BACKGROUND: Laparoscopic ventral hernia repair (LVHR) is a widely recognized procedure for treating ventral hernias, yet managing postoperative pain remains difficult. To enhance pain control following LVHR, we conducted a prospective evaluation of the effectiveness of ultrasound-guided transversus abdominis plane (TAP) block.
PATIENTS AND METHODS: Our study was a prospective double-blinded randomized controlled trial conducted from March 2021 to June 2022 which included 52 subjects, randomized into two groups (Groups T and P) of 26 each, by computer-generated simple randomization. After taking written informed consent, an ultrasound bilateral TAP block was given to both the groups in which Group T received the drug (0.375% of levobupivacaine 40mL), and Group P was a placebo (received 0.9% normal saline). Visual Analog Scale (VAS) for pain, the need for rescue analgesia, the time to ambulation within 24h, and the length of postoperative stay were used to assess the primary outcomes of the study.
RESULTS: The mean age was 56.5 years (SD = 8.814) in Group T and 53.57 years (SD = 9.161) in Group P. The average duration of surgery was 77.5min for Group T and 75.96min for Group P. Postoperative stay averaged 26.76h (SD = 7.941) in Group T and 31h (SD = 12.109) in Group P. It was observed that there was a statistically significant difference in VAS, the requirement for rescue analgesia, and ambulation between the two groups at 2, 6, and 12h. However, no significant difference was observed at 24h or in the averaged postoperative stay.
CONCLUSION: LVHR with mesh is a proven technique, but controlling postoperative pain remains a difficulty. An ultrasound-guided TAP block with a long-lasting local anesthetic, such as bupivacaine, can markedly lessen early postoperative pain and decrease the reliance on narcotics after LVHR.
TRIAL REGISTRATION: Clinical trial registry information: Clinical trial registry name: CTRI. Trial number: CTRI/2020/09/007897 (Registered on 04/09/2020) trial registered prospectively.
CONTEXT: Inguinal hernia is a common surgical condition, with over 20 million repairs worldwide annually. Recurrent inguinal hernias occur in 14% of men and 7% of women, with recurrence rates three times higher than primary cases. Recommendations for the surgical approach to recurrent hernias lack strong evidence.
AIMS: This study examines the outcomes of recurrent inguinal hernia surgeries and the patient factors influencing the choice of surgical technique.
METHODS: We conducted a retrospective cohort study at Pirogov City Clinical Hospital (2017-2023). Patient data were collected from medical records and surveys on short-term outcomes. The focus was on recurrence rates and chronic pain syndrome (CPS). Follow-up included physical exams and ultrasound.
STATISTICAL ANALYSIS USED: Data were analyzed using MS Excel and Jamovi 2.3.21. Categorical data are shown as counts and percentages, and continuous data as median (Me) and interquartile range (Q1-Q3). Statistical tests included the Student t test, Mann-Whitney test, Pearson’s chi-square, and the log-rank test for recurrence rates. A P-value < 0.05 was considered significant.
RESULTS: A total of 187 patients had TAPP (n = 130) or Lichtenstein (n = 57) repairs. TAPP was preferred for prior mesh or non-mesh repairs, and Lichtenstein for prior TAPP. Our assessment of surgical trends showed a preference for open mesh repair in older patients (P = 0.04), those presenting with extensive hernias (P < 0.01), indirect inguinal hernias (P = 0.016), and individuals with a prior diagnosis of prostatic disorders (P < 0.01). Nevertheless, this sample of patients demonstrated a statistically significant increase in postoperative sensory disturbances (10.64%, P = 0.05). Seven recurrences (6.6%) occurred in the TAPP group, though not significantly different. Long-term outcomes were similar between groups.
CONCLUSION: The optimal surgical approach for recurrent inguinal hernia remains unclear. Patient characteristics play a significant role in surgical decision-making.
CONTEXT: Hernias are common surgical conditions that may require emergency interventions due to complications such as strangulation, bowel obstruction, or ischemia. These situations significantly impact clinical outcomes and necessitate robust risk assessment tools.
AIMS: To evaluate mortality risk and surgical outcomes in emergency hernia repair patients using the Charlson comorbidity index (CCI) and to optimize clinical decision-making processes.
SETTINGS AND DESIGN: A retrospective study conducted at our General Surgery Clinic from 2021 to 2023.
MATERIALS AND METHODS: Data from 159 patients undergoing emergency hernia surgery were retrospectively analyzed. Variables included demographic data, hernia types, surgical interventions, and clinical outcomes. CCI and American Society of Anesthesiologists scores were calculated, and their impacts on mortality were assessed using logistic regression and chi-square tests.
STATISTICAL ANALYSIS USED: Logistic regression, chi-square tests, and cross-tabulation analyses.
RESULTS: Patients with a CCI score of 3-4 showed a significantly higher mortality risk (P = 0.000), while those with scores ≥5 exhibited elevated but statistically insignificant mortality risks (P = 0.141). Mortality was significantly associated with intestinal resection (P = 0.001). The time of presentation correlated with the likelihood of requiring resection (P = 0.000).
CONCLUSION: CCI is a reliable predictor of mortality risk in emergency hernia repair patients. Early risk assessment and timely intervention are crucial for improving outcomes.
BACKGROUND: Ventral hernias refer to a weakening or defect in the abdominal wall through which abdominal contents can protrude. Ventral hernia is a frequent problem in surgical practice which includes primary and incisional. Mesh repair is still the gold standard. Open approaches include retro-rectus (Rives-Stoppa) and onlay repair.
OBJECTIVES: The purpose of this study is to evaluate and compare the outcomes of both repairs in terms of efficacy and techniques, time taken for surgery, postoperative pain, length of hospital stays, complications, and recurrence.
MATERIALS AND METHODS: A retrospective study of 40 patients was carried out in all ventral hernia patients based on clinical and demographic parameters with a Tanaka index less than 25% and defect size less than 10 cm.
RESULTS: The results overall were more promising toward retro-rectus repair in terms of surgical site infections, skin necrosis, seroma, hematoma, and duration of drain placement (mean duration 2.85 ±0.75 days in retro-rectus group and 5.1 ±2.47 days in onlay group). However, onlay repair was associated with less time taken for surgery (mean duration 97.25 ±10.69 min for retro-rectus and 70.25 ±8.66 min for onlay), less postoperative pain, and shortened hospital stay (4.85 ±1.31 days for retro-rectus group and 3.10 ±1.02 days for onlay). There was no recurrence in both groups in our study.
CONCLUSION: Both approaches have their own pros and cons. The rate of complications and recurrence is lower with retro-rectus repair; however, onlay repair has less intricacies associated with surgery, a lesser learning curve, and an overall straightforward procedure compared to the one mentioned before.
PURPOSE: Repair of congenital diaphragmatic hernia (CDH) includes both mini-invasive and open approaches. We aimed to conduct a comprehensive meta-analysis comparing the outcomes of thoracoscopic and open CDH repairs in the pediatric population.
MATERIALS AND METHODS: A literature review using as keywords “thoracoscopy,” “open surgery,” and “CDH” was performed. The primary endpoints of the study were to evaluate mortality as well as major intraoperative and postoperative complications, including CDH recurrence. Secondary endpoints were the use of a patch, the length of stay, and operative time.
RESULTS: On 88 papers, 20 met the inclusion criteria (902 patients: 458 treated thoracoscopically and 444 undergone open surgery). There was no significant difference in major postoperative complications (P = 0.695) or use of patch (P = 0.282). Conversely, the thoracoscopic approach significantly reduces mortality (P = 0.001) and length of stay (P < 0.001). Open surgery reduces the incidence of major intraoperative complications (P < 0.001), recurrences (P = 0.025), and operative time (P < 0.001).
CONCLUSION: According to our analysis, open surgery seems to reduce intraoperative complications and recurrences. Moreover, thoracoscopy seems to show an improvement in mortality and length of stay. However, the lack of randomization in all the analyzed studies could represent a potential bias in the final conclusion and need a careful evaluation.
INTRODUCTION: The association between pregnancy and the risk of developing ventral hernias is unclear. This study aimed to assess the risk of developing a primary ventral hernia requiring repair and whether increasing parity is associated with a greater risk of developing a ventral hernia.
MATERIALS AND METHODS: This nationwide cohort study included women born between 1950 and 1980 who were registered in the Swedish Medical Birth Register (MBR). Data on pregnancies and vaginal or cesarean sections were retrieved from the birth register. The cohort was cross-matched with the National Patient Register (NPR) to identify subsequent primary hernia repairs.
RESULTS: This study included 1,630,754 women born between 1950 and 1980. Among these, 1,588,609 (97.4%) were registered in the MBR. The incidence rates for umbilical hernia repair (UHR) and epigastric hernia repair (EHR) were 13.2/100,000 person-years and 5.4 per 100,000 person-years, respectively. When compared with women registered for one delivery, the incidence rate ratio for UHR was higher among those with two deliveries (1.18, 95% CI:1.12-1.24) and among those registered with ≥3 deliveries (1.48 95% CI: 1.41-1.56). The incidence rate ratios were 1.29 (95% CI: 1.20-1.39) and 1.34 (95% CI: 1.24-1.45) for EHR among women with two and ≥3 registered deliveries, respectively.
CONCLUSION: A history of more than one pregnancy is associated with an increased incidence of umbilical and epigastric hernias.
Mesh erosion following hiatal hernia repair is a rare but serious postoperative issue. It can lead to esophageal stenosis, gastric and esophageal fistulae, and may necessitate extensive surgical tissue removal and reconstruction. Therefore, employing minimally invasive and appropriate treatment strategies is crucial for patient management. We present the case of a 65-year-old woman who experienced mesh erosion after hiatal hernia repair. She underwent laparoscopic surgery followed by staged endoscopic treatment, resulting in complete removal of the mesh with preservation of organs and avoidance of major surgery. This combined laparoscopic-endoscopic approach represents an optimal method for managing such complications.
Hernia repair remains one of the most common operative procedures performed by general surgeons and herniologists (hernia specialists). Congenital or acquired hernias fall into predictable categories: inguinal, ventral or abdominal, and incisional. Inguinal hernias are the most common accounting for roughly 70% of all hernias. Ventral, abdominal, and incisional hernias are interrelated and their prevalence varies. Other obscure or less common types of hernias include interparietal, obturator, femoral, and interstitial, and their prevalence is around 1%-2% at most. During our operative week, a unique patient presented for evaluation. Until that moment, our team of United States-based adult and pediatric surgeons lacked exceptional first-hand experience with inguinal interstitial hernias. These are generally recognized after previous abdominal wall trauma or surgeries as well as in the setting of congenital defects due to a testis that has not descended. Here, we present a rare case of an inguinal interstitial hernia containing an undescended left testicle that traversed through the internal ring, pivoting lateral and passing parallel to the inguinal canal and into the superficial thigh. Along its course, it traveled through the abdominal wall fascia protruding into the lower extremity, followed by the fascia lata, allowing the testicle and the hernia sac to reside in the left lower extremity thigh anterior compartment.
This case report describes a case of persistent abdominal wall pain following totally extraperitoneal inguinal hernia repair. The patient is a high-profile soccer player. The pain was undulant, imaging studies did not reveal any specific reason, and conservative treatments failed throughout a year. Surgical exploration revealed abdominal cutaneous nerve entrapment syndrome (ACNES) due to compression of fibrotic scar tissue around the suture material used for fascial closure. Surgical neurectomy provided relief of the pain. ACNES should be included within the possible causes of persistent pain after laparoscopic procedures such as inguinal hernia repairs. Lateral port entries over the rectus muscle sheath carries this risk. Chronic pain in the patient can be treated surgically with excision of the involved nerve.
Umbilical hernia is a common condition, but spontaneous rupture with omental evisceration, particularly in the absence of ascites or other risk factors, is extremely rare. We present a case of omental evisceration through a long-standing umbilical hernia in an adult male without any underlying conditions typically associated with elevated intra-abdominal pressure. The patient was treated successfully with emergency surgery, and the postoperative course was uneventful. A literature review revealed only four other reported cases of spontaneous umbilical hernia rupture without ascites in adults. Our case adds to the limited data available and emphasizes the importance of timely surgical intervention even in stable patients. Spontaneous rupture of umbilical hernias without ascites remains a rare occurrence, and this report serves to raise clinical awareness for the management of such cases in emergency settings.
Surgeons occasionally encounter lumbar hernias in their career, and the diagnosis needs a high index of suspicion. Of lumbar hernias, inferior lumbar hernias are less frequently encountered. A young male presenting with features of acute appendicitis was taken up for emergency laparoscopic appendicectomy. Interestingly, the appendix was found incarcerated in the right inferior lumbar triangle. After completion of appendicectomy, the narrow hernia defect was primarily sutured without mesh reinforcement. We focused on recognizing the presence of such rare hernia in par with Amyand’s hernia.
Congenital diaphragmatic hernia (CDH) is a rare developmental anomaly typically observed in neonates but can occasionally present in adults. CDH results from incomplete diaphragm development, leading to herniation of abdominal organs into the thoracic cavity, causing respiratory and gastrointestinal issues. This report discusses a 23-year-old male diagnosed with a right-sided congenital Bochdalek’s hernia. The patient presented with generalized abdominal pain, nausea, and respiratory symptoms. Imaging revealed a significant right diaphragmatic defect with herniation of multiple abdominal organs into the thoracic cavity. Initial laparoscopic attempts to reduce the hernia were unsuccessful due to dense adhesions, necessitating an open surgical approach. The herniated organs were reduced, and the diaphragmatic defect was repaired using non-absorbable sutures and a composite mesh. Postoperative recovery was complicated by transient abdominal compartment syndrome, which was managed conservatively. The patient recovered well and remained symptom-free during the 6-month follow-up period.
Internal hernias are a rare cause of acute intestinal obstruction, accounting for approximately 5.8% of all cases. Pericecal hernias, the second most common type of internal hernia, remain challenging to diagnose preoperatively, owing to the lack of specific clinical signs. Abdominal computed tomography is an essential examination, as it allows the diagnosis of acute intestinal obstruction, especially its etiology and signs of severity, such as intestinal ischemia. We report a case of a 35-year-old man who presented with small bowel obstruction with suspicion of pericecal hernia. An emergency laparotomy confirmed the diagnosis of a retrocecal hernia with the identification of four loops of ischemia requiring resection. Our case highlights the importance of considering this diagnosis in cases of acute abdominal pain, especially in acute intestinal obstruction, and emphasizes the crucial role of surgery in confirming the diagnosis, preventing complications, and treating the obstruction.
Incisional hernia (IH) is not rare and is prone to a number of different complications. We present herein a case of a huge IH originating from a Pfannenstiel incision, complicated by bowel strangulation with gangrene and perforation and subsequent abdominal wall necrosis. The clinical presentation was delayed until a frank peritonism developed due to intestinal gangrene, accompanied by a large, full-thickness necrosis of the abdominal wall. The patient presented septic shock and was managed by extensive debridement, peritoneal toilet and drainage, intestinal resection, and ileostomy. The open abdomen treatment was established and subsequent intra-abdominal negative pressure therapy. After the resolution of sepsis and granulating tissue formation, stoma closure and implant of a biological mesh completed the treatment, achieving full healing of the abdominal wall. The open abdomen, coupled with intra-abdominal negative pressure therapy, is a well-established method for the management of abdominal wall defects due to congenital disorders, abdominal wall tumors, necrotizing infections, previous abdominal surgeries, trauma, and trauma-associated infections. Complications in large IH in obese patients may have a misleading clinical presentation causing delays in treatment and resulting in challenging situations. However, accurate treatment like that employed in this case warrants good results reducing hospital stays and costs.
The term intercostal hernia (IH) refers to conditions where either the lung or abdominal viscera herniate through a defect in the intercostal space. Abdominal viscera can herniate through an intercostal space with (transdiaphragmatic IH) or without (abdominal IH) an associated diaphragm injury. Primary IHs are extremely rare, with only one case previously described in the literature. Here, we present the second case of a primary spontaneous abdominal intercostal hernia reported in the literature. The computed tomography scan revealed no rib fractures or diaphragm injuries, but it did reveal that the patient had two extra lumbar ribs, with the hernial defect located between the 12th and 13th right rib. Primary spontaneous IHs are extremely rare, so it could be hypothesized that they might not truly exist as a distinct clinical entity, suggesting an unrecognized cause that would classify them as acquired hernias, such as an extra pair of ribs or congenital diseases.