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   Table of Contents - Current issue
Coverpage
October-December 2022
Volume 5 | Issue 4
Page Nos. 159-228

Online since Saturday, December 24, 2022

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REVIEW ARTICLES  

Current status of inguinal hernia management: A review p. 159
Patrick J McBee, Ryan W Walters, Robert J Fitzgibbons
DOI:10.4103/ijawhs.ijawhs_36_22  
Groin hernias are the most common reason for primary care physicians to refer patients for surgical management. Patients often present with a bulge in the groin that is associated with pain in two-thirds of cases. Diagnosis is usually clinical, with physical exam and history being sufficient enough to confirm diagnosis without imaging. Groin hernias may be associated with morbidity and can become complicated by incarceration or strangulation, requiring emergent surgical repair. However, the risk of strangulation is sufficiently low in asymptomatic or minimally symptomatic patients with inguinal hernias that an initial approach of watchful waiting is safe and appropriate. Chronic pain and hernia recurrence are other potential complications that support a watchful waiting approach in asymptomatic patients. Patients with symptomatic hernias should be offered surgical repair. The objective of this paper is to review the current status of the clinical diagnosis and management of patients with inguinal hernias.
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ORIGINAL ARTICLES Top

Endoscopic and endoscopically assisted mini or less open sublay mesh repair (EMILOS and MILOS) of abdominal wall hernias: Update and 10-year experience of a single insitution p. 165
Wolfgang Reinpold, Cigdem Berger, Reinhard Bittner
DOI:10.4103/ijawhs.ijawhs_61_22  
Introduction: Abdominal wall hernia and incisional hernia repair are among the most frequent operations in general surgery. However, despite the use of mesh and other recent improvements, the open mesh techniques and laparoscopic IPOM repair have specific disadvantages and risks. Materials and Methods: To minimize complications of the existing open and laparoscopic techniques we developed the endoscopic Mini- or Less Open Sublay (EMILOS) and endoscopically assisted Mini- or Less Open Sublay (MILOS) concept. We report on our large series of minimally invasive sublay repair of and ventral incisional hernias. The operation is performed transhernially with light-holding laparoscopic instruments either under direct, or endoscopic visualization, while the abdominal wall is circumferentially elevated with retractors. An endoscopic light tube was developed to facilitate this approach (Endotorch,TM Wolf Company). Each MILOS operation can be converted to standard total extraperitoneal gas endoscopy (EMILOS repair) once an extraperitoneal space of at least 8 cm has been created. The technique allows minimal invasive repair of ventral hernias with concomitant rectus diastasis. In large eventrations E/MILOS m. transversus abdominis release (TAR) can be performed. All MILOS operations were prospectively documented in the German Hernia registry Herniamed. Technical modifications and improvements from the inception of the E/MILOS concept including variants of the EMILOS technique are addressed. Results: The total and surgical complication rates of 1745 E/MILOS incisional hernia operations were 4.6% and 3.1%, respectively. The reoperation rate was 1.7%. Haemorrhage, seroma, enterotomy, infection and bowel obstruction were detected in 1.0, 0.9, 0.2, 0.3 and 0.4 percent of the cases, respectively. The recurrence rate after one year was 1.2%. Chronic pain at rest, at activities and chronic pain requiring therapy was reported in 3.8, 7.4 and 3.6 percent, respectively. Conclusion: The MILOS technique allows minimally invasive transhernial repair of incisional hernias using large retromuscular / preperitoneal meshes with low morbidity. The technique is reproducible, cost effective, easy to standardize and combines the advantages of open sublay and the laparoscopic IPOM repair.
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Outcomes of transversus abdominis plane block in ventral hernia repair: A propensity score matching analysis using a national database p. 179
Mazen R Al-Mansour, Dan Neal, Cristina Crippen, Tyler Loftus, Thomas E Read, Patrick J Tighe
DOI:10.4103/ijawhs.ijawhs_37_22  
BACKGROUND: Transversus abdominis plane (TAP) block is often used for post-operative analgesia in ventral hernia repair (VHR). Most studies evaluating TAP in VHR are single-center studies. Our objective was to evaluate the outcomes of TAP in VHR using a national database. MATERIALS AND METHODS: We conducted a retrospective cohort study using Vizient Clinical Database. We included outpatient VHR in adults between 2017 and 2019. Patient, hernia, operative, and hospital characteristics were collected. The patients were divided into two groups depending on whether or not they received TAP. One-to-one propensity score matching (PSM) was used to create balanced groups. Rate of overnight stay, in-hospital opioid prescribing, and costs were compared between both groups. RESULTS: A total of 108,765 patients met the inclusion criteria. After PSM, there were 1,459 patients in each group. There were no statistically significant differences in baseline characteristics between the matched groups. There was no difference in the rates of overnight stay between the two groups (no-TAP=6%, TAP=7%, odds ratio [OR]=1.3, 95% confidence interval [CI] [0.997,1.77]). There were no clinically significant differences in the percentage of patients prescribed opioids (no-TAP=96%, TAP=95%, OR=0.70, 95% CI [0.50, 0.99]) or mean number of opioid doses prescribed (no-TAP=2.7, TAP=2.7, mean pairwise difference [MPD]=0.02, 95% CI [–0.10, 0.13]). The TAP group was associated with higher median direct cost ($4,400 vs. $3,200; MPD=$1,200, 95% CI [$1,000, $1,400]) and total cost ($7,100 vs. $5,200; MPD=$1,900, 95% CI [$1,600, $2,100]) when compared with the no-TAP group. CONCLUSION: We found no evidence that TAP in outpatient VHR was associated with the reduction in the rate of overnight stay or in-hospital opioid prescribing. However, TAP was associated with higher procedural costs.
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Can the preemptive use of lornoxicam or paracetamol prevent pain after inguinal hernia repair? A randomized prospective double-blind placebo controlled trial p. 185
Alp Alptekin, Zafer Ergul, M Ercan Sonmez, Celil Ugurlu, Haluk Gumus, Hakan Kulacoglu
DOI:10.4103/ijawhs.ijawhs_43_22  
INTRODUCTION: Nonsteroidal anti-inflammatory drugs have become a popular part of multimodal analgesic regimens particularly in ambulatory surgery. This study was designed to search the efficacy of preoperative administration of lornoxicam or paracetamol in patients who underwent open inguinal hernia repair. MATERIALS AND METHODS: American Society of Anesthesiologists Classification (ASA) I–III male patients with unilateral primary inguinal hernia scheduled for elective prosthetic repair under general anesthesia were randomly assigned to three groups. Group I patients were infused 100-ml normal saline 30 min before anesthesia (placebo), whereas Group II and Group III patients were given 8 mg lornoxicam or 1,000 mg paracetamol intravenously in 100-ml normal saline. Postoperative pain was treated with patient controlled intravenous morphine. Postoperative pain scores were evaluated with visual analog scale (VAS) in the recovery room and at 1st, 6th, 12th, and 24th hours postoperatively in all groups. Total amount of analgesics. Liker scale and SF-36 form was also used at 4th week follow-up in order assess quality of life. RESULTS: Totally 88 patients were completed the study (G1 = 28, G2 = 30, and G3 = 30). Preemptive use of both lornoxicam and paracetamol resulted in significantly lower recovery room VAS scores in comparison with placebo group (3.93, 3.73, and 5.25). Both lornoxicam and paracetamol groups (G2 and G3) displayed better results at 12th h than placebo group (P = 0.04). VAS scores at 24th hour were similar in three groups. Total morphine consumptions were also similar between the groups at all times. Total postoperative 1-week oral analgesic use was significantly less in G2 (lornoxicam), and G3 (paracetamol) in comparison with G1 (placebo). Quality of life indicators in Likert Scale and SF-36 form were also not different. CONCLUSION: Preemptive use of both lornoxicam and paracetamol may be effective in early postoperative pain control in patients undergo elective open inguinal hernia repair. However, there seems to be no difference between the efficacies of the two agents.
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Evaluation of diaphragmatic omental hernias by radiology: A prevalence study p. 192
Fatih Cankal, Berin T Demir, Ali Köksal
DOI:10.4103/ijawhs.ijawhs_44_22  
INTRODUCTION: This study aimed to describe the radiological features of omental hernias originating from the diaphragm and their localization on the diaphragm, examine their relationship with the thoracic and abdominal organs, and present guiding data to clinicians in operational planning. MATERIALS AND METHODS: This study was obtained as a result of retrospective scanning of the images of 824 patients aged 18–65 who applied for thorax and/or upper abdomen computerized tomography (CT). The patients’ thorax and upper abdomen regions were examined in detail and divided into two groups of individuals with and without hernias. Hernia types, content, localization, and effect types of patients with hernia were recorded and analyzed separately. RESULTS: Diaphragmatic hernia was detected in 197 (23.9%) of 824 patients. While 50.8% of these patients were female, 49.2% were male. Of the patients diagnosed with diaphragmatic hernia, 49.2% (n = 97) had Morgagni hernia, 30.5% (n = 60) had Bochdalek hernia, and 17.8% had hiatal hernia. While Morgagni hernia had anterior localization in 82.5%, Bochdalek hernia was generally localized on the left side (75.8%), and hiatal hernias were sliding type with a rate of 84.2%. The highest effect was observed in Bochdalek hernias (71.1%). Omental tissue (59.4%) was observed most frequently in Morgagni hernias, while stomach content (91.9%) was found to be the highest in hiatal hernias (P < 0.05). DISCUSSION–CONCLUSION: Diaphragmatic omental hernias are rare. The rarity, as well as the uncertain and nonspecific presentations, contributes to the retard in diagnosis. Commonly, the presentation in the adult age group is that of recurrent chest infection and rarely with gastroesophageal reflux and esophagitis. Physicians caring for these patients should be aware of this, and a high index of suspicion is recommended to obviate delay in diagnosis with its associated morbidity. We think the radiological features of diaphragmatic hernias should be detailed in determining and applying the optimal treatment approach. In addition, contrary to what was thought, we found that the prevalence of diaphragmatic hernia in our population is higher than that reported in the literature.
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CASE REPORTS Top

Management of an inguinal mixed Littré hernia and incidental cryptorchidism: A case report p. 200
Sofía N Gamboa Miño, Manuel E Zeledón, Aníbal J Solari, Gustavo H Alcántara
DOI:10.4103/ijawhs.ijawhs_5_22  
INTRODUCTION: Littré hernia is defined as the presence of a Meckel’s diverticulum in any hernia sac. The case of an adult with Littré hernia associated with a cryptorchidic testicle in the inguinal canal has not been previously reported. Treatment of this rare case is controversial on many fronts. This report highlights the management of a case with an inguinal mixed Littré hernia and incidental cryptorchidism. CASE PRESENTATION: A 32-year-old male patient with an incarcerated right inguinal hernia presented to the emergency department. An incarcerated mixed Littré hernia was discovered associated with a cryptorchidic testicle. A Lichtenstein hernioplasty and an orchidopexy were performed without resection of Meckel’s diverticulum. DISCUSSION: There is currently no consensus on the treatment of a Littré hernia nor incidental cryptorchidism in an adult patient. Controversies arise on whether to perform diverticulectomy or not and the type of hernia repair. This case had the added unique feature of an undiagnosed cryptorchidic testicle in an adult, a pathology that also prolongs controversies on whether it is necessary to resect. CONCLUSION: Treatment of a Littré hernia, Meckel’s diverticulum, and cryptorchidism in adult patients continues to be a challenge. Given the lack of guidelines that establish appropriate treatment, it must be decided on a case by case basis; however, a conservative approach seems to be safe.
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Femoral nerve injury following transabdominal preperitoneal inguinal hernia repair: A case report p. 204
Yimin Xu, Xiangyu Shao, Zhenling Ji, Junsheng Li
DOI:10.4103/ijawhs.ijawhs_20_22  
Chronic postoperative pain is a complication of open and laparoscopic inguinal hernia surgery. The most important factor to the development of postoperative pain is nerve injury. Of all nerve injuries, the damage to the femoral nerve is very rare. Electromyogram and nerve conduction velocity may provide the clue to proper treatment. The authors present a rare case of femoral hernia injury following transabdominal preperitoneal inguinal repair for a primary right inguinal hernia and emphasize the importance of non- or atraumatic mesh fixation during laparoendoscopic inguinal hernia repair.
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Congenital spigelian hernia and ipsilateral undescended testis: An ongoing etiological debate - A case report p. 209
Mustafa Okumuº, Elbrus Zerbaliyev, Arzu Akdağ
DOI:10.4103/ijawhs.ijawhs_38_22  
The etiopathogenesis of the relationship of congenital Spigelian hernia with ipsilateral undescended testis is still being debated. We have reviewed previous discussions of etiopathogenesis and presented our thoughts on the topic without mentioning the well-known diagnostic and treatment. On examination of a male newborn, swelling was detected in the right lower quadrant of the abdomen and the right testis could not be palpated. The infant was diagnosed with an ipsilateral undescended testis and a congenital Spigelian hernia after a consultation with a pediatric surgeon. A defect with a prominent margin of approximately 2–3 cm in diameter was detected during the surgery. The right orchiopexy and anatomical repair of the defect were done in the same session. In addition to Spigelian hernias, other ventral hernias can also appear with undescended testicles. We think that the main pathology is an ectopically located testis caused by abnormal gubernacular migration.
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Mesh infection of Mycobacterium fortuitum after inguinal hernia repair: A rare case report and literature review p. 212
Lu Chen, Gengwen Huang
DOI:10.4103/ijawhs.ijawhs_39_22  
PURPOSE: Inguinal hernia repair is one of the most common operations worldwide. The standard procedure now is tension-free hernioplasty with mesh implantation. Mesh repairs obviously reduce the rate of hernia recurrence and alleviate the pain. However, mesh infection is one of the most serious complications, which usually causes secondary operation. At present, no standard treatment measures of mesh infections, especially for rare pathogens such as nontuberculous mycobacteria (NTM), are available. MATERIALS AND METHODS: We present an unusual case of Mycobacterium fortuitum infection of implanted mesh after inguinal hernia repair. Medline and PubMed databases were searched using the keywords mentioned subsequently, and the literature on treatment measures of mesh infection of M. fortuitum and other subtypes of NTM after inguinal hernia repair is reviewed. RESULTS: Mesh infections of M. fortuitum are very rare after inguinal hernia repair. The infection is hard to diagnose and complex to treat. However, it has characteristic clinical manifestations. With early recognition and specific tests, clinicians can still confirm the infection. Treatments include antibiotics and surgical intervention. Mesh displantation is considered to be necessary and needs to be conducted as soon as possible. CONCLUSION: When a mesh infection is present, it is important to check the wound before obtaining bacteriological evidence. Once the mycobacteria infection is suspected, corresponding tests should be taken immediately. With appropriate treatment, patients will likely make a full recovery.
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Emergency presentation of Flood syndrome requiring immediate repair of umbilical hernia: A case report p. 218
Adianto Nugroho, Yuanita Permata, Indah Jamtani, Aditomo Widarso, Rofi Y Saunar
DOI:10.4103/ijawhs.ijawhs_42_22  
Long-term ascites and liver illness in its last stages might occasionally result in Flood syndrome. The abrupt surge of ascitic fluid that occurs along with an umbilical hernia that spontaneously ruptures gives rise to the syndrome's name. We described a patient who had cirrhosis and valvular heart disease in the past and had Flood syndrome with intestinal evisceration. To stop the progression of intestinal necrosis and septic consequences, immediate surgery to reduce the eviscerated bowel and mesh reinforcement was performed. In summary, Flood syndrome is a serious condition that needs to be treated very away, much like other forms of intestinal evisceration. The efficient management of comorbid disorders is essential for a better therapeutic outcome.
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TECHNICAL NOTE Top

Some more time with an old friend: Small details for better outcomes with Lichtenstein repair for inguinal hernias Highly accessed article p. 221
Hakan Kulacoglu
DOI:10.4103/ijawhs.ijawhs_40_22  
Lichtenstein repair (LR) was described by Irving Lichtenstein in mid-1980s, and was announced to be the gold standard for the treatment of inguinal hernias in 1990s. The technique is a tension-free repair with a prosthetic patch. Today LR is one of the most widely used surgical methods in the world, but it is hard to talk about uniformity in the technique among surgeons. Almost every surgeon has made some modifications to the technique and produced somewhat different repairs independently. In this paper, the original LR and the suggested modifications by the Institute are reviewed, and some critical points are presented with intraoperative photographs. LR is an economic choice, easy to learn, and can be performed with local anesthesia especially when the patient is frail. The technique requires a permanent prosthetic patch. Mesh fixation should be done with separate sutures preferably with monofilament absorbable material. Mesh size should not be kept small, and a 2-cm overlap should be provided beyond the pubic tubercle. A 15 cm × 7 cm commercial mesh can be trimmed and used. Mesh should extend laterally to the internal inguinal ring for 5–6 cm. A proper technique in LR is important for low recurrence and chronic pain rates. Therefore, every surgeon at every level of her/his carrier must know how to perform a decent LR.
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