Ultra-micro instrument in laparoscopic transabdominal preperitoneal (TAPP) hernioplasty

This study aimed to explore the feasibility of ultra-micro instruments in the laparoscopic repair of inguinal indirect hernia. This retrospective study included 83 patients with an indirect inguinal hernia who underwent elective surgery from January 2020 to December 2021. All patients were divided into the traditional laparoscopic group and ultra-micro laparoscopic group. The data on operation time, blood loss, ventilation time, hospital stays, complication, postoperative pain degree was collected and compared between the two groups. Of these 83 patients, 25 assigned to the ultra-micro group used ultra-micro instruments while 58 were assigned to the traditional group. The traditional group had a lower mean operation time (57.07 min) than the ultra-micro group (69.60 min) p < 0.05, while ultra-micro group patients had a shorter hospital stay (2 days) than the traditional group (3 days) p < 0.05. The ultra-micro group experienced significantly less pain for 6 h, 1 day, and 2 days postoperatively (2, 1, 0 points) compared to the traditional group (4, 2, 1 points) p < 0.05. There was no significant difference in blood loss, ventilation time, or complication between the two groups. Using ultra-micro instruments is safe and feasible. Patients have less postoperative pain and a smaller incision than the traditional laparoscopic instrument. It is worthy of clinical promotion.

Emergency totally laparoscopic surgery for appendicitis in right Amyand's hernia associated to symptomatic left inguinal hernia: A case report

INTRODUCTION AND IMPORTANCE

Amyand's hernia is a rare type of inguinal hernia which contains vermiform appendix in the inguinal sac, seldom complicated by acute appendicitis. It is usually repaired by open inguinal approach, but laparoscopic technique has been increasingly described in literature; nevertheless, standard of care is far from being defined. Here we report the case of Amyand's hernia complicated by acute appendicitis and simultaneous symptomatic left inguinal hernia, both repaired by laparoscopic technique.

CASE PRESENTATION

A 85-years-old man presented with acute appendicitis in Amyand's hernia and simultaneous incarcerated left inguinal hernia.

CLINICAL DISCUSSION

After complete preoperative work-up, the patient underwent laparoscopic appendectomy and laparoscopic bilateral hernia repair with mesh.

CONCLUSION

Laparoscopic approach may be safe and feasible for Amyand's hernia treatment in emergency setting when performed by expert hands, with minimized risk of surgical site infection (SSI), quick recovery and reduced hospital stay. Laparoscopic hernia repair with mesh can be a reasonable approach in selected cases of bilateral or recurrent hernia, and concomitant intrabdominal inflammation, especially when contamination is scarse and limited to a restricted area.

Transabdominal preperitoneal (TAPP) repair for emergency groin hernia: a systematic review

PURPOSE

Laparoscopic groin hernia repair has evolved and gained popularity and laparoscopic transabdominal preperitoneal (TAPP) procedure provides an opportunity to evaluate the peritoneal cavity and both inguinal areas without the need for additional dissection. There is still a paucity of evidence to support TAPP repair in the emergency setting. In this systematic review, we aim to evaluate the feasibility and safety of TAPP repair for incarcerated and strangulated groin hernias.

METHODS

PRISMA guidelines were followed for literature search and established inclusion and exclusion criteria were applied. Data were extracted and analyzed for the outcomes of interest.

RESULTS

Overall, 8 studies were included in the review, comprising 316 patients. Patients characteristics and outcomes were limitedly reported. Only 3 cases of conversion to open approach were reported and 2 recurrences were diagnosed. Postoperative complications are inconsistently reported but mostly refer to minor complications. There were no mortality cases. Visceral resections were performed in 25 cases due to ischemia, mostly extracorporeally.

CONCLUSION

Laparoscopy is a game changer and TAPP approach is a feasible, safe, and effective technique for the emergent repair of groin hernias. Further studies and prospective randomized data are needed to establish its role in the emergent groin hernia management.

A case of indirect inguinal bladder hernia treated with laparoscopic transabdominal preperitoneal repair with high peritoneal incisional approach

BACKGROUND

Inguinal herniation of the urinary bladder is uncommon and those descending into the scrotum are even rarer. Although open anterior repair has been used for inguinal bladder hernia, the efficacy of laparoscopic herniorrhaphy has been reported in recent years.

CASE PRESENTATION

A 63-year-old man presented with an irreducible right groin and scrotal bulge associated with voiding difficulty. Abdominal ultrasonography showed a dislocation of the urinary bladder descending into the right scrotum. Abdominal CT imaging revealed that a part of the bladder and small intestine was herniating into the scrotum through the internal inguinal ring and running laterally to the inferior epigastric artery. Under the diagnosis of indirect inguinal bladder hernia, the patient underwent trans-abdominal preperitoneal hernia repair (TAPP). The bladder herniated into the scrotum through the internal inguinal ring was replaced to the original position. Then the myopectineal orifice was exposed and covered with polypropylene mesh, where a horizontal peritoneal incision 4 cm above the hernia orifice, i.e., the high peritoneal incision approach (HPIA), allowed an easy peeling of the peritoneum and hernia sac. The patient's postoperative course was uneventful and the voiding difficulty resolved. The patient continued to do well without recurrence at 20 months after surgery.

CONCLUSION

Preoperative evaluation with abdominal ultrasonography and CT scan allowed a precise diagnosis of a groin hernia with voiding difficulty. TAPP with HPIA was useful in the treatment of inguinal bladder hernia because this technique facilitated a quick confirmation of the hernia contents, secure dissection of the whole protruded bladder, and adequate replacement of the bladder to the original position without any injury.

RAWS4all project: validation of a new silicone model for robotic TAPP inguinal hernia repair

BACKGROUND

Trans-abdominal pre-peritoneal (TAPP) hernia repair is a complex procedure that presents several challenges. Even though, due to the high prevalence of inguinal hernia, TAPP technique is increasing in frequency and robotic Abdominal Wall Surgery (rAWS) is emerging as a valuable tool in this regard. Although inguinal TAPP procedure principles have been published and simulation is needed, the availability of validated models remains scarce.

METHODS

A new low-cost model was developed to simulate inguinal rTAPP repair. For validity assessment, a new TAPP-specific fidelity questionnaire and assessment scale were developed to compare the performance of novices and experts in the simulated procedure. The models used were assessed at 60 min for execution and quality score.

RESULTS

Twenty-five residents and specialists from all over the country participated in this study. Execution, quality, and global performance was higher in the seniors group compared to juniors (8.91 vs 6.36, p = 0.02; 8.09 vs 5.14, p < .001; and 17 vs. 11,5, p < .001, respectively). Overall fidelity was assessed as being very high [4.41 (3.5-5.0), α = .918] as well as face [4.31 (3.0-5.0), α = .867] and content validity [4.44 (3.2-5.0), α = .803]. Participants strongly agreed that the model is adequate to be used with the DaVinci® Robot [4.52 (3.5-5.0), α = .758].

CONCLUSION

This study shows face, content, and construct validity of the model for inguinal TAPP simulation, including for robotic surgery. Therefore, the model can be a valuable tool for learning, understanding, practicing, and mastering the TAPP technique prior to participating in the operating room.

The outcome of closure of inguinal hernia with laparoscopic percutaneous extraperitoneal closure in young adults

BACKGROUND

Hernioplasty is one of the most commonly performed surgeries. However, the optimal procedure for young adults has not been defined yet. Our study compared the outcomes of laparoscopic percutaneous extraperitoneal closure (LPEC) in young adults with outcomes in children.

MATERIAL AND METHODS

We retrospectively reviewed patients aged 0-30 years who underwent LPEC. Data regarding age, sex, hernia type, surgical time, pre-intraoperative laterality, contralateral patent processus vaginalis (CPPV), and complications were analyzed.

RESULTS

LPEC was performed on 2642 patients in our hospital. Of these, 51 patients were young adults (aged 15-30 years). Asymptomatic CPPV in unilateral patients was frequent in the <15-year age group (50.2%) compared to the 15-30-year age group (15.9%). The median surgical time was shorter in the <15-year age group (19 min, interquartile range [IQR]: 24-33) compared to that of the 15-30-year age group (33 min, IQR: 23.3-40.8).

CONCLUSIONS

This is the first report on the outcomes in young adult patients who underwent LPEC. The median surgical time was longer in the 15-30-year age group than in the <15-year age group. The median follow-up was 4.7 years with no intra-postoperative complications, such as postoperative bleeding, infection, persistent pain, and recurrence. LPEC is an effective, cosmetic, and safe surgical treatment in young adults and children.

Laparoscopic versus robotic TAPP/TEP inguinal hernia repair: a multicenter, propensity score weighted study

PURPOSE

The objective of this retrospective study was to assess safety and comparative clinical effectiveness of laparoscopic inguinal hernia repair (LIHR) and robot-assisted inguinal hernia repair (RIHR) from multi-institutional experience in Taiwan.

METHODS

Medical records from a total of eight hospitals were retrospectively collected and analyzed. Patients primarily diagnosed of inguinal hernia, recurrent inguinal hernia or incarceration groin hernia patients who either underwent laparoscopic or robot-assisted inguinal hernia repair between January 2018 and December 2022 were included in the study. Baseline characteristics, intra-operative and post-operative results were analyzed. To compare two cohorts, overlap weighting was employed to balance the significant inter-group differences. We also conducted subgroup analyses by state of a hernia (primary or recurrent/incarceration) and laterality (unilateral or bilateral) that indicated complexity of surgery.

RESULTS

A total of 1,080 patients who underwent minimally invasive inguinal hernia repair from 8 hospitals across Taiwan were collected. Following the application of inclusion criteria, there were 279 patients received RIHR and 763 patients received LIHR. In the baseline analysis, RIHR was more often performed in recurrent/incarceration (RIHR 18.6% vs LIHR 10.3%, p = 0.001) and bilateral cases (RIHR 81.4 vs LIHR 58.3, p < 0.001). Suturing was dominant mesh fixation method in RIHR (RIHR 81% vs LIHR 35.8%, p < 0.001). More overweight patients were treated with RIHR (RIHR 58.8% vs LIHR 48.9%, p = 0.006). After overlap weighting, there were no significant difference in intraoperative and post-operative complications between RIHR and LIHR. Reoperation and prescription rates of pain medication (opioid) were significantly lower in RIHR than LIHR in overall group comparison (reoperation: RIHR 0% vs. LIHR 2.9%, p = 0.016) (Opioid prescription: RIHR 3.34 mg vs LIHR 10.82 mg, p = 0.001) while operation time was significantly longer in RIHR (OR time: RIHR 155.27 min vs LIHR 95.30 min, p < 0.001).

CONCLUSIONS

This real-world experience suggested that RIHR is a safe, and feasible option with comparable intra-operative and post-operative outcomes to LHIR. In our study, RIHR showed technical advantages in more complicated hernia cases with yielding to lower reoperation rates, and less opioid use.

[Da Vinci robotic complex in hernia repair surgery]

OBJECTIVE

To review the first robotic hernia repairs performed at the Ilyinsky Hospital, evolution of this technology, learning curve and early outcomes.

MATERIAL AND METHODS

There were 17 procedures at the Ilyinskaya Hospital between 2021 and 2023 (13 men and 4 women). Mean age was 60 years, body mass index 28 kg/m2. ASA grade 1 was observed in 1 patient, grade 2 - 14 ones, grade 3 - 2 patients. Ventral, inguinal and umbilical hernias were diagnosed in 7, 8 and 2 cases, respectively. Ventral hernias required IPOM+ procedure in 3 cases, eTEP-RS procedure in 2 cases and eTEP-RS-TAR procedure in 2 cases. Patients with inguinal hernia underwent transabdominal preperitoneal hernia repair. In case of umbilical hernia, TARUP procedure was performed in 1 case and vTAPP procedure in 1 case.

RESULTS

Mean surgery time was 2 hours 38 min (min 1 hour 35 min, max 10 hours 11 min). There was one intraoperative complication (bleeding from epigastric artery). The follow-up period ranged from 3 months to 3 years. There were no recurrent hernias. Postoperative complications were noted in 2 cases. One patient was diagnosed with epididymitis after TAPP, 1 patient - with seroma after eTEP-RS procedure. All complications were relieved by conservative treatment. Bleeding from a. epigastrica inferior was diagnosed after removal of the trocar at the end of surgery. This event required suturing.

CONCLUSION

Robotic hernia repair appears to be technically feasible and safe. This approach provides favorable results regarding quality of life and recurrence rate.

Nationwide analysis of open groin hernia repairs in Italy from 2015 to 2020

INTRODUCTION

Inguinal hernia repair is one of the most commonly performed operations in general surgery. A total of 130.000 inguinal hernia repairs are performed yearly in Italy, and approximately 20 million inguinal hernias are treated worldwide annually. This report represents the trend analysis in inguinal hernia repair in Italy from a nationwide dataset for the 6-year period from 2015 to 2020.

MATERIALS AND METHODS

Based on regional hospital discharge records, all the inguinal hernia repairs performed in public and private hospitals in Italy between 2015 and 2020 were reviewed based on diagnosis and procedure codes. For the aim of this study, data from the AgeNas (The National Agency for Regional Health Services) data source were analyzed.

RESULTS

Elective inguinal hernia repairs outnumbered urgent operations over the 6-year study period, ranging from 122,737 operations in 2015 to 65,780 in 2020 as absolute numbers, and from 87.96 to 83.3% of total procedures in 2019 and 2020 respectively, with an annual change ranging from - 66.58%, between 2020 and 2019, to - 2.49%, between 2019 and 2018 (mean = - 18.74%; CI =- 46.7%-9.22%; p < 0.0001).

CONCLUSIONS

This large-scale review of groin hernia data from a nationwide Italian dataset provides a unique opportunity to obtain a snapshot of open groin hernia repair activity. More specifically, there is a trend to perform more elective than urgent procedures and there is a steady decrease in the amount of open hernia repairs in favor to laparoscopy.

Bilateral inguinal hernia repair and male fertility: a randomized clinical trial comparing Lichtenstein versus laparoscopic transabdominal preperitoneal (TAPP) technique

BACKGROUND

The effects of hernia repair on testicular function remain uncertain, regardless of the technique used. Studies that analyze testicular volume and flow after hernia repair or hormonal measurements are scarce and show contradictory results. This study aimed to evaluate the impact of bilateral inguinal hernia repair on male fertility in surgical patients in whom the Lichtenstein and laparoscopic transabdominal preperitoneal (TAPP) techniques were used.

METHODS

A randomized clinical trial comparing open (Lichtenstein) versus laparoscopic (TAPP) hernia repair using polypropylene mesh was performed in 48 adult patients (20 to 60 years old) with primary bilateral inguinal hernia. Patients were evaluated preoperatively and 90 and 180 postoperative (PO) days. Sex hormones (Testosterone, FSH, LH and SHGB) analysis, testicular ultrasonography, semen quality sexual activity changes and quality of life (QoL) were performed. Postoperative pain was evaluated using the visual analog scale (VAS).

RESULTS

Thirty-seven patients with aged of 44 ± 11 years were included, 19 operated on Lichtenstein and 18 operated on TAPP. The surgical time was similar between techniques. The pain was greater in the Lichtenstein group on the 7th PO day. The biochemical and hormonal analyses, testicular ultrasonography (Doppler, testicular volume, and morphological findings) and sperm quality were similar between groups. However, the sperm morphology was better in the Lichtenstein group after 180 days (p < 0.05 vs. preoperative) and two patients who underwent Lichtenstein hernia repair had oligospermia after 180 days. The QoL evaluation showed a significant improvement after surgery in the following domains: physical function, role emotional, bodily pain and general health (p < 0.05). On comparison of Lichtenstein vs. TAPP none of the domains showed statistically significant differences. No patient reported sexual changes.

CONCLUSION

Bilateral inguinal hernia repair with polypropylene mesh, whether using Lichtenstein or TAPP, does not impair male fertility in terms of long-term outcomes.

TRIAL REGISTRATION

Approved by the Ethics Committee for the Analysis of Research Projects (CAPPesq) of the HC/FMUSP, Number 2.974.457, in June 2015, Registered on Plataforma Brasil in October 2015 under Protocol 45535015.4.0000.0068. Registered on Clinicaltrials.gov, NCT05799742. Enrollment of the first subject in January 2016.

No evidence for fixation of mesh in laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To investigate the differences in hernia recurrence and chronic postoperative inguinal pain (CPIP) in randomized, controlled trials comparing fixation and non-fixation of the mesh in laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair.

METHODS

A multi-database systematic search was conducted for randomized, controlled trials comparing fixation versus non-fixation of the mesh in TAPP inguinal hernia repair. All eligible papers were assessed for risk of bias using the revised Cochrane risk of bias tool for randomized trials (RoB 2.0). Quality of evidence was evaluated using the GRADE system. Meta-analyses were performed regarding recurrence and CPIP using RevMan.

RESULTS

Seven prospective, randomized controlled trials were included. Laparoscopic TAPP inguinal hernia repair was performed in 1732 patients with 737 procedures performed without fixation and 995 procedures with fixation of the mesh. Despite all trials being RCTs, the trials were limited by substantial bias and the quality of evidence was low regarding hernia recurrence and very low regarding CPIP. Pooled estimates from meta-analyses were an OR of 2.80 (95% CI 0.61-12.77) for hernia recurrence and a mean difference in visual analogue scale (VAS) of 0.17 (95% CI 0.90-1.24) for CPIP, respectively.

CONCLUSION

The current evidence is very uncertain and mesh fixation may have little to no effect regarding hernia recurrence and chronic postoperative inguinal pain in patients operated with TAPP inguinal hernia repair.

Single-incision laparoscopic transabdominal preperitoneal hernioplasty: 1,054 procedures and experience

PURPOSE

Although there have been numerous studies on single-incision laparoscopic inguinal hernia repair (SIL-IHR), the short- and long-term outcomes in patients from a large single institution who underwent single-incision laparoscopic transabdominal preperitoneal hernioplasty (SIL-TAPP) have rarely been reported. The purpose of this study is to evaluate the short- and long-term outcomes of SIL-TAPP and its safety and feasibility in patients from a large single institution.

METHODS

The details of 1,054 procedures in 966 patients who underwent SIL-TAPP at the Affiliated Hospital of Nantong University from January 2015 to October 2022 were retrospectively analysed. SIL-TAPP was performed completely through the umbilicus using conventional laparoscopic instruments. Short-term and long-term outcomes of SIL-TAPP were collected by outpatient and telephone follow-ups. In addition, we further compared the operation time, length of postoperative hospital stay, and postoperative complications of patients with simple and complicated unilateral inguinal hernias.

RESULTS

A total of 1,054 procedures were performed for 878 unilateral inguinal hernias and 88 bilateral inguinal hernias. In total, there were 803 (76.2%) indirect inguinal hernias, 192 (18.2%) direct inguinal hernias, 51 (4.8%) femoral hernias and 8 (0.8%) combined hernias. The mean operative time was 35.5 ± 17.0 min for unilateral inguinal hernias and 51.9 ± 25.5 min for bilateral inguinal hernias. There was one (0.1%) conversion to two-incision laparoscopic transabdominal preperitoneal hernioplasty. No intraoperative haemorrhages, inferior epigastric vessel injury or nerve damage occurred. Postoperative complications were minor and could be resolved without surgical intervention. The mean length of hospital stay was 1.3 ± 0.8 days. The median follow-up was 44 months, no trocar hernia occurred, and there was one (0.1%) recurrence. The operation time in the complicated inguinal hernia group was significantly higher than that in the simple inguinal hernia group (38.9 ± 22.3 vs. 35.0 ± 15.6, p = 0.025). The length of postoperative hospital stay and complication rate of the complicated inguinal hernia group were slightly higher than those of the simple inguinal hernia group, but the difference was not statistically significant.

CONCLUSION

SIL-TAPP is safe and technically feasible, and both short- and long-term outcomes are acceptable.

MEsh FIxation in Laparoendsocopic Repair of Large M3 inguinal hernias: multicenter, double-blinded, randomized controlled trial-study protocol for a MEFI Trial

BACKGROUND

International guidelines of groin hernia treatment strongly recommend to fixate the mesh in large M3 medial defects during TAPP/TEP procedures. The main purpose of fixation is to decrease the recurrence rate which is alarmingly high in case of those defects. In 2022, a team consisting of hernia surgeons and scientists from universities of technology conducted an experimental study with the use of 3D groin model to verify the hypothesis that fixation is not necessary in above cases. Experiment showed that rigid and anatomically shaped meshes are able to maintain its position in the groin without fixation. Similar conclusions were recently published in Swedish database registry analysis. To confirm above results, we decided to conduct a multicenter randomized controlled trial.

METHODS

Main objective of MEFI Trial is to verify the hypothesis that non-fixation of spatial, standard polypropylene meshes is non-inferior to fixation of flat, polypropylene lightweight meshes in M3 hernias by laparoendoscopic approach. Eleven large surgery centers in Poland having proficiency in laparoendoscopic groin hernia repairs were recruited for this study. Recurrence in 12-month follow-up was set as a primary endpoint. Pain sensation (Visual Analog Scale) and incidence of other complications (hematoma, seroma, SSI) were also noted. Based on the statistical analysis, minimal sample size in both arms was established at 83-102. The first arm (control) consists of patients undergoing a repair with the use of a flat, macroporous mesh with fixation using histoacryl glue. In the second arm, patients will be operated with the use of anatomically shaped, standard-weight mesh without fixation. Study will be double-blinded (patient/surgeon). After the dissection of preperitoneal space, surgeon will open a sealed envelope and find out which technique he will have to perform. Follow-up will be performed by Study Secretary (also blinded to the method used) via phone call 3 and 12 months after surgery.

DISCUSSION

Based on experimental study and recent registry analysis, we believe that the recurrence rate in both groups would be on the same level, giving hernia societies a strong argument for amending the guidelines.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05678465. Registered on 10 January 2023.

Comparison of transumbilical single-incision laparoscopic TAPP versus conventional laparoscopic TAPP in the elderly: A retrospective analysis

BACKGROUND

To analyze and compare the clinical efficacy of transumbilical single-incision laparoscopic surgery TAPP(SILS-TAPP) and conventional laparoscopic TAPP(CL-TAPP) in the treatment of senile inguinal hernia.

METHODS

From January 2019 to June 2021, a total of 221 elderly patients (≥60 years old) with inguinal hernia received SILS-TAPP and CL-TAPP in General Surgery Department of Affiliated Hospital of Nantong University. The perioperative indicators, postoperative complications and follow-up of the two groups were compared to explore the feasibility and superiority of SILS-TAPP in the treatment of inguinal hernia in the elderly.

RESULTS

There was no difference in demographic characteristics between the two groups. The mean operation time (28.6 ± 4.2 min vs 28.2 ± 5.3 min) in the SILS-TAPP group was not significantly different from that in the CL-TAPP group (Ρ = 0.623), and there was no significant increase in hospital costs(Ρ = 0.748). The intraoperative blood loss (7.4 ± 3.4 ml), VAS score on the postoperative day (2.2 ± 0.7), mean time of resuming activity (8.2 ± 1.9 h) and mean postoperative hospital stay (0.8 ± 0.2 d) in the SILS-TAPP group were better than those in the CL-TAPP group (Ρ < 0. 05).There was no statistical difference in the overall incidence of intraoperative (Ρ = 0.128) and postoperative complications (Ρ = 0.125) between the two groups.

CONCLUSION

Single-incision laparoscopic surgery TAPP (SILS-TAPP) is feasible and effective in elderly patients, providing a new alternative surgical method for patients who can tolerate general anesthesia.

Concurrent strangulated obturator hernia and femoral hernia repair via TAPP approach: A case report

An obturator hernia is a rare pelvic hernia with high mortality. Early diagnosis and treatment are essential to reduce postoperative complications. The treatment of choice for obturator hernias is surgery. In an emergency, laparotomy to resolve herniated viscera and complications is often the choice. However, some researchers have shown the feasibility of laparoscopy. The laparoscopic approach has several benefits over the open approach, including reduced postoperative pain, early mobilization, shorter length of stay, and lower postoperative morbidity rates. We report the case of an 81-year-old woman with a right-side obstructed obturator hernia. The patient was hospitalized with an acute onset of inner thigh pain and bowel obstruction. The obturator hernia was diagnosed preoperatively by an abdominopelvic CT scan with the image of protrusion of an ileal loop in the right obturator foramen. The patient was treated by an emergency laparoscopy. The right obturator hernia and a concurrent right femoral hernia were confirmed during the operation. The hernia defect was repaired with a mesh large enough to cover all hernia foramen. The patient recovered without any complications. Emergency laparoscopic repair for obstructed obturator hernia was safe and effective.

Standardization and learning curve in laparoscopic hernia repair: experience of a high-volume center

PURPOSE

Groin hernias are a common condition that can be treated with various surgical techniques, including open surgery and laparoscopic approaches. Laparoscopic surgery has several advantages but its use is limited due to the complexity of the posterior inguinal region and the need for advanced laparoscopic skills. This paper presents a standardized and systematic approach to trans-abdominal pre-peritoneal (TAPP) groin hernioplasty, which is useful for training young surgeons.

METHODS

The paper provides a detailed, step-by-step description of the TAPP based on evidence from literature, anatomical knowledge, and the authors' experience spanning over 30 years. The sample includes 487 hernia repair procedures, with 319 surgeries performed by experienced surgeons and 168 surgeries performed by young surgeons in training. The authors performed a descriptive analysis of their data to provide an overview of the volume of laparoscopic hernioplasty performed.

RESULTS

The analysis of the data shows a low complication rate of 0.41% (2/487) and a low recurrence rate of 0.41% (2/487). The median duration of the surgery was 55 min, while the median operation time for surgeons in training was 93 min, specifically 83 min for unilateral hernia and 115 min for bilateral hernia.

CONCLUSIONS

The TAPP procedure appears, to date, comparable to the open inguinal approach in terms of recurrence, postoperative pain and speed of postoperative recovery. In this paper, the authors challenge the belief that TAPP is not suitable for surgeons in training. They advocate for a training pathway that involves gradually building surgical skills and expertise. This approach requires approximately 100 procedures to achieve proficiency.

Is laparoscopic TAPP the preferred approach for the treatment of inguinal hernia? Technique, indications and future perspectives

The repair of inguinal hernia is one of the most frequently performed surgeries in General Surgery units. The laparoscopic approach for these hernias will be clearly considered as the gold standard, based on its advantages over the open approach. There are no clear advantages of the transabdominal preperitoneal approach (TAPP) over the totally preperitoneal approach (TEP), although it has been shown to be more reproducible, presenting a shorter learning curve, although it presents more possibilities of developing trocar site hernias. Laparoscopic TAPP could be superior to TEP in the following indications: incarcerated hernias, emergencies, previous preperitoneal surgery, previous Pfanestiel-type incision, recurrent hernias, inguinoscrotal hernias and obese, being also a better alternative for females. Robotic TAPP is a safe approach with similar results to laparoscopy; however, it is related to an increase in costs and operating time. The value of this technology for the repair of complex hernias (multiple recurrences, inguino-scrotal or after previous preperitoneal surgery) remains to be determined, since they represent a certain challenge for the conventional laparoscopic approach. On the other hand, robotic repair of inguinal hernias may be a way to reduce the learning curve before addressing complex ventral hernias. Finally, artificial intelligence applied to the laparoscopic approach to inguinal hernia will undoubtedly have a significant impact in the future especially to determine the best the indications for this approach, on the performance of a safer technique, on the correct selection of meshes and fixation mechanisms, and on learning curve.

Incarerated femoral hernia in women - A critical view on approach options

INTRODUCTION AND IMPORTANCE

In the literature there is few information on femoral hernias while best surgical approach to groin hernia in women is in recent discussion ([1], [2]). Focused on femoral hernia our purpose is to present a possible pathway for incarcerated female hernia approach demonstrated on four cases.

CASE PRESENTATION

Four female patients (77-90 y) with suspected incarcerated inguinal unilateral hernia undergoing repair at our department between December 2017 and December 2018 are presented. In three patients emergency laparoscopy by single port approach confirmed incarceration. Bowel was reduced and femoral hernia diagnosed. A TAPP repair was performed. The fourth patient had multiple previous abdominal operations due to anal carcinoma, so laparoscopic approach was not recommended. A transinguinal open approach also showed an incarcerated femoral hernia.

CLINICAL DISCUSSION

In case of suspected incarcerated inguinal hernia accurate identification of a femoral hernia is necessary especially in female elderly patients. If possible endoscopic approach is preferred and offers exploration of both sides, checking bowel for vitality and fixing the hernia. If bilateral hernia is present, both sides should be addressed. Surgeons not used to TAPP should perform diagnostic laparoscopy with reduction of hernia sac and check of content and switch to TEP if experienced or open procedure. If open approach is necessary checking for femoral hernia is also mandatory and preperitoneal mesh placement is recommended with or without ligation of inferior epigastric vessels.

CONCLUSION

Femoral hernias in women are not rare and in open repair techniques easily overseen. The endoscopic approach is preferred. With open approach the exploration via transversalis fascia is mandatory.

No prostate? No problem: robotic inguinal hernia repair after prostatectomy

Traditional teaching suggests that prior pelvic operations, including prostatectomy, are a contraindication to laparoscopic inguinal hernia repair. Despite the growing use of robotic platforms in inguinal hernia repair, there are few studies describing robotic-assisted inguinal hernia repairs (RIHR) in this patient population. This study aims to demonstrate that RIHR is safe and effective in repairing inguinal hernias in patients who had previously undergone prostatectomy. We retrospectively reviewed RIHR cases performed from March 2017 to October 2021 by a single surgeon at our university-affiliated community hospital. Cases were reviewed for preoperative considerations, operative times and complications, and postoperative outcomes. A total of 30 patients with prior prostatectomy underwent transabdominal preperitoneal (TAPP) RIHR with mesh. Sixteen of the 30 patients had undergone robot-assisted laparoscopic prostatectomy (RALP), while 14 patients underwent open resection. Seven of the patients had received post-resection radiation and 12 had previous non-urologic abdominal operations. When compared to all RIHRs performed over the same period, duration of surgery was increased. There were no conversions to open surgery. Postoperatively, one patient developed a repair site seroma which resolved after 1 month. Mean follow-up time was 8.0 months. At follow-up, one patient reported experiencing intermittent non-debilitating pain at the repair site and one patient developed an inguinoscrotal abscess of unknown relation to the repair. No patients reported hernia recurrences nor mesh infection. This review suggests that TAPP RIHR can be a safe and effective approach to inguinal hernia repair in patients who have previously undergone prostatectomy, including those who received radiation and those who underwent either open or robotic resections.

A Comparative Evaluation of Extended Total Extraperitoneal Repair Versus Standard Total Extraperitoneal Repair and Transabdominal Preperitoneal Repair of Inguinal Hernias

Background and Objectives

Laparoscopic inguinal hernia repair (LIHR) includes transabdominal preperitoneal repair (TAPP), standard totally extraperitoneal repair (TEP), and now extended TEP (eTEP). However, there is still a paucity of well conducted, peer reviewed comparative studies regarding the advantages, if any, of eTEP. This study aimed to compare the data of eTEP repair with that of TEP and TAPP repair.

Methods

Two hundred twenty patients were randomly assigned to one of three groups of eTEP (80), TEP (68), and TAPP (72) after matching for age, sex, and clinical extent of hernia. Permission of ethics committee was taken.

Results

Comparison with TEP showed, mean operating time for eTEP was significantly longer in the first 20 patients, subsequently there was no difference. Conversion rates of TEP to TAPP was significantly higher. The other peroperative and postoperative parameters did not differ. Similarly, on comparison with TAPP, there was no difference in any of the parameters. eTEP, also had shorter operating time and less incidence of pneumoperitoneum when compared to published TEP and TAPP studies.

Conclusion

All the three laparoscopic hernia approaches had similar outcomes. eTEP cannot be advocated as a substitute for TAPP or TEP.The choice of procedure should be the surgeon's choice. However, eTEP does combine the advantage of both TAPP, in the form of a large working space and of TEP, by being totally extraperitoneal. eTEP is also easier to learn and teach.

Robotic inguinal hernia repair: is the new Da Vinci single port platform providing any benefit?

BACKGROUND

The utilization of the robot for inguinal hernia repairs has increased in the past years. The new Da Vinci Single Port (SP) system provides the benefits of single-incision procedures and might overcome the technical difficulties of previous single-incision techniques. The aim of this study was to evaluate the safety and feasibility of the SP transabdominal preperitoneal inguinal hernia repair (SP-TAPP) and compare its outcomes to the robotic multiport technique (MP-TAPP).

METHODS

A prospective cohort of patients who underwent a robotic SP-TAPP and MP-TAPP between 2012 and 2022 was analyzed. Primary endpoints were same-day discharge, morbidity, and inguinal recurrence rates. Secondary endpoints included conversion, operative time, port-site incisional hernia, and chronic pain.

RESULTS

MP-TAPP and SP-TAPP were performed in 378 (81.3%) and 87 (18.7%) patients, respectively. Demographics were similar between groups. There were no conversions or intraoperative complications. Mean operative (MP-TAPP: 93.2 vs. SP-TAPP: 78.1 min, p = 0.003) and recovery time (MP-TAPP: 160.8 vs SP-TAPP: 112.6 min, p < 0.001) were significantly shorter in the SP group. Same-day discharge rate was higher (MP-TAPP: 86.5% vs. SP-TAPP: 97.7%, p = 0.001) after SP-TAPP; 30-day morbidity, readmissions, and chronic pain rates were similar between groups. After a mean follow-up of 30.6 months for MP-TAPP and 13.3 months for SP-TAPP, inguinal hernia recurrence and port-site incisional rates were similar between groups.

CONCLUSION

Robotic SP-TAPP is safe and feasible. When compared to MP-TAPP, it showed similar postoperative morbidity, higher same-day discharge rates, and a quicker postoperative recovery. Further studies are needed to confirm the benefits of the SP platform.

Is mesh fixation necessary in laparoendoscopic techniques for M3 inguinal defects? An experimental study

BACKGROUND

Although international guidelines recommend not fixing the mesh in almost all cases of laparoendoscopic repairs, in case of large direct hernias (M3) mesh fixation is recommended to reduce recurrence risk. Despite lack of high-quality evidence, the recommendation was upgraded to strong by expert panel. The authors conducted a research experiment to verify the hypothesis that it is possible to preserve the mesh in the operating field in large direct hernias (M3) without the need to use fixing materials.

METHOD

The authors conducted an experiment with scientists from Universities of Technology in a model that reflects the conditions in the groin area. By simulating conditions of the highest possible intra-abdominal pressure, they examined the mesh behavior within the groin and its ability to dislocate under the forces generated by this pressure. The experiment involved six spatial implants and one flat macroporous mesh.

RESULTS

Heavyweight spatial meshes and lightweight spatial-individualized meshes showed no tendency to dislocate or move directly to the orifice, which was considered a rapid hernia recurrence. Lightweight meshes, both spatial and flat, underwent significant migration and shifting toward the hernial orifices.

CONCLUSION

Based on the results, we believe that mesh fixation is not the only alternative to preventing recurrence in complex defects. Similar effects can be achieved using a larger, more rigid, and anatomically fitted implant. The type of implant (rather than its fixation) seems to be a key factor from the point of view of mechanics and biophysics. Clinical trials confirming the results in vivo will allow to supplement or amend the guidelines for the treatment of large inguinal hernias.

Serious gaming and virtual reality in the multimodal training of laparoscopic inguinal hernia repair: a randomized crossover study

BACKGROUND

The aim of this study was to assess the transferability of surgical skills for the laparoscopic hernia module between the serious game Touch Surgery™ (TS) and the virtual reality (VR) trainer Lap Mentor™. Furthermore, this study aimed to collect validity evidence and to discuss "sources of validity evidence" for the findings using the laparoscopic inguinal hernia module on TS.

METHODS

In a randomized crossover study, medical students (n = 40) in their clinical years performed laparoscopic inguinal hernia modules on TS and the VR trainer. TS group started with "Laparoscopic Inguinal Hernia Module" on TS (phase 1: Preparation, phase 2: Port Placement and Hernia Repair), performed the module first in training, then in test mode until proficiency was reached. VR group started with "Inguinal Hernia Module" on the VR trainer (task 1: Anatomy Identification, task 2: Incision and Dissection) and also performed the module until proficiency. Once proficiency reached in the first modality, the groups performed the other training modality until reaching proficiency. Primary endpoint was the number of attempts needed to achieve proficiency for each group for each task/phase.

RESULTS

Students starting with TS needed significantly less attempts to reach proficiency for task 1 on the VR trainer than students who started with the VR trainer (TS = 2.7 ± 0.6 vs. VR = 3.2 ± 0.7; p = 0.028). No significant differences for task 2 were observed between groups (TS = 2.3 ± 1.1 vs. VR = 2.1 ± 0.8; p = 0.524). For both phases on TS, no significant skill transfer from the VR trainer to TS was observed. Aspects of validity evidence for the module on TS were collected.

CONCLUSION

The results show that TS brought additional benefit to improve performances on the VR trainer for task 1 but not for task 2. Skill transfer from the VR trainer to TS could not be shown. VR and TS should thus be used in combination with TS first in multimodal training to ensure optimal training conditions.

Influence of the hernia sac treatment method on the occurrence of seroma after laparoscopic transabdominal preperitoneal hernia repair

PURPOSE

To determine whether transection of the hernia sac during laparoscopic transabdominal preperitoneal hernia repair (TAPP) affects the occurrence of seroma, and to explore the risk factors for seroma.

METHODS

In total, 330 consecutive male patients with indirect inguinal hernia who underwent TAPP repair at the Qingdao University Affiliated Hospital from January 2020 to June 2021 were retrospectively enrolled in this study. According to the intraoperative hernia sac treatment, patients were divided into a completely reduced sac group and a transected sac group.

RESULTS

Among the 330 inguinal hernia male patients, 240 received hernia sac reduction and 90 received hernia sac transection. Fifty-four patients developed seroma, with an incidence of 16.4%. In patients with a hernia defect measuring ≥3 cm and extension into the scrotum, the difference in the incidence of seroma between the two treatment groups approached significance (P = 0.052). The risk factors for seroma, high body mass index, hernia sac ≥3 cm, extension of the hernia into the scrotum and operation time were significantly associated with postoperative seroma.

CONCLUSION

This study showed that the incidence of seroma after TAPP was as high as 16.4%. For patients with a hernia sac that is too large and descended extends into the scrotum, transection may be better than complete dissection of the hernia sac and preventive measures should be taken for patients with high body mass index, hernia sac measuring ≥3 cm, and a high risk of the hernia extending into the scrotum.

Quality of Life after Desarda Technique for Inguinal Hernia Repair-A Comparative Retrospective Multicenter Study of 120 Patients

Inguinal hernia repair, according to Desarda, is a pure tissue surgical technique using external oblique fascia to reinforce the posterior wall of the inguinal canal. This has provided an impetus for the rethinking of guideline adherence toward minimally invasive and mesh-based surgery of inguinal hernia. In this study, a retrospective analysis of this technique was conducted in two German hospitals. Between 6/2013 and 12/2020, 120 operations were performed. Analysis included patient characteristics, duration of operation, length of hospital stay, and perioperative complications. Data were used to achieve a matched-pair analysis comparing Desarda to laparoscopic transabdominal preperitoneal (TAPP) hernia repair. Propensity scores were calculated based on five preoperative variables, including sex, age, American Society of Anesthesiology classification, localization, and width of the inguinal hernia in order to achieve comparability. Additionally, we assessed pain level and quality of life (QoL) 12 months postoperatively. The focus of our study was a comparison of QoL to a reference population and TAPP cohort. The study population consisted of 106 male and 14 female patients, and the median age was 37.5 years. The median operation time was 50 min, and the median length of hospital stay was 2 days. At a follow-up of 17 months, the median recurrence rate was 0.8%, and two cases of chronic postoperative pain were recorded. Postoperative QoL does not significantly differ between Desarda and TAPP. In contrast, Desarda patients had a significantly higher QoL compared with the reference population. In summary, Desarda's procedure is a good option as a pure tissue method for inguinal hernia repair.

Risk factors for early and late morbidity in patients with cardiovascular disease undergoing inguinal hernia repair with a tailored approach: a single-center cohort study

BACKGROUND

Inguinal hernia repair is a common procedure in surgery. Patients with cardiovascular disease have an increased operative risk for postoperative morbidity. The study aimed to identify the most beneficial surgical procedure for these patients.

METHODS

Patients undergoing elective surgery for unilateral or bilateral inguinal hernia between December 2015 and February 2020 were included. The cohort was divided into the group of patients with (CVD group) and without (NO group) cardiovascular disease and analyzed according to the postoperative morbidity distribution and correlated to the surgical technique used.

RESULTS

Of the 474 patients included 223 (47%) were operated on using the Lichtenstein technique and 251 (53%) using TAPP, respectively. In the CVD group the Lichtenstein procedure was more common (n = 102, 68.9%), in the NO group it was TAPP (n = 205, 62.9%; p < 0.001). 13 (8.8%) patients in the CVD group and 12 (3.7%) patients in the NO group developed a postoperative hematoma (p = 0.023). In the further subgroup analysis within the CVD group revealed cumarine treatment as a risk factor for postoperative hematoma development, whereas the laparoscopic approach did not elevate the morbidity risk.

CONCLUSION

CVD is a known risk factor for perioperative morbidity in general surgery, however, the TAPP method does not elevate the individual perioperative risk.

Robotic versus laparoscopic transabdominal preperitoneal (TAPP) approaches to bilateral hernia repair: a multicenter retrospective study using propensity score matching analysis

BACKGROUND

Since the introduction of minimally invasive surgery, new techniques like transabdominal preperitoneal (TAPP) repair have progressively gained acceptance for the treatment of groin hernia. Laparoscopic TAPP (LTAPP) is recommended for bilateral repairs. Likewise, the introduction of robotic platforms has promised additional surgical benefits for robotic TAPP (RTAPP), which are yet to be confirmed. This study compared multicenter data obtained from patients undergoing bilateral inguinal hernia repair with RTAPP, performed during the preliminary learning curve period, versus conventional LTAPP.

MATERIALS AND METHODS

All consecutive bilateral inguinal hernia patients from four Italian centers between June 2015 and July 2020 were selected. A propensity score model was used to compare patients treated with LTAPP versus RTAPP, considering sex, age, body mass index, current smoking status, overall comorbidity, hernia classification (primary or recurrent), and associated procedures as covariates. After matching, intraoperative details and postoperative outcomes were evaluated.

RESULTS

In total, 275 LTAPP and 40 RTAPP were performed. After matching, 80 and 40 patients were allocated to the LTAPP and RTAPP cohorts, respectively. No intraoperative complications or conversion to open surgery occurred. However, a longer operative time was recorded in the RTAPP group (79 ± 21 versus 98 ± 29 min; p < 0.001). Postoperative visual analog scale (VAS) pain scores (p = 0.13) did not differ and complication rates were similar. There were no clinical recurrences in either group, with mean follow-up periods of 52 ± 14 (LTAPP) and 35 ± 8 (RTAPP) months. A statistical difference in length of hospital stay was found between the groups (1.05 ± 0.22 vs 1.50 ± 0.74 days; p < 0.001).

CONCLUSION

In this patient population, outcomes for bilateral inguinal hernia repair appear comparable for RTAPP and LTAPP, except for a shorter recovery after laparoscopic surgery. A longer operative time for robotic surgery could be attributable to the learning curve period of each center.

Nationwide analysis of laparoscopic groin hernia repair in Italy from 2015 to 2020

Since its introduction, the minimally invasive treatment of groin hernias has become widely accepted as a viable alternative to open surgery. Still, the rates and reasons for its adoption vary highly among countries and the regions within a country. After almost thirty years since its introduction, its spread is still limited. The present study, conducted under the auspices of AGENAS (Italian National Agency for Regional Services), aims at giving a snapshot of the spreading of minimally invasive and robotic techniques for the treatment of groin hernia in Italy. This study is retrospective, with data covering the period from 1st January 2015 to 31st December 2020. AGENAS provided data using the operation and diagnosis codes used at discharge and reported in the International Classification of Diseases 9th revision (ICD9 2002 version). Admissions performed on an outpatient basis, i.e., without an overnight stay of at least one night in hospital, were excluded. A total of 33,925 laparoscopic hernia repairs were performed during the considered period. Overall, a slight increase in the number of procedures performed was observed from 2015 to 2019, with a mean annual change of 8.60% (CI: 6.46-10.74; p < 0.0001). The number of laparoscopic procedures dropped in 2020, and when considering the whole period, the mean annual change was - 0.98% (CI: - 7.41-5.45; p < 0.0001). Urgent procedures ranged from 335 in 2015 to 508 in 2020 referring to absolute frequencies, and from 0.87% to 9.8% in relative frequencies of overall procedures in 2017 and 2020, respectively (mean = 4.51%; CI = 3.02%-6%; p < 0.001). The most relevant observation that could be made according to our analysis was that the adoption of the laparoscopic approach knew a slow but steady increase from 2015 onward.

Laparoscopic transabdominal preperitoneal repair for recurrent obturator hernia initially treated by open mesh plug repair: A case report with video

An 80-year-old woman presented to our emergency department with vomiting which had begun half a day prior to presentation. She had undergone open mesh plug repair for a right obturator hernia 1 year prior to presentation. Computed tomography detected recurrence of the right obturator hernia. Since intestinal viability was maintained, manual reduction of the incarcerated intestine was performed. The patient was admitted to our department to monitor delayed intestinal perforation. Laparoscopic transabdominal preperitoneal repair for obturator hernia was performed 5 days after admission. A self-fixating mesh was placed over the obturator hernia defect and femoral ring without tacking. The patient was discharged on postoperative day 6 without postoperative complications. At the 4-month follow-up, no signs of hernia recurrence or neuropathy were observed. Laparoscopic transabdominal preperitoneal repair for recurrent obturator hernia status post-open mesh plug repair by using self-fixating mesh is a safe and suitable procedure.

Can a new role, the (Trainee) Associate Psychological Practitioner (T/APP), add value in General Practice? Results from the pilot year evaluation

Background:

The deployment of (Trainee) Associate Psychological Practitioners (T/APPs) to deliver brief psychological interventions focusing on preventing mental health deterioration and promoting emotional wellbeing in General Practice settings is a novel development in the North West of England. As the need and demand for psychological practitioners increases, new workforce supply routes are required to meet this growth.

Aims:

To evaluate the clinical impact and efficacy of the mental health prevention and promotion service, provided by the T/APPs and the acceptability of the role from the perspective of the workforce and the role to T/APPs, patients and services.

Methods:

A mixed-methods design was used. To evaluate clinical outcomes, patients completed measures of wellbeing (WEMWBS), depression (PHQ-9), anxiety (GAD-7) and resilience (BRS) at the first session, final session and at a 4–6 week follow-up. Paired-samples t-tests were conducted comparing scores from session 1 and session 4, and session 1 and follow-up for each of the four outcome measures. To evaluate acceptability, questionnaires were sent to General Practice staff, T/APPs and patients to gather qualitative and quantitative feedback on their views of the T/APP role. Quantitative responses were collated and summarised. Qualitative responses were analysed using inductive summative content analysis to identify themes.

Results:

T-test analysis revealed clinically and statistically significant reductions in depression and anxiety and elevations in wellbeing and resiliency between session 1 and session 4, and at follow-up. Moderate–large effect sizes were recorded. Acceptability of the T/APP role was established across General Practice staff, T/APPs and patients. Content analysis revealed two main themes: positive feedback and constructive feedback. Positive sub-themes included accessibility of support, type of support, patient benefit and primary care network benefit. Constructive sub-themes included integration of the role and limitations to the support.

Conclusions:

The introduction of T/APPs into General Practice settings to deliver brief mental health prevention and promotion interventions is both clinically effective and acceptable to patients, General Practice staff and psychology graduates.

Diagnosis and Treatment of Inguinal Hernias after Surgical Treatment of Prostate Cancer, Current State of the Problem

(1) Purpose: To compare and evaluate the immediate and long-term results of the use of various hernioplasties for the treatment of inguinal hernias after surgical treatment of prostate cancer; to determine the possibility of performing transabdominal preperitoneal (TAPP) hernioplasty and total extraperitoneal (eTEP) hernioplasty in patients with inguinal hernia during surgical treatment of prostate cancer. (2) Method: This study is a clinical analytical prospective study, without the use of randomization. The study included 220 patients with inguinal hernia, who were randomly divided into two groups (group A (n = 100) and group B (n = 120)). Patients in group A received eTEP, and those in group B received TAPP. The end points of the study were the results associated with the operation itself and the prognosis of the disease in the two groups. (3) Results: Group A: five patients had a scrotal hematoma, in 10 cases nosocomial pneumonia or infectious complications from the postoperative wound. The overall rate of early postoperative complications was 15%. In group B, the following postoperative complications were reported: one case of intestinal injury, six cases of acute urinary retention, eight cases of scrotal hematoma and 12 cases of nosocomial pneumonia or infectious complications from the postoperative wound were admitted. The overall incidence of early postoperative complications was 22.5%. There was no statistically significant difference in the incidence of postoperative complications between the two groups (χ2 (3) = 2.54, p > 0.05). (4) Conclusion: During the analysis of the obtained results, no statistically significant difference was found in the duration of hospitalization, the volume of blood loss, the severity of pain syndrome, postoperative complication incidence and recurrence incidence (p > 0.05); however, the comparison groups differed in the duration of the operation: the operation time in group A was much longer compared to group B (p < 0.05).

Evaluation of the Factors Influencing on Intraoperative Difficulty Scores of Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair

Background: Inguinal hernias are the leading surgical diseases in the world. There are different surgical procedures reported for the treatment. Some problems are thought to be encountered when performing laparoscopic surgery in these patients, such as risk of severe complications and the prolonged operative duration. Aim: The objective of this study was to specify the complexity of the transabdominal preperitoneal (TAPP) procedure by using an intraoperative scoring system and examine the scores with these patients' predictive factors. Materials and Methods: A prospective study was conducted in patients who underwent inguinal hernia surgery with TAPP. Previous lower abdominal surgery, previous (open) hernia surgery, body mass index (BMI), type of hernia, duration of the surgery, scoring the difficulty of the operation in five various stages using the visual analog scale (VAS) score (1. Mobilizing the peritoneum/dissection of the inferior peritoneal flap. 2. Dissection of internal ring or vas deference or hernia sac. 3. Visualization of Cooper's ligament. 4. Mesh placement. 5. Peritoneal closure.) and the time of discharge were recorded. Results: In this study, 137 patients were included. "BMI" and "previous lower abdominal surgery" have significantly higher scores, time of surgery, and hospital stay compared with other risk factors (P < .005). Conclusion: This study showed that patient's BMI and previous lower abdominal surgery could create technical difficulty with the TAPP procedure, but it is not necessary to avoid this laparoscopic technique because of these situations and can be performed safely.

Varying convalescence recommendations after inguinal hernia repair: a systematic scoping review

PURPOSE

The most recent international guideline on inguinal hernia management recommends a short convalescence after repair. However, surgeons' recommendations may vary. The objective of this study was to give an overview of the current convalescence recommendations in the literature subdivided on the Lichtenstein and laparoscopic inguinal hernia repairs.

METHODS

In this systematic review, three databases were searched in August 2021 to identify studies on inguinal hernia repairs with a statement about postoperative convalescence recommendations. The outcome was convalescence recommendations subdivided on daily activities, light work, heavy lifting, and sport.

RESULTS

In total, 91 studies fulfilled the eligibility criteria, and 50 and 58 studies reported about convalescence recommendations after Lichtenstein and laparoscopic repairs, respectively. Patients were instructed with a wide range of convalescence recommendations. A total of 34 Lichtenstein studies and 35 laparoscopic studies recommended resumption of daily activities as soon as possible. Following Lichtenstein repairs, the patients were instructed to resume light work after median 0 days (interquartile range (IQR) 0-0), heavy lifting after 42 days (IQR 14-42), and sport after 7 days (IQR 0-29). Following laparoscopic procedures, the patients were instructed to resume light work after median 0 days (IQR 0-0), heavy lifting after 14 days (IQR 10-28), and sport after 12 days (IQR 7-23).

CONCLUSION

This study revealed a broad spectrum of convalescence recommendations depending on activity level following inguinal hernia repair, which likely reflects a lack of high-quality evidence within this field.

Three-point mesh fixation in robot-assisted transabdominal preperitoneal (R-TAPP) repair of 208 inguinal hernias: preliminary results of a single-center consecutive series

PURPOSE

The aim of this study was to assess the efficacy of our mesh fixation technique in robot-assisted transabdominal preperitoneal inguinal hernia repair (R-TAPP). The primary outcome was the recurrence rate. Secondary outcomes were postoperative pain, chronic pain, and return to normal activities.

METHODS

Between January 2018 and December 2019, we performed 208 consecutive R-TAPP in 161 patients and the mesh was fixed by three intracorporeal stiches using a Polyglactin 910 (Vicryl®) 3-0 suture. Patients were followed up at 10 and 30 days after surgery with a clinical evaluation for detection of early complications, postoperative pain, need for analgesics, return to normal activities, and satisfaction rate. Patients were further followed up at study conclusion in February 2021 for recurrence and chronic pain detection.

RESULTS

Painkillers were stopped by 57% of the patients after the first postoperative day and by 96% after 1 week. Chronic pain (> 3 months after surgery) was observed in three patients (1.8%) and only one of them was treated with percutaneous ilioinguinal-iliohypogastric nerve infiltration. After a mean follow-up of 24.0 ± 6.7 months, only 1 recurrence (0.48%) was clinically detected and confirmed by a CT-scan.

CONCLUSIONS

The 3-point mesh fixation technique is feasible during robot-assisted TAPP repair for inguinal hernia and seems to be a viable alternative to other fixation methods. Further long-term controlled investigations are needed to understand if this technique is effective in influencing recurrence and chronic pain rates.

Can a Fully Articulating Electromechanical Laparoscopic Needle Driver Compare with a Robotic Platform in Transabdominal Preperitoneal Inguinal Hernia Repair?

Background: Enhanced laparoscopic instruments are filling the gap between straight-stick laparoscopic equipment and robotic platforms. We sought to evaluate the performance and cost of the HandX™ device during mesh fixation and peritoneal flap closure of transabdominal preperitoneal (TAPP) inguinal hernia repairs. Methods: The video recordings of a consecutive series of TAPP surgeries using the articulated needle driver device were compared with a series of surgeries on the DaVinci robotic platform by a single surgeon. Two critical steps of the procedure were analyzed: mesh fixation and peritoneal closure. A cost analysis between the two platforms was completed. Results: We analyzed 27 cases using the new needle driver and 27 cases using the DaVinci Surgical Robotic system. To evaluate the learning curve (LC) with the HandX device, we created three groups (G1, G2, and G3). The two latter groups were combined and called after LC. Mean fixation time using the DaVinci system was 258.1 seconds (±100.4) compared with 391.5 (±95.9) using the articulating handheld laparoscopic needle driver after LC (P < .001). The average time for peritoneal closure was 418.6 (±192.1) seconds for DaVinci and 634.5 (±159.5) seconds for HandX (P < .001). When comparing the after-LC HandX cases and the DaVinci system stratified by side, there was no significant difference in peritoneal closure in the right side (520.1 seconds (84.3) with the HandX versus 444.2 seconds (229.7) using the DaVinci system (P = .353). When evaluating direct cost of the instruments, HandX cases had a lower cost (310 USD) when compared with the cost of using DaVinci (973 USD). Conclusions: The new smart articulating needle driver may be a cost-effective means of bringing some of the benefits of the robotic platform to laparoscopy.

Lichtenstein versus transabdominal preperitoneal (TAPP) inguinal hernia repair for unilateral non recurrent hernia: A multicenter short term randomized comparative study of clinical outcomes

Background

The repair of inguinal hernia is still one of the most prevalent surgical procedures done worldwide. Among all repair techniques, open Lichtenstein repair is the most globally conducted. In the past few decades, laparoscopic technique for inguinal hernia repair has increased technical demand. Trans-abdominal pre-peritoneal (TAPP) technique is the main approach, which is featured by less postoperative pain and early recovery.

Objective

The current work is a short-term study to make a comparison between open Lichtenstein repair of inguinal hernia as well as laparoscopic trans-abdominal preperitoneal repair of inguinal hernia (TAPP) for unilateral non recurrent hernia regarding intraoperative, postoperative complications and hospital stay.

Patients and methods

The present prospective randomized study recruited 100 male subjects from General Surgery Department of Al-Azhar University Hospitals and Ain Shams university hospitals suffering from oblique inguinal hernia (unilateral non recurrent hernia) with an age above 18 years and good overall health, who were randomized into two groups: Group A: 49 cases were subjected to laparoscopic trans-abdominal pre-peritoneal repair (TAPP). Group B: 51 cases were subjected to open Lichtenstein repair.

Results

This study detected less post-operative pain day 0, day 1, day 7 and 1 month postoperatively. There was no significant difference at 6 months post-operatively.

Conclusion

Finally, we concluded that TAPP repair for inguinal hernia (unilateral non recurrent hernia) safer with less early post-operative pain. Also, it has fewer complications, with a significantly longer operative time.

•

Inguinal hernia can be treated with either open surgical technique (Lichtenstein) or laparoscopic technique (transabdominal preperitoneal repair).

•

TAPP repair for inguinal hernia safer with less early post-operative pain.

•

There is no statistical difference as regard to surgical complications and post-operative recurrence.

Adding Laparoscopic Iliopubic Tract Repair to Transabdominal Preperitoneal Hernioplasty for Treatment of Recurrent Inguinal Hernia After Totally Extraperitoneal Hernioplasty

Background: In patients with recurrent inguinal hernia (IH) after totally extraperitoneal (TEP) hernioplasty, re-TEP hernioplasty is difficult because of fibrotic adhesions. Re-laparoscopic hernioplasty is possible by changing the approach from extraperitoneal to transabdominal. If iliopubic tract repair (IPTR), mainly used in the past for the open approach, is added as a laparoscopic procedure, re-laparoscopic hernioplasty is possible when treating recurrent IH. We aimed to evaluate the safety and feasibility of alternate transabdominal preperitoneal (TAPP) hernioplasty supplemented by IPTR for treating recurrent IH after TEP hernioplasty. Methods: We retrospectively evaluated 2600 patients with IHs who underwent TAPP hernioplasty from January 2015 to December 2020. Among patients with recurrent IH, those who underwent primary TEP were included in the study. For reoperation, TAPP hernioplasty was performed and IPTR was added. IPTR was performed by suture closure of the internal inguinal ring by the iliopubic tract and medial aponeurotic arch of the transversus abdominis muscle. Results: Of the 35 patients (33 males and 2 females) with recurrent IH after primary TEP hernioplasty, 51% (18/35) of patients had recurrence within 2 years of the first operation. There were 28 recurrent IHs of the same type as the original, and 7 cases of a different type. The mean TAPP operation time was 41 minutes. Chronic inguinodynia and re-recurrence was not observed. One patient had inferior epigastric vessel injury, which was successfully repaired. Conclusion: Adding laparoscopic IPTR to TAPP hernioplasty is safe feasible treatment for recurrent IH after TEP hernioplasty.

Adolescent inguinal hernia repair: a review of the literature and recommendations for selective management

BACKGROUND

The choice of how to repair inguinal hernias in adolescents has historically been a matter of experience and differed between pediatric surgeons who traditionally performed a high ligation of the sac and general surgeons who typically perform a repair using mesh. This up-to-date review thoroughly examines the subject and discusses the suitability of both types of repairs in this unique age group.

METHODS

A 20-year Pub Med search was performed for the following terms: adolescent hernia repair including reports of mesh hernia repair in adolescents and postoperative complications including chronic inguinal pain and recurrences.

RESULTS

The evidence in the literature suggests that while there appears to be no difference between the two types of repairs with regards to recurrence and complications, changes in the pelvic floor physiology in adolescents suggest that a selective, individualized approach can be recommended depending on the size and nature of the presenting pathology.

CONCLUSIONS

A selective approach to the inguinal hernia in adolescent patients based on the size of the defect appears justified.

[Pain and quality of life after laparoscopic transabdominal preperitoneal hernioplasty with different ways of fixing the peritoneum. Results of early completion randomized clinical trial]

OBJECTIVE

To compare and statistically evaluate the severity of pain syndrome and quality of life depending on the method of fixation of the parietal peritoneum during laparoscopic hernia repair (suture fixation or the use of tack fixation).

METHODS

A randomized clinical trial was conducted from May to June 2021 at the Lomonosov Moscow State University Medical Center. It was planned to observe patients for a year. In the first group, the fixation of the parietal peritoneum was performed using suture fixation, in the second group, the peritoneal flap was fixed using a fixation device. In the course of statistical data processing, it was planned to study the dependence of the duration of the operation, the severity of the pain syndrome in the early postoperative period, the frequency of complications, the quality of life of patients in the postoperative period on the chosen method of the fixation of the parietal peritoneum.

RESULTS

At the initial stage of the study, 8 patients with inguinal hernias were selected in the first group during randomization, and 6 patients were selected in the second group. Each patient of the second group in the early postoperative period had a more pronounced local pain, protective muscle tension in the projection of fixation of the parietal peritoneum with tacks, which was accompanied by negative psychoemotional reactions, an increase in the dose of analgesic drugs. Due to the revealed features of the early postoperative period in patients of second group, it was considered unethical and inappropriate to continue the study within the protocol.

CONCLUSION

The results obtained do not allow us to draw statistically supported conclusions. The solution of the problem of the peritoneal flap fixation method is possible in two ways: abandoning stapler fixation in favor of suture or conducting additional clinical studies with an analysis of the impact of the choice of peritoneal fixation technique not only on acute and chronic postoperative pain, but on quality of life in the early and delayed postoperative periods.

Comparison between TAPP & Lichtenstein techniques for inguinal hernia repair: A retrospective cohort study

Background

Worldwide, inguinal hernia repair is one of the commonest surgeries. The best treatment option to primary hernia has been investigated, but there still remains lack of evidence about the ideal approach. Therefore, this study aimed to compare the outcomes of inguinal hernia repair using transabdominal preperitoneal procedure (TAPP) & Lichtenstein techniques.

Materials and methods

This was a retrospective cohort study, conducted at Department of General & Minimal Invasive Surgery, SKIMS Medical College, Bemina, Srinagar. For performing the analysis, we used SPSS. Continuous variables were expressed as mean and standard deviation, and the categorical ones were presented as frequencies and percentages.

Results

A total of 60 patients were included (30 in each group). The mean age of the patients in both groups was around 54 years, and all patients were males. In unilateral cases the operating time was greater in the TAPP group than the Lichtenstein group (p < 0.001); however, in the bilateral cases, the operating time was significantly greater in the Lichtenstein than the TAPP group (p = 0.003). The pain scores, in unilateral cases, were significantly lower in the TAPP group than the Lichtenstein group (p < 0.001). The overall complication rate in the TAPP group was 6.7% while in the Lichtenstein group it was at 23.3%. In unilateral and bilateral cases, the patients significantly returned to work earlier in the TAPP group than those in the Lichtenstein group (p < 0.001).

Conclusion

TAPP and Lichtenstein techniques are both safe and reliable techniques for inguinal hernia repair. However, TAPP repair showed lesser post-operative pain, earlier discharge from the hospital, earlier return to usual activities, better cosmetic outcomes, and less persisting pain. However, there was no significant difference in the complication rate and TAPP repair was more costly for the patient.

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In unilateral inguinal hernia, operating time was significantly greater in TAPP group.

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In bilateral hernia, operating time was significantly greater in Lichtenstein group.

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In all cases, pain was significantly lower with TAPP than Lichtenstein groups.

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The overall complication rate was not significant between the two groups.

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Occult hernias on the opposite side could be identified in the TAPP group.

Laparoscopic transabdominal preperitoneal obturator hernioplasty with self-gripping mesh: A case report with operative video

INTRODUCTION

We investigated the effectiveness of a self-gripping mesh, which has microgrips attached to fibrous tissue, in laparoscopic transabdominal preperitoneal (TAPP) obturator hernia (OH) repair to minimize the risk of postoperative pain and obturator nerve injury.

PRESENTATION OF CASE

The patient was an 80-year-old woman who was transferred to our emergency department with abdominal pain in the right lower quadrant and low back pain that began half a day prior to presentation. Computed tomography (CT) detected right OH. Based on the results of the laboratory examination and dynamic CT, intestinal viability was maintained. Ultrasonography-assisted manual reduction of the incarcerated intestine was performed, followed by admission to our department to check for delayed perforation of the intestine. Laparoscopic TAPP OH repair was performed on day seven as an elective surgery. A self-gripping mesh was placed over the OH defect and the femoral ring without tacking. The patient was discharged on postoperative day four, without any complications.

DISCUSSION

Tacking of the mesh at the lateral and dorsal sides of the obturator canal is dangerous due to the presence of the obturator nerve and vessels. Self-gripping mesh use in laparoscopic TAPP OH repair is a rational decision in terms of avoiding tacking or suturing around the obturator canal while maintaining stable fixation of the mesh to prevent recurrence.

CONCLUSION

Laparoscopic TAPP OH repair with self-gripping mesh is a rational treatment option that reduces the risk of obturator nerve injury while maintaining the secure fixation of a mesh to prevent recurrence.

A "sacless hernia" with the orifice obscured by a preperitoneal lipoma: A case report

Introduction and importance

With the widespread use of laparoscopic inguinal hernia repair, it is known that some clinically evident inguinal hernias lack a peritoneal sac and are referred to as “sacless hernias”.

Presentation of case

A 61-year-old man presented with a left inguinal bulge. On physical examination, the diagnosis of bilateral inguinal hernias was made, and laparoscopic transabdominal repair was performed. Intraoperatively, the left peritoneal hernia orifice was not identified from the peritoneal cavity and there was only a lipoma. Pressing the lipoma with forceps from inside the peritoneum confirmed the presence of a hernia. The preperitoneal space was opened and the hernia orifice revealed.

Discussion

The terminology and definition of sacless hernias are poorly defined, even though this is not a rare condition. Consistent with Russell's dogma, there are arguments that any prolapse can only be called a hernia if there is an accompanying peritoneal sac. The proportion of patients with sacless hernias and pure cord lipomas are very similar and these conditions are often confused. Detailed and repeated physical examination may distinguish a sacless hernia from a pure lipoma. A watchful waiting strategy is useful and ensures safety.

Conclusion

Once the diagnosis of inguinal hernia is made on physical examination, open the preperitoneal cavity if a peritoneal hernia orifice was not identified during laparoscopy.

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The exact terminology and definition of a “sacless hernia” is still unclear and there were very few literatures, despite this situation has been commonly known.

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Attention should be paid not to confuse a sacless hernia with a spermatic cord lipoma. Preoperative physical examination and diagnosis is a key to distinguish them.

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Once a robust diagnosis of inguinal hernia is made by physical examination, open the preperitoneal cavity if the peritoneal hernia orifice was not identified during laparoscopy.

Current status and future perspectives of robotic inguinal hernia repair

With more than 5500 da Vinci Surgical System (DVSS) installed worldwide, the robotic approach for general surgery, including for inguinal hernia repair, is gaining popularity in the USA. However, in many countries outside the USA, robotic surgery is performed at only a few advanced institutions; therefore, its advantages over the open or laparoscopic approaches for inguinal hernia repair are unclear. Several retrospective studies have demonstrated the safety and feasibility of robotic inguinal hernia repair, but there is still no firm evidence to support the superiority of robotic surgery for this procedure or its long-term clinical outcomes. Robotic surgery has the potential to overcome the disadvantages of conventional laparoscopic surgery through appropriate utilization of technological advantages, such as wristed instruments, tremor filtering, and high-resolution 3D images. The potential benefits of robotic inguinal hernia repair are lower rates of complications or recurrence than open and laparoscopic surgery, with less postoperative pain, and a rapid learning curve for surgeons. In this review, we summarize the current status and future prospects of robotic inguinal hernia repair and discuss the issues associated with this procedure.

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.

Feasibility of Laparoscopic Transabdominal Preperitoneal Hernioplasty for Incarcerated Inguinal Hernia

Background/Objectives:

An incarcerated inguinal hernia (IncIH) is defined as an irreducible inguinal hernia. The problems caused by long-term incarceration are adhesion between the incarcerated organ and hernial sac and difficulty in reduction of the edematous incarcerated organ. The present study was performed to evaluate the feasibility of laparoscopic transabdominal preperitoneal (TAPP) hernioplasty to treat chronic IncIH.

Methods:

This retrospective study included 154 patients aged >20 years who were treated for IncIH from January 1, 2015 to October 31, 2020. Patients were categorized into those with symptoms for ≥ 3 months (chronic IncIH group, 134 patients) and those with symptoms for < 3 months (acute IncIH group, 20 patients).

Results:

The type of incarcerated organ differed between groups. The most frequently incarcerated organ was the intestine (85%, 17/20) in the acute IncIH group and the omentum (98%, 131/134) in the chronic IncIH group (p < 0.000). Compared with the chronic IncIH group, the acute IncIH group had a higher prevalence of pre-operative inguinal pain (85%, 17/20 vs 3%, 4/134; p < 0.000) and a lower prevalence of adhesion between the incarcerated organ and the hernial sac (5%, 1/20 vs 37%, 49/134; p = 0.011). Organ resection was performed in 1 patient in the acute IncIH group and 19 in the chronic IncIH group.

Conclusion:

In patients with chronic IncIH, TAPP hernioplasty was used to successfully resolve adhesion between the incarcerated organ and the hernial sac, avoiding organ resection by enabling intra-abdominal reduction in many patients. TAPP hernioplasty may be a feasible surgical method for the treatment of IncIH.

Laparoscopic versus open hernia repair in patients with incarcerated inguinal hernia

INTRODUCTION

Laparoscopic approach is employed very rarely in the treatment of patients with incarcerated inguinal hernia. The aim of the present study was to evaluate the safety and benefits of laparoscopic hernioplasty (TAPP) in the treatment of incarcerated inguinal hernia.

METHODS

It was a retrospective clinical study focused on comparison of perioperative and postoperative outcomes of laparoscopic and open hernia repair of incarcerated inguinal hernia. All adult patients undergoing surgery for incarcerated inguinal hernia at the University Hospital Ostrava between 2014 and 2018 were included in the study.

RESULTS

In total, 31 patients were enrolled into the study (20 patients with open hernia repair and 11 patients with laparoscopic transabdominal preperitoneal hernioplasty [TAPP]). Operative time was shorter in the laparoscopic group (69.5 vs 82.2 min, p=0.444); length of hospital stay was significantly shorter in the TAPP group (3.45 vs 8.5 days, p=0.010). Postoperative complications were more frequent in the open hernia repair group (40% vs 0.0%, p=0.134); the difference was not statistically significant.

CONCLUSION

Laparoscopic hernioplasty provides a safe and effective operating technique for patients with incarcerated inguinal hernia.

An inguinal hernia that arose after robot-assisted radical prostatectomy and the repair of an intraoperative external iliac vein injury: A case report

This case involved a 63-year-old man. He underwent robot-assisted radical prostatectomy (RARP) for prostate cancer. One year after the operation, he consulted our hospital about left inguinal swelling. Under a diagnosis of a left external inguinal hernia, transabdominal preperitoneal repair (TAPP) was performed under general anesthesia. The inside of the hernia orifice had been damaged by the RARP, and the resultant fibrosis was so marked that it was difficult to dissect the preperitoneal space. Furthermore, an external iliac vein injury occurred during the operation. The bleeding was controlled, and we used laparoscopic continuous non-absorbable sutures to repair the external iliac vein injury. The number of TAPP procedures performed after radical prostatectomy has been increasing in recent years, but dissecting the preperitoneal space inside a hernia orifice is difficult. Although external iliac vein injuries are rare complications of TAPP procedures, they can be laparoscopically repaired.

Inguinal hernia TAPP repair using Senhance® robotic platform: first multicenter report from the TRUST registry

PURPOSE

The purpose of this article was to provide feasibility and safety results of robotic transabdominal preperitoneal inguinal hernia repair (Robotic TAPP).

METHODS

We included 271 cases of robotic inguinal hernia TAPP repair using the Senhance^® robotic platform from four different centers between March 2017 and March 2020. Key data points were intraoperative and postoperative complication rate, operating time, length of hospital stay, postoperative pain score and time required to get back to a daily routine that were inserted in the TransEnterix European Patient Registry for Robotic assisted Laparoscopic Procedures in Urology, Abdominal Surgery, Thoracic and Gynecologic Surgery (TRUST).

RESULTS

We report 203 cases of unilateral and 68 cases of bilateral inguinal hernia repairs. Mean operative time was 74 ± 35 min (range 32-265 min), postoperative complications occurred in five (1.85%) cases, the intraoperative complication rate was five (1.85%). The average subjective patient-related pain score after the procedure was 3 ± 1.9 (range 1-9), length of hospital stay was 39 ± 28 h (range 4-288 h), and recovery time was 9.65 ± 8 days (range 1-36 days).

CONCLUSION

Robotic inguinal hernia TAPP repair shows inspiring results. It is a safe and doable procedure. However, cost analysis should be performed in future to show the superiority over other techniques.

Case Report: How an Iliac Vein Lesion During Totally Endoscopic Preperitoneal Repair of an Inguinal Hernia Can Be Safely Managed

Inguinal hernia repair is a common surgical procedure with an acceptably low complication rate. However, complications with potentially life-threating consequences may occur in rare cases. These complications might be very challenging to manage, even more in laparo-endoscopic interventions compared to open repair. One of these challenges can be the treatment of an intraoperative injury to the iliac vein. To the best of our knowledge, a lesion of the iliac vein during TEP (totally endoscopic preperitoneal) for inguinal hernia repair, and a safe technique for its management have not been reported yet. We report the case of a 75-year-old male patient with previous abdominal surgery scheduled for TEP repair of an inguinal hernia. During surgery, the iliac vein was damaged. If we had performed a laparotomy in this situation, the potentially life-threatening condition of the patient could have deteriorated further. Instead, to avoid a potential CO₂ associated embolism, the preperitoneal pressure was gradually reduced, and the positive end expiratory pressure (PEEP) was increased in the manner that a balance between excessive bleeding and potential development of a CO₂ embolism was achieved. The injured vein was sutured endoscopically, and in addition a hemostatic patch was applied. We then continued with the planned surgical procedure. Thrombosis of the sutured vein was prevented by prophylactic administration of low molecular weight heparin until the 14th postoperative day. We conclude that in case of major vein injury during TEP, which might happen irrespective of prior abdominal surgery, the preperitoneal pressure and PEEP adjustment can be used to handle the complication.