Diagnostic Laparoscopy as Decision Tool for Re-recurrent Inguinal Hernia Treatment Following Open Anterior and Laparo-Endoscopic Posterior Repair

Indications and Outcomes of a Hybrid Method Combining Laparoscopic and Anterior Approaches for Inguinal Hernia Repair

Introduction

Surgery for complex inguinal hernia (IH) (recurrent IH or IH after radical prostatectomy (RP)) may be difficult because of the presumed scar or adhesion in the retropubic space. A hybrid method combining the laparoscopic and anterior approaches (HLAA) in a bidirectional surgical technique may be an option in complex IH cases.

Methods

Patients at our institution who underwent IH repair for complex IH using HLAA from April 2018 to November 2019 were included. We retrospectively evaluated the patient characteristics, IH diagnosis, intraoperative variables, complications, and hernia recurrence during the follow-up period.

Results

Twenty patients were involved in this study. Seven patients underwent hLAA for recurrent IH, whereas the remaining 13 underwent hLAA for IH after RP. Five patients had bilateral IH, all of whom had IH after RP. The type of IH was lateral in 21 patients, medial in six patients, and lateral and medial in two patients. Hernia repair was performed using a patch alone in two patients and a plug and patch in 18 patients. Seroma or hematoma was observed in five patients, and one patient experienced chronic pain. No hernia recurrence was observed during the median follow-up period of 24 months.

Conclusion

hLAA could facilitate precise diagnosis and intraoperative confirmation of repair for recurrent IH and IH after RP. The intraoperative findings and the cause of recurrence can be easily shared among surgeons in hLAA. Further investigations are necessary to determine the long-term efficacy of hLAA in a larger cohort.

Robotic re-TAPP: a minimally invasive alternative for the failed posterior repair

OBJECTIVE

to describe the use of the robotic platform in inguinal hernia recurrence after a previous laparoscopic repair.

METHODS

patients with recurrent inguinal hernias following a laparoscopic repair who have undergone robotic transabdominal preperitoneal between December 2015 through September 2020 were identified in a prospectively maintained database. Outcomes of interest included demographics, hernia characteristics, operative details and rates of 30-day surgical site occurrence, surgical site occurrences requiring procedural interventions, surgical site infection and hernia recurrence were abstracted.

RESULTS

nineteen patients (95% male, mean age 55 years, mean body mass index 28) had 27 hernias repaired (N=8 bilateral). Average operative time was 168.9 ± 49.3min (range 90-240). There were two intraoperative complications all of them were bleeding from the inferior epigastric vessel injuries. Three SSOs occurred (N=2 seromas and N=1 hematoma. After a median 35.7 months follow-up (IQR 13-49), no recurrence has been diagnosed. One patient developed chronic postoperative inguinal pain.

CONCLUSIONS

on a small number of selected patients and experienced hands, we found that the use of the robotic platform for repair of recurrent hernias after prior laparoscopic repair appears to be feasible, safe and effective despite being technically demanding. Further studies in larger cohorts are necessary to determine if this technique provides any benefits in recurrent inguinal hernia scenario.

Transabdominal preperitoneal repair for a recurrent inguinal hernia after Kugel procedure using the medial umbilical ligament: A case report

The Kugel procedure resulted in extensive adhesion in the preperitoneal space. Performing a transabdominal preperitoneal repair (TAPP) for recurrent hernia after Kugel procedure is extremely difficult. In this case report, we present the case of a 81-year-old male who presented with recurrent inguinal hernia after Kugel procedure 8 years ago. Transabdominal laparoscopy was performed first. Indirect hernia formed inferior to the lateral edge of the previous mesh was diagnosed under laparoscopy. The patient's medial umbilical ligament (MUL) was big enough and could be completely released by separating the Retzius space. Finally, TAPP was successfully performed by using the MUL to create and close the preperitoneal space. No perioperative complications or hernia recurrence was observed 1 year after the surgery. Using the MUL to deal with preperitoneal problems was practical and feasible.

Laparoscopic treatment (reTAPP) for recurrence after laparoscopic inguinal hernia repair

PURPOSE

For inguinal hernia recurrences, the European Hernia Society guidelines recommend laparo-endoscopic repair (LR) following a previous open surgery (OS) and, conversely, OS following previous laparo-endoscopic repair. Laparoscopic treatment of recurrences after previous LR is controversial. The purpose of this study was to determine the safety, feasibility, and reliability of a repeated transabdominal preperitoneal laparoscopic repair (reTAPP) for a recurrent hernia.

METHODS

We analyzed and compared a series of patients with recurrent inguinal hernia after LR who underwent repair by a conventional approach with similar patients who underwent reTAPP between January 2010 and December 2018.

RESULTS

Between January 2010 and December 2018, 2488 transabdominal preperitoneal laparoscopic inguinal hernia (TAPP) repairs were performed. Recurrence was observed in 46 (1.8%). Of these patients, 18 (39%; Group 1; G1) underwent conventional open repair (Lichtenstein technique) and 28 (61%; Group 2; G2) reTAPP. In G2, repair was successful in 24 patients (86%); however, four cases (14%) needed conversion to OS because of technical difficulties. Two patients re-recurred (4.3%), one in G1 which was resolved in a third approach with a reTAPP and the other in G2 which was resolved with OS.

CONCLUSION

ReTAPP surgery for recurrences after previous TAPP repair proved to be safe and was associated with a shorter length of hospital stay and morbidity and recurrence rates comparable to OS at a highly specialized center. Randomized studies with a larger number of cases are necessary to confirm these findings and draw more robust and objective conclusions.

What is the outcome of re-recurrent vs recurrent inguinal hernia repairs? An analysis of 16,206 patients from the Herniamed Registry

INTRODUCTION

The proportion of recurrent repairs in the total collective of inguinal hernia repairs among men is 11.3-14.3% and among women 7.0-7.4%. The rate of re-recurrences is reported to be 2.9-9.2%. To date, no case series has been published on second and ≥ third recurrences and their treatment outcomes. Only case reports are available.

MATERIALS AND METHODS

In an analysis of data from the Herniamed Registry the perioperative and 1-year follow-up outcomes of 16,206 distinct patients who had undergone first recurrent (n = 14,172; 87.4%), second recurrent (n = 1,583; 9.8%) or ≥ third recurrent (n = 451; 2.8%) inguinal hernia repair between September 1, 2009 and July 1, 2017 were compared.

RESULTS

The intraoperative complication rate for all recurrent repairs was between 1-2%. In the postoperative complications a continuous increase was observed (first recurrence: 3.97% vs second recurrence: 5.75% vs ≥ third recurrence 8.65%; p < 0.001). That applied equally to the complication-related reoperation rates (first recurrence: 1.50% vs second recurrence: 2.21% vs ≥ third recurrence 2.66; p = 0.020). Likewise, the re-recurrence rate rose significantly (first recurrence: 1.95% vs second recurrence: 2.72% vs ≥ third recurrence 3.77; p = 0.005). Similarly, the rate of pain requiring treatment rose highly significantly with an increasing number of recurrences (first recurrence: 5.21% vs second recurrence: 6.70% vs ≥ third recurrence 10.86; p = < 0.001).

CONCLUSION

The repair of re-recurrences in inguinal hernia is associated with increasingly more unfavorable outcomes. For the first recurrence the guidelines should definitely be noted. For a second and ≥ third recurrence diagnostic laparoscopy may help to select the best possible surgical technique.

Hybrid method with explorative laparoscopy and anterior open approach for re-recurrent inguinal hernia

The new guidelines of the HerniaSurge group recommend that only an expert hernia surgeon should repair a re-recurrent inguinal hernia. We report the efficacy of the hybrid method with explorative laparoscopy and anterior open approach for re-recurrent inguinal hernia repair. A 61-year-old man underwent anterior open preperitoneal mesh repair for right inguinal direct hernia and laparoscopic transabdominal preperitoneal repair for recurrence. Two years after the second surgery, re-recurrent inguinal hernia was confirmed. We carried out explorative laparoscopy for the re-recurrent inguinal hernia, which revealed a re-recurrent hernia orifice. We performed the anterior open approach while observing from the abdominal cavity. Explorative laparoscopy can help in accurately determining the orifice of the re-recurrent inguinal hernia. Based on that information, the hernia sac can be reached through the shortest route using the anterior open approach.

Novel Transabdominal Preperitoneal Hernioplasty Technique for Recurrent Inguinal Hernia: Overlapping of Whole Posterior Wall with Newly Added Mesh and Pre-Existing Mesh by Closing Hernia Defect

Purpose: In some patients with recurrent inguinal hernias who have undergone previous laparoscopic herniorrhaphy, dissecting the entire posterior wall is difficult due to mesh adhesion. We applied a novel transabdominal preperitoneal (TAPP) hernioplasty technique that involves closing of the hernia defect and implantation of a newly added mesh while preserving the pre-existing mesh for inguinal hernia recurrence after laparoscopic herniorrhaphy. This study was performed to evaluate this novel technique for treatment of recurrent inguinal hernias. Methods: We evaluated 24 adult patients (23 male, 1 female; mean age, 55.8 ± 14.0 years; range, 26-77 years) with recurring inguinal hernias. A modified TAPP (mTAPP) procedure involving closing of the defect and implantation of an 8 × 6-cm² newly added mesh was performed. The new technique covered the whole posterior wall with pre-existing mesh. Results: Among the 24 patients, there were 12 direct hernias and 12 indirect hernias. The mean postoperative pain scores after 1 week were 2.5 and 2.0 in patients with direct and indirect hernias, respectively, and the mean duration until return to normal activities was 8.5 and 7.5 days in patients with direct and indirect hernias, respectively. The mean follow-up period was 21.0 ± 17.0 (range, 2-56) months. No chronic inguinodynia or rerecurrence was observed. Conclusions: In this novel mTAPP procedure for recurring inguinal hernias, closing sutures prevented mesh migration, and complete posterior wall overlap was possible using the pre-existing mesh and newly added mesh. The mTAPP procedure was an effective operation with few recurrences and complications.