Extraperitoneal Research Articles

ETep-retromuscular Repair for Ventral Hernia; a Technique Closest to Ideal

Introduction. Ventral hernia represents a problem for the surgeon and patients alike. eTEP repair is a technique that is minimally invasive, provides lower overall complication rates, decreased wound complications and the recurrence rates and shortens the length of stay in the hospital. Case. We present a case of a 48 year old patient who was admitted to our hospital for elective treatment of recurrent umbilical hernia. The patient had umbilical hernia repair 4 years ago, suture repair without mesh placement was performed according to the information given by the patient. On inspection there is visible supraumbillical scar, 12 cm in length with hernia bulging under the scar which is partially reducible on pressure. Discussion. The eTEP technique is closest to ideal because the abdominal cavity is not penetrated, is lessening the risk of visceral lesions and trocar site hernias, allows local or regional anesthesia, gives unsurpassed views of inguinal region and hernias and reproduces the technique of Rives-Stoppa. In favor to overcome the limitations deriving from the limited surgical field and restricted port set up, this technique has been modified based on the normal anatomy of the abdominal wall naming it depen­dently of the extension of the dissection and the location of the hernia. Conclusion. The extended-TEP (e-TEP) technique is based on the anatomical principle that the extraperitoneal space can be reached from almost anywhere in the anterior abdominal wall. It provides the most of the benefits for the patients but also requires great surgical skill and understanding of the anatomy of the anterior abdominal wall.

Randomized Control Study of Extra Peritoneal Verses Trans Peritoneal Cesarean Section in View of Operative Morbidity

Introduction: Increase incidence of caesarean section is a major concern in todays era. Ceaser may be performed in one of the three way, by classic technique, by lower segment or by some form of extraperitoneal cesarean section. The earliest extraperitoneal technique used was Latzko’s as introduced by Dr Henry Burns. Extraperitoneal cesarean section is a useful method of preventing postoperative morbidity in form of infections & adhesions. Early ambulation , Start oral fluids immediately and get the patient out of bed as soon as the anesthesia worn off are supposed to be advantages of this new study of old technique. Objective: To evaluate advantages or disadvantages of extra peritoneal caesarean section over trans peritoneal caesarean section. Study Design: Single blinded Randomized prospective control triel were performed over 66 patients in our tertiary care institute. Intra operative complications morbidity and outcome compaired by scaling signs, symptoms & examination findings by single consultant. Results: Patients of ECS had better score for postoperative pain, ambulation & oral intake there were less requirement of analgesic in ECS group. Postoperative nausea, shoulder pain febril episodes peritonitis genitourinary tract infection & bowel discomfort were very minimal in ECS group compaire to TCS group. Conclusion: An extra peritoneal csection is definitely advantageous over transperitoneal approach of lower segment caesarean section. There is no need for postoperative starvation, and ileus after this method is rare. Early mobilization reduces the risk of thrombosis and shortens postoperative pain. Less pain makes early commencement of breastfeeding easier within the first hours after the operation. This will also help contraction and involution of the uterus. Early removal of stitches reduces the risk of infection and keloids.

A case of non-occlusive mesenteric ischaemia caused by pelvic fracture due to fall trauma

BackgroundNon-occlusive mesenteric ischaemia (NOMI) is a condition in which intestinal ischaemia arises due to spasms of peripheral blood vessels; however, there is no obstruction of the main arteries. Risk factors include hypertension, diabetes, and increasing age, but the traumatic injury triggering NOMI onset is rarely reported. We report a case of NOMI caused by a pelvic fracture due to a fall injury.Case presentationA 77-year-old man was transported to the hospital due to a fall injury. CT revealed a pelvic fracture and a haematoma in the pelvic extraperitoneal space. The next day, the patient developed shock, and CT revealed an increase in haematoma size. Both internal iliac arteries were embolized by transcatheter arterial embolization (TAE). The next day’s CT revealed intestinal necrosis of the ascending colon, and emergency surgery was planned. During surgery, necrosis was identified in the serosa of the ascending, transverse, and sigmoid colon. We performed subtotal excision from the ascending colon to the sigmoid colon. On postoperative day 10, melena was observed, and CT revealed partial thickening of the small intestine and a decrease in the contrast effect. Considering the post-total colectomy and general condition, we proceeded with conservative treatment. Over time, the patient developed liver and renal dysfunction and died 16 days after surgery.ConclusionsWe experienced a case of NOMI caused by bleeding from a pelvic fracture. It is important to keep in mind the risk of developing NOMI in traumatic bleeding to avoid missing this diagnosis.

A prospective randomized comparison of short-term outcome of laparoscopic, totally extra-peritoneal and trans-abdominal pre-peritoneal repairs for inguinal hernia

Background: Laparoscopic repair of inguinal hernia is steadily gaining popularity among general surgeons. Laparoscopically the preperitoneal space can be approached in two different ways, as a result of which two techniques of laparoscopic repair have emerged. We performed this study to compare the two techniques in a randomized setting in order to ascertain, if possible, which of these techniques is preferable when there is a choice. Methods: This randomized, comparative study was conducted at Shri Mahant Indiresh hospital, Dehradun over a period of three years. Patients with unilateral, uncomplicated, inguinal hernia were randomized into two groups for undergoing surgery using either of these techniques. Patients’ demography and both intraoperative and postoperative variables were compared between the two groups.Results: Mean duration of surgery and mean pain scores in early postoperative period were found to be higher for transabdominal preperitoneal (TAPP) group as compared to totally extraperitoneal (TEP) group. Intraoperative and postoperative complications as well as hospital stay were not significantly different between the two groups.Conclusions: In this study TEP has been found to have an edge over TAPP in some respect but as per the available evidence both techniques are safe and choice of procedure may be tailored according to individual cases.

Video-Assisted Peritoneal Dialysis Placement in COVID-19 Patients

Video-Assisted Peritoneal Dialysis Placement in COVID-19 Patients

Treatment of small (< 2cm) umbilical hernias: guidelines and current trends from the Herniamed Registry.

Based on meta-analyses and registry data, the European Hernia Society and the Americas Hernia Society have published guidelines for the treatment of umbilical hernias. These recommend that umbilical hernia should generally be treated by placing a non-absorbable (permanent) flat mesh into the preperitoneal space with an overlap of the hernia defect of 3cm. Suture repair should only be considered for small hernia defects of less than 1cm. Hence, the use of a mesh in general is subject to controversial debate particularly for small (< 2cm) umbilical hernias. This analysis of data from the Herniamed Registry now presents data on the treatment of small (< 2cm) umbilical hernias over the past 10years. Herniamed is an Internet-based hernia registry in which hospitals and surgical centers in Germany, Austria and Switzerland can voluntarily enter data on their routine hernia operations. Between 2010 and 2019, data were entered into the Herniamed Registry by 737 hospitals/surgery centers on a total of 111,765 patients with primary elective umbilical hernia repair. The prospective data were analyzed retrospectively for each year and statistically compared. Due to a higher number of cases, the years 2013 and 2019 were compared for the perioperative outcome and the years 2013 and 2018 for 1-year follow-up. Fisher's exact test was applied for unadjusted analyses between the years, using a significance level of alpha = 5%. For post hoc tests of single categories, a Bonferroni adjustment for multiple testing was implemented. A mesh technique was used to treat 45.4% of all umbilical hernias. The proportion of small (< 2cm) umbilical hernias in the total collective of umbilical hernias was 55.6%. Suture repair was used consistently over the 10-year period to treat around 75% of all small (< 2cm) umbilical hernias. Preperitoneal mesh placement as recommended in the guidelines was used only in 1.8% of cases. Between 2013 and 2019, stable values of 2 and 0.7% were observed for the postoperative complications and complication-related reoperations, respectively, with no relevant effect identified for the surgical technique. At 1-year follow-up, significantly higher rates of pain at rest (2.6 vs. 3.3), pain on exertion (5.7 vs. 6.6), and recurrences (1.3 vs. 1.8) (all p < 0.05) were identified for 2018 compared with 2013. A suture technique is still used to treat 75% of patients with small (< 2cm) umbilical hernias. The pain and recurrence rates are significantly less favorable for 2018 compared with 2013.

A novel technique of robotic preperitoneal approach for Morgagni hernia repair.

Morgagni hernia (MH) is a rare, congenital diaphragmatic hernia. We developed a novel robotic-assisted technique to repair MH which enables dissection into the preperitoneal space, facilitating closure of the diaphragmatic defect and placement of a synthetic mesh. Between August 2017 and August 2020, 8 consecutive patients with MH were repaired by robotic-assisted transabdominal preperitoneal (r-TAPP) approach. A preperitoneal plane is developed at the level of the falciform ligament and extended toward the diaphragmatic defect. The pocket is dissected inferior to the defect to allow 3 to 5 cm overlap of synthetic mesh. Excision of the hernia sac followed by closure of defect is performed. A synthetic mesh is deployed in the preperitoneal space with wide overlap. This technique using the robot provides superior optics and ergonomics for dissection while isolating the mesh from underlying viscera and avoiding the need for suturing or tacking of the mesh. Data of patients who underwent r-TAPP were reviewed. Mean operating time was 113 minutes. Mean pain visual analog scale score was 5/2 on post-operative days 1/7. Average hospital stay was 1.8 days. One patient developed superficial cellulitis related to the abdominal drain. There were no procedure-related complications, 30-day readmissions, or hernia recurrences at a mean follow-up of 10 months. A robotic-assisted preperitoneal approach is a novel, safe, and anatomically justified alternative technique for MH repair that may lead to improved post-operative outcomes.

Supine extraperitoneal laparoscopic nephroureterectomy without patient repositioning.

To describe a novel technique allowing laparoscopic nephroureterectomy with bladder cuff excision and lymphadenectomy, in a complete supine position, without patient repositioning. Between January 2016 and October 2018, 20 consecutive patients with upper urinary tract urothelial carcinoma underwent supine extraperitoneal laparoscopic nephroureterectomy. The patients were placed in the complete supine position. A 4-cm pararectal skin incision was made and the extraperitoneal space was developed. We used a unique port placement that permits complete access for nephroureterectomy, bladder cuff excision and concomitant lymphadenectomy. Operative parameters and pathological data were analyzed. The median age was 70years (range 49-88years), the mean operative time was 234min (range 175-293min) and the mean estimated blood loss was 67mL (range 50-200mL). There were no intraoperative complications, and no patients required transfusion or open conversion. The median number of removed lymph nodes was 10; only one patient had node metastasis. The total operative time and time for nephroureterectomy were significantly longer in the first 10 patients (first group) than in the second 10 patients (second group). Times required for bladder cuff excision and lymphadenectomy did not differ between the two groups. Our novel technique, which enables completion of the entire procedure of nephrouretectomy with bladder cuff excision and lymphadenectomy in the supine position without patient repositioning, is safe and minimizes operative time while maintaining oncological efficacy. We believe this approach might become a standard option for patients with upper urinary tract urothelial carcinoma.

Drainage decreases the seroma incidence in laparoscopic transabdominal preperitoneal (TAPP) hernia repair for large inguinoscrotal hernias

BackgroundSeroma is a common and inevitable postoperative complication in transabdominal preperitoneal (TAPP) hernia repair, especially in patients with large inguinoscrotal hernias. However, studies have rarely reported drainage in TAPP for large inguinoscrotal hernias. MethodsSixty-five patients with 78 large indirect inguinoscrotal hernias who underwent TAPP procedure with drainage between September 2016 and December 2019 were enrolled in this study. 181 patients with Type Ⅲ indirect inguinal hernias (European Hernia Society (EHS) classification, hernia defect >3 cm) who underwent TAPP without drainage (no-drainage group) between January 2019 and December 2019 were included for a comparison. In the drainage group, a 12-Fr drainage tube was inserted into the distal hernia sac via the preperitoneal space to decrease the incidence of seroma. ResultsThere was no conversion to open procedures in all the patients. The operative time (56.5 ± 8.4 VS 54.8 ± 9.6 min, unilateral; 95.8 ± 10.4 VS 92.1 ± 13.9 min, bilateral), blood loss (5.9 ± 1.9 VS 5.6 ± 1.7 mL), visual analogue scale score on postoperative day 1 (2.3 ± 0.5 VS 2.2 ± 0.5) and postoperative hospital stay (1.1 ± 0.3 VS 1.0 ± 0.2 days) in the drainage group were equivalent to those in the no-drainage group (p > 0.05). The mean length of drainage was 5.2 ± 1.3 days. The drainage group had a significantly lower incidence of seroma than the no-drainage group (1.5% VS 9.4%, p = 0.037). The postoperative complications including haematoma, recurrence and chronic pain were comparable in the two groups. ConclusionDrainage with appropriate duration is a feasible, safe and effective measure to decrease the incidence of seroma in TAPP for patients with large inguinoscrotal hernias.

Refractory pelvic fracture-associated hemorrhage after preperitoneal packing: now what?

A male patient in his 50s presented after a high-speed motorcycle crash. On arrival to the trauma bay, his primary survey was intact with normal vital signs. He had an...

Grafting Islets to a Dissected Peritoneal Pouch to Improve Transplant Survival and Function.

Although the liver is the primary site for clinical islet transplantation, it poses several restrictions, especially limited tissue volume due to portal vein pressure. We evaluated the preperitoneal space as an extrahepatic islet transplant site to deliver high tissue volumes and sustain long-term graft function. A peritoneal pouch was formed by dissecting the parietal peritoneum from the transversalis fascia of mice. Syngeneic C57BL/6 donor islets were transplanted into the peritoneal pouch of diabetic mouse recipients. Blood glucose was monitored for islet function, and miR-375 was analyzed for islet damage. Islet graft morphology and vascularization were evaluated by immunohistochemistry. [F] fluoro-D-glucose positron emission tomography/computed tomography was used to image islet grafts. Transplantation of 300 syngeneic islets into the peritoneal pouch of recipients reversed hyperglycemia for >60 days. Serum miR-375 was significantly lower in the peritoneal pouch group than in the peritoneal cavity group. Peritoneal pouch islet grafts showed high neovascularization and sustained insulin and glucagon expression up to 80 days posttransplantation. A peritoneal pouch graft with high tissue volume (1000 islets) could be visualized by positron emission tomography/computed tomography imaging. Human islets transplanted into the peritoneal pouch of diabetic nude mice also reversed hyperglycemia successfully. Islets transplanted into a dissected peritoneal pouch show high efficiency to reverse diabetes and sustain islet graft function. The preperitoneal site has the advantages of capacity for high tissue volume, enriched revascularization and minimal inflammatory damage. It can also serve as an extrahepatic site for transplanting large volume of islets necessitated in islet autotransplantation.

Clinical characteristics of inguinal bladder hernias and total extraperitoneal repair.

Bladder hernia is relatively rare in cases of inguinal hernia. In some instances, bladder hernia may be treated as inguinal hernia if bladder prolapse is not recognized. Because of the rarity of inguinal bladder hernias, there are no related detailed reports from studies performed at a single institution. In our hospital, patients with suspected inguinal hernia undergo CT in the prone position, enabling the diagnosis of bladder hernia preoperatively. This study aimed to clarify the clinical characteristics of inguinal bladder hernias and consider noteworthy points in their laparoscopic treatment. This retrospective analysis included data from 32 consecutive patients with bladder hernia in 1126 patients with inguinal hernia. In each patient, the lengths of the hernial orifice and prolapsed bladder were measured on the CT images and intraoperatively. Totally extraperitoneal (TEP) repair was performed in all patients, who were then followed for 1 year postoperatively. Inguinal bladder hernia was detected on CT in 32 of 1126 patients (2.8%). Among them, only five (15.6%) had urological symptoms such as pollakiuria or the sensation of residual urine. The 32 patients were classified into three groups according to hernia subtype: intraperitoneal (n=12, 37.5%), para-peritoneal (n=15, 46.9%), and extraperitoneal (n=5, 15.6%). The prolapsed bladder of the extraperitoneal type was significantly shorter than that of the other subtypes. The prolapsed bladders were directly identified in the extraperitoneal space and repaired safely with TEP. One recurrence (3.1%) occurred 2 months postoperatively. Preoperative CT and TEP are useful for the definitive diagnosis and treatment of inguinal bladder hernia.

Diagnostic value of laparoscopic inguinal allohernioplasty in detection of occult hernias of inguinal region

Aim. To evaluate diagnostic value of laparoscopic inguinal allohernioplasty in identification of occult forms of hernias of the inguinal region.&#x0D; Materials and Methods. The study was conducted on the basis of the results of surgical treatment of patients with inguinal hernias on the base of the Department of Hospital Surgery of RyazSMU in Ryazan State Emergency Care Hospital and on the base of the Department of Surgery, Obstetrics and Gynecology of Additional Postgraduate Education Faculty in Ryazan Regional Clinical Hospital, from 2015 to 2020 (n=207). Operations were performed with the absence of contraindications to narcosis and carboxyperitoneum, and if patients desired to be operated on by the proposed method. In all the patients included into the study, hernioplasty was performed using laparoscopic approach, with preperitoneal placement of the endoprosthetic mesh. For purity of the experiment, only polypropylene meshes were used. Standard meshes from monofilament polypropylene were used with surface density 65-80 g/m2 and volumetric porosity 80-85%. Meshes 15x15 cm dimension were used with cut angle with 7.5A cm catheti.&#x0D; Results. Of 207 patients, 28 were operated on for bilateral inguinal hernias. Only in one of them hernia was diagnosed in the preoperative stage. In the rest 27 patients, an occult hernia was found opposite to the previously diagnosed side. In 17 patients, besides hernias diagnosed in the preoperative and intraoperative stages, occult hernias were detected in the process of dissection of the preperitoneal space.&#x0D; Conclusion. Laparoscopic inguinal allohernioplasty permits to diagnose occult hernias that were not detected in the preoperative examination: femoral, obturator, inguinal hernias on the contralateral and/or unilateral side. This permits to perform hernioplasty taking into account the intraoperative finding, in one surgical procedure without subjecting the patient to repeated hospitalization, narcosis and operation.

A preliminary multicenter evaluation of endoscopic sublay repair for ventral hernia from China

BackgroundFor ventral hernia, endoscopic sublay repair (ESR) may overcome the disadvantages of open sublay and laparoscopic intraperitoneal onlay mesh repair. This retrospective study presents the preliminary multicenter results of ESR from China. The feasibility, safety, and effectiveness of ESR were evaluated; its surgical points and indications were summarized.MethodsThe study reviewed 156 ventral hernia patients planned to perform with ESR in ten hospitals between March 2016 and July 2019. Patient demographics, hernia characteristics, operative variables, and surgical results were recorded and analyzed.ResultsESR was performed successfully in 153 patients, 135 with totally extraperitoneal sublay (TES) and 18 with transabdominal sublay (TAS). In 19 patients, TES was performed with the total visceral sac separation (TVS) technique, in which the space separation is carried out along the peritoneum, avoiding damage to the aponeurotic structure. Endoscopic transversus abdominis release (eTAR) was required in 17.0% of patients, and only 18.3% of patients required permanent mesh fixation. The median operative time was 135 min. Most patients had mild pain and resume eating soon after operation. No severe intraoperative complications occurred. Bleeding in the extraperitoneal space occurred in two patients and was stopped by nonsurgical treatment. Seroma and chronic pain were observed in 5.23 and 3.07% of patients. One recurrence occurred after TAS repair for an umbilical hernia.ConclusionESR is feasible, safe, and effective for treating ventral hernias when surgeons get the relevant surgical skills, such as the technique of “partition breaking,” TVS, and eTAR. Small-to-medium ventral hernias are the major indications.

Extraperitoneal staged stapling closure of the double-barreled stomas: a new modification of the old technique

Introduction One distinct disadvantage of Paul Mikulicz double-barreled colostomy is the need to apply an enterotome to the stoma for several days to crush the intervening spur before the double-barreled colostomy is closed. A new modification of the old technique was applied to omit the usage of the enterotome and avoid the riskiest complications of colostomy closure. Aim The aim of this study was to evaluate the efficacy and safety of this new technique, staged stapling closure of the double-barreled stomas, to publicize its use for all temporary stomas. Patients and methods Being a new technique, only 20 patients were included in this study. They all were old patients of both sexes. This new technique is accomplished in three stages: stage I is to perform the original double-barreled enterostomy in its native manner, stage II: 1 week later after in the outpatient clinic without the need for anesthesia, sterilization, or bowel preparation, where the spur between the two limbs of the enterostomy is divided using GIA stapler, and stage III: where 2 weeks later, under local or spinal anesthesia, extraperitoneal closure of the stoma was done with double-layer sutures. Results This study was carried out between November 2018 and January 2020 on 20 patients, aged 64–86 years, comprising 12 males and eight females. Only one (5/%) case was complicated with leakage and wound gaping. She had another trial of closure 2 weeks later, which succeeded. At the end, all patients were discharged home, with open bowel, normal defecation, and surgically stable. There was no mortality throughout our study. Conclusion Extraperitoneal staged stapling closure of the double-barreled enterostomy is a safe and easy technique to close temporary stomas with no need for another laparotomy and without the risk of peritonitis or obstruction.

Polypropylene mesh versus double face mesh in totally extraperitoneal laparoscopic inguinal hernia repair

Background Inguinal hernia is the commonest type of hernia. Repair of the inguinal hernia is one of the most widely recognized surgeries done all over the world. With the advancement in knowledge, laparoscopic hernioplasty has become very popular, accounting for ∼15–20% of hernia repair, with great results. Objectives In this study, we have tried to determine if there is a significant difference between using conventional polypropylene mesh and double face mesh (polypropylene+vicryl) in totally extraperitoneal (TEP) laparoscopic hernia repair. Patients and methods This study had been conducted on 20 patients with inguinal hernia, who were divided into two groups. Group A represented patients who underwent TEP repair of an inguinal hernia using polypropylene mesh, and group B represented patients who underwent TEP repair of inguinal hernia with double face mesh. Results Regarding operative time, same operative time was seen in both groups. Nevertheless, much longer time was noticed in case of the peritoneal tear in group A. There were no intraoperative complications encountered in both groups, such as bleeding, visceral injuries, and conversion to transabdominal preperitoneal or open technique; however, peritoneal tear occurred in both groups. Regarding the postoperative period, there was no difference in the postoperative parameters between both groups, including pain, hospital stay, and recurrence. Nevertheless, the cost in the double face mesh group is significantly higher than polypropylene mesh group. Conclusion TEP approach is an acceptable procedure for inguinal hernia repair with less visceral and vascular injuries. There was no difference in outcome between TEP repair of inguinal hernia either using the polypropylene or double face mesh. Randomized studies on a larger number of patients are needed to confirm the results.

Short Term Outcome of Laparoscopic Trans-Abdominal Preperitoneal (TAPP) Inguinal Hernia Repair Without Mesh Fixation, a Comparative Study

Background: Laparoscopic repair of groin hernia is gaining popularity, most surgeons follow up the consensus of mesh fixation especially by tissue penetrating methods, as mesh fixation helps prevent recurrence it also, may cause nerve injuries leading to acute and/or chronic postoperative pain, many alternatives for mesh fixation do exists as use of self-gripping mesh, use of absorbable tacks, use of fibrin glue and the mesh placement in the extra-peritoneal space without fixation as we tried to investigate in this study. Patient and method: 46 patients undergoing laparoscopic trans-abdominal preperitoneal repair of groin hernia were randomly allocated into two equal groups, A (group of mesh fixation with absorbable tacks) and B (group of mesh no fixation). Preoperative, operative, and postoperative data in both groups, namely recurrence rate, acute and chronic pain, and local complications were statistically analyzed in comparison to each other. Results: Throughout the analysis of the data there were no statistically significant differences between both groups regarding demographic data, hernia side, and hernia type. the operative time, acute pain score, and incidence of chronic pain were longer in the fixation group without statistical significance, we recorded one case of recurrence in the non-fixation group but without statistical significance. Conclusion: Mesh placement in the preperitoneal space during laparoscopic trans-abdominal pre-peritoneal repair of inguinal hernia is a safe efficient method as it is not associated with increased recurrence rate or postoperative pain.

Short Term Outcome of Laparoscopic Trans-Abdominal Preperitoneal (TAPP) Inguinal Hernia Repair Without Mesh Fixation, a Comparative Study

Background: Laparoscopic repair of groin hernia is gaining popularity, most surgeons follow up the consensus of mesh fixation especially by tissue penetrating methods, as mesh fixation helps prevent recurrence it also, may cause nerve injuries leading to acute and/or chronic postoperative pain, many alternatives for mesh fixation do exists as use of self-gripping mesh, use of absorbable tacks, use of fibrin glue and the mesh placement in the extra-peritoneal space without fixation as we tried to investigate in this study. Patient and method: 46 patients undergoing laparoscopic trans-abdominal preperitoneal repair of groin hernia were randomly allocated into two equal groups, A (group of mesh fixation with absorbable tacks) and B (group of mesh no fixation). Preoperative, operative, and postoperative data in both groups, namely recurrence rate, acute and chronic pain, and local complications were statistically analyzed in comparison to each other. Results: Throughout the analysis of the data there were no statistically significant differences between both groups regarding demographic data, hernia side, and hernia type. the operative time, acute pain score, and incidence of chronic pain were longer in the fixation group without statistical significance, we recorded one case of recurrence in the non-fixation group but without statistical significance. Conclusion: Mesh placement in the preperitoneal space during laparoscopic trans-abdominal pre-peritoneal repair of inguinal hernia is a safe efficient method as it is not associated with increased recurrence rate or postoperative pain.

Anorectal injury related to a personal watercraft: a case report and literature review

BackgroundDouche injury is a rare consequence of water recreation activities. Generally, this type of trauma occurs when people fall into the water in a sitting position during high-speed activities such as using a personal watercraft (PWC). Here, we report a rare case of anorectal injury caused by water jets from a PWC during sudden acceleration from rest.Case presentationA 21-year-old male passenger on a PWC fell off backward from the rear seat when the craft suddenly accelerated. He fell into the water in a supine position with his legs open, and the water jets of the PWC struck his perineum directly. Thereafter, bleeding from the anus was seen, and he was transferred to our hospital. On physical examination, there was a deep laceration interrupting the external anal sphincter in the posterior rectal wall. Abdominal computed tomography revealed a full-layer perforation of the posterior rectal wall and leakage of feces into the extraperitoneal space, but intraperitoneal free air was not seen. Laparoscopic sigmoid loop colostomy and primary suturing of the sphincter and mucosa were performed. He did not have any complications and was discharged from our hospital 16 days after the surgery. His anal function was almost perfectly preserved, and his diverting colostomy was closed 4 months later.ConclusionAnorectal injuries related to PWCs can occur not only while traveling at high speeds, but also when suddenly accelerating from rest. A diverting colostomy should be performed for this type of trauma. In these trauma cases, clinicians must suspect complex and life-threatening anorectal injuries early.

Evaluation of mesh fixation versus non-fixation in laparoscopic mesh hernioplasty in inguinal hernias

Background: Laparoscopic inguinal hernia repair (LIHR) is usually done by two methods, which vary in approach to the preperitoneal space; transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP). This study aimed at comparing the effect of mesh fixation and non-fixation in terms of operative time, hospital stay, analgesic requirement, complications and cost analysis with respect to fixation device in LIHR.Methods: This prospective randomized comparative study included 60 patients of inguinal hernias admitted to the Department of Surgery at Rajendra Hospital, G.M.C, Patiala from July 2016 to September 2017 (duration of study was 15 months). Cases were divided into two groups by draw of lots with group A as mesh fixation (n=30) and group B as non-fixation (n=30).Results: The results were calculated with chi square test (p value). Results were found to be not significant in two groups in the terms of postoperative analgesia, complications i.e. (intraoperative, postoperative and long term) postoperative hospital stay and time to return for work. The cost of procedure was found to be very high in Group A and results were highly significant (p&lt;0.001).Conclusion: LIHR repair without mesh fixation shows advantages over mesh fixation, which includes significant less cost of surgery, with comparable intraoperative, postoperative and long-term complications (with no increase in hernia recurrence), hospital stay and mean operative time. Hence, our study favours LIHR without mesh fixation a valuable alterative option.