An extraperitoneal approach for complex flank, iliac, and lumbar hernia.

PURPOSE: The aim of this paper is to propose our four-step technique, an open extraperitoneal approach for complex flank, lumbar, and iliac hernias. METHODS: A big polypropylene mesh is placed, covering and reinforcing all the lateral abdominal wall in an extraperitoneal space. Its borders are retroxiphoid fatty triangle and the costal arch cranially and the retropubic space caudally, psoas muscle, and paravertebral region posteriorly and contralateral rectus muscle medially. Mesh dimensions do not depend from the defect size, but prosthesis has to cover all the lateral abdominal wall. RESULTS: No major complications have been reported. The mean length of stay is 4.8 days (range 3-11). Mean follow-up is 44.8 months (range 5-92). One recurrence (4.5%) has been reported at the 1-year clinical evaluation. CONCLUSION: In conclusion, we believe that regardless size and location of the defect, every complex lateral hernia requires the same extensive repair because of the critical anatomy of the region with a big medium-heavyweight polypropylene mesh placed in an extraperitoneal plane, the only one that allows adequate covering of the visceral sac. Our technique is a safe, feasible, and reproducible treatment for this challenging surgical problem.

Original concepts in anatomy, abdominal-wall surgery, and component separation technique and strategy.

BACKGROUND: The abdominal wall can be considered comprised of two compartments: an anterior and a posterior compartment. The anterior compartment includes the anterior rectus sheath and the rectus muscle. The posterior compartment comprises the posterior rectus sheath, the transversalis fascia, and the peritoneum. When a large defect in the anterior compartment has to be corrected, for example, a rectus diastasis or large incisional hernia, an action on the anterior compartment is necessary; therefore, an anterior component separation has to be considered. If a loss of substance is present in the posterior compartment, a trasversus abdominis release should be accomplished. METHODS: We propose an original anterior compartment mobilisation, by a posterior approach. Dissection of the posterior rectus sheet proceeds until the linea semilunaris is reached. Incision of the anterior rectus sheath permits a mobilisation of the anterior compartment by a posterior approach. A mesh is placed in a sublay position. If the abdominal wall presents a loss of substance of the posterior compartment, a transversus abdominis release (TAR) can be performed in the same time. RESULTS: No hernia recurrences, no wound infection, and no mesh infection have been reported. CONCLUSIONS: The anterior compartment mobilization permits mobilization towards the midline of rectus muscle and restoration of anterior compartment, with low morbidity rate; it can be easily associated to a large sublay mesh placement, it allows the preservation of the neurovascular bundles and rectus muscle trophism, and it can be associated with a concomitant TAR procedure for the restoration of the PC, if necessary.

Open mesh vs. suture umbilical hernia repair: systematic review and updated trial sequential meta-analysis of randomized controlled trials.

PURPOSE: To examine the updated evidence on safety, effectiveness, and outcomes of mesh versus suture elective umbilical hernia (UH) repair and to explore the timely tendency variations favouring one treatment over another. METHODS: MEDLINE and CENTRAL databases were consulted. A systematic review, pairwise meta-analysis, and trial sequential analysis (TSA) were conducted. RESULTS: Six RCTs were included for a total of 742 patients. Overall, 383 (51.6%) underwent mesh, while 359 (48.4%) underwent suture repair. The estimated pooled postoperative recurrence RR was 0.27 (95% CI 0.13-0.53; p < 0.001). The TSA showed a statistically significant timely tendency in favour of mesh repair with a boundary cross curve (Z = 1.96) before reaching the information size. The estimated pooled seroma, haematoma, and wound infection RR were 1.45 (p = 0.368), 0.54 (p = 0.196), and 0.71 (p = 0.375), respectively. The TSA for wound-related complications showed partial, non-significant results. CONCLUSIONS: Elective UH mesh repair seems to be associated with reduced risk of postoperative recurrence compared to simple suture repair with a statistically significant timely trend endorsed by the TSA. Definitive considerations concerning the cumulative effect for seroma, haematoma, and wound infection are premature. Further studies are warranted to endorse these results and deeply investigate the timely tendency variations.

Primary inguinal hernia: systematic review and Bayesian network meta-analysis comparing open, laparoscopic transabdominal preperitoneal, totally extraperitoneal, and robotic preperitoneal repair.

PURPOSE: The Open Lichtenstein technique, the Laparoscopic Trans-Abdominal PrePeritoneal (TAPP), the Totally Extra Peritoneal (TEP), and the robotic TAPP (rTAPP) are commonly performed. The aim of the present network meta-analysis was to globally compare short-term outcomes within these major surgical techniques for primary unilateral inguinal hernia repair. METHODS: PubMed, EMBASE, and Web of Science were consulted. A fully Bayesian network meta-analysis was performed. RESULTS: Sixteen studies (51.037 patients) were included. Overall, 35.5% underwent Open, 33.5% TAPP, 30.7% TEP, and 0.3% rTAPP. The postoperative seroma risk ratio (RR) was comparable considering TAPP vs. Open (RR 0.91; 95% CrI 0.50-1.62), TEP vs. Open (RR 0.64; 95% CrI 0.32-1.33), TEP vs. TAPP (RR 0.70; 95% CrI 0.39-1.31), and rTAPP vs. Open (RR 0.98; 95% CrI 0.37-2.51). The postoperative chronic pain RR was similar for TAPP vs. Open (RR 0.53; 95% CrI 0.27-1.20), TEP vs. Open (RR 0.86; 95% CrI 0.48-1.16), and TEP vs. TAPP (RR 1.70; 95% CrI 0.63-3.20). The recurrence RR was comparable when comparing TAPP vs. Open (RR 0.96; 95% CrI 0.57-1.51), TEP vs. Open (RR 1.0; 95% CrI 0.65-1.61), TEP vs. TAPP (RR 1.10; 95% CrI 0.63-2.10), and rTAPP vs. Open (RR 0.98; 95% CrI 0.45-2.10). No differences were found in term of postoperative hematoma, surgical site infection, urinary retention, and hospital length of stay. CONCLUSIONS: This study suggests that Open, TAPP, TEP, and rTAPP seem comparable in the short term. The surgical management of inguinal hernia is evolving and the effect of the adoption of innovative minimally invasive techniques should be further investigated in the long term. Ultimately, the choice of the most suitable treatment should be based on individual surgeon expertise and tailored on each patient.

Primary unilateral not complicated inguinal hernia with an effective, cheap, less invasive, and easy operation: the Trabucco repair.

BACKGROUND: In modern abdominal wall hernia surgery, the achievement of the most effective tailored repair for each specific defect with the less possible invasiveness, the quicker recovery, the lower costs and the fewer risk of local occurrences, recurrences and chronic pain is the most desirable and cutting-edge goal. METHODS: Since 1989 about 4219 primary unilateral not complicated inguinal hernias have been treated with specific indications with a sutureless and minimally invasive anterior open approach. The great majority of these procedures were performed under local anaesthesia in a day surgery regimen, with a systematic and careful nerve sparing, preservation of cremasteric muscle, and with a 3-5 cm skin incision. RESULTS: The minimally invasive sutureless nerve sparing open approach has shown a very low rate of seromas (0.45%), haematomas (0.24%) and infections (0.07%) while the width of skin incision challenges even laparoscopy. A significant reduction of both postoperative pain (2.7%) and chronic neuralgia (0.047%) has led to excellent outcomes in patients, also in terms of quality of life. Compared to the Lichtenstein's tension-free technique, which is at now the gold standard open treatment for primary inguinal hernia worldwide, there are no significant differences in the observed recurrence rate (well below 1%). CONCLUSION: In our experience of almost 30 years we have been able to experiment and refine more and more the sutureless technique proposed by Trabucco for the treatment of primitive inguinal hernia, peer to peer, improving the local anaesthesia and the ability to detect hidden defects during the repair (Spigelian included), reducing the width of the incisions and tractions on the tissues, introducing the concept of a gentle and bloodless "finger surgery" according to a minimally invasive, extremely anatomic, safe, inexpensive, very effective anterior open approach.