Transversalis Fascia Research Articles

Radiographic Assessment of Inflatable Penile Prosthesis Reservoir Location Variability in Contemporary Practice

ABSTRACT Introduction Inflatable penile prosthesis (IPP) reservoirs are typically placed into the Space of Retzius (SOR), High Submuscular Space (HSM), or alternative locations via a transinguinal (TI) approach or a lower abdominal counter incision (CI). A cadaver study showed variability in reservoir location after TI-HSM placement (JSM: 2016 Sep;13(9):1425-1431). Objective We sought to evaluate reservoir location using cross-sectional imaging following contemporary IPP insertion. Methods We retrospectively reviewed our institutional database and identified men who underwent virgin penoscrotal IPP insertion from 2007 to 2019. We then identified those men who subsequently underwent cross-sectional imaging prior to October 2019. Radiologists blinded to reservoir placement technique evaluated cross-sectional imaging and categorized each reservoir location in relation to the abdominal wall musculature, transversalis fascia, and peritoneum. Statistical analysis was performed using Chi-squared and Fisher's exact tests. Results Among 561 men who underwent virgin IPP insertion during the 12 year study period, 114 had cross-sectional imaging subsequently obtained: 29 TI-SOR, 80 TI-HSM, and 5 CI-HSM (Table). TI-HSM reservoirs were more likely than TI-SOR to be located anterior to the transversalis fascia (14 vs. 48%, p=0.001). TI-HSM reservoirs were less likely than TI-SOR to be located in the preperitoneal space (62 vs. 18%, p<0.001). Rates of retroperitoneal reservoir location were similar between the TI-HSM and TI-SOR groups. Among all 561 patients (131 TI-SOR, 405 TI-HSM, and 25 CI-HSM), rates of reservoir-related complications requiring operative intervention were similar between groups (5 vs. 2 vs. 0%, p = 0.24). Conclusions Roughly half of the TI-HSM reservoirs in this series appeared to be located posterior to the transversalis fascia on cross-sectional imaging. Although preperitoneal and retroperitoneal locations were common in both groups, reservoir related complications were rare. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific and Coloplast

Inflatable penile prosthesis reservoir placement—Are we ready for a paradigm change?

In 2002, Steve Wilson pioneered new procedures for alternative placement of reservoirs for inflatable prostheses in patients who have suffered damage to the space of Retzius following pelvic surgery or obliteration of the transversalis fascia by mesh hernia repair. Since then, surgical techniques and tools for ectopic reservoir placement have gradually gained acceptance to minimize palpability, and the risk of visceral and vascular lesions for high risk patients has been all but eliminated. Lockout valves and high submuscular placement techniques are now recommended, and reports of vascular, bowel or bladder injuries are uncommonly rare. While surgeons continue their search for safer and more effective placement methods, new skills and instruments are constantly being introduced to make recommendations to minimize complications and provide safety and functionality. Additional studies and comparisons of techniques are needed to achieve a consensus of best practice for reservoir placement solutions.

Evaluation of Sensory Loss Obtained by Circum-Psoas Blocks in Patients Undergoing Total Hip Replacement: A Descriptive Pilot Study.

PurposeThe transversalis fascia (TF) encases the quadratus lumborum and psoas major (PM) muscles, respectively, after they split caudalward approximately at the level of the iliac crest. The branches of the lumbar plexus variably exit medially and laterally from the TF-encased PM muscle. We hypothesized that the local anesthetic (LA) injections around the anterolateral edge of PM at the supra-iliac level and into the retro-psoas compartment at the L5/S1 level, which termed as the circum-psoas blocks, could block the lumbar plexus branches. Therefore, here we evaluated the sensory loss caused by the circum-psoas blocks.MethodsA total of 26 patients scheduled for total hip replacement were recruited for the study. After anesthesia induction, the ultrasound-guided circum-psoas blocks were performed in the lateral position with the affected side upward, in which the 0.3% ropivacaine was injected posterior to the TF and around the anterolateral edge of PM muscle at the supra-iliac level (25 mL), and into the retro-psoas compartment at the L5/S1 level (20 mL). The sensory block dermatomes and the muscle strength of quadriceps femoris were evaluated at 2 h or 6 h after surgery, respectively. The postoperative pain scores and opioid consumption were recorded.ResultsThe median (interquartile range) highest and lowest dermatomes of sensory block were T10 (T9–T10) and S2 (S2–S2), respectively. The muscle strength of the quadriceps femoris evaluated at 6 h post-surgery was 4 (4–5) points. Total postoperative equivalent milligrams of oral morphine consumption in the first 24 h were 11.3 ± 3.6 mg.ConclusionThe circum-psoas blocks may be a promising approach for postoperative analgesia of hip surgery, since they provide a dermatomal coverage of sensory block from T8–11 to S1–3.Clinical Trial RegistrationChinese Clinical Trial Registry, clinical trial number ChiCTR2100051247.

Analgesic effects of different concentrations of ropivacaine in transversalis fascia plane block during laparotomy

ObjectiveTo explore the analgesic effects of different concentrations of ropivacaine in transversalis fascia plane (TFP) block during laparotomy.MethodsNinety patients who underwent laparotomy admitted to our hospital from March 2019 to March 2020 were selected as the study subjects and were divided equally into a low concentration group, a medium concentration group, and a high concentration group according to the randomized grouping method. The low concentration group adopted 0.4% ropivacaine 40 ml, the medium concentration group was given 0.5% ropivacaine 40 ml, and the high concentration group was given 0.6% ropivacaine 40 ml. The hemodynamic indexes and the incidence of adverse reactions in the two groups were compared. The Numerical Rating Scale (NRS) was used to assess the postoperative pain in the three groups, the Bruggrmann comfort scale (BCS) was used to assess the comfort level in the three groups, and the Mini-mental State Examination (MMSE) was used to evaluate the postoperative cognitive function of the three groups of patients.ResultsThe mean artery pressure (MAP) and heart rate (HR) levels at T1 and T2 were significantly lower in the medium concentration group than in the other two groups (P < 0.05). The low concentration group had a significantly higher NRS score at T2 than the medium concentration group and the high concentration group (P < 0.05). A significantly higher BCS score was observed in the high concentration group than the other two groups (P < 0.05). There were significantly higher Ramsay scores and MMSE scores in the medium concentration group than in the low concentration and high concentration groups (P < 0.05). The overall incidence of adverse reactions of the high concentration group was significantly higher than that of the low concentration group (P < 0.05), but showed similar results with the medium concentration group.ConclusionThe medium concentration group exhibits a better analgesic effect than the low concentration group and higher safety than the high concentration group. Therefore, the use of medium concentration ropivacaine in TFP block may provide a referential basis for clinical treatment.

Low lying pubic tubercle: A predictor of development of inguinal hernia

All the inguinal hernias begin within a single weak area called myopectoneal orifice, the natural mechanisms in our body which support this area are oblique direction of the inguinal canal in abdominal wall, the tension mechanism of transversalis fascia and presence of aponeurotic extensions from the transverse abdominis aponeurotic arch in the posterior wall of the inguinal canal. As the distance from pubic tubercle to the horizontal line joining two anterior-superior iliac spine increases, the inguinal canal becomes less oblique that leads to increased risk of development of inguinal hernia. The present project was planned to study the role of low-lying pubic tubercle in development of inguinal hernia. The present case control study was conducted in our institute from June 2018 to April 2019 taking 100 cases and 100 control meeting inclusion criteria. In all patients, following parameters SS line, ST line, height, weight was recorded and evaluated. The mean value of ST line in our study group is7.3476±0.16354cm significantly greater (p=0.05) than the controls the mean value being 6.9242±0.12620cm. Group of people with low-lying pubic tubercle are at high risk of developing inguinal hernia.

English

BACKGROUND Incisional hernia is defined as an abnormal protrusion of a viscus through the musculo-aponecrotic layer of a surgical scar and occurs in 5 – 15 % of laparotomy closures. Mostly they are iatrogenic. Postoperative infection is the most common cause. Collagen is responsible for most of the strength of the wound. There are 13 types of collagen with 25 different polypeptide chains. The fiber forming collagen are type 1,2,3,5 and 11. Synthesis of collagen is complex. METHODS 63 patients undergoing repair for Incisional hernias were studied for their by demographic details such as age, gender, social status and nutritional status after taking informed consent. A small bit of non-scarred skin was taken located away from the site of previous surgery and scar tissue. A small piece of transversalis fascia also taken under direct vision away from any scar, hernia defects, or other pathology. The two bits were fixed in 20 % formaldehyde. They were sectioned and examined after staining with Hematoxylene and eosin stain for abnormal collagen patterns and discontinuity in collagen bundles. RESULTS Total cases studies – 50. 26 (52 %) patients were in the age group of 30 to 40 years, followed by 12 (24 %) in the age group of 40 to 50 years. 09 (18 %) were in the age group of 20 to 30 years. The risk factors noted in the 50 subjects in the study were tabulated in Table 6 showed 20 (40 %) had lax abdominal wall, 12 (24 %) had Diabetes Mellitus, 09 (18 %) had Anaemia, 05 (10 % had malignancy and 04 (08 %) had jaundice. Among the 50 patients 31 (62 %) were found to have abnormal collagen tissues and 19 (38 %) had normal collagen tissues. CONCLUSIONS Defective collagen tissue formation was the cause for Incisional hernia especially in the elderly female patients. Emergency surgeries, lower abdominal incisions were more prone to Incisional hernias. Wound infection, malnutrition, Anemia, associated malignancy, pulmonary infections and co-morbidity played an important role in its causation. KEY WORDS Wound Healing, Collagen, Incision and Hernia

Initial entry via the left upper quadrant with an optical trocar in laparoscopic bariatric surgery.

Laparoscopic bariatric surgery (BS) is not readily performed in Japan. To facilitate safe initial access to the abdominal cavity, we insert an optical viewing trocar at a unique site in the left upper quadrant (LUQ). Herein, we describe the technique, its advantages, and outcomes. Briefly, the optical trocar is inserted just below the left subcostal margin, 8cm from the midline. On insertion, layers of the abdominal wall are visualized on the monitor. Depending on the angle of insertion, five, seven, or eight layers are seen. In assessing our initial entry technique, used in 21 obese patients undergoing laparoscopic sleeve gastrectomy, we found median insertion time to be 25 seconds. There were no related complications. In nearly all (20/21) patients, the abdominal wall was visualized as seven layers: subcutaneous fat, anterior rectus sheath, rectus abdominis muscle, posterior rectus sheath, transverse abdominis muscle, transversalis fascia, and peritoneum. Understanding the layers of the abdominal wall visualized during optical trocar insertion in the LUQ will provide for safe and rapid initial entry in patients undergoing laparoscopic BS and can further the widespread acceptance of laparoscopic BS.

Intravesical reservoir erosion as a late complication of a 3-piece inflatable penile prosthesis: ectopic placement in a high-subrectus space: a rare case report

Background: Inflatable penile prosthesis (IPP) is the mainstream treatment of refractory erectile dysfunction (ED). Usually, Space of Retzius (SOR) is the usual IPP reservoir placement space, however, more concerns regarding this space complication have emerged due to its anatomical proximity to some major structures. Intravesical reservoir erosion is the most common reported reservoir complication. Hematuria is the main presentation, sometimes, dysuria and urinary tract infection take place. We present a case of late intravesical reservoir erosion after 3 years of IPP implantation. Methods: Revision surgery was made including placement of AMS Conceal® reservoir in an ectopic high-subrectus space and anterior to transversalis fascia, contralaterally. Results: Recently, ectopic placement has gained popularity among implanters due to its safety and efficacy. Specifically, submuscular space placement, after inventing the lock-out valve to avoid undesirable auto-inflation due to the high back-pressure. Conclusion: Ectopic placement utilizes more choices in cases like hostile pelvis for implanting a 3-piece IPP instead of a malleable prosthesis. Ectopic placement is safe and highly acceptable between high-volume implanters, which may prime a new era of reservoir placement.

Efficacy of regional blocks or local anaesthetic infiltration for analgesia after caesarean delivery: a network meta-analysis of randomised controlled trials.

Caesarean delivery is common and can cause severe postoperative pain but injection of local anaesthetic at various sites for regional blocks or local anaesthetic infiltration may reduce this. We aimed to compare and rank these sites. We searched PubMed, Google Scholar, EMBASE and CENTRAL to June 2021 for randomised controlled trials and performed a random-effects Bayesian model network meta-analysis. The primary outcome was dose of parenteral morphine equivalents in the first 24 postoperative hours. We used surface under cumulative ranking probabilities to order techniques. We analysed 114 trials (8730 participants). The ordered mean (95% credible interval) reduction in morphine equivalents, from 34 mg with placebo, were as follows: ilio-inguinal 15 (1-32) mg; ilio-inguinal-iliohypogastric 13 (6-19) mg; transversalis fascia 11 (4-26) mg; erector spinae 11 (10-32); transverse abdominis 9 (4-13) mg; wound catheter infusion 8 (2-15) mg; quadratus lumborum 8 (1-15) mg; wound infiltration 8 (2-13) mg; and no intervention -4 (-10 to 2) mg. Ordered efficacies for injection sites were different for other relevant outcomes, including pain (to 4-6 h and to 24 h) and time to rescue analgesia: there was no single preferred route of injection. The ordered mean (95% credible interval) reduction in dynamic pain scores (0-10 scale) at 24 h compared with placebo were as follows: wound infusion 1.2 (0.2-2.1); erector spinae 1.3 (-0.5 to 3.1); quadratus lumborum 1.0 (0.1-1.8); ilio-inguinal-iliohypogastric 0.6 (-0.5 to 1.8); transverse abdominis 0.6 (-0.1 to 1.2); wound infiltration 0.5 (-0.3 to 1.3); transversalis fascia -0.8 (-3.4 to 1.9); ilio-inguinal -0.9 (-3.6 to 1.7); and no intervention -0.8 (-1.8 to 0.2). We categorised our confidence in effect sizes as low or very low.

PATIENT-CENTERED ANALGESIA OF THE ANTERIOR ABDOMINAL WALL IN CHILDREN OF DIFFERENT AGES: OWN EXPERIENCE

Introduction. Regional anesthesia in pediatric practice is one of the most valuable and safest tools for perioperative pain management. The advantages of regional anesthesia are early recovery of children, reducing opioid consumption, postoperative pain, respiratory complications, nausea, vomiting, as well as health care costs. The aim of the study was to analyze the data on the effect of the quadratus lumborum block and the transversalis fascia block on the duration and effectiveness of postoperative analgesia and propose a model of combining two blocks with a single injection. Materials and methods. Today there is growing interest in the use of new methods of regional anesthesia, especially the anterior and posterior torso blocks. The quadratus lumborum block and the transversalis fascia block are aimed at providing analgesia over the T7-L1 dermatomes, namely the ilio-inguinal and iliac nerves, which extend from the lateral portion of the psoas major, the lower edge of the 12th rib; however, there is evidence of cranial spread to the T4 – T5 dermatomes, and caudal spread to the L2 – L3 dermatomes. Currently, there are enough publications concerning the quadratus lumborum block and the transversalis fascia block. Results. For adequate perioperative multimodal anesthesia, the authors proposed a combination of the transversalis fascia block and the quadratus lumborum block with a single injection and ultrasound guidance. Conclusions. The advantages of the proposed method include simplicity, less invasiveness, adequate analgesia during surgery, as well as during the postoperative period (exclusion of somatic and visceral components), as evidenced by the assessment on a visual analogue scale (no more than two points). In addition, it significantly reduces the perioperative opioid use.

OV08 TREATMENT OF THE INGUINAL HERNIA USING THE SHOULDICE REPAIR

Abstract Aim The Shouldice procedure is a layered reconstruction of the posterior wall in inguinal hernia repair and currently the preferred method if the layers of the abdominal wall are of good quality, the wish of the patient for a non-mesh repair and if a mesh method is not possible or available. The correct performance of the reconstruction of the posterior wall is essential part of the operation. Material and Methods A life educational video was made with the four-layer reconstruction in detail. The first layer of the reconstruction starts at the medial corner and the conjoint tendon is sutured to the caudal flap of the transversalis fascia using a continuous non resorbable suture. The second layer of the reconstruction is made by approximating the cranial flap of the transversalis fascia and the posterior part of the inguinal ligament. The third layer starts at the level of the deep internal inguinal ring and approximates the lower border of the internal oblique muscle with the inguinal ligament. The fourth and final layer approximates the internal oblique muscle again with the inguinal ligament. Results The four-layer reconstruction after splitting the transversalis fascia is shown in detail since treatment of the hernia sac is like the other techniques. Conclusions The instructional video can be used for the resident training as a start in a hernia course followed by the execution on a model before the actual execution on a patient.

OV01 A LOW-COST HERNIA MODEL FOR THE TRAINING OF THE SHOULDICE AND THE LICHTENSTEIN INGUINAL HERNIA REPAIR

Abstract Aim Based on an international European survey, residents prefer to study inguinal hernia repair through lectures or video-demonstrations or want to practice either on simulation or cadaveric models. Simulation models in inguinal hernia are scarce or expensive. Material and Methods A low-cost model was developed that can be produced everywhere with the aid of the instruction video: “How to build an inguinal hernia model”. Initially, the model was designed to practice the Lichtenstein technique but after some minor modifications (adding the conjoint tendon, enough slack in the transversalis fascia) it was also possible to practice the Shouldice technique on the same model. It only needs the removal of the stitches of the third and fourth layer before the Lichtenstein can be performed. Results The model was used for several studies with students and residents and proved to be realistic and was approved by an international survey among experienced hernia surgeons. It has been used once in a national training session of residents. Conclusions The video shows the execution of both procedures on the same model.

P114 ROBOTIC INGUINAL HERNIA REPAIR (RTAPP): ANATOMY LESSONS AND RESULTS OF A CASUISTIC OF 302 OPERATED HERNIAS

Abstract Aim The purpose of this study is to apply the resources of robotics to inguinal hernia repair (r-TAPP) and to investigate where specific optimizations to the surgical technique of can be achieved. Material and Methods The results of 302 consecutive r-TAPP surgeries performed over an 18-month period are presented. It is a cohort study without a control group. The study was approved by the ethics committee (Ref. No. 2019-02046). Decisions on interventions (suturing of the transverse fascia or fibrin glue sealing of the inguinal canal) and mesh size were made intraoperatively. Patients were followed up six weeks postoperatively. Results In every fourth patient, a femoral, obturator, or Spieghel hernia was diagnosed in addition to symptomatic inguinal hernia. Mesh fixation with absorbable suture at 4 points was matured. The operative time averaged 71 minutes for unilateral, 103 minutes for bilateral and 95 minutes for unilateral recurrent hernias. 48% of procedures were performed by residents. Seroma incidence decreased from 15.0% in the first period to 5.1% in the third study period. None of the patients experienced pain symptoms due to nerve lesion. The study provided new clarity about the blood supply patterns of the lipoma, the course of the genital branch and the constitution iliac fascia. Conclusions Suturing of the transversal fascia, fibrin glue sealing of the inguinal canal, and suture fixation of the mesh are steps who must be validated in future studies. Robotics provides optimal conditions for residents training, without learning curve on the patient and with predictable OR times. Postoperative seroma formation and complication rate of r-TAPP are low.

Radiographic Assessment of Inflatable Penile Prosthesis Reservoir Location Variability in Contemporary Practice

Inflatable penile prosthesis (IPP) reservoirs are typically placed into the Space of Retzius (SOR) or alternative locations including the High Submuscular (HSM) space via transinguinal (TI) or counter incision (CI) techniques. A cadaver study showed variability in reservoir location after TI-HSM placement. To evaluate reservoir location using cross-sectional imaging following IPP insertion. We retrospectively reviewed our institutional database and identified men who underwent virgin penoscrotal IPP insertion between 2007 and 2019. We then identified those men who subsequently underwent cross-sectional imaging prior to October 2019. Radiologists evaluated cross-sectional imaging in a blinded manner and categorized reservoir locations as follows: 1) submuscular; 2) posterior to the external oblique fascia and lateral to the rectus abdominis musculature; 3) preperitoneal; 4) retroperitoneal; 5) intraperitoneal; 6) inguinal canal; 7) subcutaneous. Patients were stratified by reservoir placement technique, transinguinal space of Retzius (TI-SOR), transinguinal high submuscular (TI-HSM), or counterincision high submuscular (CI-HSM). Clinical characteristics and outcomes were reviewed and compared. Statistical analysis was performed using Chi-squared and Fisher's exact tests. Variability exists in the TI placement of SOR and HSM reservoirs, CI-HSM reservoirs were associated with a low level of variability. Among 561 men who underwent virgin IPP insertion during the 12-year study period, 114 had postoperative cross-sectional imaging (29 TI-SOR, 80 TI-HSM, and 5 CI-HSM). Among the 114 patients imaged, TI-HSM reservoirs were more likely than TI-SOR to be located anterior to the transversalis fascia (48 vs 14%, P < .01) and were less likely to be located in the preperitoneal space (18 vs 62%, P < .01). Rates of intraperitoneal reservoir location were similar between the TI-HSM and TI-SOR groups (5 vs 7%, P = .66). Among imaged CI-HSM reservoirs, 4 (80%) were anterior to the transversalis fascia and 1 (20%) was within the inguinal canal. Among all 536 transinguinal cases (131 TI-SOR and 405 TI-HSM), rates of reservoir-related complications requiring operative intervention were similar between groups (5 vs 2%, P = .24). No complications were noted among the 25 patients in the CI-HSM cohort. The level of variability seen in this study did not seem to impact patient safety, complications were rare in all cohorts. This study is the first and largest of its kind in evaluating reservoir positioning in live patients with long-term follow-up. This study is limited in its retrospective and nonrandomized nature. Despite variability with both TI-HSM and TI-SOR techniques, reservoir related complications remain rare. Kavoussi M, Cook G, Nordeck S, et al. Radiographic Assessment of Inflatable Penile Prosthesis Reservoir Location Variability in Contemporary Practice. J Sex Med 2021;18:2039-2044.

Efficacy of ultrasound-guided transversalis fascia plane block in pediatric ureteroneocystostomy surgery.

Efficacy of ultrasound-guided transversalis fascia plane block in pediatric ureteroneocystostomy surgery.

Radical direct inguinal hernia surgery

E. Balogh (Zentrbl. F. Chir. No. 44/1929) suggests, when opening the inguinal canal, to dissect longitudinally the fascia transversa and separate it from all sides as far as possible from the underlying preperitoneal fatty tissue. Then, on the inside of the transverse fascia, apply a purse-string suture, removing the peritoneum with the instrument inward. Further, the operation ends, typically according to Basini.

Laparoscopic iliopubic tract repair to treat recurrent pediatric inguinal hernia

BackgroundCongenital defects, such as open processus vaginalis and the canal of Nuck, are common causes of primary pediatric inguinal hernia (PIH). However, in some patients, PIH occurs via acquired defects rather than congenital defects. The most representative cause of PIH is recurrent hernia. Recurrent PIH is treated with high ligation (HL), which is the same method that is used to treat primary PIH. However, the re-recurrence rate of recurrent PIH is high. This study aimed to compare laparoscopic iliopubic tract repair (IPTR) with laparoscopic HL for the treatment of recurrent PIH after primary PIH repair.MethodsFrom June 2013 to March 2019, 126 patients (< 10 years old) with recurrent PIH were retrospectively enrolled. Patients were divided into two groups according to the operative technique: laparoscopic HL (58 patients) and laparoscopic IPTR (68 patients). With HL, the hernial sac was removed and the peritoneum closed. With IPTR, iliopubic tract and transversalis fascia sutures were applied.ResultsThere were no cases of conversion to open surgery. Re-recurrence only occurred in the HL group; no patients in the IPTR group developed re-recurrence (8.6% [5/58] vs. 0.0% [0/68], respectively; p = 0.044). The mean duration from re-operation to re-recurrence in these five patients was 10.6 months. Other surgical outcomes and complications did not differ between the two groups.ConclusionsLaparoscopic IPTR is an effective surgical treatment for reducing re-recurrence of recurrent PIH.

1630 Laparoscopic Repair of Linea Arcuata Hernia Presenting as Generalised Abdominal Pain - a Case Report

Abstract Background Arcuate line hernia (LAH) is an abnormal ascending herniation of intraperitoneal structures over the linea arcuate, between the rectus abdominus muscle and the posterior layer of its sheath. It is a rare clinical entity often associated with non-specific abdominal pain, posing a significant diagnostic challenge. The true prevalence is unknown, and diagnosis is almost always radiological. Case Report We report the case of a 57-year-old lady investigated extensively for frequent episodes of generalised abdominal pain. No palpable hernial defect or other pathology was identified on clinical examination. Subsequent computed tomography(CT) of the abdomen and pelvis revealed a 95 x 74 mm arcuate line hernia(LAH) anterior to the transversalis fascia, containing small bowel loops. She underwent an elective laparoscopic repair involving closure of the hernial defect with 2-0 knotless barbed sutures and reinforcement with a 20 x 15 cm underlay mesh. Postoperative recovery was uneventful, with complete resolution of her symptoms. One year after the repair there were no signs of recurrence. Discussion To our knowledge, only eleven prior cases of symptomatic LAH have been reported in the literature. There is no conclusive evidence regarding most appropriate diagnostic imaging, treatment approach and follow up regimen. Clinical diagnosis is difficult. Existing literature suggests use of CT scan as the primary imaging modality for diagnosis. The laparoscopic approach is safe, feasible and has certain advantages. This includes confirmation of diagnosis, excludes the presence of concomitant hernias and enables inspection of herniated viscera. Prosthetic mesh reinforcement is considered to minimise recurrence. Long term follow-up of these patients is required

Comparison of laparoscopic transabdominal preperitoneal hernioplasty and laparoscopic iliopubic tract repair for Nyhus type II hernia in women.

Indirect inguinal hernia with a dilated internal ring but an intact posterior inguinal wall is classified as Nyhus type II. Females have a higher incidence of indirect hernia than direct hernia. The purpose of this study was to evaluate the efficacy of laparoscopic iliopubic tract repair (IPTR) compared with laparoscopic transabdominal preperitoneal (TAPP) hernioplasty in treating women with Nyhus type II hernia. This retrospective study included 318 women aged ≥ 20years who were treated for Nyhus type II hernia from January 2013 to December 2018. The patients were categorized into two groups in accordance with the operative technique: the TAPP group (33 patients) and the IPTR group (285 patients). In the IPTR group, intraabdominal suturing of the iliopubic tract and transversalis fascia arch was performed without mesh implantation. The mean operation time was shorter in the IPTR group (17.2 ± 3.9min) than the TAPP group (20.5 ± 8.1min, p = 0.028). The postoperative complication rate was higher in the TAPP group than the IPTR group [6.1% (2/33) vs. 0.4% (1/285), respectively; p = 0.001]. Inguinodynia occurred in one patient in the TAPP group and no patients in the IPTR group. The hospital stay did not significantly differ between the two groups. The numeral rating scale pain scores at 1day and 1week postoperatively did not significantly differ between the two groups. There was no recurrence in either group. Laparoscopic IPTR was safe and feasible for treating Nyhus type II hernia in women.

Ultrasound-guided peripheral trunk block technique: A new approach gradually stepping onto the stage of clinical anesthesia.

In recent years, with the continuous development and validation of new visualization, the ultrasound-guided peripheral trunk block becomes more mature and has a more extensive and broader implementation scope in clinical anesthesia. Based on this, we reviewed and summarized the literature on peripheral trunk nerve block include: paraspinal block, retrolaminar block, plane block of erect spinal muscle, transverse convex to pleural midpoint block, block of the trapezius muscle and anterior serratus muscle, anterior serratus muscle block, thoracic nerve block, abdominal transverse fascia block, type-I block of quadratus lumborum, type-II block of quadratus lumborum, type-III block of quadratus lumborum, block of the sheath of rectus abdominis. This paper reviews the ultrasound-guided peripheral trunk block technique, including development history, anatomic basis, implementation methods, advantages and disadvantages of nerve block technique, and describes the bottleneck and difficulties of nerve block technique at present.