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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Inguinal hernia repairs represent one of the most common general surgery operations worldwide. Advances in the understanding of groin anatomy, operative technique, and prosthetics have improved the efficacy of these repairs with overall low recurrence rates and favorable outcomes. Chronic postherniorrhaphy inguinal pain has arguably become the most important and most frequent complication of inguinal hernia repair, with significant impact on patients' quality of life. Neuropathic inguinodynia may be caused by direct nerve injury, manipulation, entrapment, scarring, and interaction with mesh. Development of chronic postinguinal hernia repair pain is independent of the method of hernia repair as all inguinal hernia repair techniques may potentially cause injury. Understanding the neuroanatomy of the inguinal canal and the potential mechanisms for injury leads to lower rates of nerve injury and chronic pain and helps to guide prevention and treatment of inguinodynia. In this article, the neuroanatomy of the anterior inguinal canal and the prevention of nerve injury are addressed.

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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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BACKGROUND: Deep knowledge of anatomy is essential for the success of any surgical intervention. This is especially true for inguinal hernia repair, due to the complex anatomical structure of the groin. METHODS: Observation and documentation of the pathology of the groin in >15,000 laparoscopic inguinal hernia repairs and careful study of the literature describe the anatomy in cadaver preparation. RESULTS: The large variability of the course of the nerves and the utmost importance of the bilaminar structure of the transversalis fascia for a precise dissection of the pelvic floor as well as for the placement of a large flat mesh are described in detail. CONCLUSION: Competent knowledge of the anatomy of the groin facilitates the operative performance, enables a tissue-protective dissection, and may provide an uncomplicated postoperative course.

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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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INTRODUCTION: Whether antibiotic prophylaxis can really reduce the rate of surgical site infections (SSIs) or rather tends to increase the risk of antimicrobial resistance development is being increasingly questioned even for elective surgery in a clean surgical field. Since compared with the open technique, the laparoendoscopic technique per se reduces the SSI rate, that possibility must also be considered for laparoendoscopic repair of inguinal and abdominal wall hernias despite these techniques always using a mesh as a foreign body. MATERIALS AND METHODS: A systematic search of the literature was conducted in Medline/PubMed and the Cochrane database. Thirty-two relevant publications were identified. RESULTS: Overall, there is a paucity of studies on antibiotic prophylaxis in laparoendoscopic hernia surgery. Those studies available are not able to demonstrate that the use of antibiotic prophylaxis in laparoendoscopic repair of inguinal and abdominal wall hernias has a definite effect on the SSI rate. Hence, antibiotic prophylaxis can be omitted with for patients with no risk factors. But that does not apply for patients with risk factors, such as obesity, diabetes mellitus, emergency surgery, contaminated surgical field, recurrent hernia, chronic obstructive pulmonary disease, abdominal aortic aneurysm, prior SSI, long operative time, and other factors influencing the SSI rate. CONCLUSION: Further studies are urgently needed on antibiotic prophylaxis in laparoendoscopic hernia surgery in particular in association with risk factors.

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BACKGROUND: The incidence of incisional hernia following surgery is a major economical and clinical burden for healthcare. METHODS: This report reviews and consolidates pertinent literature related to hernia prevention to give surgeons a solid framework on the current perspectives and emerging topics related to incisional hernia prevention. RESULTS: Pertinent anatomy and fundamentals of laparotomy closures are reviewed. Recommended closures of laparotomy incisions include the use of monofilament, slowly absorbing suture in a running fashion with a 4:1 suture to wound length ratio using a short stitch technique. The use of prophylactic mesh reduces the rate of incisional and parastomal hernias in high-risk patients. CONCLUSION: The current fundamentals of hernia prevention including pertinent anatomy and surgical techniques for appropriate laparotomy closures should be known to surgeons operating on the abdominal wall. The use of prophylactic mesh to reduce incisional and parastomal hernias has shown promise, and further research is needed to evaluate long-term efficacy.

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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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OBJECTIVES AND BACKGROUND: Ventral hernias are a frequent reason for surgical consultation, and its incidence is higher in the obese population. In this article, we analyze the relationship between obesity and abdominal wall pathology and its influence in surgical results. PROCEDURE: A literature search strategy was performed to analyze this relationship. RESULTS: Obesity is not only a risk factor for the appearance of abdominal wall hernias and incisional hernias but also for complications after ventral hernia repair. Obesity also increases the risk of incarceration and recurrence after repair. In these patients, the laparoscopic approach minimizes the risk and comorbidity generated by obesity in abdominal wall surgery obtaining better results. Joint surgery with laparoscopic bariatric surgery seems to be a feasible technique with lower recurrence rates in different studies. Despite these results, conclusive studies are still insufficient to make recommendation concerning hernia repair in patients undergoing bariatric surgery. CONCLUSIONS: There is a strong association between obesity and abdominal wall hernias, and the laparoscopic approach seems to offer better results regarding comorbidity of obesity.

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BACKGROUND: Following herniorrhaphy, deep surgical site infections with mesh involvement (dSSI-MI) traditionally necessitate mesh removal, putting patients at risk for hernia recurrence. There is no consensus about managing infected mesh, as salvage strategies are poorly reported. We describe our outcomes following dSSI-MI at two high-volume hernia centers. MATERIALS AND METHODS: A retrospective review of hernia repairs complicated by dSSI-MI with subsequent salvage attempt was undertaken. Outcome measures included duration of antibiotic use, recurrent dSSI-MI, need for mesh excision, postoperative complications, and hernia recurrence. RESULTS: Thirteen patients underwent attempted mesh salvage (female = 8, median age = 64, and median body mass index = 30.6). 62% had an average of 1.5 prior mesh repairs, and 23% had prior surgical site infection. Twelve underwent open ventral or parastomal hernia repairs, while one patient had a prophylactic mesh augmentation. Three cases required concomitant bowel surgery. Eight dSSI-MIs resulted from gastrointestinal tract complications. All patients received antibiotics for median of 17 days. 92% required operative management of dSSI-MI (100% incision and drainage, 66% debridement of soft tissue). Negative-pressure wound therapy (NPWT) was utilized in 92% for an average of 26 days. One patient was successfully managed without an operation. With a median follow-up of 34 months, there were two recurrent hernias, only one requiring repair. CONCLUSIONS: Despite requiring significant postoperative care (reoperations, prolonged antibiotics, and NPWT), mesh salvage without complete explantation is feasible following dSSI-MI, with a low rate of recurrent hernia formation or long-term infections. Salvage attempts were undertaken primarily in patients with retromuscular macroporous polypropylene, suggesting that repair type and mesh choice influence the decision-making for salvage.

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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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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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PURPOSE: Stoma reversal sites are a common location for incisional hernias. We aim to evaluate fascial defects at previous stoma sites in patients with a history of colorectal cancer. METHODS: This was a retrospective cohort study from a single center. We included adult patients diagnosed with colorectal cancer, who underwent stoma reversal from 2011 to 2018 with at least one postoperative computed tomography scan. RESULTS: Of 92 patients, 40 (43%) were female, with a mean age of 58 years. Fascial defects were noted in 45 (49%) patients, with stoma-site hernias present in 24 (26%) patients. Posterior sheath defects were not associated with subsequent hernia development, and most hernias occurred within 2 years. Body mass index >30 was associated with increased risk of stoma-site hernia (odds ratio 11.9, P = 0.002), but smoking, hypertension, stoma type, pathologic stage, and chemotherapy within 90 days were not found to be significant. CONCLUSIONS: The incidence of stoma-site hernias is high. Obesity appears to be a significant risk factor for the development of these hernias and most hernias occur quickly following surgery.

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BACKGROUND: The extent of inflammatory and oxidative stress response varies with different surgical procedures. The aim of the study was to compare the same between total extraperitoneal repair and Lichtenstein repair for inguinal hernia. MATERIALS AND METHODS: Men, aged 18–60 years with an ASA score of 1, presenting with primary unilateral indirect inguinal hernia were randomized to total extraperitoneal repair (TEP) and Lichtenstein repair. Blood samples were collected an evening before surgery and postoperatively at 2, 24, and 48 h to compare the levels of highly sensitive C-reactive protein (hs-CRP), malondialdehyde (MDA), and neutrophil: lymphocyte ratio between the two modes of repair. RESULTS: Both modalities of repair cause a significant inflammatory response in the body (P < 0.05). The rise in the level of serum hs-CRP and neutrophil: lymphocyte ratio was significantly more in the open surgery group as compared to the TEP group at 2, 24, and 48 h postoperatively (P < 0.05). The levels of serum MDA were distinctively higher (P = 0.042) only at 2 h after surgery in the former group. CONCLUSION: Endoscopic repair is associated with a significantly lesser oxidative response than Lichtenstein repair based on this study (P < 0.05). Although this might be one of the bases for lesser postoperative pain and earlier return to activity in TEP repair, more randomized studies are required to draw a definitive conclusion.

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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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PURPOSE: Although the size of the hernia plays an active role in the use of the mesh, the counter-view is that the use of the mesh should be preferred regardless of the size of the hernia. In our study, the clinical results of two different mesh types applied under elective conditions to small-and medium-sized umbilical hernia cases were examined. PATIENTS AND METHODS: Between January 2015 and May 2018, intraperitoneal Ventralex ST repair and onlayprolene mesh repair were performed in 88 primary small and medium umbilical hernia cases. Demographic data, duration of surgery, length of hospital stay postoperative complications, and recurrence were recorded. RESULTS: Eighty-eight patients were analyzed including 54 males and 34 females – a mean age of 50.3 years. The duration of the surgery in Ventralex ST group was 35.9 ± 4.1 min. (P < 0.05). Comparing to the visual analog scale (VAS) values of the 1^st day, the decrease in VAS values in both groups on the 7^th day was statistically significant (P < 0.05). The rates of early and late postoperative complications, such as seroma, hematoma, wound infection, and recurrence, were similar between the procedures. The mean follow-up period was 23 months (with range 7–46 months), and no recurrence was observed in both groups. CONCLUSION: We think that the Ventralex ST mesh performed with open surgical technique under elective conditions for primitive umbilical hernias can be safely used because of its quick applicability and low rates of complication and recurrence.

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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: 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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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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OBJECTIVE: The objective of the study was to investigate the clinical utility of the transversus abdominis muscle release (TAR) procedure in complex abdominal wall reconstruction. MATERIALS AND METHODS: Retrospective study of 32 patients with complex abdominal wall defects admitted to Hangzhou First People's Hospital between January 2016 and December 2017. Clinical materials were collected and analyzed. RESULTS: Among 32 cases of large incisional hernias, there were 19 males (59.4%) and 13 females (40.6%). Mean age was 64.41 ± 12.11 years, body mass index was 30.00 ± 5.97 kg/m², and mean width of the abdominal defect was 11.34 ± 1.82 cm. Twenty-four cases were midline incisional hernias with one case of planned incisional hernia after severe pancreatitis, and three cases were lateral. Five cases were recurrent incisional hernias. All patients underwent retromuscular mesh repair, with abdominal wall reconstruction using the TAR procedure. The operative time was 151.59 ± 28.64 min, and estimated blood loss was 118.12 ± 83.41 cm³. Length of hospital stay was 13.66 ± 2.72 days. Two cases had a superficial surgical site infection, five had Type II seroma, and one had intestinal obstruction. All postoperative complications resolved with nonsurgical therapy. No mesh infection, fistula, recurrence, or postoperative bulging was reported during follow-up. CONCLUSION: Posterior component separation through TAR is a reliable and effective technique for complex abdominal wall reconstruction. Long-term follow-up is needed to assess potential recurrence.

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OBJECTIVE: The objective of this study is to assess the prophylactic and therapeutic effects of initiative content reduction on intra-abdominal hypertension in obesity patients with huge abdominal incisional hernia. MATERIALS AND METHODS: In this study, the retrospective cohort/descriptive research methods were applied. We collected the clinical data of a total of 62 obesity patients with single-onset huge abdominal incisional hernia who were admitted to Beijing Chaoyang Hospital of Capital Medical University for treatment between January 2011 and December 2015. In the operation, the initiative content reduction was performed. Following observation indexes were recorded as follows: (1) Surgical condition: surgical duration, length of resected intestinal tract, and length of stay (LOS) in hospital; (2) postoperative recovery: cardiac, pulmonary, hepatic and renal functions, and and intravesical pressure; (3) incidence of postoperative complications: infection of incision and intestinal fistula; and (4) patients' condition in follow-up. Return visits in outpatient service were required respectively at 1 week, 1 month, 3 months and 6 months after surgery, and 1 year after follow-up, the follow-up was carried out through telephone. Recurrences of hernia and late-onset infection were the question to be asked in follow-up, and June 2016 was set as the deadline of follow-up. RESULTS: (1) Surgical condition: The surgeries were successfully carried out for 62 patients, in which surgical duration was (115 ± 22) min, the length of resected intestinal tract was (207 ± 64) cm, and LOS was (14.5 ± 1.9) d. (2) Postoperative recovery: the intravesical pressure of patients was decreased in comparison with the level before operation, and after surgery, no hepatic, renal and respiratory dysfunctions were observed. (3) Incidence of postoperative complications: There were four patients with infection of incision; however, no intestinal fistula was found in any patients. (4) Follow-up: follow-up was performed for 62 patients, and the average length of follow-up was 35 months, during which three patients suffered recurrence of incisional hernia. CONCLUSION: For obesity patients with huge abdominal hernia, the application of initiative content reduction can effectively prevent the postoperative intra-abdominal hypertension, which is considered as an effective and feasible therapeutic procedure.

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