Conclusion: The direct contact of foreign bodies with the intra-abdominal organs increases the risk of adhesion; therefore, the remaining PDs under the polypropylene mesh should be repaired. Sealing PDFs with LS is a simple method that does not increase the inflammatory response, fibrosis, and the risk of adhesion formation.

Needlescopic sutureless repair of congenital inguinal hernia: A randomized controlled study

Congenital inguinal hernia [CIH] can be treated laparoscopically using various methods documented in the literature. Many authors have recommended dividing the sac and stitching peritoneal defects. Other studies claimed that peritoneal disconnection alone is sufficient. In this study, the feasibility, operative time, recurrence rate, and other postoperative complications of needlescopic disconnection of the CIH sac with or without peritoneal defect suturing were compared. A prospective controlled randomized trial was conducted between January 2020 and December 2022. Two hundred and thirty patients who met the study requirements were included. Patients were assigned at random to either Group A or Group B. A group of 116 patients (Group A) had needlescopic separation of the neck of the sac and peritoneal defect closure. The remaining 114 patients (Group B) underwent needlescopic separation without peritoneal defect closure (Sutureless group). A total of 260 hernial defects in 230 patients were repaired using needlescopic disconnection with or without suturing of the defect. There were 89 females (38.7%) and 141 males (61.3%), with a mean age of 5.14 ± 2.79 years. In Group A, the mean operation time was 27.98 ± 2.89 for a unilateral hernia and 37.29 ± 4.68 for a bilateral one, whereas, in Group B, the mean operation time was 20.37 ± 2.37 and 23.38 ± 2.22 for a unilateral and bilateral hernia, respectively. In terms of the operating time, whether unilateral or bilateral, there was a significant difference between the groups. There was no significant difference between groups A and B in the mean Internal Ring Diameter [IRD], which was 1.21 ± 0.18 cm in group A and 1.19 ± 0.11 cm in group B. Throughout the follow-up period, there was no postoperative hydrocele formation, recurrence, iatrogenic ascending of the testes, or testicular atrophy. All patients had nearly invisible scars with no keloid development at 3 months follow-up. Needlescopically separating the hernia sac without stitching the peritoneal defect is feasible, safe, and less invasive. It provides outstanding cosmetic results with a short operative time and no recurrence.

A modified Rives–Stoppa technique with composite mesh (FLaPp) in large incisional hernia: a multicentric retrospective cohort study

Summary Background Large incisional hernias (LIH) are challenging conditions, often necessitating complex surgical procedures such as transversus abdominis muscle release (TAR). We evaluated the feasibility and effectiveness of tension-free abdominal wall repair of LIH with an innovative modified Rives–Stoppa procedure employing a composite free lateral polypropylene (FLaPp) prosthesis. Methods Symptomatic patients affected by LIH and treated with FLaPp composite prosthesis between April 2010 and December 2016 were retrospectively analyzed. The FLaPp prosthesis is made up of two layers: an internal layer based on a polypropylene film that can be used in contact with the intestinal loops to address the posterior peritoneal defect, and an external layer based on a macroporous lightweight mesh, with which a classic repair according to Rives–Stoppa is carried out. Results Forty-three patients were enrolled in the study. All hernias were W3. Early complications were seroma (16.3%), hematoma (11.6%), wound infection (7.0%), and bowel injury (2.3%). Late complications were sinus tract (4.7%), occasional pain (2.3%), and stiff abdomen (9.3%). The median operative time was 126 min and median hospitalization was 8 days. At the median follow-up of 40 months (range 37.5–117), the recurrence rate was 9.3% (4/43). Conclusion Use of FLaPp mesh with a tension-free surgical approach is an effective strategy for managing LIH in selected cases with the presence of a posterior defect, with low rates of complications and recurrences.

Design and Performance Evaluation of a Novel Automatic Stapling Device for Knotless Barbed Suture in Laparoscopic Surgery.

This study developed a novel automatic stapling device for improving the speed and stability of suturing in laparoscopic surgery. The stapling device included 3 components: driver module, actuator module, and transmission module. A negative water leakage test of the in vitro intestinal defect model preliminarily demonstrated the safety of the new automatic stapling device. The suturing time for skin and peritoneal defects through the automatic stapling device was significantly shorter than that through the ordinary needle-holder suture (P < .05). These 2 suture methods had good tissue alignment. The automatic suture showed less inflammatory cell infiltration and lower inflammatory response scores at the tissue incision on days 3 and 7 after surgery compared with the ordinary needle-holder suture, with statistically significant differences (P < .05). In the future, the device needs to be further optimized and the experimental needs to be supplemented to provide some evidence for clinical use. This novel automatic stapling device for knotless barbed suture designed in this study has advantages of shorter suturing time and milder inflammatory responses than the ordinary needle-holder suture, safe and feasible in laparoscopic surgery.

Laparoscopic Abdomino-perineal Resection Followed by Early Postoperative Acute Small Bowel Obstruction- A Case Report with Review of Literature

Abdominoperineal Resection (APR) is the long established therapeutic surgical procedure for cancers of the lower rectum. With the advent of minimal access surgery, APR too has come under its ambit. The large pelvic peritoneal defect and raw area left behind, after dissection are unique to APRs. This report describes the case of a 75-year-old male patient diagnosed with low rectal cancer, who underwent a laparoscopic APR and developed an early post-operative adhesive acute small bowel obstruction. Having failed a trial of conservative management, the same was successfully managed by a re-look laparoscopy. The risk of postoperative adhesions decreases significantly with laparoscopy. APR (whether open or laparoscopic), is a unique operation that causes the formation of a large pelvic raw area, which is very prone to attracting small bowel adhesion/s. The advent of various anti-adhesion barriers (liquid and films) has helped in decreasing the incidence of adhesions. However, in spite of the availability of a wide array of options, there is no consensus among surgeons as to the most optimum agent. Ideally, a tension free closure of the pelvic peritoneal defect formed during APR should be attempted. Failing this, covering of the wide pelvic raw area by a dual mesh or an anti-adhesion barrier agent (fluid or film) or omentopexy have been reported as adhesion preventing manoeuvres. Interceed® promises to be a useful long term adhesion preventing barrier option.

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.

V-054 LAPAROSCOPIC REPAIR OF TWO CASES WITH OBTURATOR HERNIA; EARLY DAIGNOSED AND SUCCESSFUL RESULTS

Abstract Aim Obturator hernia is a rare type of groin site hernias. Early diagnosis may prevent intervention on gastrointestinal tract. In this report, we present two octogenarian female patients with early diagnosed obturator hernia. Material &amp; Methods In first case, 83-year-old female admitted to the Emergency Room(ER) for her left groin site pain. Physical examination was unremarkable except mild tenderness on left groin site. There was no abdominal distention. Ultrasound was negative for surgical aspect. Computerized tomography(CT) scans revealed left sided obturator hernia. Laparoscopic trans abdominal pre-peritoneal (TAPP) repair was planned. Peritoneum was opened about 4–5 cm cranial side of the hernia defect and preperitoneal space was prepared. Cone-shaped 5×5 cm polypropylene mesh have placed in the obturator canal. Afterwards 15×15 cm polypropylene mesh was placed to the groin area, covering all possible hernia sites. The mesh was fixed by tuckers and the peritoneal defect was closed. Second case, 84-year-old female admitted to ER with left groin and knee. There was no sign of inguinal hernia on physical examinitation except mild tenderness on left groin site. CT proved the intestinal segment within the left-sided obturator hernia sac. TAPP repair with mesh plug was planned. Peritoneum was opened and previously prepared cone-shaped 15×15 cm polypropylene mesh have placed in the obturator canal and fixed by tuckers. The peritoneal defect was closed and operation completed. Results Both patients were discharged at postoperative day 2. 60 day-postoperative periods were uneventfull. Conclusion The most crucial factor affecting the results is timing of surgery in obturator hernia.

A Novel Hidden Stitching Method for Preventing Complications in Laparoscopic Hernia Repair.

Barbed suture provides a rapid and effective method for closure in minimally invasive surgery. However, postoperative complications involving barbed suture have been reported in recent years. The aim of this study is to introduce a novel hidden stitching technique for peritoneal closure in laparoscopic hernia repair. This study retrospectively analyzed the data of patients with laparoscopic transabdominal preperitoneal patch (TAPP). In the hidden stitch (HS) group, the barbed suture was hidden on the dorsal side of the peritoneum and two stitches were returned in the opposite direction after the suture reached the end point. In the non-hidden stitch (NHS) group, the barbed sutured was exposed in the peritoneal cavity with a tail stump of approximately 10mm preserved to prevent the peritoneal sutures from loosening. Twenty-seven patients in the HS group were compared with 53 in the NHS group. There were no differences in age, body mass index, surgical bleeding, or length of hospital stay between the two groups. The peritoneal defect closure time was slightly longer (3 min) in the HS group, but the overall operation time was not significantly extended. There were 8 cases of postoperative complications (P = .035) including 4 cases of bowel obstruction due to the tail of the barbed thread penetrating the small intestine mesenteric and two cases of seroma. There were no postoperative complications in the HS group. The hidden stitch method is a safe and feasible peritoneal closure technique that may reduce postoperative complications caused by barbed suture in laparoscopic hernia repair.