Background: Flank hernias are uncommon and challenging to repair. Discussion of flank hernia repair is scarce in the literature. We present a novel approach to repair flank incisional, traumatic, and denervation hernias with a “hybrid” approach using an open repair in conjunction with the robotic platform for laparoscopic intraperitoneal mesh fixation. Materials and Methods: A retrospective analysis was conducted on all patients who received a “hybrid” repair from April 2014 through January 2020 by a single surgeon. Patient and hernia characteristics, operative techniques, and outcomes were evaluated. Each patient underwent a similar operation with an intraperitoneal mesh as well as an onlay mesh. Minor technique changes including quilting and wound vac placement were developed and compared. Results: Twenty-five patients were included in the study. Outcomes analyzed included wound infection (8.0%), seroma formation (16.0%), hematoma formation (12.0%), mesh infection (0.0%), weight gain (16.0%), hernia recurrence (4.0%), reoperation (12.0%), and chronic pain (25.0%). Compared to the drain placement group, quilting of the subcutaneous tissue was more likely to result in seroma (17.6% vs. 12.5%, P = 0.618) and hematoma (17.6% vs. 0.0%, P = 0.296). Use of negative pressure incisional wound vac did not impact the incidence of wound infection (12.5% vs. 6.2%, P = 0.565), seroma (12.5% vs. 17.6%, P = 0.618), or hematoma formation (12.5% vs. 11.8%, P = 0.704). Conclusion: The “hybrid” repair represents a novel approach to flank hernias. Improved visualization of the intraperitoneal portions of the operation using the robotic platform allows for accurate mesh fixation. In experienced hands, this approach provides safe and satisfactory outcomes similar to a purely open repair.

Background: Abdominal wall hernias constitute a significant cause of morbidity and mortality globally, but more importantly, they present a more pathetic situation in rural areas of sub-Saharan Africa and other developing nations. In our setting, the rate of elective repair is still too low and many cases present late, often with complications. This study aimed at documenting the spectrum, barriers to early repair, and factors that influence the outcomes of repair. Materials and Methods: A prospective study of adult patients surgically treated for abdominal wall hernia in rural southeast Nigeria between January 2014 and December 2019. Results: Overall, 975 patients were recruited: 706 (72.4%) had simple uncomplicated hernias, whereas the rest (269, 27.6%) presented in the emergency. Inguinal hernias comprised 74.1% of the cases followed by primary midline hernias (14.5%). Delayed presentation was common, with only 2.3% presenting within three months and the main reason being financial constraint (31.0%) followed by ignorance (12.2%). A third (324, 33.2%) of the patients harbored complete inguinoscrotal/inguinolabial hernias. Nearly a quarter (240, 24.6%) had comorbid illnesses, 14.9% harbored recurrent hernias, and more than a third (43.4%) had hernias with defect sizes >5 cm. Wound infection rates were 34.6% in the emergency group, 26.2% in the elderly, 20.7% for those with recurrent hernias, and 17.1% in those with comorbidities. Morbidity rates were greater in patients with hernia defects >10 cm (37.8%), inguinoscrotal/inguinolabial hernias (18.5%), and those who received bowel resection (56.7%). Generally, elevated wound infection and high overall morbidity rates were associated with emergency presentation (P = 0.000), advancing age (P = 0.030), procedures performed by a nonspecialist surgeon (P = 0.014), and large hernia variants (P = 0.000). Overall, mortality rate was 2.9%, but it was 9.7% in those with emergency repair. The main independent predictors of mortality were intestinal resection (P = 0.000), delayed presentation (0.003), advanced age (0.020), and comorbidities (P = 0.002). Conclusion: Delayed presentation, often in an emergency setup, is common among patients with abdominal wall hernias in our rural practice. Financial impediments and ignorance were the main barriers to early presentation and elective repair. Consequently, morbidity and mortality rates were high, especially in the setting of advancing age, delayed presentation, coexisting medical conditions, and bowel resection.

PURPOSE: In laparoscopic transabdominal preperitoneal repair (TAPP), the use of a larger mesh has been shown to reduce the rate of recurrence of hernia. However, recurrence may still be observed occasionally, especially in procedures performed by inexperienced surgeons. The purpose of this study was to clarify the learning curve of TAPP and to establish a procedure that precluded the possibility of recurrence. MATERIALS AND METHODS: We analyzed the learning curve based on operative time, recurrence, and complication in a single surgeon’s experience of 1,000 consecutive TAPP. In addition, by examining cases showing recurrence, techniques necessary to prevent recurrence were clarified. RESULTS: The operative time stabilized after 60 cases and continued to reduce thereafter. Recurrence of nine hernias in eight patients within 1 year of surgery was observed up to the 482nd case. Recurrence or intraoperative complication was not confirmed since then. Recurrence after primary inguinal hernia repair presented as indirect hernia-type recurrence. The causes of recurrence were incomplete parietalization in indirect sliding hernia, insufficient dissection of the lateral dorsal side, and up-rolling mesh placement with the lateral dorsal side. CONCLUSION: Recurrence can be prevented by sufficiently dissecting the preperitoneal space on the lateral dorsal side and taking care to avoid up-rolling of the mesh while it is being placed.

Introduction: Laparoscopic repair of groin hernia (LRGH) is widely accepted for elective cases, but its use in emergency cases remains controversial. We aimed to compare postoperative outcomes between elective and emergent transabdominal preperitoneal (TAPP) repairs. Materials and Methods: Patients undergoing emergent LRGH (EM-LR) using a TAPP technique between June 2014 and December 2019 were included for analysis. A case-control cohort of patients undergoing elective LRGH (EL-LR) in the same period was identified and matched (1:3) on gender, age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, active smoking, and hypertension. Preoperative variables and postoperative outcomes were compared between both groups. Results: A total of 15 EM-LR were matched with 45 EL-LR. In patients undergoing EM-LR, the median time from onset of symptoms to surgery was 12 (1–168) h. No differences were found regarding the operative time (EM-LR: 107 min vs. EL-LR: 117 min, P = 0.37) and hernia defect size (EM-LR: 3.6 cm vs. EL-LR: 4.1 cm, P = 0.48). Although small bowel obstruction was observed in all emergent cases, no patients required enterectomy. Emergent cases were performed more frequently by specialist surgeons (EM-LR: 87% vs. EL-LR: 24%, P < 0.001). Mean hospital stay was 3.1 and 0.3 days after EM-LR and EL-LR, respectively (P < 0.001). Overall 30-day morbidity was similar between groups (EM-LR: 6.6% vs. EL-LR: 4.4%, P = 0.43). After a mean follow-up of 28.2 months, no recurrence was observed. Conclusion: EM-LR had similar overall morbidity and recurrence rates than elective repairs. Prompted surgical exploration and use of laparoscopy should be encouraged for the management of complicated inguinal hernias.

A 14-year-old girl presented with a swelling over the right groin for 2 years associated with amenorrhea. She also had cyclical pain over the swelling every month. On further evaluation, she had a right inguinal hernia with right ovary and uterus in the hernia sac. She underwent inguinal exploration and hernial sac was identified. She underwent hernioplasty and was discharged uneventfully. The presence of uterus in a hernial sac is a rare entity. The risk of complications and chances of untoward injury during the unprecedented surgical procedure warrants a careful evaluation before surgery.

Congenital diaphragmatic hernia is a life-threatening anomaly with the high mortality rate in infancy. Very rarely they remain silent and manifest in the adult life. Once they manifest, the symptoms vary and are not easy to diagnose. The entity also has associated problems in the form of hypoplastic lungs and loss of domain of the abdomen. In such cases, the diagnosis is most often based on clinical suspicion and radiological confirmation. The treatment options are open abdominothoracic procedures or laparoscopic procedures. Once hernia is reduced, the defect is closed and should be reinforced with prosthetic mesh. Here we present a case of congenital diaphragmatic hernia in a teenager presenting with cardiac symptoms. The challenges faced in managing the case are discussed.

The objective of this case study is the management of small necked diaphragmatic hernia in a patient with hostile abdomen. Case study describes the technique of uniportal video-assisted thoracoscopic surgery (U-VATS) for management of diaphragmatic hernia. This is a novel case for the management of diaphragmatic hernia using a patch utilizing minimally invasive cardiac surgical instrumentation via U-VATS approach. U-VATS is a feasible option for the management of diaphragmatic hernia in a patient with hostile abdomen.

Persistent Müllerian duct syndrome (PMDS) is an unusual form of internal male pseudohermaphroditism in which Müllerian duct derivatives are seen in phenotypically normal males, with 46, XY karyotype. PMDS is an outcome of defective functioning of the Müllerian inhibiting factor (MIF) or its receptor. MIF causes degeneration of the Müllerian duct in the fetus. PMDS clinically manifests as cryptorchidism or inguinal hernia, although it is mostly undetected until puberty. We report a rare case of PMDS in a 45-year-old male patient with right-sided cryptorchidism and contralateral inguinal hernia. Upon exploration of the hernial sac, it contained a uterus-like mass with attached left testis. Biopsy and subsequent histopathological examination of the mass confirmed the presence of endometrial glands.

Enteroatmospheric fistula (EAF) is a rare and devastating surgical complication with significant management challenges. Abdominal wall reconstruction (AWR) at the time of definitive repair represents the major challenge in patients with large abdominal wall defects with associated loss of abdominal domain. Herein, we describe a case of EAF with significant loss of domain for which AWR was achieved using an innovative combined approach of preoperative botulinum toxin A (BTA), extensive transversus abdominal release (TAR), and abdominal reinforcement with biosynthetic mesh. This approach achieves primary abdominal closure, providing the option of a single definitive reconstructive procedure for EAF. Further studies with long-term follow-up are required to assess the long-term durability of this approach.

Hernia repair is one of the most common procedures performed by general surgeons worldwide. Rates of recurrence have significantly decreased with the use of mesh; however, this foreign material has its own inherent complications. We present a rare and unusual complication of giant pseudocyst formation after femoral hernia repair. Pseudocysts have mostly been described after incisional hernia repairs and there are only a handful of cases reported after groin hernia repair in the literature. To the best of our knowledge, this is the first reported case of pseudocyst after femoral hernia repair.