Intraoperative adjunctive techniques to reduce seroma formation in laparoscopic inguinal hernioplasty: a systematic review

The mentoring effects of learning curve of total extraperitoneal hernioplasty: the CUSUM analysis of the pioneer and second-generation surgeon

BACKGROUND

Most studies demonstrated that the learning curve of total extraperitoneal hernioplasty (TEP) is around 30-80 cases. All these studies were performed by a single surgeon who had little or no experience of TEP repair before. However, with mentoring by experienced surgeon, the second-generation surgeon may get more familiar with the anatomy and procedures of TEP than the pioneer surgeon. Besides, the surgical caveats would be further understood and pitfalls avoided by mentoring with the pioneer surgeon. The aims of this study were to investigate the effects of mentoring by pioneer surgeon to the second-generation surgeon in the TEP operation by comparing the learning curve and complications of pioneer and second-generation surgeon.

METHODS

We retrospectively reviewed our TEP cases performed by the two surgeons, the pioneer surgeon and the second-generation surgeon, in general surgery department in Chang Gung Memorial Hospital, Keelung division. The reviewed period was between January 2016 and December 2021. The pioneer surgeon performed the TEP surgery by himself. The second-generation surgeon attended 20-30 cases of TEP done by pioneer surgeon. Then, the pioneer surgeon mentored the second-generation surgeon's first 10 TEP cases. By comparing the operation time, the intraoperative and post-operative complications, cumulative sum (CUSUM) learning curve was used for analysis.

RESULTS

The CUSUM analysis reveals that the learning curve of TEP is around 45 procedures in the pioneer surgeon and 30 procedures in the second-generation surgeon. The median operation time in pioneer surgeon and second-generation surgeon is 103.5 vs 90 min (p = 0.03). The overall intraoperative and post-operative complications between pioneer and second-generation surgeon reveal no significant difference. After crossing the learning curve, the operation time of pioneer surgeon and the second-generation surgeon decreased significantly, from 114 to 93 min (p = 0.008) and from 103 to 87.2min (p = 0.032), respectively. However, there was no significant difference in the overall post-operative complications.

CONCLUSIONS

By mentoring with the pioneer surgeon, the second-generation surgeon may achieve the learning curve quicker than the pioneer surgeon in terms of operation time. After reaching the learning curve, the operation time before and after learning curve reveal significant different in both surgeons while the overall post-operative complications reveal no significant different.

Infection-Resistant Polypropylene Hernia Mesh: Vision & Innovations

The surgical repair of hernias, a prevalent condition affecting millions worldwide, has traditionally relied on polypropylene (PP) mesh due to its favorable mechanical properties and biocompatibility. However, postoperative infections remain a significant complication, underscoring the need for the development of infection-resistant hernia meshes. This study provides a comprehensive analysis of current advancements and innovative strategies aimed at enhancing the infection resistance of PP mesh. It presents an overview of various research efforts focused on the integration of antimicrobial agents, surface modifications, and the development of bioactive coatings to prevent bacterial colonization and biofilm formation. Additionally, the synergistic effects of novel material designs and the role of nanotechnology in optimizing the anti-infective properties of PP mesh are explored. Recent clinical outcomes and in vitro studies are critically examined, highlighting challenges and potential future directions in the development of next-generation hernia meshes. Emphasis is placed on the importance of interdisciplinary approaches in advancing surgical materials with the ultimate goal of improving patient outcomes in hernia repair.

Percutaneous inguinal canal semi-closure during laparoscopic repair for large indirect inguinal hernia

BACKGROUND

Factors such as a large lateral hernia and insufficient prosthetic overlap have been associated with hernia recurrence after laparoscopic transabdominal preperitoneal (TAPP) repair. The effectiveness of defect closure in reducing recurrence during laparoscopic hernia repair has been previously reported. We developed a novel technique called percutaneous inguinal canal semi-closure (PICS) to reinforce laparoscopic mesh repair.

PURPOSE

To assess whether this technique is both safe and practical in a clinical setting, focusing on postoperative factors such as recurrence, complications, and postoperative pain.

METHODS

A retrospective analysis of consecutive patients undergoing TAPP for L3 hernia repair.

RESULTS

In total, 58 patients who underwent TAPP for L3 inguinal hernias were included, 27 of whom (46.6%) underwent TAPP with PICS, while 31 (53.4%) underwent standard TAPP without PICS. No recurrences were observed in the PICS group, compared to two recurrences in the control group, although this difference did not reach statistical significance. The incidence of postoperative complications was comparable between groups (48.1% vs. 45.2%, respectively). The median procedure time of PICS was 7.3 min. Patients in the PICS group reported higher pain scores than the control group for up to 21 days postoperatively, but no chronic pain was observed in either group.

CONCLUSION

The modified laparoscopic technique involving PICS for large indirect inguinal hernias appears safe and feasible.

Little influence of the abandoned sac on seroma formation following laparoscopic transabdominal preperitoneal repair of lateral inguinal hernia

BACKGROUND

The impact of completely reducing or transecting a hernia sac on seroma formation in laparoscopic surgery for lateral inguinal hernias remains debated. To date, no studies have compared the incidence of seroma in hernia sacs left untouched versus other surgical approaches. Abandoning the hernia sac involves avoiding manipulation of the inguinal canal, unlike the manipulation required for transection or reduction of the hernia sac.

PURPOSE

This study aimed to determine whether manipulation of the inguinal canal contributes to seroma formation following transabdominal preperitoneal (TAPP) repair.

METHODS

A retrospective cohort study was conducted, including 476 of the 584 lateral inguinal hernia lesions treated with TAPP during the study period. Seroma occurrence 4 weeks post-surgery was assessed in the unmanipulated group (n = 233) and the manipulated group (n = 243). Risk factors were analyzed using univariable and multivariable methods, and findings were validated based on hernia classification and estimated hernia volume.

RESULTS

Seroma was observed in 23 cases (9.9%) in the unmanipulated group and 28 cases (11.5%) in the manipulated group, without statistically significant differences. Bendavid staging emerged as the strongest predictor of seroma risk in both univariable (odds ratio 7.1, 95% CI 4.0-12.6, p < 0.001) and multivariable analyses (odds ratio 5.2, 95% CI 3.6-7.6, p < 0.001). The likelihood of seroma increased with advancing Bendavid stage (p < 0.001). Lesions complicated by seroma had significantly larger estimated hernia volumes across stages (Stage 2, p < 0.01; Stage 3, p < 0.01).

CONCLUSION

The abandoned sac does not appear to influence seroma formation following laparoscopic repair of lateral inguinal hernias. Key determinants of seroma formation include hernia stage and volume.

Establishment of a Predictive Model for Seroma Formation After TAPP Repair for Unilateral Indirect Inguinal Hernia in Males

BackgroundInguinal hernia repair, particularly using TAPP, is common in males, and acclaimed for minimal invasiveness but often complicated by seromas, significantly affecting recovery and health care costs.MethodsThis retrospective study analyzed data from 266 male patients with unilateral indirect inguinal hernia who underwent transabdominal preperitoneal (TAPP) repair. We divided the patients into a training set (n = 188) and a validation set (n = 78). We employed logistic regression to identify independent risk factors for post-TAPP seroma and developed a nomogram to predict the occurrence of seromas. The model's accuracy was evaluated using receiver operating characteristic (ROC) curves, Hosmer-Lemeshow goodness-of-fit test, calibration curves, and decision curve analysis (DCA).ResultsPostoperatively, 20.3% of patients developed a seroma. Multivariate logistic regression analysis highlighted several independent risk factors for seroma formation: the use of anticoagulants, an internal ring defect ≥5 cm, scrotal hernia, incarcerated hernia, and transected hernia sac (P < 0.05). The ROC curves for the training and validation sets demonstrated areas under the curve of 0.893 (95% CI: 0.845-0.942) and 0.864 (95% CI: 0.765-0.963), respectively, indicating good model fits (P > 0.05). DCA confirmed significant clinical applicability of the model.ConclusionThe findings suggest that the use of anticoagulants, an internal ring defect ≥5 cm, scrotal hernia, incarcerated hernia, and transected hernia sac are significant independent risk factors for seroma formation after TAPP repair. Clinical consideration of these factors and proactive preventive measures are essential. Although many of these factors are non-modifiable, understanding them is crucial for preoperative risk assessment and patient management.

The current role of barbed sutures in fascial closure of ventral hernia repair: a multicenter study using the abdominal core health quality collaborative database

BACKGROUND

Barbed sutures (BS) have been increasingly used in the last two decades across surgical disciplines but little is known about how widespread their adoption has been in ventral hernia repair (VHR). The aim of this study was to document the use of barbed sutures in VHR in a multicenter database with associated clinical and patient-reported outcomes.

METHOD

Prospectively collected data from the Abdominal Core Health Quality Collaborative database was retrospectively reviewed, including all adult patients who underwent VHR with fascial closure from 2020 to 2022. A univariate analysis compared patients with BS against non-barbed sutures (NBS) across the preoperative, intraoperative, and postoperative timeframes including patient-reported outcomes concerning quality of life and pain scores.

RESULTS

A total of 4054 patients that underwent ventral hernia repair with BS were compared with 6473 patients with non-barbed sutures (NBS). Overall, BS were used in 86.2% of minimally invasive ventral hernia repairs and about 92.2% of robotic surgery compared to only 9.6% of open procedures. Notable differences existed in patient selection, including a higher BMI (32 vs 30.5; p < 0.001), more incisional hernias (63.3% vs 51.1%; p < 0.001), wider hernias (4 cm vs 3 cm; p < 0.001), and higher ASA score (p < 0.001) in patients with BS. Outcomes in patients with BS included a shorter length of stay (mean days; 1.4 vs 2.4; p < 0.001), less SSI (1.5% vs 3.6%; p < 0.001), while having similar SSO (7.6% vs 7.3%; p = 0.657), readmission (3.0 vs 3.2; p = 0.691), and reoperation (1.5% vs 1.45%; p = 0.855), at a longer operative time (p < 0.001). Hernia-specific questionnaires for quality of life (HerQLes) and pain in patients with BS had a worse preoperative score that was later matched and favorable compared to NBS (p = 0.048). PRO concerning hernia recurrence suggest around 10% at two years of follow-up (p = 0.532).

CONCLUSION

Use of barbed sutures in VHR is widespread and highly related to MIS. Outcomes from this multicenter database cannot be reported as superior but suggest that barbed sutures do not have a negative impact on outcomes.

A nomogram prediction model for postoperative seroma/hematoma in elderly subjects after TAPP

BACKGROUND

Formation of seroma/hematoma is one of the most common postoperative complications following laparoscopic inguinal hernia repair. This study aimed to identify risk factors associated with seroma/hematoma and construct a prediction model.

METHODS

Elderly subjects undergoing laparoscopic Transabdominal preperitoneal Patch Plasty (TAPP) were included in this study. The observation endpoint was set as the occurrence of seroma/hematoma within 3 months after TAPP surgery. Independent risk factors were identified through preliminary univariate screening and binary logistic regression analysis. These risk factors were then used to construct a nomogram predictive model using R software.

RESULTS

A total of 330 patients were included in the analysis, of which 51 developed seroma/hematoma, resulting in an incidence rate of 15.5%. Obesity (OR: 3.54, 95%CI: 1.45-8.66, P = 0.006), antithrombotic drug use (OR: 2.73, 95%CI: 1.06-7.03, P = 0.037), C-reactive protein (CRP) ≥ 8 (OR: 2.72, 95%CI: 1.04-7.10, P = 0.041, albumin/fibrinogen ratio (AFR) < 7.85 (OR: 2.99, 95%CI: 1.28-7.00, P = 0.012), and lymphocyte/monocyte ratio (LMR) < 4.05 (OR: 12.62, 95%CI: 5.69-28.01, P < 0.001) were five independent risk factors for seroma/hematoma. The nomogram model has well predictive value for seroma/hematoma, with an AUC of 0.879.

CONCLUSIONS

The nomogram model based on obesity, antithrombotic drug, CRP, AFR, and LMR has a proved good predictive value and it has potential in clinical practice.

Primary abandonment of the sac in the management of scrotal hernias: a dual-institution experience of short-term outcomes

PURPOSE

Management of scrotal hernias presents as a common challenge, with operative interventions to address these hernias associated with higher rates of morbidity compared to those of less-complex pathology. Surgeons have advocated for the use of techniques such as primary abandonment of the distal sac as a potential means to reduce complications for operative intervention, with preliminary findings demonstrating feasibility. We sought to assess outcomes related to primary sac abandonment among patients undergoing minimally invasive (MIS) repair of scrotal hernias.

METHODS

A review of prospectively maintained databases among two academic hernia centers was conducted to identify patients who underwent MIS inguinal hernia repairs with primary sac abandonment. Patient demographics, hernia risk factors, intraoperative factors, and postoperative outcomes were evaluated. Short-term outcomes related to patient-reported experiences and surgical-site occurrences requiring procedural intervention were queried.

RESULTS

Sixty-seven male patients [median age: 51.6 years; interquartile range (IQR): 45-65 years] underwent inguinal hernia repair with primary sac abandonment. Anatomic polypropylene mesh was used in 98.5% cases. Rates of postoperative complications were low and included postoperative urinary retention (6%), clinically identified or patient-reported seromas/hematomas within a 30-day follow-up period (23.9%), deep venous thrombosis (1.5%), and pelvic hematoma (1.5%). No seromas or hematomas necessitated procedural interventions, with resolution of symptoms within three months of their operation date.

CONCLUSION

We report a multi-center experience of patients managed with primary abandonment of the sac technique during repair of inguinoscrotal hernias. Utilization of this technique appears to be safe and reproducible with a low burden of short-term complications.

Endo-laparoscopic scrotal hernia surgery: which technique must we choose to reduce seroma-sac transection or complete sac reduction? A prospective study

Seroma formation is one of the important postoperative problems in inguinal hernia surgery, especially after scrotal hernia surgery. The present study aimed to present primarily the incidence of seroma after reduction and transection of the hernia sac in endo-laparoscopic scrotal hernia repair, and secondarily the results of early postoperative complications. Patients were divided into two groups TAPP and TEP. These groups were also divided into transection and reduction subgroups. In the reduction group, the hernia sac was completely dissected and pulled to the peritoneal area, while in the transection group, the neck of the hernia sac was cut by ligating, and its distal part was fixed to the posterior abdominal wall. The groups were compared, and data were analyzed. The reduction was performed in 13 (43.33%) of the 30 patients included in the study, and transection in 17 (56.67%). Seroma developed in 2 (15.38%) of the reduction group and 7 (41.18%) of the transection group. There was no statistical difference between the groups (p = 0.229). Cord and testicular complications were seen in 6 (20%) patients, 5 (38.46%) in the reduction group, and 1 (5.88%) in the transection group. No statistical difference was detected between the groups (p = 0.061). Although not statistically significant, seroma was more common in transection, while cord and testicular complications were more common in reduction. If dissection of the hernia sac is difficult, the complete reduction should not be insisted on, and the neck of the sac should be transection by ligating, and its distal part should be fixed to the posterior abdominal wall.

The Relationship Between Small Peritoneal Flap Defects and Postoperative Seroma in TAPP Repair of Inguinal Hernias

OBJECTIVE

Total abdominal preperitoneal (TAPP) is one of the most frequently used surgical treatment methods in the treatment of inguinal hernia (IH). One of the most common early postoperative complications after hernia repair is seroma/hematoma. In this study, we aimed to study the role of unclosed peritoneal flap defects on the development of postoperative seroma.

MATERIAL AND METHODS

The study was performed retrospectively in 2 university hospitals. All patients over the age of 18 years who underwent laparoscopic TAPP surgery in Istanbul Yeni Yüzyıl University Gaziosmanpaşa Hospital General Surgery Clinic and Van Yüzüncü Yıl University Faculty of Medicine General Surgery Clinic between January 1, 2018, and December 31, 2021, were included. Patients were divided into those with peritoneal defects (group 1) and those without (group 2). Whether there was a peritoneal defect or not was compiled from video recordings. In addition, risk factors affecting the development of seroma were determined.

RESULTS

A total of 250 patients, 16 (6.4%) women and 234 (93.6%) men, were included in the study. There were bilateral hernias in 35 (14%) patients, and a total of 320 hernias were analyzed in the study. It was determined that an American Society of Anaesthesiologists (ASA) III score increased the risk of seroma 15.97 fold (P<0.001, 95% CI, 4.94 to 51.56), direct hernia type increased risk 7.1 fold (P<0.03, 95% CI, 1.204 to 42.422), hernia descending into scrotum increased risk 22.48 fold (P<0.001, 95% CI, 6.66 to 75.84) and closure of the peritoneal flap completely without leaving any defect increased the risk of seroma 8.67 fold (P<0.001, 95% CI, 3.254 to 23.115).

CONCLUSIONS

The presence or leaving of small-diameter defects on the peritoneal flap may reduce seroma development without increasing the risk of complications. Prospective randomized studies are required to reach definitive conclusions.

Transabdominal preperitoneal versus hybrid procedures for treating irreducible inguinal hernias: A retrospective controlled study

BACKGROUND

Inguinal hernia is a common condition; however, irreducible inguinal hernias are rare. In this retrospective study, two laparoscopic procedures for irreducible inguinal hernia were compared.

MATERIALS AND METHODS

The study cohort comprised 88 patients who had undergone laparoscopic repair of primary irreducible inguinal hernias between 1 June 2011 and 31 December 2019. The patients were retrospectively divided into Hybrid (Group H) and Standard Transabdominal Preperitoneal (TAPP) Groups (Group S). Patient characteristics, hernia details, and intraoperative and postoperative complications were compared between study groups.

RESULTS

There were no significant differences between the two groups in baseline characteristics, including age, sex, body mass index, hernia type, operation time, hospital stay, cost, and duration of follow-up. No recurrence or surgical site infection occurred in either group. There were no significant differences between the two groups in incidence of spermatic vessel injury (0% vs. 2.04%, P = 0.370), vas deferens injury (0% vs. 6.12%, P = 0.116), epigastric vessels injury (0% vs. 4.08%, P = 0.202), scrotal hematoma (7.69% vs. 2.04%, P = 0.206), dysuria (5.13% vs. 8.16%, P = 0.575), fever (17.95% vs. 16.32%, P = 0.841), seroma (25.64% vs. 32.65%, P = 0.474), chronic pain (0% vs. 2.04%, P = 0.370), sensation of a foreign body (2.56% vs. 2.04%, P = 0.870), or pain on ejaculation (0% vs. 2.04%, P = 0.370). The incidence of acute pain was higher in Group H than in Group S (43.59% vs. 8.16%, P = 0.000).

CONCLUSION

The hybrid TAPP procedure is a safe and feasible means of treating irreducible inguinal hernias. Though it is associated with a higher incidence of postoperative acute pain than the standard TAPP procedure, it may have advantages in avoiding injuries to the vas deferens and spermatic vessels.

Assessment of Surgical and Quality-of-Life Outcomes Between Laparoscopic Versus Open Inguinal Hernia Repair in Geriatric Patients

Introduction: Inguinal hernia repair is a common surgery, especially in the elderly population. However, the decision to perform surgery in elderly patients can be challenging due to higher complication rates. Laparoscopic inguinal hernia surgery is less commonly used in the elderly population despite its advantages. In this study, we aimed to investigate the safety and advantages of laparoscopic inguinal hernia surgery in elderly patients. Methods: We retrospectively compared the preoperative and postoperative (PO) data and Short Form-36 (SF-36) forms of elderly patients who underwent laparoscopic transabdominal preperitoneal and open inguinal hernia surgery. The primary outcomes were PO pain scores and complication rates. Results: A total of 79 patients with an age range between 65 and 86 years, who presented with inguinal hernias to Cekirge State Hospital's General Surgery Department between January 2017 and November 2019, were included. Seventy-nine patients underwent laparoscopic transabdominal preperitoneal technique and Lichtenstein hernia repair. The laparoscopic group had a lower rate of PO complications and less analgesic medication consumption and usage time compared with the open group. Furthermore, compared with the open group, the laparoscopic group had lower PO pain scores and higher SF-36 scores for physical function, physical role, pain, and general health at the 30th and 90th days after surgery. Conclusion: Our study suggests that laparoscopic inguinal hernia surgery can be safely performed in elderly patients with lower complication rates and faster recovery times compared with open surgery. The advantages of laparoscopic surgery, such as lower PO pain scores and faster recovery times, were also observed in elderly patients.

A systematic review and meta-analysis of hernia sac management in laparoscopic groin hernia mesh repair: reduction or transection?

BACKGROUND

There is no consensus regarding hernia sac management during laparoscopic hernia repair, and this systematic review and meta-analysis aimed to compare the postoperative outcomes of sac reduction (RS) and sac transection (TS) during laparoscopic mesh hernia repair.

METHODS

We conducted a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) 2020 and AMSTAR 2 (Assessing the Methodological Quality of Systematic Reviews) guidelines. We used the RevMan 5.4 statistical package from the Cochrane collaboration for meta-analysis. A random effects model was used.

RESULTS

The literature search yielded six eligible studies including 2941 patients: 821 patients in the TS group and 2120 patients in the RS group. In the pooled analysis, the TS group was associated with a lower incidence of seroma (OR = 1.71; 95% CI [1.22, 2.39], p = 0.002) and shorter hospital stay (MD = -0.07; 95% CI [-0.12, -0.02], p = 0.008). There was no significant difference between the two groups in terms of morbidity (OR = 0.87; 95% CI [0.34, 2.19], p = 0.76), operative time (MD = -4.39; 95% CI [-13.62, 4.84], p = 0.35), recurrence (OR = 2.70; 95% CI [0.50, 14.50], p = 0.25), and Postoperative pain.

CONCLUSIONS

This meta-analysis showed that hernia sac transection is associated with a lower seroma rate and shorter hospital stay with similar morbidity, operative time, recurrence, and postoperative pain compared to the reduction of the hernia sac.

PROTOCOL

The protocol was registered in PROSPERO with ID CRD42023391730.

Fascia defect closure versus non-closure in minimal invasive direct inguinal hernia mesh repair: a systematic review and meta-analysis of real-world evidence

PURPOSE

Laparoscopic and robotic inguinal hernia mesh repair are both common surgical procedures worldwide. Postoperative hernia recurrence and seroma formation are important concerns. In ventral hernia, primary defect closure in laparoscopic surgery reduces the recurrence rate. However, there is no synthetic evidence of direct inguinal hernia defect closure versus non-closure in minimal invasive surgery. Therefore, this study investigated the efficacy of defect closure in patients undergoing minimal invasive direct inguinal hernia mesh repair.

METHODS

Eligible studies were identified through a search of PubMed, Embase, Cochrane Library, and CINAHL from their inception until March 2022. Studies examining defect closure in laparoscopic direct inguinal hernia repair were included, and a meta-analysis was performed using the random-effect model. Sensitivity analyses were performed by removing one study at a time. The primary outcomes were hernia recurrence and seroma formation. Acute and chronic postoperative pain, operation time, and length of hospital stay were the secondary outcomes.

RESULTS

Five nonrandomized studies and one randomized controlled trial were included. Pooled analysis revealed defect closure might reduce the hernia recurrence rate (risk difference, - 0.02; 95% confidence interval [CI] - 0.04 to - 0.00; p = 0.02). The result of seroma formation (odds ratio, 0.49; 95% CI 0.17-1.46; p = 0.20) showed no significant difference. Moreover, no significant differences were observed in acute postoperative pain, chronic pain, length of hospital stay, and operation time.

CONCLUSIONS

Our study indicated defect closure seems to be an option to reduce the direct inguinal hernia recurrence rate. No significant benefits were shown in seroma formation and other secondary outcomes. Our study was mostly based on nonrandomized studies and underestimated the effect of defect closure; thus, further high-quality studies are required to draw definitive conclusions.

Laparoscopic total extraperitoneal (TEP) inguinal hernia repair with preperitoneal closed-suction drainage reduced postoperative complications

BACKGROUND

Although laparoscopic total extraperitoneal (TEP) inguinal hernia repair has the advantages of less bleeding, less trauma, less pain, and fast recovery, there are several issues that need to be addressed. This study aims to evaluate the effectiveness of preperitoneal closed‑suction drainage on reducing postoperative complications in TEP inguinal hernia repair.

METHODS

A retrospective analysis of 122 patients who underwent TEP inguinal hernia repair between June 2018 and June 2021 was performed. The patients were divided into the drainage group and the non-drainage group according to whether the drainage tube was placed or not. Clinical data, surgical procedures and outcome of these patients were collected and analyzed to assess the effectiveness of drainage.

RESULTS

A total of 122 patients undergoing TEP surgery were screened, of which 22 were excluded. Most of the patients were male with right indirect inguinal hernia. There was no difference in the mean length of hospital stay between the two groups. Postoperative pain was alleviated by preperitoneal closed‑suction drainage 24 h after operation (p = 0.03). The rate of complications such as scrotal edema, seroma and urinary retention in the drainage group was significantly lower than that in the non-drainage group (p < 0.05). Multivariate regression analysis showed that drainage was beneficial to reduce postoperative complications (OR, 0.015; 95% CI, 0.002-0.140; p < 0.01). In addition, it was worth noting that in subgroup analysis, patients with hernia sac volume > 10 cm³ might receive more clinical benefits by placing drainage tube.

CONCLUSION

In TEP inguinal hernia repair, placing drainage tube is a simple and feasible traditional surgical treatment, which can promote postoperative recovery without increasing the risk of infection, especially in patients with large hernia sac volume.

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

Background

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.

Patients and Methods

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.

Results

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 30^th 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.

Conclusion

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.

Seroma-prevention strategies in minimally invasive inguinal hernia repair

BACKGROUND:

The rise of minimally invasive inguinal hernia repair has seen both the laparoscopic and robotic approaches increase in popularity in recent years. Despite this, seroma formation remains a common complication, and the aim of this study is to evaluate the current evidence on seroma-prevention strategies in minimally invasive inguinal hernia repair.

MATERIALS AND METHODS:

Four databases (PubMed, Scopus, Embase, and Cochrane Library) were searched from inception to November 15, 2021. All studies describing the use of intraoperative adjuncts to reduce postoperative seroma formation in patients undergoing laparoscopic or robotic inguinal and inguinoscrotal hernia repair were included. Meta-analyses were performed using Review Manager (Version 5.4).

RESULTS:

2,382 articles were identified in the initial database search, and 40 articles were included in the final analysis. In this analysis, there was a significantly lower incidence of seroma formation in the drain group when compared to the no-drain group (P < 0.00001). Other strategies aimed at reducing the dead space involving the transversalis fascia (TF) and hernia sac such as TF inversion with tacking, Endoloop closure of TF, barbed suture closure of TF, distal sac fixation, and complete dissection of the sac have shown promising results as well.

CONCLUSIONS:

While there is currently insufficient evidence to recommend the routine use of any one of the interventions analyzed, the use of drains, the management of the TF, and the hernia sac have showed potential in reducing seroma formation.

Evaluation and Comparison on the Results of Totally Extraperitoneal Laparoscopic Surgery under General and Spinal Anesthesia for Inguinal Hernia

Background

Totally extraperitoneal (TEP) hernia repair surgery is one of the recently considered hernioplasty methods. Here, in the current study, we aimed to compare the results of TEP hernia repair surgery in the two groups of general anesthesia and spinal anesthesia.

Materials and Methods

This is a randomized clinical trial that was performed in 2018-2019 in Isfahan on 106 patients undergoing TEP inguinal hernia repair. Patients were randomly divided into two groups. The first group underwent TEP inguinal hernia repair surgery under general anesthesia and the second group of patients underwent TEP inguinal hernia repair surgery under spinal anesthesia. Data regarding surgery duration, intensive care unit admission, pain of patients, mean of analgesic injections after the surgery, and complications such as urine retention, seroma, and hematoma, and wound infection were collected. Data were compared between two groups.

Results

We found significantly higher duration of surgery in the spinal anesthesia group (P = 0.02). Patients in the spinal anesthesia group had shorter duration of nutrition regime beginning (P = 0.002) and lower frequencies of urine retention (P = 0.001). Further analysis showed that the mean pain severity was significantly lower in spinal anesthesia group compared to general anesthesia during postoperation measurements (P = 0.001) and patients in spinal anesthesia group received less postoperation analgesics compared to the other group (P = 0.001).

Conclusion

TEP surgery under spinal anesthesia was associated with better clinical results such as lower postoperative pain and analgesics injections compared to general anesthesia.

Effects of intraoperative fixation of residual hernia sac on postoperative seroma in laparoscopic transabdominal preperitoneal inguinal hernia repair: a prospective randomized controlled trial

The study was aimed to evaluate a prospective randomized controlled trial (RCT) In laparoscopic transabdominal preperitoneal inguinal hernia repair (TAPP), whether fixation of the residual sac after transecting the hernia sac can reduce the severity of postoperative seroma. A total of 252 male patients with a primary unilateral indirect inguinal hernia who underwent TAPP from September 2018 to November 2022 were recruited. Patients were randomized to the control group (CG)and the experimental group (EG). In the experimental group, after the hernia sac was transected, the residual sac was fixed to the lower edge of the rectus abdominis, while it was left in the preperitoneal space in the control group. Close follow-up was arranged to observe the incidence of seroma and other postoperative complications. All 214 patients were discharged successfully. 106 patients were randomly assigned to the control group, and 108 patients were assigned to the experimental group. There was no significant difference in the incidence of postoperative fluid extraction between the experimental group and the control group (11.1% VS.10.4%, p = 0.862), but the patients with seroma after the operation had fewer repeated extraction (0% VS. 45.5%, P = 0.033). The incidences of other postoperative complications were comparable in the two groups. In the treatment of indirect inguinal hernia with TAPP, after transecting the hernia sac, suturing and fixing the residual sac to the inferior edge of the rectus abdominis can reduce the incidence of repeated aspiration.

Does closure of the direct hernia defect in laparoscopic inguinal herniotomy reduce the risk of recurrence and seroma formation?: a systematic review and meta-analysis

PURPOSE

Recurrence is a known complication to inguinal herniotomy with an incidence of 10 to 15 percent (Hernia Surge Group in Hernia 22:165, 2018). Previous studies have shown that direct hernia or large defects are risk factors for postoperative seroma formation (Morito et al. in Surg Endosc https://doi.org/10.1007/s00464-021-08814-2 , 2021). These types of defects are often closed during open herniotomy (Rosenberg et al. in Dan Med Bull 58: C4243, 2011). This is not routine during laparoscopic surgery. A recent study has indicated that closure of the medial defect during laparoscopy may reduce recurrence and seroma formation. As a result, we performed the present systematic review to evaluate the efficacy of this add on to the standard procedure.

METHODS

An extensive search was carried out in PubMed and Embase. All studies involving adults undergoing laparoscopic direct hernioplasty were enrolled and screened with predefined inclusion criteria, to be part of a systematic review with data synthesis and meta-analysis.

RESULTS

The search identified 108 publications of which four met the inclusion criteria. Two studies (Ng et al. in Hernia 24:1093-1098, 2020; Usmani et al. in Hernia 24:167-171, 2020) showed reduced risk of recurrence. The remaining studies (Zhu et al. in Surg Laparosc Endosc Percutan Tech 29:18-21, 2019; Li and Zhang in Surg Endosc 32:1082-1086, 2018) reported no recurrence in any of the patients included. Two articles (Usmani et al. in Hernia 24:167-171, 2020; Zhu et al. in Surg Laparosc Endosc Percutan Tech 29:18-21, 2019) showed a decrease in risk of postoperative seroma, one showed a significant increase (Ng et al. in Hernia 24:1093-1098, 2020). None of the included studies showed an increase in the risk of postoperative pain or postoperative complications.

CONCLUSION

This review suggests that closure versus non-closure of the medial hernia defect in laparoscopic inguinal hernioplasty reduces the risk of recurrence and seroma formation without an increase in postoperative pain or complications. Further randomized controlled trials are needed for further evaluation.

Curative effect of different drainage methods on laparoscopic inguinal hernia repair: A meta-analysis

BACKGROUND

Laparoscopic inguinal hernia repair has developed rapidly as an important surgical method for inguinal hernia repair; however, postoperative complications, especially postoperative seroma, are becoming an important factor hindering its development. Many studies have shown that placing a negative-pressure drainage tube in the preperitoneal space can effectively reduce postoperative seromas. Accordingly, this study aimed to compare differences in postoperative seroma between surgical procedures with drainage tubes (DRG) and those without drainage tubes (nonDRG).

METHODS

PubMed/Medline, EMBASE, Cochrane Library, China National Knowledge Infrastructure, and Wanfang databases were searched from the establishment of the database to May 1, 2021. Odds ratio (OR), mean difference (MD), standardized mean difference (SMD), and 95% confidence interval (CI) were selected as the effect scale indices for the evaluation of the difference in seroma, operation time, hospital stay time, blood loss, and recovery time. All of these were compared using RevMan 5.3 Software.

RESULTS

Sixteen studies involving 4369 patients, 2856 in the DRG group and 1513 in the nonDRG group, were included. The incidence of seroma in the DRG group was lower than that in the nonDRG group (OR = 0.16, 95% CI: 0.07-0.35, P < .001). Additionally, the operation time (min) in the DRG group was longer than that in the nonDRG group (MD = 3.67, 95% CI: 2.18-5.17, P < .001). Nevertheless, no significant differences were found in hospital stay (days) (SMD = 0.22, 95% CI: -0.10-0.54, P = .17), blood loss (mL) (MD = 0.28, 95% CI: -0.14-0.69, P = .19), and recovery time (h) (SMD = 0.54, 95% CI: -0.60-1.69, P = .35) between the 2 groups.

CONCLUSION

Despite the slightly prolonged operation time, negative pressure drainage in the preperitoneal space during laparoscopic inguinal hernia repair can significantly reduce the occurrence of postoperative seroma without increasing blood loss, recovery, and hospital stay.

Zig Maneuver in Total Extraperitoneal Inguinal Hernia Repair

BACKGROUND

The difficulties in the hernia sac dissection in repairing large inguinal hernias with the endoscopic total extraperitoneal (TEP) technique prolong the operation and increase the risk of injury. This study investigates the effectiveness of the Zig maneuver (ligation of the hernia sac at the deep inguinal ring) in TEP in male patients with L3 inguinal hernia by European Hernia Society classification.

MATERIALS AND METHODS

A total of 224 male patients with L3 inguinal hernia who underwent laparoscopic TEP surgery in 2018 and 2019 were retrospectively screened and included in the study. The patients were divided into 2 groups as Zig group (n=99) and the non-Zig group (n=125), depending on whether the Zig maneuver was performed during TEP application.

RESULTS

The mean patient age was 45.49 for the non-Zig group and 47.12 for the Zig group. The median operative time was 50 minutes in the non-Zig group and 43 minutes in the Zig group (P<0.005). The median value of the postoperative first 24 hours pain score was 3 in the non-Zig group and 2 in the Zig group (P=0.033). Scrotal edema was 7.2% in the non-Zig group and 1% in the Zig group (P=0.023). According to logistic regression analysis, the Zig maneuver reduced the probability of scrotal edema by 87% in almost the entire population (odds ratio=0.130, 95% confidence interval: 0.016-1.047). There was no statistically significant difference between the groups in terms of early and late recurrence.

CONCLUSIONS

Zig maneuver shortened the operative time and significantly reduced the feeling of pain in the first 24 hours postoperatively in male patients with indirect L3 hernia who underwent endoscopic TEP. It also significantly reduced the likelihood of scrotal edema in almost the entire population. As a result, the Zig maneuver is an effective method that could be applied during endoscopic TEP.

Indocyanine green fluorescent lymphography during open inguinal hernia repair in a patient who developed postoperative ultrasonic hydrocele: A case report

BACKGROUND

To our knowledge, no reports of indocyanine green (ICG) fluorescent lymphography during inguinal hernia repair currently exist. We report the case of a patient who underwent ICG fluorescent lymphography during open inguinal hernia repair.

CASE PRESENTATION

A 63-year-old man was referred to our department for treatment of a right inguinal hernia, during which an ICG lymphography was performed. The patient had a history of robot-assisted radical prostatectomy for prostate cancer. Following induction of general anesthesia, 0.25 mg of ICG was injected into the right testicle and the scrotum was gently massaged, after which an open inguinal hernia repair was performed. During the operation, fluorescence from the ICG was observed in two lymphatic vessels in the spermatic cord. The ICG fluorescent vessels were resected due to the strong adhesion between the lymphatic vessels and the hernia sac. ICG leakage was observed in the resected vessels. An open tension-free technique was performed using an open mesh plug. The patient was discharged one day postoperatively. The histological diagnosis of the resected vessel was a lymphatic vessel. He had a slight postoperative hydrocele that was detected at the follow-up clinic 10 days postoperatively during ultrasonic examination (ultrasonic hydrocele).

CONCLUSION

We report the use of ICG fluorescent lymphography during open inguinal hernia repair in a patient who developed postoperative ultrasonic hydrocele. This case may indicate a relationship between lymphatic vessel injury and hydrocele.

Robotic hernia surgery I. English version : Robotic inguinal hernia repair (r‑TAPP). Video report and results of a series of 302 hernia operations

The treatment of inguinal hernias with open and minimally invasive procedures has reached a high standard in terms of outcome over the past 30 years. However, there is still need for further improvement, mainly in terms of reduction of postoperative seroma, chronic pain, and recurrence. This video article presents the endoscopic anatomy of the groin with regard to robotic transabdominal preperitoneal patch plasty (r‑TAPP) and illustrates the surgical steps of r‑TAPP with respective video sequences. The results of a cohort study of 302 consecutive hernias operated by r‑TAPP are presented and discussed in light of the added value of the robotic technique, including advantages for surgical training. r‑TAPP is the natural evolution of conventional TAPP and has the potential to become a new standard as equipment availability increases and material costs decrease. Future studies will also have to refine the multifaceted added value of r‑TAPP with new parameters.

Investigation of risk factors for postoperative seroma/hematoma after TAPP

BACKGROUND

Seroma/hematoma formation is the most common postoperative complication after laparoscopic inguinal hernia repair. The occurrence of seroma/hematoma remains unclear. The aim of this study was to determine the risk factors for seroma/hematoma formation after transabdominal preperitoneal patch plasty (TAPP).

METHODS

The study enrolled 359 groin hernia patients treated by TAPP at Kumamoto Medical Center between 2014 and 2019. The primary outcome was risk factors for postoperative seroma/hematoma formation after TAPP. The secondary outcomes included recurrence of hernia, postoperative complications, and hospital stay.

RESULTS

Among the 359 patients, the incidence rate of seroma/hematoma was 16% (n = 69 patients), and the recurrence rate was 0.3% (n = 1 patient, both sides). In total, there were 452 lesions. Japan Hernia Society (JHS) type II was present in 23% (n = 106) of the total cases but was significantly more common in the postoperative seroma/hematoma group (40%; P = 0.0082). Meanwhile, JHS type I-3 comprised 27% of the total JHS type I group but was significantly higher in the postoperative seroma/hematoma JHS type I group (40%; P = 0.016). Compared with JHS type I, the multivariable odds ratio for postoperative seroma/hematoma formation in JHS type II was 2.77 (95% CI 1.54-4.95). Compared with JHS grade 1/2, the multivariable odds ratio for postoperative seroma/hematoma formation in JHS grade 3 was 2.27 (95% CI 1.28-4.03).

CONCLUSIONS

Internal inguinal hernia and hernia size ≥ 3 cm were considered risk factors for postoperative seroma/hematoma formation after TAPP.

CHALLENGES TO THE 10 GOLDEN RULES FOR A SAFE MINIMALLY INVASIVE SURGERY (MIS) INGUINAL HERNIA REPAIR: CAN WE IMPROVE?

Background:

Since publication of our paper “Ten Golden Rules for a Safe MIS Inguinal Hernia Repair” we have received many questions. As the authors, we feel it is important to address these topics as a follow-up to our paper.

Aim:

To discuss in more details the main points of controversy, review the rules and update de recommendations.

Method:

The questions and discussions came mainly over five rules, numbered 3, 5, 6, 7, 10. We analyzed all the comments about recommendations and update some technical principles.

Results:

Rule 3 - Removing normal fat plugs from the obturator canal is unnecessary and therefore is not recommended; Rule 5 - transection of the uterine round ligament (1 cm proximal to the deep ring) facilitates adequate dissection. When performed in this way it does not appear to be associated with complications; Rule 6 - transection of huge sacs are safer than over-dissection of the cord structures. Whether dissecting completely the sac or abandon the distal part it results in less postoperative seromas is an ongoing debate; Rule 7 - any retroperitoneal structure traversing the internal ring is or play a role like a hernia. Failing to identify and remove the lipoma will ultimately result in the patient experiencing a recurrence; Rule 10 - in TAPP peritoneum should preferably be closed with suture than tackes.

Conclusion:

10 Golden Rules emphasize the most important surgical tips and technical steps that allow the safe performance of MIS repairs of inguinal hernias, regardless the technique.

Sac transection versus sac reduction during laparoscopic herniorrhaphy: A systematic review and meta-analysis

Hernia repair techniques have evolved recently; however sac handling remains a critical step. Transection of the herniated sac as opposed to total sac reduction may simplify the procedure. However, residual sac tissue may increase the risk for seroma formation. We performed a systemic review and meta-analysis to evaluate the safety and feasibility of transecting the hernia sac during laparoscopic herniorrhaphy. Relevant literature search was performed in PubMed, EMBASE, SCORPUS, and the Cochrane Library databases. Relevant studies that compared total reduction with transection of the herniated sac during laparoscopic herniorrhaphy were included. The primary outcome measure was the incidence of seromas. We also analyzed secondary outcomes including operative duration, postoperative pain scores, complications, and hernia recurrence rate. Of the 330 studies identified, four studies published between 2002 and 2020, with sample sizes ranging from 70 to 520 patients, met the inclusion criteria. Overall, 848 hernias were evaluated. We observed a high incidence of seroma formation in the sac transection group compared to that in the sac reduction group (OR 2.41; 95% CI 1.39 to 4.17, P = 0.002), but the groups did not differ significantly with respect to factor such as operative duration, postoperative complications, and pain score. Herniated sac transection during laparoscopic herniorrhaphy might be associated with a higher risk of seroma formation than that observed with sac reduction. The former approach did not show any significant benefits compared to the latter approach with respect to operative duration and postoperative complications.

[Robotic hernia surgery : Part I: Robotic inguinal hernia repair (r‑TAPP). Video report and results of a series of 302 hernia operations]

The treatment of inguinal hernias with open and minimally invasive procedures has reached a high standard in terms of outcome over the past 30 years. However, there is still need for further improvement, mainly in terms of reduction of postoperative seroma, chronic pain, and recurrence. This video article presents the endoscopic anatomy of the groin with regard to robotic transabdominal preperitoneal patch plasty (r‑TAPP) and illustrates the surgical steps of r‑TAPP with respective video sequences. The results of a cohort study of 302 consecutive hernias operated by r‑TAPP are presented and discussed in light of the added value of the robotic technique, including advantages for surgical training. r‑TAPP is the natural evolution of conventional TAPP and has the potential to become a new standard as equipment availability increases and material costs decrease. Future studies will also have to refine the multifaceted added value of r‑TAPP with new parameters.

Robotic Direct Inguinal Hernia Repair: To Plicate or Not to Plicate?

BACKGROUND

Closure of the direct inguinal defect with plication in minimally invasive direct inguinal hernia repair may have potential benefits in terms of reducing postoperative surgical site events (SSEs) and recurrences. However, these advantages remain unclear, particularly in the robotic literature. This is the first comparative study to investigate the outcomes after robotic direct inguinal hernia repair (RDIHR) with defect plication.

MATERIALS AND METHODS

Among patients who underwent RIHR between 2013 and 2020, those who underwent RDIHR were selected. Patients were then stratified into 2 groups based on defect plication status, and univariate analyses were used to compare variables across preoperative, intraoperative, and postoperative timeframes.

RESULTS

A total of 225 RDIHRs were performed in 176 patients, where 74 were assigned to the Plication (+) group and 102 patients were assigned to the Plication (-) group. There was a significantly higher proportion of females in the Plication (-) group (10.8% vs. 1.4%, P=0.015), which accounts for the higher incidence of accompanying femoral hernias in this group. While most M1 hernia defects were left patent, most M2 and M3 hernias were plicated. Larger mesh sizes were used in the Plication (+) group (P<0.001). Three SSEs were observed in the Plication (-) group versus 2 SSEs in the Plication (+) group. No significant differences in postoperative outcomes were found between the 2 groups.

CONCLUSIONS

Postoperative seroma incidence, pain scores, and recurrence rates were similar between the 2 study groups. Multicenter studies with larger populations and higher complication counts are needed to establish the role of defect plication in RDIHR.

The Management of Indirect Inguinal Hernia Sac in Laparoscopic Inguinal Hernia Repair: A Systemic Review of Literature

BACKGROUND

The aim of this study is to investigate the current management strategy of indirect hernia sac during laparoscopic inguinal hernia repair.

OBJECTIVES

The aim was to evaluate the various indirect hernia sac management strategies when performing laparoscopic inguinal hernia repair.

DATA SOURCES

Major databases (PubMed, Embase, Springer, and Cochrane Library).

REVIEW METHODS

MeSH and free-text searching include "laparoscopic inguinal hernia" "TAPP," "TEP," "inguinal hernia," "indirect inguinal hernia sac," "distal sac," "sac transection," "sac ligation," and "sac reduction."

RESULTS

The present study enrolled 7 trials, 4 studies compared the results of indirect hernia sac transection and complete sac reduction. The pooled results indicated that indirect hernia sac transection was associated increased seroma formation (odds ratio=2.74, 95% confidence interval: 1.41-4.31), and there was no statistical difference in the incidence of postoperative pain, operative time, hernia recurrence, and time to return to normal activity between the sac transection and sac reduction groups. Two studies reported the application of adjuncts in the management of distal sac during laparoscopic large inguinoscrotal hernia repair. The seroma formation could be reduced by adjuncts of fixing the distal hernia sac to posterior abdominal wall with either suture or tacks.

CONCLUSION

Indirect sac transection during laparoscopic indirect inguinal hernia repair is associated with a higher incidence of postoperative seroma. Additional adjuncts to the divided distal hernia sac, including distal sac fixation with either suture or tacks, are effective methods to prevent postoperative seroma.

A randomised controlled study on the effects of hernial sac stump fenestration on ultrasound seroma prevention in laparoscopic Type III inguinal hernia repair

Background

The incidence of ultrasound seromas has significantly increased after large hernial sac surgery. Several methods are available for preventing ultrasound seromas, but the clinical results are poor. It has also been demonstrated that hernial sac stump fenestration during laparoscopic incisional hernia repair surgery can significantly decrease the incidence of ultrasound seromas.

Materials and Methods

Ninety patients aged 18-75 years who were treated in our hospital for primary Type III indirect inguinal hernia from March 2017 to March 2018 were randomised to a preventive fenestration group and a control group. All patients underwent transabdominal preperitoneal repair. The number of ultrasound seromas in the inguinal regions and ultrasound seroma volume on day 6 and months 1 and 3 after surgery in the two groups were compared. The secondary outcomes included length of surgery, urinary retention, acute pain, chronic pain, length of hospitalisation, recurrence rate and other complications.

Results

There were no significant differences in demographic characteristics. Ultrasound seroma incidence and ultrasound seroma volume on day 6 and months 1 and 3 after surgery were significantly lower in the preventive fenestration group than that in the control group. There were no significant differences in the length of hospitalisation or incidence of acute pain or urinary retention between the two groups.

Conclusions

Hernial sac stump fenestration after hernial sac transection in inguinal hernia repair surgery is a simple method that can effectively reduce post-operative ultrasound seromas.

PRIMARY ABANDON-OF-THE-SAC (PAS) TECHNIQUE: PRELIMINARY RESULTS OF A NOVEL MINIMALLY INVASIVE APPROACH FOR INGUINOSCROTAL HERNIA REPAIR

BACKGROUND

Laparoscopic best approach of repairing inguinoscrotal hernias are still debatable. Incorrect handling of the distal sac can possibly result in damage to cord structures and negative postoperative outcomes as ischemic orquitis or inguinal neuralgia.

AIM

To describe a new technique for a minimally invasive approach to inguinoscrotal hernias and to analyze the preliminary results of patients undergoing the procedure.

METHODS

A review of a prospectively maintained database was conducted in patients who underwent minimally invasive repair using the "primary abandon-of-the-sac" (PAS) technique for inguinoscrotal hernias. Patient´s demographics, as well as intraoperative variables and postoperative outcomes were also analyzed.

RESULTS

Twenty-six male were submitted to this modified procedure. Mean age of the case series was 53.8 years (range 34-77) and body mass index was 26.8 kg/m2 (range 20.8-34.2). There were no intraoperative complications or conversion. Average length of stay was one day. No surgical site infections, pseudo hydrocele or neuralgia were reported after the procedure and two patients presented seroma. No inguinal hernia recurrence was verified during the mean 21.4 months of follow up.

CONCLUSION

The described technique is safe, feasible and reproducible, with good postoperative results.

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

BACKGROUND

Seroma is a common and inevitable postoperative complication in transabdominal preperitoneal (TAPP) hernia repair, especially in patients with large inguinoscrotal hernias. However, studies have rarely reported drainage in TAPP for large inguinoscrotal hernias.

METHODS

Sixty-five patients with 78 large indirect inguinoscrotal hernias who underwent TAPP procedure with drainage between September 2016 and December 2019 were enrolled in this study. 181 patients with Type Ⅲ indirect inguinal hernias (European Hernia Society (EHS) classification, hernia defect >3 cm) who underwent TAPP without drainage (no-drainage group) between January 2019 and December 2019 were included for a comparison. In the drainage group, a 12-Fr drainage tube was inserted into the distal hernia sac via the preperitoneal space to decrease the incidence of seroma.

RESULTS

There was no conversion to open procedures in all the patients. The operative time (56.5 ± 8.4 VS 54.8 ± 9.6 min, unilateral; 95.8 ± 10.4 VS 92.1 ± 13.9 min, bilateral), blood loss (5.9 ± 1.9 VS 5.6 ± 1.7 mL), visual analogue scale score on postoperative day 1 (2.3 ± 0.5 VS 2.2 ± 0.5) and postoperative hospital stay (1.1 ± 0.3 VS 1.0 ± 0.2 days) in the drainage group were equivalent to those in the no-drainage group (p > 0.05). The mean length of drainage was 5.2 ± 1.3 days. The drainage group had a significantly lower incidence of seroma than the no-drainage group (1.5% VS 9.4%, p = 0.037). The postoperative complications including haematoma, recurrence and chronic pain were comparable in the two groups.

CONCLUSION

Drainage with appropriate duration is a feasible, safe and effective measure to decrease the incidence of seroma in TAPP for patients with large inguinoscrotal hernias.

Suture and Fixation of the Transversalis Fascia during Robotic-Assisted Transabdominal Preperitoneal Hernia Repair to Prevent Seroma Formation after Direct Inguinal Hernia Repair

Background. Seroma formation after videoendoscopic repair of inguinal hernias, known as "pseudorecurrence", may vary from an asymptomatic, self-limiting occurrence to a painful, chronic problem. The aim of this study was to investigate the incidence of postoperative seroma in robotic-assisted transabdominal preperitoneal hernia repair (R-TAPP), modified by suturing and fixating the transversalis fascia to the Cooper ligament. Methods. The study was approved by the local ethics committee (2019-01132 CE-3495). Patients undergoing R-TAPP for direct inguinal hernia from October 2017 to December 2019 were included. In all patients, a barbed running suture of the transversalis fascia was performed to close the cavity resulting from the direct hernia reduction and to fix it to the Cooper ligament, then a lightweight mesh was placed. Demographic and clinical data were collected and analysed. Results. Over the study period, 67 R-TAPP in 51 patients were identified. All patients were male, with a mean age of 63.1 ± 12.7 years. There was 1 case of conversion to open surgery due to adhesions of the caecum to the groin as a result of perforated appendicitis. The mean length of the hospital stay was 1.8 ± .6 days. After discharge, no cases of seroma or recurrence at 30 days nor chronic pain at a mean follow-up of 10.3 ± 6.8 months was detected. Conclusions. In the treatment of direct inguinal hernia with R-TAPP, suturing and anchoring the transversalis fascia to the Cooper ligament are safe, feasible and recommendable in order to prevent postoperative seromas.

Does primary closure of direct inguinal hernia defect during laparoscopic mesh repair reduce the risk of early recurrence?

PURPOSE

Hernia recurrence is an important complication following inguinal hernia repair. Primary closure of ventral hernia defects laparoscopically has been shown to reduce the risk of recurrence and seroma formation. The results for ventral hernias may potentially be applied to direct inguinal hernias. Our aim was to evaluate the value of primary closure of direct defects during laparoscopic inguinal hernia mesh repair in reducing the incidence of early recurrence.

METHODS

A retrospective, single-center cohort study was conducted on cases performed from August 2016 to February 2018. Patients with direct inguinal hernias undergoing elective laparoscopic mesh repair were included. When performed, the direct hernia defect was primarily closed with extracorporeal non-absorbable interrupted sutures followed by standard placement of a lightweight mesh covering myopectineal orifices. Early recurrence was defined as occurring within 1 year of surgery.

RESULTS

A total of 75 direct inguinal hernias in 53 patients who underwent surgery and completed at least 1 year of follow-up were analyzed. The mean age of patients was 63 years (range 44-82 years); with majority of patients being male (98.1%). There were no significant differences observed between the two patient populations in terms of demographics, mean operative time and risk factors. In 9 (16.9%) patients, the direct hernias were recurrent hernias and all underwent open mesh repair during the index hernia surgery. The majority of hernia repairs (63 hernias in 45 patients, 85%) were performed via the totally extraperitoneal (TEP) approach. 19 patients (35.8%) with 28 direct inguinal hernias underwent primary closure of the direct defect prior to mesh placement; while, 34 patients (64.2%) with 47 direct hernias did not undergo primary closure. There were 3 direct hernia recurrences (6.4%) at 1 year post-operatively, and all occurred in the non-closure group. In comparison, there were no recurrences in the closure group; however, this difference was not statistically significant (p = 0.289) in our study due to the small sample size.

CONCLUSION

Closure of direct inguinal hernia defects during laparoscopic mesh repair has been shown to reduce the incidence of early hernia recurrence in our retrospective study but future randomized controlled trials with large numbers would enable us to draw more robust conclusions and perhaps change the way we perform laparoscopic inguinal hernia repair.

Appropriate mesh size in the totally extraperitoneal repair of groin hernias based on the intraoperative measurement of the myopectineal orifice

BACKGROUND

Insufficient coverage of the area of a possible groin hernia is an important risk factor in hernia recurrence. To prevent recurrence, it is important to use the appropriate mesh size based on the size of the myopectineal orifice (MPO), which is the weak area of the abdominal wall where inguinal hernias occur. We aimed to estimate the appropriate mesh size for groin hernias by investigating MPO size.

METHODS

Four hundred and six patients underwent groin hernia repair using a totally extraperitoneal (TEP) approach at the Zeze Hospital between July 2009 and December 2017. We investigated patients' backgrounds, MPO components dimensions, and hernia recurrence, and evaluated the appropriate mesh size.

RESULTS

The 359 male and 47 female patients had an average age of 63 ± 15 years. In 171, 147, and 88 cases, hernias were localized to the right, left, and bilaterally, respectively. The number of lateral, medial, femoral, and combined hernias was 317, 124, 11, and 42, respectively. The 95th percentile for the horizontal and vertical lengths in cases of hernia orifice ≥ 3 cm were 9.6 cm and 7.0 cm, respectively, while it was 9.2 cm and 6.4 cm in cases of hernia orifice < 3 cm. We added 2 cm and 3 cm to the 95th percentile for the length and width of the MPO, resulting in 13.2 × 10.4 cm and 15.6 × 13.0 cm in cases with hernia orifice < 3 cm and ≥ 3 cm, respectively. Relapse after TEP occurred in 1 patient (0.2%).

CONCLUSION

The appropriate mesh size for TEP repair, derived from intraoperative MPO measurements, was estimated as 13.2 × 10.4 cm and 15.6 × 13.0 cm when the hernia orifice was < 3 cm and ≥ 3 cm, respectively. Using appropriate mesh sizes based on MPO measurement may reduce groin hernia recurrence after TEP.

Effect of direct defect closure during laparoscopic inguinal hernia repair ("TEP/TAPP plus" technique) on post-operative outcomes

PURPOSE

Seroma formation and recurrence in large inguinal hernia still remain an important clinical complication despite decades since the advent of mesh repair.

METHODS

In our prospective comparative analysis, we want to evaluate the effect of direct hernia defect closure on surgical outcomes in patients undergoing laparoscopic inguinal hernia repair in two tertiary care institutions in Singapore. The direct hernia defects were closed with non-absorbable sutures incorporating the pseudosac.

RESULTS

A group of 241 patients underwent laparoscopic inguinal hernia mesh repair for a total of 378 direct defects from April 2014 to July 2018. Of these patients, 98 (40.6%) patients underwent hernia repair without closure of their direct defect while 143 (59.4%) patients underwent direct defect closure. No significant differences were observed between the two patient populations' demographic information and the mean operative time. A total of 219 direct defects were closed and 159 direct defects were not repaired. Compared to the group that did not undergo direct defect closure, the group that had closure of the direct defects demonstrated a statistically significant reduction in recurrence (4.4% versus 0.9%, p = 0.036) and seroma formation (12.6% versus 6.4%, p = 0.045).

CONCLUSION

Direct defect closure has proven to be effective in reducing recurrence and seroma formation post-operatively in patients undergoing laparoscopic inguinal hernia repair. Randomized controlled trials will be required to further evaluate these outcomes.