Those who do not know the past cannot understand the present and cannot shape the future. (Helmut Kohl, Chancellor of Germany 1982–1998). INTRODUCTION: Historical development of open and laparoendoscopic inguinal hernia repair is presented. Advantages and disadvantages of currently used techniques as well as problems related to the implementation of the minimal invasive techniques in daily surgical work are discussed. MATERIALS AND METHODS: Intensive study of the literature and our own personal experience with the performance of transabdominal preperitoneal patch plasty (TAPP) and totally extraperitoneal patch plasty (TEP) were used. Systematic descriptions of the TAPP and TEP techniques to achieve the best results are summarized. The penetration rate of the laparoendoscopic techniques worldwide is reviewed. RESULTS: Laparoendoscopic inguinal hernia repair is superior to open surgery with respect to all pain-associated parameters. Profound knowledge of the anatomy of the groin, of the pathophysiology of hernia development as well as of the working mechanisms of the surgical techniques are described as being the key features for successful treatment. The worldwide penetration rate of TAPP/TEP is dependent on the respective country and varies between 1% and 80%. The main reasons for these striking differences are the preference of individual surgeons, available resources of the specific national health care systems, differences in training facilities, and even differences in insurance coverage. New imaging systems as well as robot-assisted techniques are still need to be evaluated sufficiently for final recommendations. CONCLUSION: TAPP and TEP are well-established techniques of minimally invasive repair of inguinal hernias. Both techniques are safe, reliable, and cost-effective. Despite some meaningful advantages in comparison to open surgery, the penetration rate in most of the countries, however, remains low. Improvement of training techniques and facilities is urgently needed. Robot-assisted techniques and the use of simulators may be the promoter of laparoscopic inguinal hernia repair in the future.

PURPOSE: The aim of this article is to establish which is the best peri- and intraoperative approach for patients with giant inguinoscrotal hernia. METHODS: A systematic review of the literature was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria through a search in PubMed, Scielo, and other resources, from January 2011 to April 2020. Prospective, retrospective, case reports, and clinical series were included. Patients who underwent emergency procedures and studies involving children or pregnant women were excluded. RESULTS: A total of 24 publications related to giant inguinal hernia were identified, which together group a total of 81 patients. The average age of the patients was 62 years. Of the 81 patients, in 10 cases (12%), loss of domain was objectively established. In patients with loss of domain, preoperative pneumoperitoneum (PPP) + botulinum toxin type A (TBA) was used in 80% of the cases. In 10% only NPP was used and in the remaining 10% only TBA was used. Regarding the repair technique, 70% used the anterior route. The most frequent surgery was Lichtenstein’s procedure (38%), followed by Stoppa’s procedure (9%) and transabdominal preperitoneal procedure (9%). The most frequent complication was the development of seromas. The median postoperative follow-up was 15 months. CONCLUSIONS: Inguinoscrotal hernias with loss of domain are rare, and therefore their management is far from being clearly defined. In those cases, where the loss of domain is confirmed, both botulinum toxin and preoperative pneumoperitoneum have been used, without documenting major complications.To repair the defect, the most widely used technique is Lichtenstein’s procedure; however, the possibility of long-term recurrence should be assessed. The retrorectal repair could reduce the risk of recurrence as it is associated with greater mesh overlap.

BACKGROUND: Obturator hernia (OH) usually presents as a surgical emergency, with open primary repair most commonly performed. Given the morbidity and high recurrence of this approach, we present a case and review the literature to evaluate the influence of the operative approach on OH repair. METHODS: A literature search via PubMed was performed. Inclusion criteria were studies that: (1) were written in English and published within 10 years; (2) included as keywords “obturator hernia” and/or “incarcerated” and/or “strangulated”; (3) reported the operative approach; and (4) reported postoperative outcomes. RESULTS: Overall, 225 studies were identified, and 53 met the inclusion criteria. Data from 425 patients were pooled. Open repair without mesh was performed in 239 (56.2%) patients, 121 (28.5%) had open repair with mesh, 44 (10.4%) had laparoscopic repair with mesh, and 21 (4.9%) had laparoscopic repair without mesh. Open repair had a mean hospital length of stay (LOS) of 13.4 days, 40.3% postoperative complications, and 9.7% 30-day mortality rate whereas laparoscopic repair had a mean LOS of 7.9 days, 3.1% postoperative complications, and no deaths. Small bowel resection (SBR) was performed in 44.7% of open and 15.4% of laparoscopic repairs. Patients with SBR demonstrated higher morbidity and mortality compared with patients without SBR. In patients without SBR, laparoscopy had advantages over open surgery in LOS, complications, and mortality rate. The overall recurrence rate was 7.7%, with a mean follow-up of 20.4 months. One (0.7%) recurrence was reported in mesh repair, whereas 28 (12.1%) recurrences were reported with tissue repair. CONCLUSION: OHs are the most common open repair without mesh. Our literature review showed that laparoscopic OH repair is associated with enhanced postoperative recovery and the use of mesh was associated with less recurrence. Further studies are still necessary to determine the optimal approach for OH repair, but laparoscopic repair with mesh should be performed when possible.

BACKGROUND: Information about outcomes for patients who undergo onlay mesh placement for umbilical hernia repair is scarce and the factors that influence adverse outcomes, such as long-term pain, are not well understood. A study of patients undergoing open umbilical hernia repair was undertaken. MATERIALS AND METHODS: Patients who underwent open umbilical hernia repair through a private surgical practice over a 13-year period using either an onlay mesh or suture alone repair were given a questionnaire following surgery to document the incidence of long-term pain or other complications. Data were then analyzed to understand any potential contributors to a poor outcome. RESULTS: The information on 346 patients was available for study. Mesh was used for repair in 327 (94.5%) patients, whereas 19 (5.5%) had suture alone repair. Early (≤30 days) complications were experienced by 73 patients (21.1%). The most common complications were seroma formation (27 patients), wound infection (13 patients), and hematoma (11 patients). Four patients developed a combination of hematoma, infection, and seroma formation. Late (>30 days) complications (other than persistent pain) were recorded for nine patients and were all wound-related problems. Long-term pain was significantly more common in those patients reporting wound complications (odds ratio: 7.01, 95% confidence interval 1.82–26.99). Recurrent umbilical herniation developed in three patients (0.9%). CONCLUSION: Onlay mesh repair for umbilical hernia repair can be performed with low rates of chronic pain and low recurrence rates; however, surgical site occurrences remain common albeit easily treatable.

BACKGROUND: In recent years, laparoscopic inguinal hernia repair has become one of the elective techniques, attributing the advantages of minimally invasive procedures to it. However, the high costs related to the need for hospitalization and materials make them a limitation at the time of its indication. OBJECTIVE: Evaluate the feasibility of performing this procedure in an outpatient surgery center and the cost analysis of an outpatient procedure regarding the same in the setting of hospitalization. Retrospective cohort study of feasibility and minimization cost. METHODS: A retrospective analysis was carried out on a prospective database in which all patients were included in those who underwent laparoscopic inguinal hernioplasty on an outpatient basis between August 2015 and June 2018. Feasibility is expressed as the percentage of patients who were referred from the outpatient surgery unit. A cost minimization study was conducted taking the average cost of performing an ambulatory procedure versus the same procedure requiring a day of hospitalization. This work has been reported in line with the CHEERS criteria. RESULTS: 116 patients were operated as outpatients, of which 109 were men (93.96%). The median age was 56.5 years (RIQ 19). 102 patients (87.93%) were operated on due to bilateral inguinal hernia, and 14 of them (12.07%) due to recurrent unilateral hernia, adding a total of 218 inguinal hernioplasties. The mean operative time in bilateral interventions was 112 minutes (DS 24) and in the unilateral recurrences it was 79 minutes (DS 13). 114 patients were discharged from the outpatient unit with 98.3% feasibility. The average postoperative stay was 2.53 h (DS 1). The average cost of ambulatory inguinal hernioplasty was $17725.1 vs $27297.3 in hospitalization. The same implies a cost reduction of 35%. CONCLUSIONS: Laparoscopic inguinal hernioplasty is a feasible and safe technique to perform on an outpatient basis. It provides a significant reduction in the costs of the procedure.

PURPOSE: Elective ventral hernia repair (ELVHR) is generally performed for chronic symptoms, including pain, increasing size, intermittent obstruction, and cosmesis. Emergent ventral hernia repair (EMVHR) indications include acute symptoms that are often concerning for strangulation. The study objective included identifying variations in perioperative characteristics as well as clinical and cost outcomes in patients who underwent ELVHR vs. EMVHR. MATERIALS AND METHODS: An IRB-approved retrospective review of ELVHR and EMVHR cases was conducted, exclusive of incidental hernias. Due to the retrospective nature of the study, patient consent was deemed unnecessary by the IRB. Demographics, perioperative characteristics, operative details, clinical outcomes, and hospital costs were included in the analyses. RESULTS: Five-hundred forty-nine patients (453 ELVHR, 96 EMVHR) underwent repair. The EMVHR characteristics included more females (P = 0.009), class 3 obesity (P < 0.001), diabetes (P < 0.001), and bleeding disorder (P = 0.009). The EMVHR indications included incarceration (69%), strangulation (12%), and perforation (2%). Fifty-six percent of EMVHR underwent repair without mesh vs. 3.5% of ELVHR. Six-month wound events and ER visits were similar between groups; hernia recurrence was noted in 4% of ELVHR and 17% of EMVHR (P < 0.001). Pharmacy, ICU, lab, ancillary services, floor, and imaging costs varied significantly between groups. Supply, OR, and total hospital costs were similar. CONCLUSIONS: The EMVHR occurs in a unique patient population with more frequent comorbidities. Incarceration and obstruction are the most common indications for repair. Costs were similar despite more frequent non-mesh repairs and four-fold increase early recurrence rates in EMVHR. Strategies to improve outcomes in EMVHR require further investigation.

PURPOSE: The objective of this study was to demonstrate an alternative option for definitive fascial closure and accelerated wound healing of catastrophic open abdominal wounds utilizing a novel technique combining a mechanical closure system with biologic xenograft. MATERIALS AND METHODS: All patients who underwent abdominal closure with a dynamic wound closure system with biologic xenograft were analyzed between 2016 and 2017. ABRA^® dynamic wound closure system was placed and adjusted daily until fascial closure was achieved. ACeLL^® urinary porcine bladder matrix was placed in midline of wound once fascial closure was achieved. Information was abstracted on patient demographics and extent of open abdomen (OA) and postoperative outcomes. RESULTS: Fifty patients underwent novel closure of the OA with mean age of 48.3 years with males comprising 72%. The average body mass index was 35.0. Majority (62%) of OAs were secondary to abdominal sepsis. The average myofascial gap prior to closure of abdomen was 19.0 cm, incision length 28.9 cm, and visceral extrusion 7.7 cm. Prior to installation, the abdomen on average had 3.6 laparotomies and was open for 8.6 days. Primary myofascial closure was achieved in 49/50 (98%) patients; 3/50 (8.3%) developed a hernia. Surgical site infection (SSI) occurred in 4/50 (8%). CONCLUSION: We present a novel technique to achieve primary myofascial closure rate in critically ill patients with OA associated with low hernia rate and SSI.

PURPOSE: Soft tissue management following ventral hernia repair (VHR) may impact wound complications and hernia recurrence. Rationales for soft tissue excision (STE) include ischemia, redundancy, potential space reduction, and cosmesis. This study evaluates outcomes among patients undergoing VHR with and without STE. MATERIALS AND METHODS: Institutional Review Board-approved review of VHR patients at a single institution from 2014 to 2018 was performed for 90-day wound complications, reoperations, and readmissions. Hernia recurrence, chronic pain, functional status, and satisfaction were assessed through telephone survey. Outcomes and costs between groups were analyzed. RESULTS: One hundred and forty-four patients underwent VHR alone; 52 patients underwent VHR/STE. Obesity, larger defects, severe chronic obstructive pulmonary disease, and higher wound classes were more prevalent among VHR/STE. Deep surgical site infection [SSI (1% vs. 8%, P = 0.018)], wound dehiscence (13% vs. 33%, P = 0.003), and return to operating room (1% vs. 12%, P = 0.005) occurred more commonly in VHR/STE. Total costs were more than 50% greater ($18,900 vs. $29,300, P = 0.001) in VHR/STE, but after multivariable analysis adjusting for risk factors, total costs of VHR/STE no longer remained significantly higher ($18,694 vs. $21,370, P = 0.095). Incidence of superficial SSI (6% vs. 6%), seroma formation (14% vs. 12%), non-wound complications (7% vs. 17%), median length of stay (4 vs. 5 days), readmissions (13% vs. 21%), hernia recurrence (38% vs. 13%), and functional status scores (71 vs. 80) did not differ significantly between groups. Overall patient satisfaction (8 vs. 10, P = 0.034) and cosmetic satisfaction (6 vs. 9, P = 0.012) among VHR/STE were greater than VHR alone. CONCLUSION: Soft tissue resection during VHR results in greater patient satisfaction without increased costs.

AIM: To report the outcomes of questionnaire assessment about the teaching of the abdominal wall surgery and the incorporation of the techniques taught during the general surgery and digestive tract surgery residency into the individual practice. METHODS: The graduated surgeons and resident doctors from 2014 to 2019 were invited to answer a standardized questionnaire about the abdominal wall surgery teaching program, mastery of specific techniques, and medical practice of each. We performed a chi-square test to evaluate whether the degree of satisfaction correlates to the degree of personal confidence and whether it correlates to performing the procedure in this practice. RESULTS: When assessing the degree of self-confidence to perform specific procedures, all students were confident in performing the Lichtenstein procedure; 22% were confident in transabdominal pre-peritoneal hernioplasty (TAPP); 77% were confident in Rives-Stoppa and anterior separation technique; and 18% were confident in Transversus Abdominis Muscle Release (TAR) technique. The statistical analysis showed a correlation between teaching program satisfaction and the degree of self-confidence only for the TAR procedure (P = 0,06). The analysis also showed a correlation between the degree of self-confidence to perform a specific procedure and its usage on daily practice only for the Rives-Stoppa procedure (P = 0,00). CONCLUSION: These results show the importance of a structured Abdominal Wall Surgery Program, as well as the continuing education evaluation and quality improvement, as the instrument exposed, which to our knowledge, is the first questionnaire to assess the teaching of the abdominal wall and it may be considered a helpful tool.

AIM: To perform a retrospective clinical audit of the long-term effects of inguinal herniorrhaphy at the Victoria hospital in Prince Albert, Saskatchewan. Our hope is that this will form a template for a possible hernia registry in Saskatchewan, Canada. PATIENTS AND METHODS: A telephonic audit was carried out for all hernia surgeries performed in the year 2000 at the hospital. Demographics such as age and sex as well as the type of surgery and the mesh used were recorded. Chronic complications were also recorded. The surgical questionnaire was adapted from an established short quality-of-life questionnaire (Qol), the EuroQol questionnaire. We then performed a chart audit to identify basic information including the surgical approach and any intraoperative complications. RESULTS: Overall, 119 herniorrhaphies were performed at the Victoria hospital in 2000; 18% of patients (21/119) responded to the telephonic survey. There was a 24% complication rate.All cases of hernial recurrence arose from an original open herniorrhaphy technique.Overall, 22% of patients (27/119) had demised since the surgery; five patients remained incarcerated; and six had dementia and could not respond to the survey.The chronic inguinodynia in four patients was managed with analgesia and non-steroidal anti-inflammatories (NSAIDs). There was no need for chemical or surgical nerve ablation procedures. CONCLUSION: Long-term clinical audits in surgery remain sparse. There remains a paucity of data for studies that are more than a decade long. This 20-year audit of inguinal herniorrhaphy is the first of its kind in Saskatchewan, Canada. We propose its use to establish a hernia database that will record chronic complications as well as surgical outcomes.This will hopefully facilitate an improved surgical technique and a universally established method of defining and documenting complications such as chronic inguinodynia and hernia recurrence. Hernia databases help to remove patient subjectivity as well as observer bias and to provide an objective scientific overview of outcomes.

A primary femorocele is an uncommon pathology wherein fluid accumulates within the sac of a femoral hernia due to occlusion of communication with the peritoneal cavity and in the absence of ascites. Here, we report the case of a primary femorocele in a 45-year-old female patient who presented to our hospital with right groin swelling. The diagnosis of a primary femorocele was only made on surgical exploration, which deferred from the initial preoperative diagnosis made using ultrasonography. Surgical excision and repair were undertaken with the use of a mesh plug.

The majority of inguinal hernia repairs today, open or laparoscopic, are performed with mesh tension-free repair. The introduction of mesh, though beneficial, posed a new set of post-operative problems related with the mesh, and mesh migration or penetration is one of the most unusual ones with considerable morbidity. Mesh migration following laparoscopic repair is rare, and only a handful of cases have been reported in the literature. Here we present the first ever case report of mesh migration and penetration through rectum developing after two years post-operatively. The mesh was removed and the patient was discharged in a stable condition.

Management of incisional hernias in patients with cirrhosis, ascites, or bowel covered only by skin poses a challenge for the reconstructive surgeon. We hypothesized that a completely extraperitoneal repair with coverage of the hernia defect with autologous tissue and onlay mesh reinforcement could be an alternative for a durable repair.