TPP (totally preperitoneal) making single incision laparoscopic inguinal hernia repair more feasible: a comparison with single incision laparoscopic totally extraperitoneal hernioplasty (SIL-TEP).

BACKGROUND: Totally preperitoneal hernioplasty (TPP) is a concept which was introduced for distinguishing with totally extraperitoneal (TEP). There is few evidence reflecting the single incision laparoscopic totally preperitoneal (SIL-TPP) characteristic. The aim of study is to demonstrate the feasibility of single incision laparoscopic totally preperitoneal hernioplasty (SIL-TPP) and compare the outcomes with the single incision laparoscopic totally extraperitoneal hernioplasty (SIL-TEP) technique. METHODS: During August 2018 and July 2022, 200 inguinal hernia patients received SIL-TPP and 56 patients received SIL-TEP in the First hospital of Ningbo university. The demographics, clinical characteristics, intraoperative and postoperative parameters were retrospectively analysed. RESULTS: SIL-TPP and SIL-TEP hernia repair were successfully conducted in all patients. There was no conversation happened in two group. Patients' demographics were comparable when compared between the two groups adding the comparison initial 52 cases analysis (P > 0.05). The mean unilateral hernia operative time was significant shorter in the SIL-TPP group than SIL-TEP group (unilateral: 81.38 ± 25.32 vs. 95.96 ± 28.54, P: 0.001). Further study of unilateral hernia operative time revealed the mean indirect hernia operative time was significant shorter in the SIL-TPP group than SIL-TEP group (indirect: 81.38 ± 25.33 vs. 95.87 ± 28.54, P: 0.001). The unilateral hernia operation time trend of initial 52 cases of two group analysis revealed the operation time of SIL-TPP reduced faster than SIL-TEP along with treating number increasing (Figs. 2 and 3). The comparison of initial equal quantity unilateral hernia patient mean operative time revealed the SIL-TPP group was significant shorter than SIL-TEP group (85.77 ± 22.76 vs. 95.87 ± 28.54, P: 0.049). The rate of peritoneum tearing of SIL-TPP group was significant high than SIL-TEP (P = 0.005). CONCLUSION: SIL-TPP hernia repair is a superior procedure and possess its own distinguished advantages. We recommend it rather than SIL-TEP for treating inguinal hernia, especially for indirect hernia. However, large-scale randomized controlled trials comparing SIL-TPP and SIL-TEP are needed to confirm these results.

Comparison of outcomes of the extended-view totally extraperitoneal rives-stoppa (eTEP-RS) and the intraperitoneal onlay mesh with defect closure (IPOM-plus) for W1-W2 midline incisional hernia repair-a single-center experience.

BACKGROUND: The eTEP technique is a new approach that has recently gained popularity in abdominal wall hernia surgery. This study aimed to compare the outcomes of the eTEP-RS and IPOM-plus procedures in W1 and W2 midline incisional abdominal wall hernia (IAWH) repairs performed by the same surgeon. METHODS: Prospectively collected data of laparoscopic abdominal wall repairs performed on 61 patients with eTEP between November 2018 and April 2022 and on 67 patients with IPOM-plus between January 2016 and April 2022 were retrospectively analyzed. A total of 74 out of 128 patients, 30 in the eTEP-RS group and 44 in the IPOM-plus group, who underwent W1-W2 midline incisional hernia repair were included in the study. The mean follow-up was 24 months in the eTEP-RS group and 45 months in the IPOM-plus group. RESULTS: There was no statistically significant difference between the groups regarding age, sex, BMI, ASA score, or active smoking. No difference was seen between the two groups in terms of the mean defect area (MDA, 28.17 cm2 vs. 27.41 cm2, p = 0.84), but the mean mesh area (MMA) and mesh/defect (M/D) ratio were higher in the eTEP-RS group (404.11 cm2 vs. 267.85 cm2, p < 0.001 and 20.96 vs. 12.36, p = 0.004). In the eTEP-RS group, the hospital length of stay (LOS) (1.48 days vs. 2.58 days, p < 0.001) and pain on the first and 10th postoperative days were significantly lower (p < 0.001), while the operative time was significantly longer (204.07 min vs. 88.33 min, p < 0.001). There was no significant difference in terms of intraoperative complications (p = 0.56), seroma formation (p = 0.83), or recurrence (p = 0.83). CONCLUSION: The eTEP-RS technique has advantages over the IPOM-plus approach, such as a shorter LOS and less early postoperative pain with W1-W2 midline IAWH repair. However, the eTEP technique has a longer operative time.

Comparison of balloon dissection and telescopic dissection of the preperitoneal space in laparoscopic totally extraperitoneal hernia repair: a systematic review and meta-analysis.

PURPOSE: Safety in creating a preperitoneal space is crucial in laparoscopic totally extraperitoneal (TEP) hernia repairs. In this systematic review and meta-analysis, we compared the outcomes of balloon dissection and telescopic dissection in patients with inguinal or femoral hernias who underwent TEP hernia repair. METHODS: We searched PubMed, Embase, Web of Science, and Cochrane databases for randomized controlled trials (RCTs) and prospective and retrospective studies published from inception to July 2022. Meta-analysis was performed using a random-effects model. The treatment outcome was measured using operation time, incidence of intraoperative hemorrhage, peritoneal laceration, conversion to other approaches, surgical site infection (SSI), hematoma, seroma formation, hernia recurrence, and postoperative pain. RESULTS: Five RCTs, one prospective study, and two retrospective studies (in total, 936 patients) were included. No significant between-group differences were noted in operation time, SSI, hematoma, seroma, recurrence rate, and postoperative pain on days 1 and 7. The conversion rate was significantly lower in the balloon group than in the telescopic group (odds ratio, 0.34; 95% confidence interval, 0.15-0.81). CONCLUSIONS: Both balloon dissection and telescopic dissection are viable techniques for creating preperitoneal space in laparoscopic TEP hernia repair and have similar operation time, complication rate, and postoperative pain. Nevertheless, the conversion rate was lower in patients undergoing balloon dissection than in those undergoing telescopic dissection.

Bilateral inguinal hernia repair by laparoscopic totally extraperitoneal (TEP) vs. laparoscopic transabdominal preperitoneal (TAPP).

BACKGROUND: The guidelines recommend laparoscopic repair for bilateral inguinal hernia. However, few studies compare the totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) techniques in bilateral inguinal hernias. This study aimed to compare the outcomes of TEP and TAPP in bilateral inguinal hernia. METHODS: We conducted a retrospective cohort study of patients operated on for bilateral inguinal hernia by TEP and TAPP repair from 2016 to 2020. Intraoperative complications, operative time, acute postoperative pain, hospital stay, postoperative complications, chronic inguinal pain, and recurrence were compared. RESULTS: A total of 155 patients were included in the study. TEP was performed in 71 patients (46%) and TAPP in 84 patients (54%). The mean operative time was longer in the TAPP group than in the TEP group (107 min vs. 82 min, p < 0.001). The conversion rate to open surgery was higher in the TEP group than in the TAPP group (8.5% vs. 0%, p = 0.008). The mean hospital stay was longer in the TAPP group than in the TEP group (p < 0.001). We did not observe significant differences in the proportion of postoperative complications (p = 0.672), postoperative pain at 24 h (p = 0.851), chronic groin pain (p = 0.593), and recurrence (p = 0.471). We did not observe an association between the choice of surgical technique (TEP vs. TAPP) with conversion rate, operative time, hospital stay, postoperative complications, chronic inguinal pain, or hernia recurrence when performing a multivariable analysis adjusted for the male sex, age, BMI, ASA, recurrent hernia repair, surgeon, and hernia size > 3cm. CONCLUSIONS: Bilateral inguinal hernia repair by TEP and TAP presented similar outcomes in our study.

Development and Implantation of 3D Anatomically Tailored Polypropylene Mesh for Laparoscopic Inguinal Hernia Repair Designed on the Basis of CT Images (the ILAM Study).

OBJECTIVE: The aim of the ILAM (Individualized Laparoscopic Anatomical Mesh) study was to create and implant a fully individualized mesh based on CT scans, taking into account the published body of knowledge about the material and mechanical behavior of the implant for laparoscopic inguinal hernia repair. SUMMARY BACKGROUND DATA: The team creating and conducting this study consisted of surgeons and engineers. A specific project was made and divided into 4 phases. METHODS: The process of development and implantation was divided into 4 milestones: CT scans and modeling based on predefined subgroups, mesh manufacture, certification and clinical evaluation. RESULTS: The result of the study was the first individually designed hernia mesh to have been implanted in a human subject. After 12 months of follow-up, no recurrences or other complications were reported. CONCLUSIONS: The new mesh provides a better anatomic fit to the patients' inguinal region geometry. Mechanical stability is ensured by the multiple contact points between the implant and the tissues, which generate friction forces. Together with the possibility of shape design (proper overlap), the authors believe that there is no need for mesh fixation. If so, the use of such design meshes can change the guidelines in laparoendoscopic hernia repair in the future.

Enhanced view totally extraperitoneal approach: A better alternative to transabdominal preperitoneal approach for irreducible inguinoscrotal and giant inguinal hernias!

The advantages of enhanced view totally extraperitoneal (eTEP) over TEP approach are well established in large inguinoscrotal, recurrent inguinal, patients with short pubis to umbilicus distance and in obese patients. Irreducible inguinoscrotal hernias (IISHs) and giant inguinal hernias (GIHs) pose a great challenge. GIHs are hernias which extend below the midpoint of the inner thigh with the patient in the standing position. Majority of these hernias are managed by open, hybrid or by transabdominal pre-peritoneal (TAPP) approach. TAPP was considered the optimal minimally invasive approach for these hernias as it provides a large working space and reduction of contents under vision. My practice of eTEP has been limited to IISH and GIH. I would like to share some technical tips to manage these cases by eTEP approach.

Endoscopic totally extraperitoneal repair for groin hernia: Experience from a tertiary care centre.

Background: Totally extra-peritoneal (TEP) and transabdominal preperitoneal (TAPP) repair are two established minimal access techniques of groin hernia surgery. TEP offers the advantage of avoiding violation of the peritoneal cavity. Aim: This study aims to describe the decade-long experience of TEP in groin hernia repair in a tertiary care teaching institute and the feasibility of the same in difficult scenarios. Materials and Methods: Retrospective analysis of the database of patients undergoing TEP repair for inguinal hernia in a single surgical unit at a tertiary teaching hospital between January 2008 and December 2019 was performed. Detailed pre-operative clinical details, operative duration, intraoperative and post-operative complications, including pain, length of post-operative hospital stay and hernia recurrence data were analysed. Results: Over 12 years' duration, 511 patients underwent endoscopic TEP mesh repair and the total number of hernias repaired was 614. Majority (97.45%) of patients were male. The mean age of the patient population was 51.3 years. Primary hernia was seen in 490 patients. The mean operating time for unilateral inguinal hernia repair was 56.8 ± 16 min and for bilateral repair 80.9 ± 25.2 min. TEP in previous lower abdominal/suprapubic surgical scars was attempted in 17 (3.3%) patients, with only one requiring conversion. The intraoperative peritoneal breach was the most common documented complication (34.8%). Seroma was seen in 9.4% of patients. Seventeen patients required conversion (14 TAPP and 3 open). Recurrence was seen in 4 (0.7) patients. Conclusion: TEP repair is an effective method of groin hernia repair and can be attempted in the majority of patients groin hernia, including patients with previous lower abdominal incisions.

Analysis of 'enhanced-view totally extra-peritoneal' (eTEP) approach for ventral hernia: Early results.

Introduction: Laparoscopic ventral hernia repair is undergoing a paradigm shift with the introduction of numerous new techniques to improve the outcomes. Enhanced-view totally extra-peritoneal (eTEP) is a novel approach for the repair of ventral herniae introduced by Belyansky et al. The key innovation lies in placing the mesh in a large retrorectus-pre-peritoneal space contrary to the widely practiced intra-peritoneal placement. This approach can be easily coupled with a component separation in the form of transversus abdominis release (TAR) for large herniae. We conducted a midterm analysis of 'eTEP' approach to ventral hernia at a high-volume tertiary care centre and present our results of over 3 years of employing this technique. Methodology: A retrospective study of 150 cases of ventral hernia repaired using eTEP approach from January 2018 to February 2021 at a tertiary care centre by a team of three surgeons. The procedures were performed by a single team of three members headed by the first author. Results: Out of total 150 cases, incisional hernia occurred in 73 cases (48.7%), primary hernia occurred in 48 cases (32%) and recurrent hernia in 29 cases (19.3%). Although the majority of incisional (87.7%) and recurrent (79.3%) ventral hernias occurred in female, the incidence of primary ventral hernia was equal at 24 cases in both genders. The majority of the cases (80.7%) underwent eTEP RS procedure, and the rest were W3 hernias, which were managed by including a component separation in the form of eTEP TAR. The operating time for eTEP TAR (222.24 min ± 32.56) compared to eTEP RS (124.33 ± 23.68) was significantly longer. The mean length of stay was significantly shorter for primary hernias (3.75 days ± 1.62) compared to recurrent (5.21 days ± 2.51) and incisional hernias (4.36 days ± 2.19) (F = 4.376) (P = 0.014). The peri-operative period was uneventful in majority of the cases. We experienced a seroma rate of 5.8% in our series. At follow-up of 1 year, 3.3% of patients complained of discomfort/bulge in the upper abdomen. There were no other surgical site occurrences (SSO) in the form infection, posterior rectus sheath disruption and skin necrosis. We observed no recurrences till date with a minimum follow-up of 1 year. Conclusion: eTEP approach to ventral hernia is a promising abdominal wall reconstruction technique. It is safe and offers good functional outcomes with restoration of abdominal wall dynamics. It is a reproducible and safe technique for tackling various types of ventral hernia. It is specifically useful in managing unusual lateral hernias, incisional and recurrent hernias with ease.

A randomised control trial study of early post-operative pain and intraoperative surgeon workload following laparoscopic mesh repair of midline ventral hernia by enhanced-view totally extraperitoneal and intraperitoneal onlay mesh plus approach.

Introduction: The aim of this study was to compare the peri-operative outcomes, especially intraoperative surgeon workload and early post-operative pain, following midline ventral hernia repair by laparoscopic enhanced-view totally extraperitoneal (eTEP) approach and laparoscopic intraperitoneal onlay mesh plus (IPOM plus) approach. Patients and Methods: This single-centre randomised control trial study was conducted from January 2020 to June 2022. A total of 60 adult patients undergoing elective ventral hernia surgery with small- and medium-sized midline defects were included. Intraoperative surgeon workload and early post-operative pain were systematically recorded and analysed for each procedure. Results: Out of 30 patients assigned to each group, 29 patients underwent eTEP mesh repair and 27 patients underwent successful IPOM plus repair. The intraoperative surgeon's workload, especially mental demand, physical demand, task complexity and degree of difficulty as reported and felt by the operating surgeon, was significantly higher in the eTEP mesh repair group compared to IPOM plus group (P < 0.001) with comparable operating room distractions (P = 0.039). The mean overall post-operative pain score on post-operative day 1 was slightly less in eTEP mesh repair (4.28 ± 1.12) group compared to IPOM plus group (4.93 ± 1.17), which was statistically insignificant (P = 0.042). The eTEP group had significantly longer operative time and length of hospital stay compared to the IPOM plus group. Conclusion: Our study revealed significantly longer operative time, higher surgical workload and increased length of hospital stay in the eTEP group with comparable early post-operative pain in both groups, thus making eTEP mesh repair a more difficult and challenging procedure.

Laparoscopic totally extraperitoneal ligation for pediatric inguinal hernia: a novel surgical treatment.

BACKGROUND: Laparoscopic repair is widely performed for the management of pediatric inguinal hernia (PIH), and different laparoscopic surgical methods are used. Herein, we present the application of laparoscopic totally extraperitoneal ligation (TEPL), which is a novel surgical method for PIH repair and is similar to traditional high ligation. METHODS: In this study, 103 pediatric patients underwent laparoscopic TEPL for inguinal hernia. Data including demographic characteristics, clinical presentation, time of surgery, length of hospital stay, and postoperative complications were analyzed retrospectively. RESULTS: The patient's median age at surgery was 4.3 years, and the median body weight at surgery was 18 kg. The preoperative diagnoses were as follows: n = 53, right inguinal hernia; n = 45, left inguinal hernia; and n = 5, bilateral inguinal hernia. All patients were discharged on the day of surgery. The operative times were 27.2 min for unilateral inguinal hernia and 28.8 min for bilateral inguinal hernia. All patients, except one who had scrotal bruise, did not present with postoperative complications. CONCLUSIONS: Laparoscopic TEPL, which is similar to traditional high ligation, is used for the treatment of PIH. Moreover, it is safe, beneficial, and feasible. Double ligation is performed on the extraperitoneal space, and the assessment of contralateral patent processus vaginalis is not complex. However, further studies should be conducted to assess for long-term outcomes.

The extended-view totally extraperitoneal (eTEP) approach for incisional abdominal wall hernias: results from a single center.

BACKGROUND: The extended-view totally extraperitoneal (eTEP) approach is a promising technique for abdominal wall hernias and has increased in popularity among hernia surgeons in recent years. This study aims to present the results of applying the laparoscopic eTEP approach for incisional abdominal wall hernias (IAWHs). METHODS: This study is a retrospective analysis of a prospectively collected dataset of 30 patients who underwent laparoscopic eTEP for IAWHs between October 2018 and March 2021 (median follow-up of 15 months). RESULTS: Thirty patients (8 male, 22 female) with a mean age, mean body mass index, and median ASA score of 53.5, 30.8, and 2, respectively, underwent the eTEP procedure for incisional abdominal wall hernias. In total, 11 (36.7%) patients had a recurrent IAWH. Seventeen (56.7%) patients were treated with eTEP RivesStoppa (eTEP-RS), whereas 10 (33.3%) patients needed the eTEP transversus abdominis release (eTEP-TAR) procedure. In three patients, conversions to other procedures (laparoscopic intraperitoneal onlay mesh-plus (IPOM-Plus) and open RivesStoppa) were needed due to intraoperative complications: iatrogenic perforation to the intestine and large peritoneal tear causing loss of the working space. The mean operative time and mean length of stay (LOS) were 203.5 min and 1.5 days for eTEP-RS and 291.5 min and 1.6 days for eTEP-TAR, respectively. Two patients developed asymptomatic seromas, and one patient developed an asymptomatic hematoma; all were treated conservatively. Only one recurrence was observed over the course of the follow-up period. CONCLUSIONS: The eTEP approach is a safe and feasible option for IAWH repair and a valuable addition to the armamentarium of hernia surgeons.

Totally extraperitoneal laparoscopic inguinal hernia repair post-radical prostatectomy.

BACKGROUND: Previous radical prostatectomy (RP) is considered a relative contraindication to the laparoscopic approach for inguinal hernia repair (LIHR). This study aimed to compare feasibility, safety and outcomes for patients undergoing totally extraperitoneal (TEP) LIHR who have previously undergone RP. METHODS: This single surgeon, case-control study was performed using a prospective database of all patients undergoing TEP LIHR between 1995 and 2020. Patients who underwent previous RP were identified and compared to matched controls. Pre-operative, operative and post-operative data were analysed. The type of RP, open, laparoscopic or robotic, was identified and operative outcomes compared between the three groups. RESULTS: 6532 LIHR cases were identified. 165 had previously undergone RP and 6367 had undergone primary LIHR without prior RP. The groups were matched for age, demographics and co-morbidities. All operations were commenced laparoscopically, three converted to open in the LIHR + RP group and none in the LIHR group. Median operative time in patients with previous RP was longer, for unilateral (40 min vs. 21 min, p < 0.0001) and bilateral (71 vs. 30 min, p < 0.0001) LIHR. The majority of cases were performed as day stay procedures. There was no difference in immediate recovery parameters including time to discharge, complication rates, return to normal function, return to driving or post-operative analgesia. At 3 months of follow-up there was no difference in hernia recurrence for unilateral (2/128 vs 6/2234, p = 0.0658) or bilateral (0/24 vs 3/1490, p ≥ 0.999) LIHR, nor chronic pain as measured by patient awareness or restriction of activity. No differences in operative and post-operative outcomes were identified between the three types of RP, other than difference in operative time (p = 0.0336). CONCLUSIONS: Previous RP should not be an absolute contraindication for TEP LIHR. Although previous RP adds complexity, in experienced hands TEP LIHR can be done safely, with outcomes equivalent to patients who have not previously undergone RP.

Robotic retromuscular abdominal wall repair using an inverted TEP (iTEP) approach: surgical technique and short-term outcomes.

PURPOSE: Robotic retromuscular abdominal wall repair (RAWR) for ventral hernias can be performed transabdominal or extraperitoneal by using an enhanced view totally extraperitoneal repair (eTEP). For defects in the meso- or epigastric region, an inverted approach can be used, starting the development of the totally extraperitoneal plane in the suprapubic region and progressing in a caudal-to-cranial direction (inverted TEP, iTEP). The aim of the study is to present the surgical technique and to report the short-term outcomes. METHODS: A retrospective analysis of a prospectively maintained database was performed, including patients who underwent a robotic RAWR using the iTEP approach between December 2019 and January 2022. The surgical technique was described, and patients' characteristics and intra- and postoperative parameters were studied and compared to the TARUP technique (robotic transabdominal retromuscular umbilical prosthetic hernia repair). RESULTS: Thirty-four patients were treated with an iTEP approach, and 14 patients underwent a TARUP procedure. The median length of stay was 1 day (range 1-3), and there were no intraoperative complications in both groups. One patient (3%) required reoperation after an iTEP approach for a small bowel internal herniation due to a rupture of the posterior rectus sheath. There were no recurrences or mortality with a median follow-up of 15 months (range 3-29) in the iTEP group, compared to 35 months (range 29-37) in the TARUP group. CONCLUSION: For defects in the upper abdominal region, a robotic RAWR with an iTEP approach appears to be safe and feasible. Long-term follow-up is needed to evaluate the late recurrence rate.

Long-term outcomes of single-incision versus multiport laparoscopic totally extra-peritoneal inguinal hernia repair: a single-institution experience of 186 consecutive cases.

PURPOSE: This retrospective study was conducted to compare the long-term outcomes of single-incision totally extraperitoneal (S-TEP) inguinal hernia repair and conventional multiport totally extraperitoneal (M-TEP) inguinal hernia repair. METHODS: The study population included 186 consecutive patients (S-TEP, n = 149; M-TEP, n = 37) who underwent elective surgery for inguinal hernia at Osaka Police Hospital between 2011 and 2013. RESULTS: No significant between-group difference was found in patient or hernia characteristics or in perioperative outcomes, with the exception of age (S-TEP group vs. M-TEP group: median 69 [IQR 60-75] years vs. 64 [55-69] years, respectively; P = 0.019). Furthermore, no significant between-group difference was found in follow-up time (5.5 [3.0-5.8] vs. 5.4 [3.1-5.7] years, P = 0.839), recurrence rate (0.6 vs. 2.4%, P = 0.358), chronic pain (1.2 vs. 0%, P = 1.000), feeling the mesh (2.3 vs. 7.1%, P = 0.142), or movement limitation (0.6 vs. 0%, P = 1.000). All chronic symptoms were "mild but not bothersome." A metachronous contralateral inguinal hernia developed in 8.1% of patients. CONCLUSION: The long-term outcomes of S-TEP repair were comparable to those of M-TEP, with rates of recurrence, chronic pain, feeling the mesh, and movement limitation falling within acceptable limits.

Concurrent laparoscopic totally extraperitoneal inguinal hernia repair and transurethral resection of prostate: Breaking with convention - A retrospective study.

AIM: This study aimed to evaluate concurrent laparoscopic totally extraperitoneal (TEP) inguinal hernia repair and transurethral resection of the prostate (TURP) with determination of outcomes. MATERIALS AND METHODS: This retrospective study was conducted at our hospital, from June 2011 to June 2020. Over 9 years, 17 patients with co-existing uncomplicated unilateral or bilateral inguinal hernia (primary/recurrent) and significant benign prostatic hypertrophy were operated in the same sitting. The following outcomes were compared: duration of the surgery, conversion to open hernia surgery, intraoperative and post-operative complications, duration of hospital stay, recurrence, time taken to resume normal activity and cost of the treatment. RESULTS: This study included 17 patients with a mean age of 65 years (range of 50-87 years). The average time taken for the surgery was 115 min with no conversion to open hernia repair. The mean post-operative stay was 3.7 days. There were four patients (23.5%) with seromas identified at day 10, only two remained at 6 weeks and none at 12 weeks. None had significant bleeding intraoperatively or postoperatively. There was no superficial or deep wound infection (including mesh infection). There was no recurrence of inguinal hernia. Two patients (11.7%) developed post-TURP urethral stricture and underwent cystoscopic stricturoplasty, 3 and 2.5 months after the initial procedure. The time taken to resume normal activity was 7 (±1) days. The hospital cost is reduced by 25% as compared to the sum of costs when both the operations are done separately. CONCLUSION: Concurrent TEP inguinal hernia repair and TURP is a practical, safe and cost-effective procedure.

[Laparoscopic totally extraperitoneal repair of strangulated groin hernia]. / Laparoskopicheski assistirovannaya total'naya ekstraperitoneal'naya plastika (laparoscopic assistant total extraperitoneal plastic ­ latep) v lechenii ushchemlennykh gryzh pakhovoi oblasti.

OBJECTIVE: To study the possibility of totally extraperitoneal repair combined with diagnostic laparoscopy in the treatment of strangulated groin hernias (Laparoscopy-Assisted Totally Extraperitoneal Plasty, LATEP). MATERIAL AND METHODS: We analyzed the results of laparoscopic totally extraperitoneal hernia repair. The trocar placement technique was modified. There were 38 patients with strangulated groin hernia. The sample included 26 patients with strangulated inguinal hernia, 9 ones with strangulated femoral hernia and 3 patients with recurrent strangulated inguinal hernia. RESULTS: LATEP was attempted in 38 patients and successful in 37 (97.3%) cases. In 1 (2.6%) patient, correction of small bowel strangulation was failed and conversion to open surgery was required. In 29 patients (76.3%), correction of strangulation was performed after laparoscopy-assisted external manipulations and careful traction from abdominal cavity. In 8 (21%) cases, strangulation spontaneously regressed before laparoscopy. Laparoscopy confirmed viability of strangulated organs in 36 patients. One (2.6%) patient required bowel resection due to small intestine wall necrosis. Later, all patients underwent totally extraperitoneal repair. We were able to prevent the contact of hernia sac fluid with the implant in all cases. At the stage of preperitoneal repair, local damage to peritoneum occurred in 9 patients. Nevertheless, sealing was not required since hernia fluid was previously removed from abdominal cavity. There were no signs of implant infection and hernia recurrence within 6-14 months. CONCLUSION: Totally extraperitoneal repair combined with diagnostic laparoscopy is possible for strangulated groin hernias.

Totally extraperitoneal repair for the 'sportsman's groin' via 'the Manchester Groin Repair': a comparison of elite versus amateur athletes.

BACKGROUND: Surgery has a recognised role in the treatment of 'sportsman's groin'. This study hypothesises that elite athletes have a superior advantage in both pre- and post-op rehabilitation and therefore will present and resume sporting activities quicker. METHODS: A retrospective analysis on a secure database of athletes presenting with groin pain that underwent surgery for 'inguinal disruption'. All data were explored via appropriate descriptive statistics and comparisons made between elite and amateur athletes. RESULTS: All patients were male (n = 144). The median age 33 years (range 14-72). The median return to sporting activity was 4.5 weeks (range 2.0-16.0) with one amateur athlete being unable to return to sporting activity. Using the mean of both sides, a comparison of VAS pain scores at pre-operative and 1 month post-operative time points showed a significant reduction (p < 0.001). Comparing 'elite' versus 'amateur' athletes, significant differences were seen in patient age (median 26 vs 40 years; p < 0.001), lead time to clinic presentation (median 62.0 vs 111.5 days; p = 0.004), and time to return to sporting activity (4 vs 5 weeks; p = 0.019). Additional MRI findings within the groin girdle were found in 89 patients (66.4%) and 34 patients (23.6%) had an MRI finding within the adductor tendon. CONCLUSION: The Manchester Groin Rrepair is an effective surgical management for 'inguinal disruption'. Elite athletes present quicker and return to sport sooner. Given the prevalence of other findings, a multidisciplinary approach to the 'sportsman's groin' is required.

Totally extraperitoneal approach for open complex abdominal wall reconstruction.

BACKGROUND: Ventral hernia repair is typically performed via a transabdominal approach and the peritoneal cavity is opened and explored. Totally extraperitoneal ventral hernia repair (TEVHR) facilitates dissection of the hernia sac without entering the peritoneal cavity. This study evaluates our experience of TEVHR, addressing technique, decision-making, and outcomes. METHODS: This is an IRB-approved retrospective review of open TEVHR performed between January 2012 and December 2016. Medical records were reviewed for patient demographics, operative details, postoperative outcomes, hospital readmissions, and reoperations. RESULTS: One hundred sixty-six patients underwent TEVHR (84 males, 82 females) with a mean BMI range of 30-39. Eighty-six percent of patients underwent repair for primary or first-time recurrent hernia, and 89% CDC wound class I. Median hernia defect size was 135 cm2. Hernia repair techniques included Rives-Stoppa (34%) or transversus abdominis release (57%). Median operative time was 175 min, median blood loss 100 mL, and median length of stay 4 days. There were no unplanned bowel resections or enterotomies. Four cases required intraperitoneal entry to explant prior mesh. Wound complication rate was 27%: 9% seroma drainage, 18% superficial surgical site infection (SSI), and 2% deep space SSI. Five patients (3%) required reoperation for wound or mesh complications. Over the study, four patients were hospitalized for postoperative small bowel obstruction and managed non-operatively. Of the 166 patients, 96%, 54%, and 44% were seen at 3-month, 6-month, and 12-month follow-ups, respectively. Recurrences were observed in 2% of patients at 12-month follow-up. One patient developed an enterocutaneous fistula 28 months postoperatively. CONCLUSIONS: TEVHR is a safe alternative to traditional transabdominal approaches to ventral hernia repair. The extraperitoneal dissection facilitates hernia repair, avoiding peritoneal entry and adhesiolysis, resulting in decreased operative times. In our study, there was low risk for postoperative bowel obstruction and enterotomy. Future prospective studies with long-term follow-up are required to draw definitive conclusions.

Appropriate mesh size in the totally extraperitoneal repair of groin hernias based on the intraoperative measurement of the myopectineal orifice.

BACKGROUND: Insufficient coverage of the area of a possible groin hernia is an important risk factor in hernia recurrence. To prevent recurrence, it is important to use the appropriate mesh size based on the size of the myopectineal orifice (MPO), which is the weak area of the abdominal wall where inguinal hernias occur. We aimed to estimate the appropriate mesh size for groin hernias by investigating MPO size. METHODS: Four hundred and six patients underwent groin hernia repair using a totally extraperitoneal (TEP) approach at the Zeze Hospital between July 2009 and December 2017. We investigated patients' backgrounds, MPO components dimensions, and hernia recurrence, and evaluated the appropriate mesh size. RESULTS: The 359 male and 47 female patients had an average age of 63 ± 15 years. In 171, 147, and 88 cases, hernias were localized to the right, left, and bilaterally, respectively. The number of lateral, medial, femoral, and combined hernias was 317, 124, 11, and 42, respectively. The 95th percentile for the horizontal and vertical lengths in cases of hernia orifice ≥ 3 cm were 9.6 cm and 7.0 cm, respectively, while it was 9.2 cm and 6.4 cm in cases of hernia orifice < 3 cm. We added 2 cm and 3 cm to the 95th percentile for the length and width of the MPO, resulting in 13.2 × 10.4 cm and 15.6 × 13.0 cm in cases with hernia orifice < 3 cm and ≥ 3 cm, respectively. Relapse after TEP occurred in 1 patient (0.2%). CONCLUSION: The appropriate mesh size for TEP repair, derived from intraoperative MPO measurements, was estimated as 13.2 × 10.4 cm and 15.6 × 13.0 cm when the hernia orifice was < 3 cm and ≥ 3 cm, respectively. Using appropriate mesh sizes based on MPO measurement may reduce groin hernia recurrence after TEP.

Laparoscopic totally extraperitoneal and transabdominal preperitoneal approaches are equally effective for spigelian hernia repair.

INTRODUCTION: Spigelian hernias (SH) are rare intraparietal abdominal wall hernias occurring just medial to the semilunar line. Several small series have reported on laparoscopic SH repair and both totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) approaches have been described. However, there are limited outcome data including both of these techniques. We present the largest series to date of laparoscopic SH repair comparing both popular approaches. METHODS: Consecutive patients (n = 77) undergoing laparoscopic SH repair from 2009 to 2019 were identified from a prospectively managed quality database. All procedures were performed at a single institution. Patients were divided based on laparoscopic approach used, TEP group (n = 37) and TAPP group (n = 40). Comparison of patient demographics, surgical characteristics, and post-operative complications between TAPP and TEP groups was made using the Wilcoxon rank-sum and Fisher's exact tests. RESULTS: Individuals undergoing TAPP had higher mean BMI (29.3 ± 5.4 vs. 26.3 ± 5.6 kg/m2; p = 0.019) and were more likely to have had prior abdominal surgery (65% vs 24.3%, (p < 0.001). Mean procedure length was 77 ± 45 min for TAPP repairs and 48 ± 21 for TEP repairs (p = 0.001). TAPP repairs had a significantly longer median LOS than TEP (25 vs. 7 h; p < 0.001). Days of narcotic use were significantly shorter after TEP repair than for TAPP (0 vs. 3; p = 0.007) and return to ADL was significantly shorter after TEP repair than for TAPP (5 vs. 7 days; p = 0.016. There were no significant differences in readmission, reoperations, SSI, or recurrence between the two groups. CONCLUSION: Our large series revealed that both preperitoneal laparoscopic approaches, TEP, and TAPP, for SH repair are equally safe, effective, and can be performed on an outpatient basis. Therefore, we suggest that the approach used for repair should be based on surgeon experience, preference, and individual patient factors.