Transversalis Fascia Research Articles

Evaluation of Darn Repair for Recurrence Rate in the Management of Indirect Inguinal Hernia

When an organ, or even part of an organ, protrudes through the inguinal canal, it is called an inguinal hernia. Two-thirds of all herniations are of the indirect inguinal subtype; they are most common in adults between 30 and 59; and men are twice as likely to be affected as women. The standard treatment for a hernia is surgery. A decrease in collagen metabolism and fibro-connective tissue in the groin is typically the root cause of an inguinal hernia. Both of these things cause the fascia transversalis to weaken. Because of this, surgeons have come up with a number of ways to strengthen the back wall of the inguinal canal. Methodology: Approximately 220 patients with indirect inguinal hernias participated in this descriptive study. The study collected data on the demographic characteristics of the patients, the clinical characteristics of the hernias, and the outcomes of the treatment. The results showed that the majority of the patients responded well to the treatment. The study also revealed that the incidence of hernia recurrence was low. Jinnah International Hospital Abbottabad and DHQ Battagram, Department of Surgery served as the study site for these individuals. Patients were followed for six months after therapy to check for problems or recurrence; darn repair was the modality of choice. Results: Results showed that darn repair had a low recurrence rate reported in the literature, despite some patients being lost to follow-up and others perceiving early complications like wound infection, seroma, hematoma formation, scrotal swelling, or prolonged postoperative pain. Restoring damaged tissues has also been shown to be less expensive than replacing damaged tissues with mesh. Tissue repair has showed potential and costs less than mesh repair for treating inguinal hernias, thus both options should be investigated. There is also a lower chance of infection with tissue repair compared to mesh repair Keywords: hernias,indirect inguinal hernia,darn repair,recurrence.

CHANGES IN THE INDICATORS OF ABDOMINAL ARTERIAL CIRCULATION WHEN APPLYING VARIOUS ANESTHETIC TECHNIQUES IN CHILDREN

Intra-abdominal hypertension and abdominal compartment syndrome result from increased intra-abdominal pressure. In addition, intra-abdominal hypertension has been reported to be an independent risk factor for pediatric intensive care unit mortality.The study aimed to compare the efficacy and the effect of various anesthetic techniques using regional anesthesia on the indicators of abdominal arterial circulation in anterior abdominal wall surgery in children.Materials and Methods. The study included 90 children at the age of 7-18 years. All children underwent anterior abdominal wall surgery under general anesthesia and were divided into 3 groups: Group I included 30 children who underwent anterior abdominal wall surgery under general anesthesia using morphine; Group II comprised 30 children who underwent anterior abdominal wall surgery under general anesthesia using the transversalis fascia plane block combined with the quadratus lumborum block 4 via a single injection; Group III included 30 children who underwent anterior abdominal wall surgery under general anesthesia using the TFPB.The manuscript was approved by the Ethics Committee of the Communal Non-Profit Enterprise “Ivano-Frankivsk Regional Children’s Clinical Hospital of Ivano-Frankivsk Regional Council”, as evidenced by an Excerpt from the Minute of the Committee Meeting No. 2 dated February 24, 2022.The results obtained were statistically processed using statistical measures of variation, correlation analysis, Student’s t-test. Differences were considered statistically significant at p<0.05. The proportions were statistically compared by using a z-test.The study is a fragment of the research project of the Department of Children Diseases of Postgraduate Medical Education Faculty, Ivano-Frankivsk National Medical University “Health Status and Adaption of Children from the Precarpathian Region with Somatic Diseases, Their Prevention” 2021-2026, state registration number 0121U111129; the author is a co-researcher.Results and Discussion. The analysis of acute pain on the selected scales found significantly higher indicators of acute pain on the FLACC scale in the group of conventional anesthesia (Group I, p<0.001) as compared to Group II, where the TFPB in combination with the QLB-4 was used. The analysis of the Likert scale responses found that, over the course of treatment, there was a significant reduction in pain indicators among patients of Group II as compared to those in Group I and Group III (p<0.001). High pain intensity in children who received conventional anesthesia led to a prolonged length of hospital stay and increased IAP (FLACC scale (rx,y=0.38±0.16, р=0.02).Conclusions. A combination of regional anesthesia techniques and conventional anesthesia leads to a reduction in IAP, and increase in APP, a decrease in the resistance index in the superior mesenteric artery and shortens the length of hospital stay as compared to conventional anesthesia management.

Efficacy of transversalis fascia plane block as a novel ındication for varicocelectomy surgery: prospective randomized controlled study

BackgroundVaricocele occurs as a result of dilatation of the pampiniform plexus in the spermatic veins. In this study, our primary aim was to evaluate the effect of Transversalis Fascia Plane Block (TFPB) on pain scores in the postoperative period in patients undergoing varicocelectomy surgery, and our secondary aim was to evaluate the effect of TFPB on analgesic consumption.MethodsThe study was initiated following local ethics committee approval, and sixty ASA I-II patients > 18y scheduled to undergo varicocelectomy and who consented to participation were enrolled. Before the procedure, the patients were randomly assigned two groups: Transversalis Fascia Plan block group (Group TFPB) or surgical incision site infiltration group (Group I).All surgeries were carried out under general anesthesia, and microsurgery using the subinguinal approach. After surgical suturing, TFPB and local infiltration blocks were applied prior to termination of anesthesia.For each block, 20 mL of 0.25% bupivacaine was utilized. Patients' demographic information, passive and active VAS ratings after surgery, usage of non steroidal anti-inflammatory medications and rescue analgesia, and the requirement for rescue analgesia, were recorded.ResultsA total of 60 patients were included in the study. In terms of demographic data, there was no difference between the groups. At all hours, there was a statistically significant decrease in favor of Group TFPB in terms of active and passive VAS scores (p < 0.001), non steroidal anti-inflammatory analgesic use (p < 0.05), and tramadol requirement (p < 0.001).ConclusionThis study has shown that TFPB can provide a more effective analgesia when compared to surgical site infiltration.

Different cellular and immunohistochemical abdominal wall cicatrization parameters evaluation in comparison with sublay, onlay, and ipom technique in an experimental rat model.

Incisional hernia (IH) occurs when there is a partial or complete solution of continuity of a fascia previously incised. Systematic reviews demonstrate that surgical treatment of IHs with the use of meshes are approximately 16%. Meta-analyses have demonstrated the superiority of mesh placement using sublay technique, but without a pathophysiological explanation. Thus, we aim to evaluate the different techniques of mesh positioning in an experimental model. Fifty rats were distributed into five groups; control; simulation (SM)-submitted to laparotomy only; onlay-the mesh was positioned in onlay fashion; retromuscular (SL)-the mesh was positioned in a sublay fashion; intraperitoneal (IPOM)-positioning of the mesh adjacent to the transversalis fascia, inside the cavity. After 60days, adhesions, tensiometry, histology, and immunohistochemistry were addressed. The IPOM group had the most adhesions, together with the SL group, with significantly relevant results. The SL group had higher values of tensiometric evaluation, while the IPOM group had the lowest mean in the tensiometry evaluation, being even lower than the SM group. Regarding histological and immunohistochemical findings, the SL group had a higher pixel number count compared to the groups, with statistical significance, in addition to higher expression of polymorphonuclear infiltrate and CD68 markers. The mesh positioning in sublay compartment is associated with the development of more pronounce minimum tensile force required for detaching the surrounding abdominal wall tissues it was incorporated. The intensity of these findings correlates to the different histological and immunohistochemical profiles observed following each repair, since SL group was characterized by a higher proportion of collagen, inflammatory, and reparative elements. Characterizing these pro-healing elements and its counterparts will allow the development of new therapeutic tools which could be added to the still far-from-ideal current therapeutic options for IH treatment.

A newer method of seroma reduction by fenestration of pseudo-sac during laparoscopic repair of direct inguinal hernia: A randomised, controlled pilot study.

Minimally invasive surgeries for inguinal hernia repair have been reduced post-operative morbidity. However, certain complications such as seroma formation are unavoidable. In this study, we introduce a newer technique of reducing seroma formation by fenestration of the pseudo-sac (thickened transversalis fascia) in patients undergoing laparoscopic hernia repair for uncomplicated direct inguinal hernia. A randomised, controlled pilot study was conducted from January 2019 to December 2020 for the patients undergoing laparoscopic hernia repair for uncomplicated direct inguinal hernia. Study participants were randomised into interventional group and control groups. Demographics, operative duration and complications including post-operative pain and seroma on days 1, 10 and 30 were analysed between both the groups. A total of 20 cases with 30 hernias were included in the study. Demographic data were comparable between the two groups. The intervention group showed a statistically significant decrease in the incidence of seroma formation on the post-operative day 10 (13.3% vs. 46.6%, P = 0.046). The mean volume of seroma on day 10 was also less compared to the non-fenestration group (2.5 vs. 6.58 ml, P = 0.048). After the 30th day, no patient had a presence of seroma. There were no statistically significant differences in terms of mean operative duration, post-operative pain and other complications. Fenestration of pseudo-sac in laparoscopic hernia repair for uncomplicated direct inguinal hernia is a simple and effective technique. It has reduced the incidence and volume of seroma formation without any increased risk of infection, acute or chronic pain and recurrence.

A Novel Technique for Cadaveric Organ Procurement: Exposure with Internal Transverse Fascia and Vertical Skin Incision

A Novel Technique for Cadaveric Organ Procurement: Exposure with Internal Transverse Fascia and Vertical Skin Incision

Клініко–анатомічне обґрунтування доцільності одномоментної залобкової простатектомії та симультанної передочеревинної герніопластики у хворих на доброякісну гіперплазію простати та пахвинну грижу

Introduction. Among the complex and unresolved issues of urology and herniology, simultaneous operations for benign prostatic hyperplasia and inguinal hernia occupy a significant place. Inguinal hernias are often found in patients undergoing surgery for benign prostatic hyperplasia, inguinal hernias also often occur after prostatectomy. The presence of an inguinal hernia impairs the quality of life of patients suffering from benign prostatic hyperplasia and carries a potential threat of entrapment. Hernioplasty in a patient with benign prostatic hyperplasia can be complicated by urinary retention in the postoperative period. Therefore, the possibility of one-time simultaneous hernioplasty during prostatectomy for benign prostatic hyperplasia is an urgent issue in both urology and abdominal surgery. The aim of the work: To substantiate the feasibility of using one-moment retropubic prostatectomy and simultaneous pre-peritoneal inguinal hernioplasty from the standpoint of the clinical and anatomical structure of the retropubic space and the back wall of the inguinal canal, as well as to study the factors that affect the occurrence of inguinal hernias after prostatectomy. Research methodology and methods. To substantiate the expediency of retropubic prostatectomy and simultaneous pre-peritoneal hernioplasty, the distance from the middle of the cystic-prostatic junction to the middle of the opening of the direct and indirect inguinal hernias was determined during the operation after removal of the hernia sac from the right and left sides. All simultaneous retropubic prostatectomies and simultaneous hernioplasty were performed from a transverse suprapubic approach, its length varied from 15 to 20 cm depending on the patient's constitution. 36 simultaneous hernioplasty operations were performed on 32 patients (hernioplasty was performed on both sides in 4 cases): an inguinal hernia was detected on the right side in 20 cases, and on the left side in 16 cases. Research results and discussions. The average distance from the middle of the cystic-prostatic junction to the middle of the direct hernia opening was 7.7 ± 1.2 cm on the right side and 7.9 ± 1.1 cm on the left side; the average distance from the middle of the cystic-prostatic junction to the middle of the indirect hernia opening was 11.8 ± 1.4 cm on the right side and 11.6 ± 1.6 cm on the left side. It was established that the operative zones of retropubic prostatectomy and simultaneous pre-peritoneal inguinal hernioplasty are located next to each other, and the maximum distance between them does not exceed 12 cm. The analysis of the literature and our own clinical and anatomical studies made it possible to identify the following anatomical factors of the occurrence of inguinal hernia after prostatectomy: dissection and stretching of the transverse fascia with mirrors, trauma to the muscles of the anterior-lateral wall of the abdomen and a decrease in their tone and sphincter function around the inguinal canal, cicatricial changes in the cystic-prostatic segment with tension in the abdominal part of the vas deferens and expansion of the internal inguinal ring and vaginal process of the peritoneum, straining during urination with an increase intra-abdominal pressure and weakening of the transverse fascia and muscle-aponeurotic structures of the inguinal area, age-related hormonal deficiency. Conclusions. A significant percentage of the formation of inguinal hernias after prostatectomy is associated with anatomical changes that occur after prostatectomy in this area. The close location of the intraoperative zone of prostatectomy to the zone of hernioplasty requires simultaneous pre-peritoneal hernioplasty of not only obvious, but also hidden (occult) inguinal hernias, as well as inguinal hernias in the initial stages of their formation during prostatectomy in patients with benign prostatic hyperplasia and inguinal hernia.

There is no fusion fascia in the abdomen and extraperitoneal fascia always surrounds the mesentery.

Toldt's fascia has always been described as a fusion fascia formed by two layers of visceral peritoneum when the mesentery attaches to the posterior abdominal wall. However, there is still no consensus about the mesentery and its surrounding fascia based on the current anatomic theories. This study aimed to determine the anatomical structures of the abdomen and provide a correct surgical plane for mesenteric-based surgery. Surgical videos of 121 patients who underwent laparoscopic operations of the digestive tract were reviewed to identify and compare the anatomical structures of the mesentery and associated fascia. Twenty-one postoperative specimens were stained with hematoxylin and eosin to indicate the histological appearance of the mesentery and its surrounding fascia. Furthermore, dynamic models had been established to explain the formation mechanism of the associated histological structures in different regions during the progression of mesenteric attachment. The fasciae surrounding the mesentery, including the submesothelial connective tissue, the subserosal connective tissue, Toldt's fascia, and "angel hair," have the same histological characteristic to extraperitoneal fascia. The general anatomical structure of the abdomen can be divided into three layers (abdominal wall, urogenital system, and digestive system) and two interlayers (transversalis fascia and extraperitoneal fascia). The extraperitoneal fascia surrounds the entire digestive system and is the natural layer separating adjacent structures from each other. Typical histological structures in the regions of posterior attachment include the fascia propria of the mesentery, mesofascial plane, extraperitoneal fascia, retrofascial plane, and anterior renal fascia. The urogenital system is surrounded by similar histological structures. There is no fusion fascia in the abdomen due to retreat of the visceral peritoneum, and all of the fasciae surrounding the mesentery are extraperitoneal fascia. This study demonstrates that the typical histological structures in the regions of attachment and mesofascial plane are the correct anatomic interface for mesenteric-based surgery.

Efficacy of Regional Blocks or Local Anaesthetic Infiltration for Analgesia After Caesarean Delivery: A Network Meta-Analysis of Randomized Controlled Trials

(Anaesthesia. 2022;77:463–474. doi: 10.1111/anae.15645) With cesarean delivery (CD) rates on the rise globally, it is important to understand the most effective methods of managing postoperative pain, which can be moderate to severe. Effective analgesia following CS has the long-term benefits such as decreasing opioid consumption, postpartum depression, and the likelihood of chronic pain. While long-acting neuraxial opioids reduce opioid requirements, breakthrough pain is not uncommon and neuraxial interventions may be contraindicated for some women. Local anesthetic infiltration has been increasingly used to reduce pain without significant adverse effects and may add the benefit of visceral analgesia. With many approach sites for treatment (direct wound infiltration, ilio-inguinal nerve, transversus abdominis plane, erector spinae plane, transverse fascia plane, and quadratus lumborum plane), it has not yet been studied if certain sites offer greater benefit over others. This network meta-analysis compares and ranks injection sites for efficacy of pain relief following CD.

COMPARATIVE STUDY BETWEEN LAPAROSCOPIC AND OPEN MESH HERNIOPLASTY IN UNILATERAL UNCOMPLICATED INGUINAL HERNIA

Inguinal and femoral hernias are the two main types of groin hernias. There are two types of inguinal hernias: direct and indirect. When abdominal contents push through the internal inguinal ring and into the inguinal canal, it results in an indirect hernia. An abdominal protrusion through the transversalis fascia within Hesselbach's triangle is referred to as a direct inguinal hernia. Hernia repair is a surgical procedure done either by laparoscopic or open method. This study compares the above surgical interventions on the basis of multiple factors to determine which of them the procedure of choice is in unilateral, uncomplicated inguinal hernia.

V-042 MOVING THE CONCEPT ASSOCIATED TO LAPAROSCOPIC INTRACORPOREAL RECTUS APONEUROPLASTY (LIRA) TO LATERAL HERNIA

Abstract Aims Lateral hernias(LH) are rare and there are difficulties associated to minimally invasive approach, LIRA-technique has been described as an alternative to simple closure of the defect. Despite this, the indications of the concept associated to this technique are beginning to expand to other complex locations. Aims of this video is to show the surgical steps for LH where the concept associated to LIRA is followed to repair this type of hernias. Material &amp; Methods 56-year-old female patient without previous surgical history. Clinical examination and CT-scan showed a LH(L2) 6.4 cm in width(W2) and a length of 6.6 cm. Results We started by opening the peritoneum and fascia, exposing the fibers of the internal oblique and the posterior rectus sheath near the border of the defect. Then, the peritoneum and the fascia transversalis, and medially the posterior aponeurosis of the rectus muscle, are opened. Also, it is important to create a lateral peritoneum flap, using a hybrid procedure that involves a partially extraperitoneal and transabdominal (TAPE), then loop-suture are used for closing the defect. Finally, the mesh is placed intraperitoneally and partially extraperitoneal. Conclusions Best surgical technique for LH is still not clear. The anatomical location of these hernias is challenging, recurrence and bulging are also frequent. Since the introduction of the concept of primary closure of the hernia defect, the surgical repair of hernias in different locations has changed, although the idea of expanding the indication of LIRA could be related to better results in term of recurrences, bulging and pain.

P-051 TAPP IN A COMMUNITY HOSPITAL SETTING : AN EXPERIENCE OF OVER 1000 CASES

Abstract Aim We want to share and discuss what we have learned from our 20-year experience in TAPP procedures Material and Methods We use only all 5 mm trocars, instruments, and 30-degree optics and we always use low intraabdominal pressure (10mmHg). The major technical trick is to carefully prepare the peritoneum flap all around, like a cone, just in order to let the mesh perfectly lie down on the inguinal area. Results Our TAPP experience is almost more than 1000 cases, elective as an emergency. We use a 10×15 cm LW macroporous monofilament polypropylene mesh. Besides the well known needed physical characteristics of the mesh, on the surgeon's side, a mesh should be smooth, stiff, wide enough to cover all the possible defects, easy to handle, and, especially for its possible use in laparoscopy, with a certain degree of and thickness just what it is needed in order to let it pass through a 5 mm trocar once rolled up. We do not use to fix the mesh anymore because we do believe in the mesh pushed versus the abdominal wall by the intra-abdominal pressure, and in the exact size of the (10×15 cm). Only in case of huge direct hernia we do “lift” without tension the transversalis fascia. Conclusions Most of the advantages of laparoscopy rely on the minimal access and therefore the benefits of this technique will be greater as the access becomes smaller, together with a no fixed LW mesh.

Elevated serum TLR4 level as a potential marker for postsurgical chronic pain in pediatric patients with different approaches to analgesia.

IntroductionThe perioperative period of any surgery is accompanied by immune suppression. The level of Toll-like receptor 4 (TLR4) is known to increase in inflammation and after nerve injury and contributes to the development of neuropathic pain. The interaction of TLRs in response to the effect of opioids results in paradoxical hyperalgesia. Regional anesthesia techniques are the standard of care for perioperative pain management in children.AimThe aim of the study was to determine and evaluate the indicators of TLR4 for different methods of pain relief in anesthetic management of hernia repair in children and their effect on pain chronification.Materials and methodsThere were examined 60 children with inguinal hernia during 2020–2022. Children were divided into 3 groups: Group I included 20 children who underwent surgery under general anesthesia using the block of the anterior abdominal wall—transversalis fascia plane block (TFPB), combined with the quadratus lumborum block (QLB-4) via a single intramuscular injection; Group II included 20 children who underwent surgery under general anesthesia using the TFPB; Group III comprised 20 children who underwent surgery under general anesthesia using opioid analgesics. The levels of TLR4 were evaluated at a discharge from the hospital, 3 and 6 months after surgery.ResultsThere was no difference in age and body weight among all groups. In Group II, boys prevailed. In Group III, the length of hospital stay was the longest (3.28 ± 0.24 days, p < 0.05, t = 4.09) as compared to children of Group II and Group I (3.0 ± 0.30 (p < 0.05, t = 2.647) and 2.1 ± 0.16 days, respectively). While staying in the surgical department, children of Group III demonstrated significantly higher FLACC and VAS scores. The prevalence of chronic pain was the highest among children of Group III (35%) as compared to those in Group II and Group I (20 and 15%, respectively). The highest increase in the level of TLR4 was found in the group of opioid analgesia on the third and sixth months after surgery (68.86 + 10.31 pg/ml and 143.15 + 18.77 pg/ml (p < 0.05, t = 6.33), respectively) as compared to patients who received regional anesthesia.ConclusionsThere were confirmed the following advantages of the transversalis fascia plane block combined with the quadratus lumborum block (QLB + TFPB) via a single intramuscular injection: ease of use; adequate perioperative pain control as evidenced by the FLACC and VAS pain assessment scales; reduced perioperative use of opioid analgesics; shortening the length of hospital stay.

Ultrasound-guided transversalis fascia plane block versus wound infiltration for both acute and chronic post-caesarean pain management - A randomised controlled trial.

Background and Aims:Ultrasound-guided transversalis fascia plane block (USG-guided TFPB) has recently been evaluated for post-caesarean acute pain management. We compared it with standard wound infiltration for both acute and chronic post-caesarean pain management.Methods:All patients undergoing caesarean section (CS) under subarachnoid block were included and randomised. Patients in group C received standard wound infiltration (20 ml of 0.375% ropivacaine) and group-T received bilateral USG-guided TFPB (20 ml of 0.375% ropivacaine) at the end of the surgery. Acute pain assessed using numeric rating scale (NRS), time to first request of analgesia and total rescue analgesic consumption in 24 hours. The incidence of chronic persistent post-surgical pain (CPSP), neuropathic pain component and quality of life (QoL) were assessed. Fisher’s exact test, Chi-square test, unpaired Student’s t-test and Mann-Whitney U test were used.Results:Sixty patients were included with 30 in each group. NRS score on rest at 6th and 24th hour and on active movement at 1st hour was significantly decreased in group T. The “time to first request of analgesia” was statistically higher in group T, that is, 10.77 ± 1.39 h versus 6.30 ± 1.60 h. Five (16.6%) and two (6.6%) patients in groups C and T, respectively, required rescue analgesia in first 24 hours. 30% (n = 6) and 10% (n = 2) patients in groups C and T, respectively, developed CPSP. The neuropathic pain component was significantly reduced and QoL was significantly improved in group T.Conclusion:TFPB is efficacious for management of both acute and chronic post-caesarean pain management.

Open Surgery for Sportsman's Hernia a Retrospective Study.

Sportsman’s hernia is a painful syndrome in the inguinal area occurring in patients who play sports at an amatorial or professional level. Pain arises during sport, and sometimes persists after activity, representing an obstacle to sport resumption. A laparoscopic/endoscopic approach is proposed by many authors for treatment of the inguinal wall defect. Aim of this study is to assess the open technique in terms of safety and effectiveness, in order to obtain the benefit of an open treatment in an outpatient management. From October 2017 to July 2019, 34 patients underwent surgery for groin pain syndrome. All cases exhibited a bulging of the inguinal posterior wall. 14 patients were treated with Lichtenstein technique with transversalis fascia plication and placement of a polypropylene mesh fixed with fibrin glue. In 20 cases, a polypropylene mesh was placed in the preperitoneal space. The procedure was performed in day surgery facilities. Early or late postoperative complications did not occur in both groups. All patients returned to sport, in 32 cases with complete pain relief, whereas 2 patients experienced mild residual pain. The average value of return to sport was 34.11 ± 8.44 days. The average value of return to play was 53.82 ± 11.69 days. With regard to postoperative pain, no substantial differences between the two techniques were detected, and good results in terms of the resumption of sport were ensured in both groups. Surgical treatment for sportsman’s hernia should be considered only after the failure of conservative treatment. The open technique is safe and allows a rapid postoperative recovery.

Understanding fascial anatomy and interfascial communication: implications in regional anesthesia.

With the extensive application of ultrasound in regional anesthesia, there has been rapid development of interfascial plane block techniques recently. Compared with neuraxial anesthesia or nerve plexus blocks, the interfascial plane blocks have many advantages, such as technical simplicity, fewer complications and comparable or better analgesia. The concept of fascial interconnectivity is fundamental in understanding the effects and complications of interfascial plane blocks. Many fascial planes are continuous and communicate with each other without a clear anatomical boundary. The prevertebral fascia of the neck, endothoracic fascia of the chest, transversalis fascia of the abdomen, and the fascia iliaca of the pelvic cavity form a natural fascial continuation. This anatomical feature suggests that the space beneath the cervical prevertebral fascia, the thoracic paravertebral space, the space between transversalis fascia and psoas muscles (psoas major and quadratus lumborum), and the fascia iliaca compartment are a confluent potential cavity. Additionally, the permeability of the fascia at different anatomical locations to local anesthetics is different, which can also influence the block effect and the incidence of complications. This article summarizes the anatomical characteristics and communication relationships of the major fascia which are related to regional anesthesia, and their relationships with block effects and complications.

The Preperitoneal Space in Hernia Repair.

The preperitoneal spaces relevant for incisional hernia repair and minimally invasive groin hernia repair are described in terms of surgical anatomy. Emphasis is put on the transversalis fascia and the urogenital fascia and its extensions, the vesicoumbilical fascia, and the spermatic sheath of Stoppa procedure. Steps in hernia surgery where these structures are relevant are reviewed.

Factors associated with TNF-alpha levels in patients with indirect inguinal hernia: A cross-sectional study

IntroductionRisk factors associated with inguinal hernia include a patent processus vaginalis due to an obliteration failure, defects in the transversalis fascia, increased intra-abdominal pressure, smoking, malnutrition, genetic factors, connective tissue defects and impaired collagen metabolism. Type I collagen predominates in the fascia, which plays a key role in the development of an inguinal hernia. Molecularly, the production of abnormal matrix components or increased inflammatory mediators in collagen such as TNF-α has a very important role in the occurrence of inflammation in inguinal hernias. The study aimed to determine the factors associated with TNF-alpha levels in patients with indirect inguinal hernias. MethodsWe evaluate the effect of TNF-α on the anterior rectus sheath tissue collagen in 46 patients with indirect inguinal hernia using a cross-sectional study design. The ELISA method was used to evaluate the levels of collagen TNF-α. We used ANOVA, Pearson's correlation test, and Spearman's correlation test to determine which results were statistically significant, defined by a p-value < 0.05. ResultsBody mass index (BMI) average results were 25.7 kg/m2. Mean clinical onset was 70.13 months across 46 samples. TNF-α levels and BMI were correlated (p = 0.009). The TNF-α levels in the clinical-grade group (p = 0.044) and the clinical onset group (p = 0.047) varied according to ANOVA. ConclusionClinical onset, BMI, clinical grade of indirect inguinal hernia, and TNF-α levels have a significant relationship.

An Extremely Rare Case Report of a Retroperitoneal Hernia Following Spinal Surgery

Introduction: Retroperitoneal hernias are extremely rare lumbar wall defects. Secondary hernias can occur after previous flank surgeries, infection or trauma. There is a paucity of literature regarding lumbar incisional hernias, most of them related to lateral approaches to the spine. Research Question: The objective of this article is to report a rare case of a retroperitoneal hernia following spinal surgery. Material and Methods: We review a rare presentation of a symptomatic acquired retroperitoneal hernia following several posterior lumbar spine approaches. An extensive literature review regarding retroperitoneal hernia and its relation to spinal surgery was performed. Results: A successful hernia repair suturing the transversalis fascia to the middle layer of the thoracolumbar fascia using a biological mesh was performed, with resolution of the hernia symptoms. Discussion and Conclusion: Although retroperitoneal hernias are extremely rare, we must emphasize the importance of an adequate surgical exposure in order to preserve the retroperitoneal and thoracolumbar fasciae as biological barriers during surgical approaches to the spine.

Laparoscopic inguinal hernia repair in bladder exstrophy, a new modified solution to an old problem: A cohort study.

PurposeOpen inguinal hernia repair in children with bladder exstrophy is challenging and associated with a high recurrence rate (15%–22%).We report our initial experience with laparoscopic repair of inguinal hernias in five children with repaired bladder exstrophy. This study is the third describing inguinal hernia repair in bladder exstrophy patients using the laparoscopic approach. In this study, we report a different laparoscopic technique.MethodsThis retrospective study was performed on data regarding laparoscopic inguinal hernia repair collected over one year (July 2019–2020). We carried out the laparoscopic inguinal hernia repair, closing the internal inguinal ring using a non-resorbable sliding knot suture and incorporating the transversalis fascia for reinforcement, followed by purse-string closure of the peritoneum.Peri- and postoperative outcome parameters, including recurrence rate, were evaluated over a follow-up period of 14 months.ResultsA total of seven male patients from July 2019 to 2020 were admitted to our center with a history of repaired bladder exstrophy and reducible inguinal hernias. Two patients had open inguinal hernia repair due to parental preference and five patients had laparoscopic repair. In the laparoscopic group three patients had bilateral inguinal hernias in one of them a metachronous hernia was discovered intraoperstively, and the remaining two patients had unilateral hernias, one on the right side and the other on the left side. All patients in the laparoscopic group had an uneventful recovery and were discharged within 24 h and there were no complications or recurrences during follow-up.ConclusionLaparoscopic inguinal hernia repair is a better alternative to managing inguinal hernias in children with bladder exstrophy.