Hernia Repair Research Articles

Surgical management of incarcerated and strangulated inguinal hernias requiring urgent surgical intervention: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma.

Patients with acutely incarcerated or strangulated inguinal hernias require urgent surgical evaluation. Most literature on inguinal hernia management focuses on elective repairs. We aimed to provide evidence-based guidelines for managing inguinal hernias requiring urgent surgical intervention. An evidence-based systematic review was performed. Clinically relevant questions regarding defined Population(s), Intervention(s), Comparison(s), and Outcome(s) were selected. These questions centered around the timing of intervention, the use of mesh, the surgical approach, and the use of antibiotics in patients who presented with incarcerated or strangulated inguinal hernias requiring urgent surgical interventions. A comprehensive literature search was completed from 1946 through March 11, 2024. The Grading of Recommendations Assessment, Development and Evaluation methodology was used in the creation of the recommendations. Consensus was achieved for all final recommendations. Of 7,038 articles reviewed, 34 met the inclusion criteria. Early intervention (<6 hours from symptom onset) was associated with a lower incidence of bowel resection (odds ratio [OR], 0.1 [0.05, 0.29]; p < 0.0001). Hernia repair with mesh was associated with decreased incidence of recurrence (OR, 0.34 [0.13, 0.87]; p = 0.02) and mixed results for surgical site infections. Laparoscopic repairs decreased recurrence rates (OR, 0.75 [0.58, 0.99]; p = 0.03) and had shorter hospital length of stay (mean difference, -3.00 [-5.54, -0.47]; p < 0.01) compared with open repairs. There were not enough studies to address the routine use of postoperative antibiotics. Quality was deemed very low with much of the literature being retrospective studies. We conditionally recommend early surgical intervention for adult patients presenting with acutely incarcerated or strangulated inguinal hernias who are deemed to require surgery. We conditionally recommend mesh repairs over primary tissue repairs and laparoscopic approaches over open approaches for this population. No recommendations can be made regarding the routine use of antibiotics. Systematic Review/Meta-analysis; Level III.

Comparative Study between Benefits of Desarda Tissue Repair Over Conventional Lichtenstein Mesh Hernioplasty

Objectives Inguinal hernia repair is one of the most commonly performed surgical procedures worldwide. The Lichtenstein Mesh Hernioplasty is the gold standard, but it is associated with potential complications, including infections and chronic pain. Desarda Tissue Repair, a non-mesh technique, has been proposed as a safer alternative, offering advantages such as reduced complications and quicker recovery. This study aims to compare the clinical outcomes, postoperative pain, complications, and recovery times between Desarda Tissue Repair and Conventional Lichtenstein Mesh Hernioplasty in patients with an inguinal hernia. Material and Methods We conducted a comparative study at the People’s Hospital, Bhopal. After approval from the ethics committee and obtaining the informed consent form from the patients, a total of 82 patients meeting the inclusion criteria from March 2023 were studied. The patients were divided into two groups. The duration of surgery, post-operative pain, surgical complications, duration of hospital stay, and time taken to return to normal activity were assessed and compared. Data were analyzed using SPSS software ver. 26.0 Results The present study demonstrated that Desarda Tissue Repair yielded significantly better outcomes compared to Lichtenstein Mesh Hernioplasty. The former was associated with shorter symptom duration, surgery time, recovery time, and hospital stay. Patients with Desarda Tissue Repair also reported significantly lower postoperative pain (mean visual analog scale-VAS score of 2.76 ± 2.02 vs. 4.88 ± 2.66, p = 0.03) and fewer complications, with no wound infections, seromas, chronic pain, or loss of sensation, compared with Lichtenstein Mesh Hernioplasty. Fewer overall complications (97.56% no complications vs. 73.17% in Lichtenstein Mesh Hernioplasty, p = 0.02) make the Desarda repair a safer and more effective option for inguinal hernia repair. Conclusion The study concludes that Desarda Tissue Repair is a safer and more effective option for inguinal hernia repair compared with Lichtenstein Mesh Hernioplasty. It is associated with shorter surgery duration, fewer complications, less postoperative pain, and faster recovery, making it preferable, especially for those wanting to avoid mesh-related complications.

Are outcomes of giant ventral hernia repair inferior? A propensity-matched analysis.

Ventral hernia repair (VHR) of large defects poses significant technical challenges due to the size of the hernia and complexity of operative techniques required for fascial closure. This study examined clinical outcomes in "giant" open VHR (GVHR), with hernia defect size (HDS) ≥ 200 cm2, versus "non-giant" open VHR (NGVHR) with HDS < 200 cm2 using a propensity-matched approach. A prospectively-maintained database from a tertiary hernia center was reviewed for patients undergoing open VHR. 1:1 propensity-score matching was performed for GVHR versus NGVHR based on age, BMI, comorbidities, fascial defect closure, primary vs recurrent repair, CDC wound class, and ASA score. A multivariable regression model evaluated whether wound complications increased odds of recurrence. CDC class III/IV wounds and concomitant intraabdominal procedures were excluded. Standard statistical analyses were performed. PSM yielded 254 well-matched pairs (all p > 0.05). Average age (59.7 ± 11.3 vs. 59.3 ± 12.3years) and BMI (32.1 ± 6.5 vs. 32.4 ± 6.6kg/m2) were similar between GVHR and NGVHR. Tobacco status was similar for current and former smokers (3.9% vs. 3.9%; 29.9% vs. 29.9%). GVHR had larger defect size (354.7 ± 132.1 vs. 103.8 ± 61.9 cm2; p < 0.001) and mesh size (1161.9 ± 450.0 vs. 771.2 ± 388.4 cm2; p < 0.001). In GVHR, Botulinum toxin injections (15.4% vs. 2.8%; p < 0.001) and component separation (50.6% vs. 23.7%; p < 0.001) were more frequent. Fascial defect was closed in 100% of both groups (p > 0.999). GVHR had higher rates of wound complications (33.5% vs. 15.4%; p < 0.001), respiratory insufficiency or failure (4.7% vs. 0.8%; p = 0.012), reoperation (9.8% vs. 4.7%; p = 0.028), and greater average length-of-stay (6.9 ± 5.1 vs. 5.0 ± 2.0days; p < 0.001). There was no statistical difference in recurrence (4.3% vs. 2.4%; p = 0.217) or follow-up (24.0 ± 37.8 vs. 27.4 ± 40.4months; p = 0.558). GVHR often required chemical and mechanical component separation to achieve fascial closure. However, with large preperitoneal mesh overlap and fascial closure, outcomes of large defects in VHR are comparable to smaller defects.

Open Anterior Mesh Repair vs Modified Open Anterior Mesh Repair for Groin Hernia in Women

ImportanceMost women in low- and middle-income countries lack access to laparoscopic methods for groin hernia repair; therefore, an open technique through which both inguinal and femoral hernias can be treated is needed. This could be an option in the absence or inability to use laparoscopic methods.ObjectiveTo determine the safety and effectiveness of open anterior mesh (OAM) repair compared with modified open anterior mesh (MOAM) repair, which includes opening the transversalis fascia and covering the femoral canal with a mesh flap.Design, Setting, and ParticipantsThis was a parallel, 2-arm, double-blind, randomized clinical trial conducted in Northern Uganda, in East Africa, at 2 public hospitals between October 2019 and February 2023. Included in the study were adult women 18 years and older with a primary groin hernia, American Society of Anesthesiologists (ASA) class I or II, and the ability to give informed consent.InterventionsOAM in the control arm and MOAM in the intervention arm.Main Outcomes and MeasuresThe primary outcome was groin hernia recurrence 1 year postoperatively.ResultsA total of 200 participants (mean [SD] age, 52.7 [14.0] years) were included in the study; 99 (49.5%) were allocated to OAM repair, and 101 (50.5%) were allocated to MOAM repair. Nearly 45% of the participants (89 of 200) had a femoral hernia; therefore, 35 of 99 participants (35.4%) in the control arm received the intervention procedure. One year postoperatively, the overall recurrence was 5.6% (11 of 195 participants), and the intention-to-treat analysis showed that 4 of 97 participants (4.1%) in the control arm and 7 of 98 participants (7.1%) in the intervention arm had recurrence (absolute difference = −3.0 percentage points; 95% CI, −9.5 to 3.4; P = .36).Conclusions and RelevanceResults of this randomized clinical trial demonstrate that the MOAM repair was a good option for groin hernia repair in women in low-resource settings. Femoral hernias were very common in the study population, and exposure of the femoral canal was essential to detect these hernias.Trial RegistrationISRCTN Identifier: ISRCTN10330683

INNOVATIONS IN LAPAROSCOPIC HERNIOPLASTY OF VENTRAL HERNIAS

Ventral hernias remain a pressing issue in surgical practice, particularly in the context of postoperative ventral hernias. Traditional open hernioplasty is a standard treatment method; however, modern advancements in endovideosurgical techniques may significantly enhance surgical efficacy, reduce postoperative complications, and expedite patient recovery. The purpose of the study. To assess the outcomes of laparoscopic prosthetic hernioplasty in ventral hernia repair and perform a comparative analysis with the conventional open approach. The study evaluated 228 patients who underwent surgical treatment for ventral hernias between 2011 and 2024. Materials and methods of research. The study enrolled 228 patients with ventral hernias treated at the surgical department of a multidisciplinary clinic of Samarkand State Medical University. Patients were divided into two groups: a control group (n=106) undergoing open hernioplasty and a main group (n=122) undergoing laparoscopic prosthetic hernioplasty. Results. Postoperative complications occurred in 43 patients, including 35 cases in the control group and 8 in the main group. Complications comprised bronchopulmonary (n=4), cardiovascular (n=5), and one fatal case following laparotomy hernioplasty. Conclusions. Comparative analysis demonstrated significant advantages of laparoscopic hernioplasty over the open approach, including reduced postoperative pain duration and earlier patient mobilization.

Round Ligament Management in Percutaneous Inguinal Hernia Repair: Comparative Outcomes Using the FLAIR Technique in Girls

Abstract Fenestrated laparoscopic-assisted internal ring-rrhaphy (FLAIR) is a refined percutaneous technique for pediatric inguinal hernia repair. Although its outcomes have been reported in boys, its application in girls, particularly in relation to round ligament management, remains underexplored. Whether to include or exclude the ligament during internal ring closure is still debated.This study evaluated the impact of round ligament management on surgical outcomes in girls undergoing FLAIR. A retrospective cohort of 69 hernias, operated on between July 2016 and December 2023, was reviewed. Patients were divided into two groups: those in whom the round ligament was included in the closure (Inclusion group) and those in whom it was deliberately spared (Exclusion group). Recurrence rates and postoperative complications were compared.All four recurrences (11%) occurred in the Inclusion group, while no recurrences were observed in the Exclusion group (p = 0.048). All recurrences occurred within 3 months postoperatively and were successfully reoperated using the exclusion technique, with no further recurrence during follow-up. No significant differences in other postoperative complications were identified between groups.FLAIR appears to be a safe and effective approach in girls, particularly when the round ligament is excluded from the closure. Exclusion was associated with zero recurrences and no increase in complications. These findings, observed over intermediate-term follow-up, suggest that sparing the round ligament may enhance repair integrity and potentially protect the ligament from entrapment, thereby preserving its anatomical function. Larger, multicenter studies with extended follow-up are needed to validate these results and guide pediatric hernia repair strategies.

Familial Case of Morris Syndrome: Clinical Observations

Hormonal regulation plays a crucial role in human sexual development. Mutations in the androgen receptor gene may cause peripheral androgen resistance, leading to characteristic phenotypic manifestations. In complete androgen resistance, patients develop a female phenotype despite disrupted sexual differentiation, which is mediated by aromatization of testosterone into estrogen. One of the typical complaints reported by patients is the presence of a groin bulge, often bilateral, which is perceived as an inguinal hernia. Surgical treatment in the form of gonadectomy may result in impaired bone mineral metabolism or masculinization; on the other hand, delayed intervention increases the risk of malignancy. This article presents a familial case of Morris syndrome with a previously undescribed AR gene mutation (NM_001011645.3) in two girls aged 14 and 6 years. Both girls were admitted for elective repair of bilateral inguinal hernias observed since birth. During hernioplasty, testes were discovered and biopsied, revealing testicular tissue in the first case and tunica albuginea in the second. Based on intraoperative findings, further evaluation was performed, including ultrasound of the genitourinary system, hormonal testing, medical genetic testing, and consultations with endocrinologist and geneticist. In both cases, androgen insensitivity syndrome was confirmed (a hemizygous AR gene variant was identified in exon 7: HG38, chrX:67721856T C, c.746T C, resulting in the amino acid substitution p.Met249Thr). DNA sequencing revealed the AR gene mutation in the mother in a heterozygous state. No pathogenic variants were identified in the father, older sister, or brother. With parental consent, both patients underwent bilateral laparoscopic gonadectomy. The study highlights the importance of age, including in relation to sexual and phenotypic development, when determining the timing of surgical intervention. It also underscores the need for a comprehensive, multidisciplinary approach to address functional, social, and gender-related issues in these patients.

A multicenter study: optical gasless trocar vs. open method for preperitoneal space establishment in ventral hernia repair

A multicenter study: optical gasless trocar vs. open method for preperitoneal space establishment in ventral hernia repair

Restoration of normal anatomy without fundoplication in non-elective incarcerated giant paraesophageal hernia repair.

The purpose of our study was to examine outcomes following a novel approach to management of incarcerated giant paraesophageal hernia in a non-elective setting. Surgical dogma has dictated performing a fundoplication, but we have hypothesized that this is unnecessary in patients without significant reflux presenting with predominantly obstructive symptoms. Patients who presented to the emergency room between January 2010 and June 2024 with symptomatic giant incarcerated paraesophageal hernia with operative repair performed during the same hospitalization were included. An absence of pre-operative reflux symptoms was required. Operative steps included hernia sac reduction, mediastinal mobilization with vagal and crural lining preservation and primary crural closure. An Angle of His reconstruction was performed, and the fundus was sutured to the left hemidiaphragm immediately anterior to the spleen. Objective follow-up was obtained via esophagram, endoscopy, and CT scan. There were 255 patients with a median age of 81years. All operations were performed with minimally invasive techniques. The median post-operative length of stay was 6days. The 30-day mortality was 3.5%, mostly related to complications of pneumonia. Objective follow-up was available in 230 patients at a median of 13months. There were 13 hiatal hernia recurrences (5.7%): 7 medium (3-4cm), and 6 large. There were 7 patients that had any heartburn at last follow-up and all were well controlled with medication. Reoperation was performed in 2 patients due to recurrent obstructive symptoms following vomiting episodes. No patient required reoperation for severe reflux. Meticulous hiatal hernia repair with crural closure and restoration of normal anatomy is a safe and effective option in patients presenting in non-elective settings without a significant reflux history. Given increased morbidity with urgent operations, elective repair of giant paraesophageal hernia should be considered in all patients.

Predicting contralateral hernia after unilateral inguinal hernia repair in children: a 5-year cohort from Bahrain

Background: Inguinal hernias are common in pediatric surgery, with unilateral presentations being most frequent. The development of a metachronous contralateral inguinal hernia (MCIH) after unilateral repair remains a concern, with reported incidence ranging from 5% to 30%. The decision to perform contralateral exploration remains controversial. Methods: We retrospectively reviewed 202 children (aged 0–14 years) who underwent open unilateral inguinal hernia repair at Salmaniya Medical Complex, Bahrain, between 2019 and 2024. Data were retrieved from operative logs and electronic records. Reoperation for recurrence or contralateral hernia development was documented. Risk factors including prematurity, hernia side, hernia sac size, and comorbidities were assessed for association with recurrence or MCIH using chi-square tests. Results: Of the 202 patients, 75.7% were male and 24.3% female. Preterm infants (&lt;37 weeks) represented 15.8%. Right-sided hernias were more common (60.9%), left side (39.1%). Large hernia sacs were noted in 61.9% of cases. Overall reoperation rate was 8.9% (18/202), with MCIH accounting for 94.4% of cases. Only one patient had a same-side recurrence. No risk factors showed statistically significant association with recurrence or MCIH (p&gt;0.3). For example, reoperation was required in 3.1% of preterm versus 10% of full-term infants (p=0.317). Conclusions: In this cohort, ~9% required reoperation, almost exclusively for MCIH. No traditional risk factors significantly predicted recurrence or contralateral hernia development. These findings suggest that routine contralateral exploration may not be necessary for all patients. Individualized decision-making is recommended, and further studies are needed to identify patients at higher risk for MCIH.

Early Versus Late Inguinal Hernia Repair in Preterm Neonates: An Updated Systematic Review and Meta-Analysis with Trial Sequential Analysis.

Early Versus Late Inguinal Hernia Repair in Preterm Neonates: An Updated Systematic Review and Meta-Analysis with Trial Sequential Analysis.

Laparoscopic repair of giant diaphragmatic hernias: evaluating the efficacy of the spider-web-like suturing technique combined with composite mesh reinforcement

Laparoscopic repair of giant diaphragmatic hernias: evaluating the efficacy of the spider-web-like suturing technique combined with composite mesh reinforcement

Lateral-dock single-port robotic-assisted extended totally extraperitoneal plasty (eTEP)-Sublay-Herniotomy-Procedure– presentation of a novel technique for robotic-assisted ventral hernia surgery (with video)

IntroductionRobotic-assisted minimally-invasive extended totally extraperitoneal plasty (eTEP)-sublay-herniotomy is one of the most promising novel techniques for the management of ventral hernia. While several techniques for multiport-robotic-assisted eTEP have been described, only very few reports on suprapubic single-port robotic-assisted eTEP-techniques have been published. The technical limitations of this access leave room for further technical development using single-port-robotic systems.MethodsWe give a detailed description of our novel lateral-dock single-port robotic-assisted eTEP-procedure (Freiburg approach, FReTEP). Feasibility of the access was demonstrated within a human cadaveric procedure, and two consecutive patients were treated using the FReTEP-procedure.ResultsTwo consecutive patients were successfully treated without postoperative complications and without early hernia recurrence using the FReTEP-procedure.ConclusionThe FReTEP-procedure is a promising novel technique for single-port-robotic-assisted ventral hernia repair. Further studies are needed to evaluate the novel procedure.

Transabdominal pre-peritoneal hernia repair: risk of operation for recurrence depends on choice of both mesh and fixation device. A study from the Danish Hernia Database

PurposeMultiple methods of mesh fixation are available in laparoscopic inguinal hernia repair, as well as multiple types of mesh. No previous studies compare all methods of fixation in TAPP against each other in regards to risk of reoperation for recurrence. In addition, there is little data comparing types of mesh or the relationship between mesh and fixation method.MethodsWe compare the tissue-penetrating methods with non-penetrative as well as no fixation, and examines the interaction of fixation method and choice of mesh. Cohort was established by way of the Danish Hernia Database, identifying patients operated with TAPP from Jan. 2010 to Dec. 2022. Cox’ regression analyses were performed, with multivariate analysis correcting for significant confounding variables, yielding adjusted hazard ratios (aHR) for reoperation for each fixation method. Follow-up analyses investigated whether differences in mesh types significantly impacted the results.ResultsAmong 49,029 TAPP repairs, 3.6% experienced reoperation for recurrence over a mean follow-up of 5.76 years. Tack fixation, the most common method, showed the highest reoperation rates (5.3% at 5 years). Glue, self-fixating meshes, and no fixation, had significantly lower risk in comparison (aHRs of 0.25, 0.21, and 0.51, respectively). Even after correcting for weight and pore size, some mesh types significantly impacted risk, with aHRs spanning 0.28 – 1.ConclusionNon-penetrative fixation methods and no fixation are associated with lower reoperation rates compared to tissue-penetrative methods, with self-fixating meshes carrying the lowest risk. In addition, we found significant differences in aHR between types of mesh.

Comparing robotic to open retromuscular ventral hernia repair: a multi-center propensity-matched analysis.

Robotic retromuscular ventral hernia repair (r-RVHR) may benefit patients by converting an open surgery (o-RVHR) to a minimally invasive approach. Current comparative trials are limited by small patient cohorts and exploratory outcomes. This study compares short- and long-term outcomes of robotic versus open retromuscular ventral hernia repairs using a nationwide registry. This propensity-matched analysis compared patients who underwent robotic or open ventral hernia repair with retromuscular mesh placement using Abdominal Core Health Quality Collaborative registry data (2014-2021). Groups were matched according to body mass index, Ventral Hernia Working Group classification, wound class, diabetes, smoking status, hernia width, and recurrent hernia repair. Primary outcome included hernia recurrence risk up to five years postoperatively evaluated two ways: 1) clinical/radiographic assessment only and 2) a pragmatic definition incorporating patient-reported bulging. Secondary outcomes included length of stay, wound morbidity, and patient-reported outcomes. 1228 r-RVHR patients were matched to 1228 o-RVHR patients. Robotic RVHR was associated with longer operative times (p < 0.001), reduced length of stay (1 vs 3days; p < 0.001), 30-day surgical site infection rates (1.7% vs 3.4%; p = 0.013), and surgical site occurrences (SSO) requiring procedural intervention (1.9% vs 3.6%; p = 0.011), but higher overall SSO (16.4% vs 11.0%; p < 0.001). Robotic RVHR showed similar two-year pragmatic recurrence rates but higher recurrence risk after three years (HR 1.46, 95% CI 1.15-1.85, p = 0.002) with no difference in clinical recurrence risk. Transversus abdominis release and surgeon experience were independently associated with reduced recurrence risk regardless of surgical approach. At five years, r-RVHR patients reported worse quality of life scores (78 vs 90; p = 0.044). Both groups experienced significant follow-up attrition over time. Robotic RVHR is associated with improved early post-operative outcomes yet may be associated with higher long-term pragmatic recurrence rates compared to open RVHR. These findings require investigation through prospective randomized trials with robust long-term follow-up.

Complex Ventral and Incisional Hernia Repair: Robotic versus Open TAR technique

Ventral hernias, both primary and incisional, constitute a significant and complex clinical entity, despite advancements in repair techniques. Complex ventral hernias, including incisional hernias (IH), pose a greater surgical challenge due to larger defect dimensions, loss of domain, altered tissue integrity and higher risk of recurrence, thereby requiring the application of advanced repair techniques. In the contemporary era of surgery, transversus abdominis release (TAR) is being established as a preferred approach for complex ventral hernia repair, with robotic-assisted TAR (r-TAR) gaining prominence due to its minimally invasive advantages. This review analysed the historical evolution of ventral hernia repair and critically summarised current evidence comparing open TAR (o-TAR) and r-TAR in terms of intraoperative details and postoperative outcomes. Considering the intricate nature of complex ventral hernias, r-TAR has emerged as a promising alternative to o-TAR, indicating potential benefits in complications and length of hospital stay.

Vertical Mesh-Mediated Fascial Traction and Negative Pressure Wound Therapy for open abdomen management in a critically ill, super-super obese patient: A case report

Open abdomen (OA) is indicated in numerous medical settings, such as trauma, abdominal sepsis, severe acute pancreatitis, and intra-abdominal hypertension. Managing an open abdomen presents a complex and challenging scenario for surgeons, requiring specialised techniques and comprehensive decision-making to prevent complications, especially in obese patients, due to increased morbidity and mortality rates. Herein we describe the use of vertical mesh-mediated fascial traction (VMMFT) in combination with negative pressure wound therapy (NPWT) to prevent fascial retraction and manage OA in a super-super obese patient who developed abdominal compartment syndrome following a massive abdominal ventral hernia repair. A 55-year-old male with a BMI of 62 kg/m2 underwent emergency exploratory laparotomy for a massive ventral hernia with bowel strangulation. Postoperatively, he developed abdominal compartment syndrome, necessitating relaparotomy and temporary abdominal closure. A traction device was introduced to facilitate vertical mesh-mediated fascial traction (VMMFT). On postoperative day six, fascial closure was achieved without complications. This case highlights the efficacy of VMMFT combined with NPWT in preventing fascial retraction, promoting abdominal wall expansion, and reducing the need for complex reconstructions. Further studies are warranted to assess its broader clinical and economic impact.

Mesh-reinforced compared with primary closure in emergent laparotomies for incarcerated ventral incisional hernias: Is the added complexity justified?

Mesh-reinforced compared with primary closure in emergent laparotomies for incarcerated ventral incisional hernias: Is the added complexity justified?

Small bowel perforation into the retro-rectus space following eTEP Rives-Stoppa repair for incisional hernia: a rare and life-threatening complication.

The enhanced totally extraperitoneal (eTEP) Rives-Stoppa repair is increasingly adopted for incisional hernia repair due to its minimally invasive approachand favorable outcomes. However, rare but severe complications, such as small bowel perforation into the retro-rectus space, may occur, necessitating prompt recognitionand management. An 80-year-old male underwent eTEP Rives-Stoppa repair for an EHS L2 incisional hernia, involving retro-rectus dissection, transversus abdominis release, and mesh placement. On postoperative day 1, he developed hypotension and extensive subcutaneous ecchymosis, without abdominal pain or fever. Initial computed tomography (CT) revealed a retro-rectus fluid collection suggestive of hemorrhage. By day 2, repeat CT showed increased free air and enteric content, indicating bowel perforation. Emergency laparotomy confirmed a dehiscent posterior rectus sheath with a perforated small bowel segment protruding into the retro-rectus space. The mesh was removed, the affected bowel resected, and temporary abdominal closure was performed due to severe inflammation and edema. The postoperative course was complicated by recurrent bacteremia and abscesses, requiring prolonged antimicrobial therapy and intensive care. The patient recovered and was transferred to a rehabilitation facility six months later. This is the first reported case of small bowel perforation into the retro-rectus space following eTEP Rives-Stoppa repair. Contributing factors included advanced age, high tension in the posterior sheath, pre-existing bowel adhesions, and increased intra-abdominal pressure from postoperative coughing. Surgeons should maintain a high index of suspicion for this life-threatening complication, particularly in elderly or frail patients, and consider early imaging for atypical postoperative symptoms to enable timely intervention.

Surgical expertise and risk of long-term complications following groin hernia mesh repair in sweden: a prospective, patient-reported, nationwide register study.

Despite the global prevalence of groin hernia repairs, there is still limited understanding regarding the impact of surgical expertise on patient outcomes, particularly since a significant portion of hernia repairs worldwide are performed by junior surgeons. This study aims to evaluate the long-term outcomes of groin hernia repairs carried out by specialist compared to those performed by resident surgeons. This observational, nationwide, population-based registry study utilized prospectively collected data from the Swedish Hernia Register as well as patient-reported outcome measures (PROM) one year after groin hernia surgery. Included patients were aged 15years or older who underwent groin hernia repair between 2012-2018. Surgical expertise was categorized as either specialist or resident surgeon. Primary outcome was dissatisfaction and chronic pain one year post-surgery. Secondary outcome was reoperation for recurrence with follow-up until 2024. Totally 62,033 groin hernia repairs were analyzed, with a response rate of 70% for PROM-questionnaire. 72% of surgeries were performed by specialists and 28% by resident surgeons. Multivariable analysis revealed no significant differences. In the specialist group, 5.7% reported dissatisfaction compared to 4.5% in the resident group (OR 0.92, 95% CI 0.84-1.02). Chronic pain was experienced by 15.4% of specialist operated patients and 15.5% of resident operated patients (OR 1.05, 95% CI 0.99-1.12). 2.6% of patients in the specialist group underwent reoperation for recurrence, compared to 2.3% in the resident group (HR 0.97, 95% CI 0.86-1.11). Groin hernia repairs represent a significant surgical procedure for resident surgeons in training. The level of surgical expertise was not found to be associated with increased long-term complications, suggesting that resident surgeons do not affect groin hernia patients negatively.