Component separation technique (CST) allows the mobilization of large musculofascial flaps of the abdominal wall and was developed for the treatment of very large, primary and incisional abdominal wall hernias. The classic open anterior CST first published by Albanese and later by Ramirez is associated with high complication rates. According to a recent literature review, CST without mesh should no longer be performed because of high recurrence rates. Classic anterior CST is associated with high rates of surgical-site occurrences and infections and should only be performed as endoscopic- and perforator-sparing anterior CST. The unfavorable results of classic CST resulted in the development of numerous new anterior and posterior CST modifications, several of them were minimally invasive. The posterior CST with transversus abdominis muscle (TAM) release (TAR) published by Novitsky et al. is an extension of the original retrorectus Rives operation and Stoppa procedure. The technique avoids vast skin flaps and allows the closure of large abdominal wall defects and insertion of very large retromuscular alloplastic standard sublay meshes without damaging the vessels and intercostal nerves. The TAR procedure is one of the major advances of abdominal wall surgery of the last decades. Several new promising minimally invasive modifications including robotic-assisted TAR have been published recently. The indications and technique of the TAM (TAR) procedure and its minimally invasive modifications are described.

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Mesh reinforcement is generally considered the standard of care in ventral hernia repair. Infection is a common complication following ventral hernia repair. Infection extending to the mesh is a complex problem. Knowledge of current treatment strategies is necessary for surgeons performing abdominal wall reconstruction. A comprehensive literature review was performed of current literature to assess risk factors and treatment options for mesh infection. Modifiable risk factors for mesh infections include active smoking, poorly controlled diabetes mellitus, abdominal skin or wound issues, and obesity. Operative factors that increase the risk of mesh infection include prior hernia repair, enterotomy and contamination of the surgical field. Of the synthetic meshes, lightweight polypropylene has the highest likelihood of salvage. Patients that are current smokers, those with other synthetic mesh types, and those infected with MRSA are rarely salvaged. Following excision of infected mesh, multi-staged abdominal wall reconstruction can be considered. Biologic or biosynthetic mesh is recommended when repairing incisional hernias following excision of infected mesh and likely represent the patient's best chance at a definitive hernia repair. Wound VAC-assisted delayed primary closure should be considered in higher-risk patients. Mesh infection is a complex complication that is commonly encountered by surgeons performing hernia repair. Prevention through patient optimization should be performed whenever appropriate. However, when patients develop a mesh infection, most will require complete mesh excision and recurrent hernia repair.

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BACKGROUND: Seroma formation is a frequent complication of laparoscopic inguinoscrotal hernia, and the most appropriate technique regarding the distal sac management in laparoscopic inguinoscrotal hernia is still debated. The aim of this study is to present a new technique to manage the large distal sac and to avoid the clinical significant seroma formation after laparoscopic inguinoscrotal hernia repair. MATERIALS AND METHODS: One hundred and ninety-five consecutive elective inguinal hernias were performed in our group in 1-year period and 12 of them were inguinoscrotal indirect hernias, defined as the hernia sac descending into the scrotum. In these inguinoscrotal hernia patients, the distal hernia sacs were transected and left in place without complete dissection out of scrotum and reduction. Then, the lower edge of the distal sac was fixed to the posterior abdominal wall cranial and lateral to the internal ring with barbed suture. The patients were prospectively followed with physical examination, and in five of them, ultrasound was performed on the 1^st day and 7^th day after the operation. The primary postoperative outcome parameter was seroma formation; the secondary parameters included groin pain, surgical complications, and early hernia recurrence. RESULTS: Only one patient developed clinical significant seroma by physical examination during the follow-up period. The patients complained no chronic groin pain, and there were no other surgical complications and early hernia recurrence in these series. CONCLUSION: Seroma formation could be effectively prevented by suspension of the lower edge of the distal sac to the posterior abdominal wall is an easy, reproducible, reliable, and cost-effective method to prevent postoperative clinical significant seroma formation after laparoscopic inguinoscrotal hernia repair. Although the early results were promising, the comparative studies and randomized controlled trials are necessary for further evaluation.

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BACKGROUND: A Spigelian hernia is rare. Diagnosis and treatment remain controversial, mainly because of its unusual presentation. The aim of this study was to report the outcomes of open treatment of eight rare cases and to evaluate our experiences in managing this condition. PATIENTS AND METHODS: We performed a retrospective and descriptive study about operated patients for Spigelian hernia in our department of surgery between 2002 and 2016. RESULTS: Eight patients were enrolled. The mean age was 52.25 years. There was a female predominance. All cases presented hernia risk factors. A painful abdominal mass presented the reason for consultation in four cases. Two of our patients had an associated inguinal hernia and one other had an umbilical hernia. In three cases, the hernia was strangulated. The diagnosis was confirmed by clinical examination in two cases and using radiological examinations in six cases. The content was a small bowel in four cases, epiploic in three cases, and colic in one case. A sublay mesh repair was performed in five cases and a primary suture in three cases. No recurrences were detected after 2 years of follow-up. CONCLUSION: Spigelian hernia is underestimated. Open sublay mesh repair is feasible and safe. It ensure a great short and long term results. The open approach is feasible and safe to treat this condition.

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BACKGROUND: The lumbar area is limited by the bone structures (superiorly by the 12^th rib and inferiorly by the iliac crest); furthermore, several important nerves, including the genitofemoral nerve, lateral femoral cutaneous nerve, and ilioinguinal and iliohypogastric nerves, are all exposed in this area after retroperitoneal dissection during lumbar hernia repair, which render the risk and challenge for lumbar hernia repair and mesh fixation. In addition, the superior and inferior lumbar hernias, although had the same name of lumbar hernia, are quite different according to the anatomical location, and there is no standard and preferred method for lumbar hernia repair. In the present study, we present our techniques of total extraperitoneal (TEP) superior and inferior lumbar hernia repair. METHODS: The TEP approaches were performed in the superior and inferior lumbar hernias. Due to the different anatomic locations of the superior and inferior lumbar hernias, the trocar sites were also different. In the present procedure, with the use of self-gripping mesh, the traumatic fixation was avoided. RESULTS: After TEP lumbar hernia repair, both patients had minimal postoperative pain and were discharged 1 day and 3 days after operation without complications, respectively. CONCLUSION: Different pathways and trocar arrangement are necessary according to the different locations of superior and inferior lumbar hernias. The use of self-gripping mesh in the retroperitoneal space avoids the traumatic fixation, and TEP could be a promising technique for primary lumbar hernia repair.

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Morgagni hernias are a rare finding in the adult population and represent 1%–3% of all congenital diaphragmatic hernias. Multiple approaches to these rare hernias have been described in the literature. Here, we present a novel technique of laparoscopic transabdominal repair using a combination of the Endo-Close device (Medtronic, Minneapolis, MN, USA) and the Ti-KNOT (LSI Solutions, Victor, NY, USA). In a patient with a large left anterior diaphragmatic defect, we performed transabdominal suturing utilizing the Endo-Close to perform primary closure of the defect, using the Ti-KNOT to secure the pledged sutures along the anterior fascia. Due to the size of the defect (7 cm × 10 cm), this primary repair was buttressed with polyester mesh. In a second patient with a smaller (6 cm × 8 cm) classic right-sided anterior diaphragmatic defect, we similarly performed laparoscopic transabdominal suturing using the Endo-Close to traverse both the anterior and posterior fascia and the Ti-KNOT to secure the sutures to perform a primary repair of the hernia. Both patients presented had an uneventful postoperative course and no indication of recurrence at 4 months. Morgagni hernias present unique technical challenges. In our experience, the combined use of transabdominal suture with laparoscopic knot placement device allowed for completion of both cases laparoscopically with minimal tension on the repairs.

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Endometriosis is a condition in which cells similar to those in the endometrium, of the uterus, grow outside of it. Mostly, it is found around the uterus but rarely may occur in other parts of the body. Endometriosis can affect any organ of the body, but inguinal hernia sac endometriosis is extremely rare. Inguinal hernia sac endometriosis appears as a painful tender swelling in the inguinal region. Here, we report a case of right inguinal hernia sac endometriosis which was diagnosed by surgical excision and biopsy.

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Spontaneous nontraumatic bowel evisceration from a ruptured long-standing abdominal wall hernia is a rare occurrence. Sporadic case reports exist describing bowel evisceration from long-standing ventral herniae, whereby baseline increased intra-abdominal pressure was rendered more pronounced due to sudden increase and/or trauma. Morbidity and mortality rates are significant, and treatment can be technically complex. We present a case of spontaneous small bowel evisceration from rupture of a recurrent ventral hernia in a patient with liver cirrhosis, who was managed with emergent surgical mesh repair and discuss the spectrum of relevant surgical techniques for this unique group of patients.

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CONTEXT: Peritoneal closure with a barbed suture during laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is a controversial subject due to the risk of postoperative intestinal adhesions and occlusions formed by this type of suture. This risk, however, was only reported in several case reports. The purpose of this study is to determine the incidence of postoperative intestinal obstructions related to the use of barbed suture materials in laparoscopic hernia repair (TAPP). PATIENTS AND METHODS: We included all patients that underwent laparoscopic TAPP inguinal hernia repair between October 2012 and October 2017. All peritoneal closures were accomplished using absorbable barbed sutures. Operative data were collected in a dedicated database and analyzed retrospectively. RESULTS: Only 3 out of the 320 patients included (0.9%) presented with an early postoperative intestinal obstruction and required further surgery. Two of the three patients (0.6%) were found to have intestinal incarceration in the peritoneal defects initially created during the hernia repair. However, the last patient had an intestinal volvulus due to adhesions formed with the barbed suture. None of the patient characteristics collected were significant risk factors for developing postoperative intestinal obstructions. CONCLUSION: In this study, peritoneal closure using barbed suture material did not increase the risk of early postoperative intestinal obstruction, in comparison to other suture materials reported in the literature. The use of barbed absorbable sutures for peritoneal closure during laparoscopic TAPP seems to be safe when sutures are cut short and covered by the peritoneum.

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INTRODUCTION: One German surgeon (Eric Mühe in 1985)* and three French surgeons** (Philippe Mouret in 1987, Jacque Perissat in 1989, and Dubois F in 1990) are credited with having performed first* laparoscopic cholecystectomy and first** video-assisted laparoscopic cholecystectomy, respectively. Laparoscopic cholecystectomy became the procedure of choice (gold standard) for benign symptomatic gallbladder disease as well as asymptomatic gallbladder stones in India. There have been adoption and acceptance for laparoendoscopic incisional/ventral hernia repair. Actually, laparoendoscopic repair of incisional/ventral hernia, laparoscopic solid organ removal (spleen and adrenal), and laparoscopic fundoplication (gold standard) have been standard of care even in the absence of Level 1 evidence over the past three decades. AIM: However, acceptance, adoption, adaptation, and performance of laparoendoscopic groin hernia surgery have been slow over the past three decades among practicing surgeons and surgical trainees. RESULTS: The laparoendoscopic groin hernia repair has yet not gained the same status as for the procedures mentioned above (VS). The reasons are multifactorial and relate to obtaining adequate and proper training covering laparoendoscopic groin hernia repair. The first and foremost reason is that endoscopic repair of groin hernia is considered an advanced laparoscopic procedure as opposed to open hernia repair. Preceptorship–proctorship (PP) model, which worked extremely effectively for teaching and learning of laparoscopic cholecystectomy, could not be established for groin hernia yet. There is no effective simulator developed for any of the standardized techniques, i.e., totally extraperitoneal (TEP) and/or transabdominal preperitoneal repair (TAPP). The complications, for example, intestinal obstruction and major vascular injury, which were never seen during open era, also brought about criticism as well hampered the growth of laparoendoscopic groin hernia repair. In emerging economies such as India and other Asian countries, high cost of laparoendoscopic repair (tacker and specialized meshes) has been responsible for reduced penetration among practicing surgeons and patients. Therefore, the laparoendoscopic repair of groin hernia has been limited to major metropolitan corporate hospitals and small number of tertiary care public hospitals in metropolitan cities. The advantages of minimally invasive approaches for the repair of groin hernias have not benefited the masses in rural and semi-urban geographic areas of India. CONCLUSION: Training opportunities for the teaching and learning laparoendoscopic repair of groin hernia have remained limited for vast majority of practicing surgeons and surgical trainees in India. With development of cadaveric (TEP and TAPP) and live anesthetized animal model (TAPP), it has been possible to establish training opportunities for practicing surgeons at few institutions. We also recommend and encourage expert surgeons to provide training opportunities for those who wish to learn the surgical skills of laparoendoscopic repair of groin hernia by giving their time for PP model. Furthermore, establishment of specialized hernia centers will go a long way to fill this void.

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AIM: Litigation is always a severe burden for every surgeon who is involved. The study aims to show the most important reasons for an allegation and how to prevent a lawsuit. METHODS: Based on the own experience as a medical advisor, ten medico-legal cases are analyzed and a systematic overview of the corresponding literature is given. RESULTS: Allegation for malpractice is not very frequent; in hernia surgery, <1% of the patients are involved. Furthermore, only in 20%–40% of these cases, the decision is in favor of the claimant. However, every case is associated with compensation ranging from roughly between $19,000 and $8,000,000. Totally the author had to perform 10 reports in legal cases for the court: In three cases, compensation had been refused, because informed consent had correctly been done, and the operative situs was clearly documented, and in the third case, the preoperative diagnostics and the operative performance had been according to the medical standard. The claim was successful in three patients because of technical failure, in two cases because of wrong indication, and in two cases because of delayed reoperation. DISCUSSION: There are five key features in the prevention of a lawsuit in surgery: (1) “informed consent:” Take the time, use a standard form, show pictures and make handwritten notes to explain in detail the indication for surgery, the technical performance of the planned intervention, and the steps of aftercare; (2) “technical performance” of the operation should follow the generally accepted medical standard. Deep knowledge of anatomy is an indispensable precondition of perfect operation; (3) a “delay in timely response” to a complication is not excusable; (4) “careful documentation” of all steps of the treatment may possibly avoid a legal case; and (5) “establishing an empathic relationship” between the surgeon and the patient and his/her relatives as well is essential for avoiding an accusation. CONCLUSION: Medico-legal implications in hernia surgery are rare, but a severe burden for every surgeon concerned and may be associated with damage to the reputation of the surgeon and high costs. The best ways of preventing such a disaster are the correct indications and operative performance according to the current medical standard and empathic aftercare.

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BACKGROUND: Lichtenstein tension-free repair is associated with postoperative complications and dysfunctions; hence, there is a need to look for a new hernia repair techniques while retaining its advantages. Desarda technique is a physiologic repair and essentially restores physiology of the inguinal canal. This single-blind, randomized controlled study was conducted to compare Desarda with Lichtenstein technique evaluating short- and long-term outcomes after 3 years of follow-up in primary inguinal hernias. MATERIALS AND METHODS: One hundred and twenty-three adult male patients with primary inguinal hernia (both direct and indirect) were randomly allocated intraoperatively to Lichtenstein repair, Mesh (M) Group or Desarda repair, nonmesh (NM) Group. Baseline characteristics were recorded before the surgery. Short- and long-term outcomes and patients responses on patient global impression of change (PGIC) and Prolo scale after surgery were recorded. RESULTS: Sixty-two patients were assigned to NM and 61 to M group. Surgery time was significantly higher for M group (P < 0.001). Postsurgical pain was significantly higher (P < 0.001) in M than NM group whereas complications were comparable. The total mean duration of follow-up for M was 35.2 months while for NM was 35.7 months. The recurrence rate was not significantly different; however, chronic groin pain was significantly higher in M compared to NM (P = 0.05). After surgery, PGIC score was consistently higher in NM group with better functionality in NM group. CONCLUSIONS: After 3 years of follow-up, Lichtenstein technique and Desarda technique results were similar. After considering the pros and cons of both the methods, a tailor-made approach is required while choosing a procedure for hernia repair.

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BACKGROUND AND AIM: Incarcerated inguinal hernia comprises a significant portion of surgical emergencies, and represents about 5%–15% of all operated inguinal hernias. Tension-free repair with mesh placement is the preferred technique for elective surgery due to its low recurrence rate. However, limited information is available on the usage of synthetic mesh in the emergent treatment because of the potentially infected surgical fields, especially in case of concomitant bowel resection. The aims of this study were to evaluate the results of mesh-based emergency hernioplasty and compare the outcomes of incarcerated inguinal hernia repair with synthetic mesh in Lichtenstein or open preperitoneal approach and to identify the risk factors for postoperative complications. METHODS: A total of 151 patients with incarcerated inguinal hernia that underwent surgery between January 2013 and December 2017 were included in this retrospective study. Demographics, surgical details, and outcomes such as surgical-site infection and recurrence were collected. Univariate analysis was employed to identify risk factors for overall complications. RESULTS: A total of 61 patients received Lichtenstein hernial repair, whereas 90 patients received open preperitoneal repair. Overall morbidity occurred in 21 patients. There was no significant difference between the two groups in terms of postoperative complications. Univariate risk factors for overall complications were age >65 years, duration of incarceration ≥8 h, American Society of Anesthesiologists grade ≥III, cardiopathy, bronchial asthma, indirect inguinal hernia, and strangulation. In multivariate analysis, no risk factors were found associating with a higher rate of overall morbidity. CONCLUSION: As for incarcerated inguinal hernia, both Lichtenstein and open preperitoneal approach with mesh are safe and effective.

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BACKGROUND: Our objective was to investigate the clinical characteristics of original laparoscopic round ligament-sparing repair technique for groin hernias in female patients. METHODS: The clinical data of 48 female patients (58 hernias) who underwent laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair using original split mesh technique at Orel Regional Hospital (Russia) between March 2009 and January 2019 were analyzed retrospectively. The aim of the study was to provide an overview about female groin hernias, preferred surgical approach, and the management of round ligament of uterus. RESULTS: There were 58 TAPP repairs in 48 patients. The average follow-up period was 43 months (min. – 3, max. – 122, Mo – 12, and Me – 43). Fifteen femoral hernias were noted in ten patients, of which two femoral hernias were incarcerated. Cysts on the round ligament of the uterus were found in four patients, and most of them underwent laparoscopic resection. Round ligaments of the uterus were preserved in all patients. An average operation time was 56 min (min. – 20, max. – 135, Mo – 40 min, and Me – 50 min). None of the cases was converted to laparotomy. All patients returned to normal activity soon and 1 (1.7%) recurrence was noted during follow-up. CONCLUSION: Laparoscopic inguinal hernia repair is well adopted around the world, but still questions remain which are related to female patients, especially regarding the function and preserving the round ligament. Based on this study, it is possible to preserve the round ligament by using the original laparoscopic TAPP keyhole technique.

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Tension has always been and remains an important concept in hernia repair. Revolutionary techniques in the field of hernia repair have generally aimed to reduce tension and thereby reduce recurrence rates. Despite the uniformly agreed upon idea that tension is an important part of hernia repair, little is known about this subject in ventral and incisional hernias. We reviewed all published journal articles related to abdominal wall tension. Articles were organized into basic science and clinical reports, and results were evaluated for type and technique of tension measurement and implications for clinical practice. Several cadaveric and clinical studies relate to the measurement of abdominal wall tension. Despite similar methods of measuring, there is no uniformly agreed upon device or measurement. Abdominal wall tension has not been correlated with hernia width, and abdominal wall tension measurement has shown to be a useful adjunct intraoperatively. Abdominal wall tension measurements likely have a role in both the research and clinical practice of hernia surgery.

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INTRODUCTION: Thromboembolic prophylaxis (TP) is an effective strategy to reduce the risk of thromboembolic events such as deep vein thrombosis and pulmonary embolism. In the absence of patient- and procedure-related risk factors, the risk of thromboembolic events is considerably low among surgical patients. Since hernia repair is thought to be a low-risk procedure, the role of TP in patients undergoing hernia surgery is a matter of debate. METHODS: A systematic search of the literature was conducted in Medline/PubMed and the Cochrane database. Forty-eight relevant publications were identified. RESULTS: Overall, there is a paucity of studies specifically investigating the impact of TP in patients undergoing hernia surgery. Available studies demonstrate that the risk of thromboembolic events with TP in inguinal hernia repair is approximately 0.1%, comparable to other low-risk procedures. Lower rates of thromboembolic events are seen in outpatient surgery. Laparoscopy and implanted mesh in the groin do not increase the risk of thromboembolic events. CONCLUSION: Due to the limited data, no recommendation for or against TP in hernia surgery can be made. Further studies are urgently needed to investigate the effect of TP on the risk of thromboembolic events in patients undergoing hernia repair.

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Large hiatus hernias are encountered with increasing frequency in aging Western populations. If certain steps are followed, repair can be safely and reliably achieved using laparoscopic approaches. However, surgeons disagree about some key steps, including the use of mesh for repair of the hiatus, lengthening of the esophagus, and the addition of a fundoplication. A narrative review of literature pertinent to laparoscopic repair of large hiatus hernia was undertaken, with priority given to information available from randomized trials. All surgeons agree that the hiatal sac should be fully dissected from the chest to reduce the stomach, and the majority add a fundoplication of some sort. Opinions diverge significantly for the addition of a Collis procedure or the use of mesh. Evidence cited to support these opinions can be prioritized differently by different individuals, and the same evidence is often be cited to support either view. Nevertheless, randomized trials of mesh versus sutured hiatal repair have yielded divergent outcomes, with the more recent studies reporting longer term outcomes failing to support the use of mesh. Surgeons seeking “anatomical perfection” will often add a Collis procedure and are more likely to use mesh. However, the alternative view is that patient satisfaction with the clinical outcome should be prioritized. When this view is taken, a Collis procedure is rarely required. The author concludes that surgeons should aim to keep this operation simple, and an approach which prioritizes careful dissection to protect hiatal structures, followed by sutured repair will deliver a good clinical outcome for most patients.

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