Optimizing Inguinal Hernia Surgery

Background and aim: To find the superiority of extended total extraperitoneal (E-TEP) repair and trans-abdominal pre-peritoneal (TAPP) mesh repair in inguinal hernia repair.Material and methods: A total of 30 patients with a unilateral or bilateral inguinal hernia (IH), and recurrent IH, following open repair were studied. Out of 30 patients, laparoscopic TAPP or E-TEP mesh repair was performed in an equal number of inguinal hernia patients. The patient's demographic parameters, duration of surgery, postoperative hospital stay, and complications were compared.Results: In the E-TEP group, 33.33% of patients had left inguinal hernia (LIH), 60% of patients were diagnosed with right inguinal hernia (RIH) and 6.67% of patients had right inguinal and right direct hernia (RDH). In the TAPP group, 33.33% of patients had LIH and 53.33% of patients were suffering from RIH. Moreover, 6.67% of patients were diagnosed with a left inguinal direct hernia, and a similar proportion of patients had a right inguinal direct hernia. The mean duration of surgery was found to be significantly higher in the TAPP group (P<0.0000). The mean postoperative hospital stay was 2.07±0.59 and 2.80±1.32 days in E-TEP and TAPP groups, respectively (P=0.044).Conclusion: In the present study, E-TEP mesh repair is a superior technique in the management of inguinal hernia as compared with TAPP repair.

ImportanceTo our knowledge, a systematic review has not yet been performed that specifically addresses the management of inguinal hernia in women. Recurrence after repair of inguinal hernia is not unusual in women and may be a previously undiagnosed femoral hernia, which is rarely seen in men.ObjectiveTo investigate rates and types of recurrences in women who had undergone repair of primary inguinal hernia.Evidence ReviewPubMed, Embase, and the Cochrane databases were searched in September 2017 for studies reporting recurrences after repair of primary inguinal hernia in women. Crude rates of recurrence (number of recurrences/number of women) were calculated after open and laparoscopic repairs, and the type of recurrent hernia was registered, if noted in the studies. This review is reported according to the PRISMA guideline.FindingsA total of 55 studies were included, comprising 43 870 women (mean age, 42-69 years; median age, 57 years). Five studies were randomized clinical trials, 14 were prospective cohort studies, 7 were prospective database studies, and 29 were retrospective cohort studies. Twenty studies reported recurrence after laparoscopic repair, with a crude recurrence rate of 1.2% (27 of 2257) (range, 0%-5%) and a median follow-up of 24 months. Thirty-seven studies reported open repair, with a crude recurrence rate of 2.4% (818 of 33 971) (range, 0%-12.5%) and a median follow-up of 36 months. The crude recurrence rate in randomized clinical trials and prospective studies was 1.2% (18 of 1525) after laparoscopic repair compared with 4.9% (490 of 10 058) after open repair. The recurrent inguinal hernia was a femoral hernia in 203 of 496 patients (40.9%) after open repair, compared with 0% of patients after laparoscopic repair. Recurrence rates were similar when open mesh vs nonmesh techniques were used.Conclusions and RelevanceRecurrence rates after repair of primary inguinal hernia in women are lower after laparoscopic repair compared with open repair. Intraoperative findings during repair of recurrent inguinal hernia are often femoral hernias in women.

There is considerable demographic overlap of inguinal hernia patients and prostate cancer patients. Previous laparo-endoscopic inguinal hernia mesh repairs can complicate subsequent radical prostatectomies due to adhesions and distortion of anatomic planes. This study aims to assess the experience of urological surgeons on the safety and feasibility of performing radical prostatectomies after laparo-endoscopic inguinal hernia mesh repair. For this cross-sectional study, an online 24 question survey was developed regarding the experience in performing a radical prostatectomy and pelvic lymph node dissection (PLND) with a prior preperitoneal inguinal hernia mesh repair. Between June 2016 and December 2017, the questionnaire was sent to all 68 urological surgeons performing radical prostatectomy in the Netherlands. The response rate of urological surgeons was 69% (n = 47). The majority (77%) of urological surgeons perform robot-assisted laparoscopic prostatectomies. A previous preperitoneal inguinal hernia repair was reported by 40% of urological surgeons in 10-30% of patients undergoing radical prostatectomy. Radical prostatectomy with prior preperitoneal inguinal hernia mesh repair is considered more difficult by 49%, predominantly because of (occasionally to always) experienced longer operating times (88.4%), increased blood loss (46.5%), difficult dissection of Retzius space (88.4%), nerve-sparing difficulties (32.6%), less adequate PLND (69.8%), and bladder- (16.3%) or peritoneal perforations (27.9%). Additionally, 11.6% had performed mesh explantation, 16.3% had aborted radical prostatectomies, and 35.7% experienced increased inguinal hernia recurrences after radical prostatectomies with prior preperitoneal inguinal hernia mesh repair. More experienced urological surgeons reported an increased difficulty for all outcomes. Laparo-endoscopic inguinal hernia mesh repair has a significant impact on performing a radical prostatectomy and PLND. Surgeons should postpone the inguinal hernia repair of patients in the workup for a radical prostatectomy, with the preferable option of performing the radical prostatectomy and inguinal hernia repair in the same procedure. Alternatively, a Lichtenstein repair can be performed.

This meta-analysis and trial sequential analysis aims to provide an update on the available randomized controlled trials (RCTs) and recommendations on using lightweight mesh (LWM) or heavyweight mesh (HWM) in laparo-endoscopic inguinal hernia repair. LWM might reduce chronic pain through improved mesh flexibility and less fibrosis formation. However, in laparo-endoscopic repair chronic pain is already rare and LWM raise concerns of higher recurrence rates. A literature search was conducted in May 2019 in MEDLINE, Embase, and the Cochrane library for RCTs that compared lightweight (≤50 g/m2) and heavyweight (>70 g/m2) mesh in patients undergoing laparo-endoscopic surgery for uncomplicated inguinal hernias. Outcomes were recurrences, chronic pain, and foreign-body sensation. The level of evidence was assessed using GRADE. Risk ratios (RR) and 95% confidence intervals (CI) were calculated by random effect meta-analyses. Trial-sequential-analyses were subsequently performed. Twelve RCTs, encompassing 2909 patients (LWM 1490 vs HWM 1419), were included. The follow-up range was 3 to 60 months. Using LWM increased the recurrence risk (LWM 32/1571, HWM 13/1508; RR 2.21; CI 1.14-4.31), especially in nonfixated mesh direct repairs (LWM 13/180, HWM 1/171; RR 7.27; CI 1.33-39.73) and/or large hernia defects. No difference was determined regarding any pain (LWM 123/1362, HWM 127/1277; RR 0.79; CI 0.52-1.20), severe pain (LWM 3/1226, HWM 9/1079; RR 0.38; CI 0.11-1.35), and foreign-body sensation (LWM 100/1074, HWM 103/913; RR 0.94; CI 0.73-1.20). HWM should be used in laparo-endoscopic repairs of direct or large inguinal hernias to reduce recurrence rates. LWM provide no benefit in indirect hernias.

Abdominal wall and inguinal hernia repair are the most frequently performed surgical procedures in the United States and Europe. However, traditional methods of mesh fixation are associated with a number of problems including substantial risks of recurrence and of postoperative and chronic pain. The aim of this systematic review is to summarize the clinical safety and efficacy of Tisseel/Tissucol fibrin sealant for hernia mesh fixation. A PubMed title/abstract search was conducted using the following terms: (fibrin glue OR fibrin sealant OR Tisseel OR Tissucol) AND hernia repair. The bibliographies of the publications identified in the search were reviewed for additional references. There were 36 Tisseel/Tissucol studies included in this review involving 5,993 patients undergoing surgery for hernia. In open repair of inguinal hernias, Tisseel compared favorably with traditional methods of mesh fixation, being associated with shorter operative times and hospital stays and a lower incidence of chronic pain. Similarly, after laparoscopic/endoscopic inguinal hernia repair, Tisseel/Tissucol was associated with less use of postoperative analgesics and less acute and chronic postoperative pain than tissue-penetrating mesh-fixation methods. Other end points of concern to surgeons and patients are the risks of inguinal hernia recurrence and of complications such as hematoma formation and intraoperative bleeding. Comparative studies show that Tisseel/Tissucol does not increase the risk of these outcomes and may, in fact, decrease the risk compared with tissue-penetrating fixation methods. When used in the repair of incisional hernias, Tisseel/Tissucol significantly decreased both postoperative morbidity and duration of hospital stay. Clinical evidence published to date supports the use of Tisseel/Tissucol as an option for mesh fixation in open and laparoscopic/endoscopic repair of inguinal and incisional hernias. Guidelines of the International Endohernia Society recommend fibrin sealant mesh fixation, especially in inguinal hernia repair. Nonfixation is reserved for selected cases.

Background: Groin hernia repair is considered to be one of the most commonly performed operations by general surgeons however, there is no gold standard operation for treatment of inguinal hernias. The optimal surgical approach must be selected individually for the patient, considering patient age, hernia size, unilaterality or bilaterality, primary or recurrent status, and type of anesthesia, occupation, and leisure activities. The laparoscopic revolution has increased the debate about the safest and most effective inguinal hernia repair. This revolution has broadened our understanding of inguinal anatomy and hernia repair. At the least, surgeons should be aware of the current indications and contraindications for laparoscopic inguinal hernia repair, because some hernias should have a laparoscopic repair. To increase versatility, surgeons should consider becoming skilled at both techniques, with the understanding that outcomes are optimal if one is committed to achieving expertise in laparoscopic repair. Objectives: Our objective in this study is to compare the outcome of mesh fixation using non-absorbable tacks versus absorbable tacks in transabdominal preperitoneal (TAPP) laparoscopic repair of inguinal hernia regarding their efficacy and postoperative complications to improve the outcome of patients undergoing surgery for inguinal hernia in Ain Shams University Hospitals. Patients and methods: The present study is a prospective, randomized comparative study that was conducted in Ain Shams University Hospitals in Egypt, and included sixty (60) patients who had inguinal hernia. The patients were divided into two groups each group including 30 patients. In the first group (Group A) titanium non-absorbable tacks were used and in the other group (Group B) absorbable tacks were used. The patients underwent a trans-abdominal preperitoneal (TAPP) laparoscopic repair of inguinal hernia using prolene mesh. The study was conducted from July 2016 to July 2017, with 12 months of follow-up post-operatively until July 2018. Results: The mean age of the patients was 36.93 ± 10.23 (19-55) and the mean BMI was 24.83 ± 2.79 (19-32). There was no significant difference between 2 groups as regard preoperative comorbidities. Patients presented mainly with swelling in the groin region 71.67%. Right sided hernia was 46.7% and bilateral hernia was 15%. There was no difference between 2 groups as regard the operative time (p-value=0.056) and intraoperative complications: bleeding (p-value=0.150) and bladder injury (p-value=0.313). Post-operative complications, postoperative hospital stay, time needed to return to normal activity and the recurrence were all alike between the 2 groups. Pain analysis was done four times, and revealed no significant difference between the 2 groups at any time of follow-up. Conclusion: Both non-absorbable tacks and absorbable tacks used in mesh fixation are similarly effective in terms of operative time, the incidence of recurrence, complications and pain at least in the first year of follow up, but it may be less painful after one year after the complete absorption of the absorbable tacks but this needs further investigations and studies containing more patients and with follow-up for longer time.

Background: Groin hernia repair is considered to be one of the most commonly performed operations by general surgeons however, there is no "gold standard" operation for treatment of inguinal hernias. The optimal surgical approach must be selected individually for the patient, considering patient age, hernia size, unilaterality or bilaterality, primary or recurrent status, and type of anesthesia, occupation, and leisure activities. The laparoscopic revolution has increased the debate about the safest and most effective inguinal hernia repair. This revolution has broadened our understanding of inguinal anatomy and hernia repair. At the least, surgeons should be aware of the current indications and contraindications for laparoscopic inguinal hernia repair, because some hernias should have a laparoscopic repair. To increase versatility, surgeons should consider becoming skilled at both techniques, with the understanding that outcomes are optimal if one is committed to achieving expertise in laparoscopic repair. Objectives: Our objective in this study is to compare the outcome of mesh fixation using non-absorbable tacks versus absorbable tacks in transabdominal preperitoneal (TAPP) laparoscopic repair of inguinal hernia regarding their efficacy and postoperative complications to improve the outcome of patients undergoing surgery for inguinal hernia in Ain Shams University Hospitals. Patients and methods: The present study is a prospective, randomized comparative study that was conducted in Ain Shams University Hospitals in Egypt, and included sixty (60) patients who had inguinal hernia. The patients were divided into two groups each group including 30 patients. In the first group (Group A) titanium non-absorbable tacks were used and in the other group (Group B) absorbable tacks were used. The patients underwent a trans-abdominal preperitoneal (TAPP) laparoscopic repair of inguinal hernia using prolene mesh. The study was conducted from July 2016 to July 2017, with 12 months of follow-up post-operatively until July 2018. Results: The mean age of the patients was 36.93 ± 10.23 (19-55) and the mean BMI was 24.83 ± 2.79 (19-32). There was no significant difference between 2 groups as regard preoperative comorbidities. Patients presented mainly with swelling in the groin region 71.67%. Right sided hernia was 46.7% and bilateral hernia was 15%. There was no difference between 2 groups as regard the operative time (p-value=0.056) and intraoperative complications: bleeding (p-value=0.150) and bladder injury (p-value=0.313). Post-operative complications, postoperative hospital stay, time needed to return to normal activity and the recurrence were all alike between the 2 groups. Pain analysis was done four times, and revealed no significant difference between the 2 groups at any time of follow-up. Conclusion: Both non-absorbable tacks and absorbable tacks used in mesh fixation are similarly effective in terms of operative time, the incidence of recurrence, complications and pain at least in the first year of follow up, but it may be less painful after one year after the complete absorption of the absorbable tacks but this needs further investigations and studies containing more patients and with follow-up for longer time.

Tension-free mesh repair is currently the gold standard treatment for inguinal hernia. Recent evidence has shown that both open and laparoscopic approaches to inguinal hernia repair can achieve good results. Lots of meshes with different properties are available on the market, but direct comparisons between them are scare. We conducted a prospective randomized controlled trial comparing a partially absorbable lightweight mesh (ULTRAPRO™) and a multifilament polyester anatomical mesh (Parietex™) in laparoscopic total extraperitoneal inguinal hernia repair. This study was a single-center, prospective randomized controlled trial to compare the surgical handling and clinical outcomes between two different types of meshes. All operations were performed using a standardized operative protocol. This study was approved by the Institutional Review Board of the Hong Kong East Cluster Health Service in 2009 (reference number: 2009-087). The study was registered in the Australian New Zealand Clinical Trial Registry (ACTRN12610000031066). From October 2009 to August 2011, 85 laparoscopic total extraperitoneal inguinal hernia repairs were performed. The mean mesh handling time was 152 s for the ULTRAPRO group and 206 s for the Parietex group (P = 0.001). There were three cases of seroma formation in the ULTRAPRO group and nine in the Parietex group (P = 0.02). The overall recurrence rate was 2.5%. It took less time to manipulate the flat mesh (ULTRAPRO) than the anatomical mesh (Parietex) in laparoscopic total extraperitoneal inguinal hernia repair, but the time difference was small. Lightweight mesh and heavyweight mesh offered similar clinical outcomes in terms of discomfort sensation and foreign body sensation during long-term follow-up.

PurposePatients who undergo robot-assisted laparoscopic radical prostatectomy (RARP) may present concurrent or secondary inguinal hernia (IH). Surgical repair of IH simultaneously with RARP has been reported. We aimed to assess the long-term efficacy of concurrent prosthetic IH repair with RARP.MethodsData for consecutive patients undergoing concurrent IH repair with RARP for localized prostate cancer at our institution between 2006 and 2017 were retrospectively analysed. Patients were matched based on age, BMI, and year of surgery, with patients undergoing RARP alone. IH repair was performed with a polyester mesh. Efficacy of IH repair was the primary outcome. Patient characteristics, perioperative data, recurrence and treatment were recorded.ResultsA total of 136 men were included, 50% treated by RARP and concurrent IH, 50% by RARP alone. Mean age was 65 years (SD 6) and mean BMI 26.8 (SD 2.5). IH was diagnosed preoperatively in 42 patients (62%) or intraoperatively in 26 patients (38%). A total 18 patients (26%) had bilateral hernias and 50 patients had unilateral hernias (right 31%, left 43%). There was no significant difference between the two groups regarding perioperative data. The herniorrhaphy added 34 min to the operative time (p < 0.001). After a mean follow-up of 106 months [SD 38], 9 patients (13%) presented recurrence of IH, with a mean time to recurrence of 43 months [SD 35]. Age was significantly associated with IH recurrence (p = 0.0007).ConclusionConcomitant IH repair and RARP appear to be a safe procedure with good long-term safety and efficacy, without significantly increasing morbidity.

A Canadian national survey: Perspectives on routine pathological examination of hernia sacs after inguinal hernia and hydrocele repair among pediatric urologists, surgeons, and pathologists

Women have a 3% lifetime chance of developing an inguinal hernia, which is not as common in men. Due to its cosmetic benefits, single-incision laparoscopic transabdominal preperitoneal (SIL-TAPP) inguinal hernia repair is becoming increasingly popular in the management of inguinal hernia in women. However, there are no studies comparing the safety and applicability of SIL-TAPP repair with conventional laparoscopic transabdominal preperitoneal (CL-TAPP) inguinal hernia repair for the treatment of inguinal hernia in women. To compare the outcomes of SIL-TAPP and CL-TAPP repair in adult female patients with inguinal hernia and to estimate the safety and applicability of SIL-TAPP repair in adult female inguinal hernia patients. We retrospectively compared the clinical information and follow-up data of female inguinal hernia patients who underwent SIL-TAPP inguinal hernia repair and those who underwent CL-TAPP inguinal hernia repair at the Affiliated Hospital of Nantong University from February 2018 to December 2020 and assessed the long-term and short-term outcomes of both cohorts. This study included 123 patients, with 71 undergoing SIL-TAPP repair and 52 undergoing CL-TAPP repair. The two cohorts of patients and inguinal hernia characteristics were similar, with no statistically meaningful difference. The rate of intraoperative inferior epigastric vessel injury was lower in patients in the SIL-TAPP cohort (0, 0%) than in patients in the CL-TAPP cohort (4, 7.7%) and was significantly different (P < 0.05). In addition, the median [interquartile range (IQR)] total hospitalization costs were significantly lower in patients in the SIL-TAPP cohort [$3287 (3218-3325)] than in patients in the CL-TAPP cohort [$3511 (3491-3599)]. Postoperatively, the occurrence rate of trocar site hernia was lower in the SIL-TAPP cohort (0, 0%) than in the CL-TAPP cohort (4, 7.7%), and the median (IQR) cosmetic score was significantly higher in the SIL-TAPP cohort [10 (10-10)] than in the CL-TAPP cohort [9 (9-10)]. SIL-TAPP repair did not increase the incidence of intraoperative and postoperative complications in female inguinal hernia patients. Moreover, female inguinal hernia patients who underwent SIL-TAPP repair had a lower probability of trocar site hernia and inferior epigastric vessel injury than female inguinal hernia patients who underwent CL-TAPP repair. In addition, female inguinal hernia patients who underwent SIL-TAPP repair reported a more aesthetically pleasing postoperative abdominal incision. Therefore, SIL-TAPP repair is a better option for the treatment of inguinal hernias in women.

Background Inguinal hernia repair is one of the most widely performed surgical procedure. Among the techniques used, the open Lichtenstein repair is still the most widely performed. However, in the last decade there has been an increased interest in the laparoscopic approach for inguinal hernia repair, mainly represented as the trans-abdominal pre- peritoneal (TAPP) technique. As described in recent studies, TAPP approach entails the benefits of minimally invasive surgery, such as less pain and early recovery. Objective s: This study aims to compare between lichtenstein repair of inguinal hernia and trans-abdominal pre-peritoneal repair of inguinal hernia (TAPP) as regard their hospital stay, cost, intra-operative &amp; post-operative complications and short term recurrence. Patients and Methods Our study was carried out on (50) male patients with inguinal hernia, 25 patients underwent laparoscopic TAPP repair and 25 patients underwent open Lichtenstein repair. We found a highly significant difference of laparoscopic TAPP Repair in decreasing post-operative pain than in open repair. Results Comparative study between the 2 groups revealed non-significant difference as regards age and sex of the patients. Comparative study between the 2 groups revealed non-significant difference as regards all socio-demographic data. Comparative study between the 2 groups revealed non-significant difference as regards type and side of hernia. Comparative study between the 2 groups revealed; highly significant increase in operative duration in laparoscopic group; compared to open group of patients; with highly significant statistical difference. Comparative study between the 2 groups revealed; highly significant decrease in post-operative pain score and post-operative hospital stay; in laparoscopic group; compared to open group of patients; with highly significant statistical difference. Comparative study between the 2 groups revealed; highly significant decrease in intra-operative complications in laparoscopic group; compared to open group of patients; with highly significant statistical difference. Conclusion Our study showed that laparoscopic TAPP approach for inguinal hernia repair reduces early post-operative pain. Furthermore, it is related to less complications, although it takes a longer operative time and higher cost.

Open preperitoneal inguinal hernia repair has many advantages and provided the initial foundation for laparoscopic inguinal hernia repair. This approach can be advantageous for large, complicated, and recurrent inguinal hernias. This chapter provides a step-by-step pictorial, with key aspects of the surgical technique required to perform an open preperitoneal, or Stoppa, repair for inguinal hernias.

Aim: To evaluate patient satisfaction undergoing inguinal hernia surgery under local anesthesia. Methods: The study was conducted in Jinnah hospital, Lahore from 2014 to 2019 including 650 clinically diagnosed patients with direct or indirect inguinal hernia with age ranging 20 to 60 years. All of these patients were operated in dedicated day care operation-theater of surgical department, where hernia surgeries under local anesthesia were done on daily basis 6 days a week. We assessed satisfaction in all patients undergoing inguinal hernia surgery with monitoring during anesthesia care known as iowa satisfaction with small anesthesia scale. Results: 80% of patients were between 20 to 45 years of age with male to female ratio 99: Right inguinal hernia patients were 55% and 45% with left inguinal hernia. In the proforma of 11 questionnaire, 96 % patients were found satisfied with the quality of anesthesia care with varying satisfactions ranging above 90 % regarding pain, feeling like throwing up, feeling relaxed as well as feeling hurt. Conclusion: Inguinal hernia surgery under local anesthesia is found profoundly satisfactory with regard to anesthetic care. Local anesthesia hernial surgery has satisfactory patient acceptability similar to those observed in a conventional regional/general anesthesia in tertiary care setup. Keywords: Inguinal hernia, local anaesthesia, satisfaction

Background: Hernia is an unusual bulging of the intra-abdominal viscera through a weak area of the abdominal wall or groin region. Inguinal hernia repair is one of the most frequently performed surgical procedures. In recent years, inguinal hernia (IH) repair was changed from pure tissue repair to prosthetic laparoscopic repair. Objective: we propose to find a new application for the well-known surgical open mesh inguinal hernia in the treatment of inguinal hernias in adults aiming to improve patients' comfort and to reduce the incidence of chronic neuralgia. Patients and Methods: . A comparative study was designed to study the outcome of different sizes of mesh used in the hernia operations. In the present study, patients diagnosed with primary unilateral inguinal hernia (n=130) were enrolled from May 2019 to March 2020 at Baquba teaching hospital in Diyala governorate. Enrolled patients were divided into two groups. Group A include patients who have inguinal hernia operated with all in one procedure (n=65) and group B included patients with inguinal hernia operated by the classical method (n=65). Spinal and general anaesthesia were used. Before incision for the patient, ceftriaxone (1gm, intravenously) was administrated over 30 min. The process was accomplished on a one-day surgery basis .According to the devised technique, a new smaller prosthesis was placed on the floor of the inguinal canal in order to strengthen all areas of weakness from which hernias may originate. The mesh was enveloped by a fibro-cremasterico sheath avoiding contact with neural structures. Follow-up was carried out at 1week, 1month, 3months for evaluation of postoperative pain using numbering scale score, need of medication, patients' comfort, and postoperative complications. Results: all patients operated by all in one procedure were discharged within 24 h from surgery. Slight pain was reported by the majority of patients and (07.69%) of them required pain medication at home. After the 1st postoperative week (95.36%) reported no pain and (04.62%) show bruising genitaliao, (01.54%) had seroma and no wound infection recorded. No relevant limitation of normal activities was reported. There have been no postoperative neuralgias. Conclusion: This new hernioplastyo technique respects the anatomy of the inguinal canal, uses a smaller mesh, and seems to avoid neuralgias with maximum comfort for the patients. We recommended to all in one technique o because gives better results and fewer complications. Keywords: Hernia ;Open mesh inguinal hernia; patients