Spigelian hernia: Our total extraperitoneal approach and a systematic review of the literature.

INTRODUCTION: Spigelian hernia is a rare lateral ventral hernia traditionally repaired through open incision with extensive dissection. Three laparoscopic techniques have been reported in the literature: intraperitoneal onlay mesh (IPOM), transabdominal preperitoneal (TAPP), and total extraperitoneal (TEP). TEP is less popular than the other approaches. We evaluated TEP's safety and effectiveness and compared different laparoscopic techniques. METHODS: All patients with Spigelian hernia who had undergone extended TEP (eTEP) repair with mesh in our center from January 2007 to February 2020 were studied. A three-port technique with a preperitoneal space created by telescope at the midline was adopted. A systematic review on laparoscopic mesh repair was performed by searching for "Spigelian hernia" and "laparoscopic" from 1999 to 2019 in the MEDLINE database. RESULTS: Seven patients underwent eTEP repair for Spigelian hernia. Five presented with abdominal mass and underwent preoperative imaging. Two were diagnosed incidentally during TEP for inguinal hernia. The mean operative duration was 65 minutes (range, 40-93 minutes). There were no open conversions or intraoperative complications. The mean length of hospital stay was 1.4 days (range, 1-3 days). The mean follow-up period was 44.3 months. One patient developed seroma. There was no recurrence or chronic pain. We identified 197 laparoscopic mesh repairs reported in 41 articles. IPOM (n = 91) was the most popular approach, followed by TAPP (n = 70) and TEP (n = 36). Laparoscopic mesh repair of Spigelian hernia is safe and offers excellent outcomes. CONCLUSION: We found the eTEP approach safe and effective for Spigelian hernia repair. IPOM, TAPP, and TEP are comparable.

Laparoscopic Total Extraperitoneal Groin Hernia Repair in Females: Comparison of Outcomes Between Preservation or Division of the Uterine Round Ligament.

Background: Laparoscopic repair has been recommended as the method-of-choice of groin hernia repair among women. Whether the round ligament of uterus should be divided to facilitate mesh placement remains controversial. This study aims to review the outcomes of laparoscopic total extraperitoneal (TEP) groin hernia repair in women and to evaluate the impact of division of round ligament. Methods: Consecutive female patients with inguinal or femoral hernias who underwent elective laparoscopic TEP repair at a single institution from 2006 to 2017 were included for retrospective analysis. Primary outcomes were postoperative pain, genital prolapse, and recurrence. Outcomes of patients who had the round ligament divided were further compared with those with round ligament preserved and multivariable adjusted analysis was performed. Results: Sixty-eight patients with a total of 77 TEP repairs were included in the 12-year study period. The mean age was 45 ± 16 years old. Incidental femoral hernia was identified in 4 patients (5.9%). There was 1 (1.3%) recurrence upon mean follow-up of 42.9 ± 37.3 months. The round ligament was divided in 67.5% of patients, and upon multivariable adjusted analysis, there were no statistically significant differences in outcomes in terms of chronic pain (odds ratio [OR] = 2.210, P = .357), paresthesia (OR = 0.241, P = .149), and genital prolapse (OR = 0.327, P = .415) when compared with patients with preserved round ligament. Conclusion: Laparoscopic groin hernia repair in women is associated with low recurrence. Division of round ligament intraoperatively facilitates mesh placement and has minimal impact on clinical outcomes.

Tension-free mesh repair of inguinal hernia in patients on continuous ambulatory peritoneal dialysis.

BACKGROUND: Peritoneal dialysis (PD) is the first-line renal replacement therapy for end-stage renal failure patients in Hong Kong. Abdominal wall hernia is a common mechanical complication of PD, and early surgical repair has been advocated to reduce complications. This study aims to review the outcomes of tension-free mesh repair of inguinal hernia in PD patients. METHODS: All PD patients who underwent elective repair of inguinal hernia from 2009 to 2015 were identified from a single centre for retrospective analysis. Primary outcomes included surgical complications, perioperative dialysis technique and recurrence. RESULTS: Twenty-one patients with a total of 26 inguinal hernia repairs were included in this 7-year retrospective study. All were males, and the mean age was 68 ± 10 years. Diabetic nephropathy (n = 9, 42.9%) and glomerulonephritis (n = 7, 33.3%) were the two most common causes of renal failure. All hernias were detected after the initiation of PD, and the mean duration of PD to hernia detection was 16 months (range 1-65 months). Lichtenstein open mesh repair was performed in all patients. Complications included seroma (n = 3, 11.5%) and ischaemic orchitis (n = 1, 3.8%). There were no mesh infection or recurrence. Twenty patients (95.2%) received intermittent peritoneal dialysis post-operatively and returned to continuous ambulatory PD in 15 to 30 days. Only one patient (4.8%) required bridging haemodialysis due to Tenckhoff catheter blockage. CONCLUSIONS: Tension-free mesh repair is associated with low morbidity and low recurrence rates in PD patients. Timely management and close collaboration with renal physicians are essential to continue PD after repair.

A Randomized Controlled Trial Comparing Short-term Outcomes of Self-Gripping (Progrip) Mesh Versus Fibrin Sealant in Laparoscopic Total Extraperitoneal Hernioplasty.

BACKGROUND: There are no data comparing the use of self-gripping mesh with standard mesh in total extraperitoneal repair (TEP). In this prospective study we aim to study the incidence of chronic pain between Progrip (PG) and standard mesh fixed by fibrin sealant (FS). MATERIALS AND METHODS: Under Institutional Review Board approval, from April 2016 to May 2017, patients with primary unilateral or bilateral inguinal hernia eligible for TEP were recruited. Before mesh insertion they were randomized into PG or FS (Tisseel). Demographics, intraoperative, and postoperative data were recorded. Patients were followed up for at least 1 year. Visual Analog Scale was used to record pain scores. Primary outcome was the incidence of chronic pain at 3 months after surgery. RESULTS: One hundred fifty patients were randomized. Of the 150 patients (193 hernias), 76 were randomized to PG and 74 randomized to FS. Demographic data such as age, presence of comorbidities, smoking history, mean body mass index was comparable in both groups. Bilateral hernias occurred in 25 (32.9%) and 18 (24.3%) patients in PG and FS group, respectively. Mean mesh deployment time was 283.7 seconds (range, 140 to 720 s) in PG group and 301.9 seconds (range, 67 to 1006 s) in FS group (P=0.30). A total of 5 patients were lost at follow-up and they were excluded from subsequent data analysis. Seroma occurred in 15 (20.3%) and 16 (22.5%) patients in PG and FS group, respectively (P=0.45). Mean Visual Analog Scale at 2 weeks (cough) was highest at 1.05 and 1.02 in PG and FS group, respectively (P=0.62). Eight (12.3%) and 15 (23.4%) patients in PG and FG group, respectively, reported pain at 3-month follow-up (P=0.1). Of those who experienced pain, majority was mild pain which did not affect activities of daily living. At a mean follow-up of 13.1±5.4 months, no recurrence was detected. CONCLUSIONS: There was no significant difference in terms of chronic pain between PG and FS group. The use of PG is effective in TEP.

Laparoscopic versus open repair for small paraumbilical hernia: A retrospective review.

INTRODUCTION: The advantages of laparoscopic surgery for ventral hernia repairs are well documented, but its application for small paraumbilical hernias has been less studied. There is no consensus regarding the best technique. METHODS: All patients who had open (suture or mesh) and laparoscopic repair of primary paraumbilical hernia between September 2007 and September 2017 in a single center were identified. Hernial defects of 2 cm or less were included; recurrent hernias were excluded. Primary outcomes included operative time, length of hospital stay, and surgical complications. RESULTS: Seventy-seven patients were recruited: 54 (70.1%) had open repair and 23 (29.9%) had laparoscopic repair. Forty-six patients (85%) in the open group had primary suture repair. The mean operative time was significantly shorter in the open group than in the laparoscopic group (27.2 vs 56.1 min, P < 0.05). The length of hospital stay in the open group was significantly shorter than in the laparoscopic group (0.8 vs 1.4 days, P = 0.00). Early complications rates were similar, with wound complications in 5.6% (3/54) of open repair patients and 4.3% (1/23) of laparoscopic repair patients (P = 1.0). Among open repair patients, 19 patients (35.2%) were successfully discharged within 12 h after operation. Two patients (3.7%) in the open simple suture group developed recurrence, but no recurrence was identified in the laparoscopic group; this was not statistically significant (P = 1.0). CONCLUSION: The laparoscopic approach is comparable to the open approach in the repair of small paraumbilical hernias. For small paraumbilical hernias, we recommend that laparoscopic repair be reserved for obese patients or those with suspected multiple hernial defects.

Elective laparoscopic totally extraperitoneal repair for Spigelian hernia: A case series of four patients.

INTRODUCTION: Spigelian hernia (SH) is uncommon. Clinical diagnosis may be difficult, but computed tomography (CT) can help to establish the diagnosis. Laparoscopic repair is increasingly performed because it is associated with low morbidity rates. Laparoscopic approaches include transabdominal preperitoneal (TAPP), intraperitoneal onlay mesh (IPOM), and totally extraperitoneal (TEP). Here, we report our experiences of TEP repair for SH. METHODS: A retrospective review was performed on all patients with SH who underwent elective laparoscopic TEP repair from 2007 to 2017 at Tung Wah Hospital, Hong Kong. RESULTS: Four patients with SH were identified in the study period: three with a preoperative diagnosis of SH confirmed by CT scan and one diagnosed incidentally during TEP repair for inguinal hernia. The patients' mean age was 66.8 years (range, 55.0-82.0 years). The mean BMI was 22.8 kg/m2 (range, 20.8-23.6 kg/m2 ). The mean size of the SH defect was 2.0 cm (range, 0.5-3.0 cm). The mean operative time was 59 min (range, 40-86 min). Concomitant direct inguinal hernia was found in one patient and repaired simultaneously. All patients were discharged on postoperative day 1. One patient developed seroma, which subsided on conservative management. At a mean follow-up of 36 months (range, 2-108 months), there was no recurrence. CONCLUSION: Laparoscopic repair for SH is preferred over the open approach as it is associated with a low morbidity rate and a short hospital stay. In our experience, TEP technique is safe and effective in laparoscopic SH repair.

Surgical management of recurrent pyogenic cholangitis: 10 years of experience in a tertiary referral centre in Hong Kong.

BACKGROUND: Recurrent pyogenic cholangitis (RPC) is common in Asia. Its management differs from centre to centre. METHODS: A retrospective review of 80 patients undergoing surgery for RPC was performed. Immediate and longterm outcomes were analysed. RESULTS: All patients underwent hepaticocutaneousjejunostomy (HCJ) for biliary drainage and stone removal. Additional hepatectomy was performed in 38 patients with intrahepatic ductal stricture or liver segmental atrophy. Twenty-three patients had residual stones and 25 had recurrent stones. All patients with residual stones underwent repeated choledochoscopy (median: four sessions) for stone removal and obtained confirmation of ductal clearance. Four patients developed cholangiocarcinoma, of which two died. The complication rate was 17.5%. Most of the complications were wound infections. No mortality related to surgery occurred. Multivariate analysis found that gender, disease extent (unilobar versus bilobar) and surgery type (HCJ alone versus HCJ with hepatectomy) were not associated with increased risk for residual or recurrent stones. A raised preoperative bilirubin level was the only risk factor identified as associated with an increased risk for recurrent stones (P < 0.001); it was not associated with an increased risk for residual stones. CONCLUSIONS: Recurrent pyogenic cholangitis is a distinct disease, the management of which requires a high level of surgical expertise. Hepaticojejunostomy is recommended as the primary drainage procedure, but hepatectomy should be reserved for complicated RPC.