Estudio comparativo de herniorrafía en emergencia y en situaciones electivas / Comparison study of herniorrhaphy at emergency and elective situations

La hernia inguinal es uno de los problemas urgentes más comunes encontrados por los cirujanos. Hubo 145 pacientes tratados debido al diagnóstico de hernia inguinal. De 44 pacientes que fueron operados en condiciones de emergencia. Alrededor de 131 casos (106 hombres y 25 mujeres) fueron tratados con reparación de malla preperitoneal abierta unilateral. Los pacientes fueron examinados en términos de complicaciones postoperatorias. Los datos recopilados incluidos como edad, sexo, historial médico, afecciones de cirugía, encarcelamiento y estrangulamiento. Hubo un total de 145 pacientes incluidos en el estudio; en el que 44 de ellos (29 hombres y 15 mujeres, rango de edad: 30-72) (Grupo I) fueron operados en condiciones de emergencia y 101 de ellas (51 hombres y 50 mujeres, rango de edad: 25-78) (grupo Ii) fueron operados en condiciones electivas. Hubo comorbilidad en 31 pacientes de grupo I y 77 pacientes del grupo II. Alrededor del 47.7% (n = 21) de los casos que se sometieron a cirugía emergente debido al encarcelamiento, mientras que el 43.6% (n = 44) de los casos que fueron operados en condiciones electivas. Había 12 hernias femorales en el Grupo I y 19 Hernia femoral en el Grupo II. No hay diferencia entre la complicación postoperatoria y las tasas de recurrencia en los casos de hernia inguinal operados en condiciones electivas y en condiciones de emergencia. Es más barato que la reparación laparoscópica, el control del dolor de plomo y la falta de dolor neuropático, tiene complicaciones menos testiculares, y es más ventajoso que otros enfoques abiertos

Inguinal hernia is one of the most common urgent problems encountered by surgeons. There were 145 patients treated due to inguinal hernia diagnosis. Out of 44 patients who were operated under emergency conditions. About 131 cases (106 male and 25 female) were treated with unilateral open preperitoneal mesh repair. Patients were examined in terms of postoperative complications. Data collected included as age, gender, medical history, surgery conditions, incarceration and strangulation. There were total of 145 patients included in the study; in which 44 of them (29 male and 15 female, range of age: 30- 72) (group I) were operated under emergency conditions and 101 of them (51 male and 50 female, range of age: 25-78) (group II) were operated under elective conditions. There was comorbidity in 31 patients of group I and 77 patients of group II. About 47.7% (n=21) of cases who underwent emergent surgery due to incarceration, while 43.6% (n=44) of cases who were operated under elective conditions. There were 12 femoral hernias in group I and 19 femoral hernia in group II. There is no difference between postoperative complication and recurrence rates in inguinal hernia cases operated under elective conditions and under emergency conditions. It is cheaper than laparoscopic repair, lead pain control and lack of neuropathic pain, has less testicular complications, and it is more advantageous than other open approaches.

Efficacy of modified thoracoabdominal nerve block through perichondrial approach following laparoscopic inguinal hernia repair surgery: a randomized controlled trial

Abstract Background: Modified thoracoabdominal nerve block through perichondrial approach is a novel fascial plane block and provides abdominal analgesia by blocking thoracoabdominal nerves. Our primary aim was to evaluate the efficacy of M-TAPA on quality of recovery and pain scores in patients who underwent laparoscopic inguinal hernia repair surgery (Trans Abdominal Pre-Peritoneal approach ‒ TAPP). Methods: Patients with American Society of Anesthesiologists (ASA) physical status I-II aged between 18 and 65 years scheduled for elective TAPP under general anesthesia were enrolled in the study. After intubation, the patients were randomized into two groups: M: M-TAPA group (n = 30) and the control group (n = 30). M-TAPA was performed with total 40 ml 0.25% bupivacaine in the M group. Surgical infiltration was performed in the control group. The primary outcome of the study was the global quality of recovery score, the secondary outcomes were pain scores, rescue analgesic demands, and adverse effects during the 24-h postoperative period. Results: The global quality of recovery scores at 24 h were significantly higher in the M group (p < 0.001). There was a reduction in the median static and dynamic NRS for the first postoperative 8 h in the M group compared to the control group (p < 0.001). The need for rescue analgesia was significantly lower in the M group compared to the control group (13 patients vs. 24 respectively, p < 0.001). The incidence of side effects was significantly higher in the control group (p < 0.001). Conclusion: In our study, M-TAPA increased patient recovery scores, and provided pain relief in patients who underwent TAPP. Register Number: NCT05199922.

Analysis of recurrent factors and therapeutic effect after laparoscopic inguinal hernia repair / 中华外科杂志

Objective: To analyze the recurrence factors and reoperation effect of laparoscopic inguinal hernia repair. Methods: A total of 41 patients with recurrence after laparoscopic repair of the inguinal hernia admitted to the Department of Hernia and Abdominal Wall Surgery, Beijing Chaoyang Hospital Affiliated to Capital Medical University from January 2017 to December 2021 were retrospectively analyzed. All patients were males, aging (62±7) years (range: 51 to 75 years). The recurrence intervals were 3 days to 7 years postoperatively. The surgical methods, causes of recurrence, and treatment outcomes of the patients were analyzed. Fisher exact probability method is used to compare the rates. Results: Among all cases, the primary surgical procedures included transabdominal preperitoneal herniorrhaphy (TAPP) in 31 cases and total extraperitoneal herniorrhaphy in 10 cases. The reoperative procedures included the TAPP of 11 cases and the Lichtenstein procedure of 30 cases. The factors of recurrent cases in all patients could be divided into 4 categories, including insufficient mesh coverage in 23 cases, mesh curling in 9 cases, mesh contractuture in 7 cases, and improper mesh fixation in 2 cases. Recurrence, infection, chronic pain, foreign body sensation didn't occur in the followed period of(M(IQR)) 18(24) months(range: 12 to 50 months). There was no statistical difference in the incidence of postoperative seroma between the TAPP and Lichtenstein procedure (3/11 vs. 20.0% (6/30), P=0.68). Conclusions: Postoperative recurrence of laparoscopic inguinal hernia is mostly caused by the lack of mesh coverage. Due to the emphasis on standardized surgical operation, a good outcome could be achieved through reoperation by the TAPP or Lichtenstein procedure.

Influencing factors of small intestinal ischemia in elderly patients with incarcerated hernia / 中华外科杂志

Objective: To investigate the factors influencing small intestinal ischemia in elderly patients with incarcerated hernia. Methods: The clinical data of 105 elderly patients admitted for surgical procedures of incarcerated hernia at Department of General Surgery, Huadong Hospital between January 2014 and December 2021 were retrospectively analyzed. There were 60 males and 45 females, aged (86.1±4.3) years (range: 80 to 96 years). They were divided into normal group (n=55) and ischemic group (n=50) according to intraoperative intestinal canal condition. The t test, χ2 test and Fisher's exact probability method were used for the univariate analysis of the factors that influence intestinal ischemia in patients, and Logistic regression was used for multifactorial analysis. Results: In all patients, 18 patients (17.1%) had irreversible intestinal ischemia with bowel resection. Six patients died within 30 days, 3 cases from severe abdominal infection, 2 cases from postoperative exacerbation of underlying cardiac disease, and 1 case from respiratory failure due to severe pulmonary infection. The results of the univariate analysis showed that there were differences in gender, history of intussusception, duration of previous hernia, white blood cell count, neutrophil percentage, C-reactive protein, type of incarcerated hernia, and preoperative intestinal obstruction between the two groups (all P<0.05). The Logistic regression results showed that the short time to the previous hernia (OR=0.892, 95%CI 0.872 to 0.962, P=0.003), high C-reactive protein (OR=1.022, 95%CI 1.007 to 1.037, P=0.003), non-indirect incarcerated hernia (OR=10.571, 95%CI 3.711 to 30.114, P<0.01) and preoperative intestinal obstruction (OR=6.438, 95%CI 1.762 to 23.522, P=0.005) were independent risk factors for the development of intestinal ischemia in elderly patients with incarcerated hernia. Conclusions: The short duration of the previous hernia, the high values of C-reactive proteins, the non-indirect incarcerated hernia, and the preoperative bowel obstruction are influencing factors for bowel ischemia in elderly patients with incarcerated hernia. A timely operation is necessary to reduce the incidence of intestinal necrosis and improve the prognosis.

Hernia vesical inguinoescrotal incarcerada: manejo quirúrgico / Incarcerated inguinoscrotal bladder hernia: surgical management

RESUMEN La hernia vesical es una entidad asociada a la hernia inguinal, con predisposición de lado derecho, en un porcentaje de 0,5 a 3%, hasta 10% en hombres, y a partir de la quinta a séptima década de vida1. La mayoría son pequeñas; la fisiopatología más común es la obstrucción mientras que la hiperplasia prostática es la principal etiología. La presentación clínica es poco específica, y el diagnóstico es en la mayoría de los casos transoperatorio. Se presenta el caso de un paciente de género masculino de 64 años, con antecedente patológico de enfermedad de Parkinson, hernia inguinal izquierda reducible hace 5 años. Acudió a consulta médica por manifestar dolor abdominal de moderada intensidad, más aumento de volumen en región inguinoescrotal izquierda. Al realizar el examen físico se constató una hernia inguinoescrotal izquierda no reducible. Con el diagnóstico de hernia inguinal incarcerada se realizó una exploración quirúrgica, con hallazgos de hernia inguinoescrotal de gran tamaño con contenido vesical y epiplón incarcerado con cambios de coloración. Se realizó entonces la reparación de la hernia. La evolución posoperatoria fue satisfactoria sin complicaciones.

ABSTRACT Bladder hernia is a condition associated with inguinal hernia, usually right-sided, in 0.5 to 3% of the cases and up to 10% in men between the fifth and seventh decade of life. Most hernias are small; the most common pathophysiology is obstruction while prostatic hyperplasia is the main etiology. The clinical presentation is unspecific, and the diagnosis is usually made during surgery. We report the case of a 64-year-old male patient with a history of Parkinson's disease and reducible left inguinal hernia 5 years before, who sought medical advice due to abdominal pain of moderate intensity, with increased volume in the left inguinoscrotal region.On physical examination a diagnosis of left-sided non-reducible inguinoscrotal hernia was made. With the diagnosis of incarcerated inguinal hernia the patient underwent surgical exploration which showed a large inguinoscrotal hernia containing the bladder and incarcerated omentum with color changes. The hernia was repaired, and the patient evolved with favorable outcome.

Anestesia local para la cirugía de la hernia inguinal entre la evidencia y la experiencia / Local Anesthesia for Inguinal Hernia Surgery between Evidence and Experience

Introducción: La cirugía de la hernia inguinal constituye uno de los procederes más comunes a nivel mundial. Se estima que el 80 por ciento son realizados con anestesia regional o general, y un 20 por ciento con local en contra de la recomendación de las sociedades internacionales que aceptan que la mayor parte de los enfermos son candidatos para este método. Objetivos: Describir la técnica de anestésica local aplicada por el propio cirujano, exponiendo sus ventajas y desventajas apoyadas en la evidencia relevante disponible. Métodos: Se realizó una revisión híbrida de tipo narrativa. Se describió el método anestésico empleado por nuestro grupo. Paralelamente, se realizó una búsqueda en las principales bases de datos para la identificación de las investigaciones que sostienen y defienden los aspectos técnicos y decisiones clínicas tomadas. Desarrollo: No existen contraindicaciones absolutas para la selección de la anestesia local, en su mayoría son relativas. El anestésico a emplear es lidocaína, aunque adjuvantes pueden ser tenidos en cuenta. La sedación pre o transoperatoria no se recomienda. El método anestésico involucra la fase subcutánea con una técnica de bloqueo de campo y fase incisional profunda con infiltración tumescente. Conclusiones: El empleo de anestesia local para la cirugía de hernia inguinal por vía anterior puede ser considerado de primera elección. Es más económica y las complicaciones urinarias y cardiovasculares se reducen. Para lograr una cirugía de igual calidad a otro método de anestesia es importante dominar la técnica anestésica(AU)

Introduction: Inguinal hernia surgery is one of the most common procedures worldwide. 80 percent of them are estimated to be performed under regional or general anesthesia; while 20 percent are performed under local anesthesia, contrary to the recommendation of international societies, which accept that most of the patients are candidates for this method. Objectives: To describe the local anesthetic technique applied by the surgeon himself, exposing its advantages and disadvantages supported by the relevant evidence available. Methods: A hybrid narrative review was carried out. The anesthetic method used by our group was described. At the same time, a search was performed in the main databases to identify the research supporting and defending the technical aspects and the taken clinical decisions. Development: There are no absolute contraindications for the selection of local anesthesia; most of them are relative. The anesthetic to be used is lidocaine, although adjuvants can be taken into account. Pre- or intraoperative sedation is not recommended. The anesthetic method involves the subcutaneous phase with a field block technique and the deep incisional phase with tumescent infiltration. Conclusions: The use of local anesthesia for inguinal hernia surgery though an anterior approach can be considered as the first choice; it is more economical, while urinary and cardiovascular complications are reduced. To achieve a surgery of equal quality to another method of anesthesia, it is important to master the anesthetic technique(AU)

Resultados de la utilización de malla única en la reparación laparoscópica transabdominal (TAPP) de hernias inguinales bilaterales directas / Outcomes of laparoscopic transabdominal (TAPP) inguinal hernia repair with single mesh in bilateral direct inguinal hernias

RESUMEN Antecedentes: La cirugía laparoscópica presenta ventajas que son claramente observadas en la reparación de hernias bilaterales y recidivadas. El uso de una malla única como alternativa en la reparación de las inguinales bilaterales laparoscópicas con técnica transabdominal (TAPP) puede reducir el índice de recidivas y las chances de dolor crónico. Objetivo: describir y analizar los beneficios del uso de una malla única en el tratamiento de las hernias inguinales bilaterales con técnica TAPP. Material y métodos: análisis retrospectivo de hernioplastias inguinales laparoscópicas directas o mixtas operadas por vía transabdominal con malla única, efectuadas en pacientes con hernias inguinales bilaterales. Resultados: entre enero de 2016 y enero de 2017 se operaron 177 pacientes con hernia inguinal. Noventa y tres (93) pacientes presentaron hernias bilaterales, de las cuales 39 fueron operadas mediante el uso de la técnica con malla única, incluidas en este estudio. Conclusión: la utilización de una malla única es una alternativa segura en el tratamiento de las hernias inguinales bilaterales directas o mixtas operadas por vía laparoscópica con técnica TAPP.

ABSTRACT Background: The laparoscopic approach has clear advantages for repairing bilateral hernias and recurrent hernias. The use of a single mesh as an option in the laparoscopic treatment of direct bilateral inguinal hernias with the transabdominal preperitoneal (TAPP) technique, may reduce the recurrence rate and chronic pain. Objective: The aim of this study is to analyze the benefits of single mesh for the treatment of bilateral inguinal hernias with the TAPP technique. Material and methods: We conducted a retrospective analysis of patients with bilateral direct inguinal hernias undergoing laparoscopic hernia repair with the TAPP technique using a single mesh. Results: Between January 2016 and January 207 177 patients underwent inguinal hernia repair. Of the 93 patients with bilateral hernias, a single mesh was used in 39, which were included in this study. Conclusion: The use of a single mesh is a safe option for the laparoscopic treatment of direct bilateral inguinal hernias with the TAPP technique.

Robotic re-TAPP: a minimally invasive alternative for the failed posterior repair / re-TAPP robótico: uma alternativa minimamente invasiva para falha da via posterior

ABSTRACT Objective: to describe the use of the robotic platform in inguinal hernia recurrence after a previous laparoscopic repair. Methods: patients with recurrent inguinal hernias following a laparoscopic repair who have undergone robotic transabdominal preperitoneal between December 2015 through September 2020 were identified in a prospectively maintained database. Outcomes of interest included demographics, hernia characteristics, operative details and rates of 30-day surgical site occurrence, surgical site occurrences requiring procedural interventions, surgical site infection and hernia recurrence were abstracted. Results: nineteen patients (95% male, mean age 55 years, mean body mass index 28) had 27 hernias repaired (N=8 bilateral). Average operative time was 168.9 ± 49.3min (range 90-240). There were two intraoperative complications all of them were bleeding from the inferior epigastric vessel injuries. Three SSOs occurred (N=2 seromas and N=1 hematoma. After a median 35.7 months follow-up (IQR 13-49), no recurrence has been diagnosed. One patient developed chronic postoperative inguinal pain. Conclusions: on a small number of selected patients and experienced hands, we found that the use of the robotic platform for repair of recurrent hernias after prior laparoscopic repair appears to be feasible, safe and effective despite being technically demanding. Further studies in larger cohorts are necessary to determine if this technique provides any benefits in recurrent inguinal hernia scenario.

RESUMO Objetivo: descrevemos nossa experiência com uso da plataforma robótica no tratamento das recidivas operadas previamente por laparoscopia, mantendo assim uma proposta minimamente invasiva a esses pacientes, apesar de haver uma predileção pela via anterior e aberta nestes casos. Métodos: foram incluídos pacientes submetidos a hernioplastia inguinal robótica transabdominal pré-peritoneal como tratamento de recidiva e que foram operados previamente por laparoscopia, entre dezembro de 2015 e setembro de 2020 e mantidos em uma base de dados ambulatorial prospectiva. Variáveis de interesse incluíram dados demográficos, características herniárias, detalhes operatórios, ocorrências do sítio cirúrgico em 30 dias (com ou sem necessidade de intervenção), infeção do sítio cirúrgico, tempo de seguimento e taxa de recidiva. Resultados: dezenove pacientes (95% masculino, média de idade de 55 anos, média de índice de massa corporal 28kg/m2) e 27 hérnias operadas (N=8 bilaterais). Média de tempo cirúrgico 168.9±49.3 min (variando 90-240). N=2 complicações intraoperatórias por lesão de vasos epigástricos inferiores. N=2 seromas e N=1 hematoma foram identificados no pós-operatório; N=1 paciente apresentou dor crônica pós operatória. Após um tempo de seguimento médio de 35.7 meses (intervalo entre quartis 13-49), nenhuma recidiva foi diagnosticada. Conclusões: o uso da plataforma robótica parece ser seguro e efetivo no tratamento das recidivas operadas previamente laparoscopia, nesse pequeno grupo de pacientes selecionados, apesar de requerer expertise em cirurgia robótica. Outros estudos com maiores casuísticas são necessários para estabelecer o papel desta técnica no cenário das hérnias inguinais recidivadas.

Técnica TAPP en manos jóvenes. Es posible reproducir los resultados de la técnica Lichtenstein para la hernia inguinal sintomática primaria unilateral / Tapp technique performed by young hands. Reproducing the results of the lichtenstein procedure for symptomatic primary unilateral inguinal hernia

RESUMEN Antecedentes: La hernioplastia inguinal es el procedimiento quirúrgico más frecuentemente realizado dentro de la Cirugía General. Se realizan anualmente 20 millones de hernioplastias; la técnica de Lichtenstein y la transabdominal preperitoneal (TAPP) mediante cirugía laparoscópica son las más utilzadas. Objetivo: El objetivo del presente estudio es valorar la factibilidad de la realización del TAPP, en un centro universitario, por parte de residentes y cirujanos jóvenes en formación. Se comparó dicho procedimiento con la técnica de Lichtenstein valorando los resultados en los primeros 30 días del posoperatorio. Las principales variables para estudiar fueron: complicaciones, dolor posoperatorio, estadía hospitalaria y costo del procedimiento. Como variables para estudiar, a largo plazo, se compararon la recidiva herniaria y el dolor crónico. Material y métodos: Se realizó un estudio observacional comparando dos técnicas quirúrgicas utilizando la base de datos del Servicio con información adquirida de forma prospectiva. Se analizaron 80 pacientes, divididos en dos grupos: hernioplastia de Lichtenstein (grupo1) y hernioplastia por TAPP (grupo 2), durante el período comprendido desde mayo de 2015 hasta mayo de 2019, en dos Centros Universitarios de Montevideo Uruguay (Hospital de Clínicas y Hospital Español). Resultados: No hubo diferencia significativa en la estadía hospitalaria y complicaciones posoperatorias. El grupo del Lichtenstein presentó una recidiva herniaria. La hernioplastia laparoscópica presentó un tiempo operatorio promedio de 20 minutos más y el costo de materiales fue mayor. Si bien el dolor posoperatorio en las primeras 24 horas fue mayor en TAPP, el dolor a las 48 horas, 7días, un mes, tres meses y seis meses fue similar en ambos grupos. Conclusión: La técnica de TAPP, para la hernia inguinal primaria unilateral, es factible de ser realizada por cirujanos jóvenes o en formación, con un porcentaje de complicaciones, dolor posoperatorio y recidivas similares al Lichtenstein, aunque con un costo de materiales y tiempo operatorio levemente mayor.

ABSTRACT Background: Inguinal hernia repair is one of the most common procedures in general surgery. Each year, 20 million surgeries for inguinal hernia repaired are performed; the most common techniques used are the Lichtenstein procedure and the transabdominal preperitoneal (TAPP) laparoscopic approach. Objective: The aim of the present study is to evaluate the outcomes of the TAPP approach performed by residents and young surgeons in training in a university center. TAPP was compared with the Lichtenstein and the outcomes at 30 days were compared. The variables considered were complications, postoperative pain, length of hospital stay and procedure-related costs. The long-term variables analyzed were recurrence and chronic pain. Material and methods: We conducted an observational study comparing two surgical techniques, using prospectively acquired information from the database of our department. The cohort was made up of 80 patients undergoing inguinal hernia repair in two university-based hospitals in Montevideo, Uruguay (Hospital de Clínicas and Hospital Español), between May 2015 and May 2019. The patients were divided into two groups: Lichtenstein procedure (group 1) and TAPP procedure (group 2). Results: There were no significant differences in length of hospital stay and postoperative complications. One patient in the Lichtenstein group presented hernia recurrence. Mean operative time was 20 minutes longer with laparoscopic hernia repair, and the cost of the materials was higher. Postoperative pain at 24 hours was greater in the TAPP group, but was similar at 48 hours, 7 days, one month, three months and six months in both groups. Conclusion: The use of TAPP technique for unilateral primary inguinal hernia is feasible to perform by young surgeons or surgeons in training, and the percentage of complications, postoperative pain and recurrences is similar to that of the Lichtenstein technique, although the cost of materials and operative time are slightly higher.

Hernia inguinal gigante en un adulto / Giant inguinal hernia in an adult

Se describe el caso clínico de un paciente de 58 años de edad con antecedentes personales de insuficiencia cardiaca congestiva mal controlada, quien acudió a emergencias del Hospital Luis Bernaza de Guayaquil, Ecuador, por presentar dolor abdominal difuso, constipación y masa inguinoescrotal gigante. Se realizan los estudios pertinentes y se diagnostica una hernia inguinoescrotal gigante con pérdida de domicilio, sin datos de obstrucción intestinal. Se empleó la técnica de Goñi Moreno durante 12 días para aumentar el diámetro de la cavidad abdominal y regresar el contenido del saco a su lugar. Se efectuó laparotomía exploratoria y hernioplastia con resultado satisfactorio y seguimiento por consulta externa durante 2 meses, sin alteraciones.

The case report of a 58 years patient with personal history of a poor controlled congestive heart failure is described, who went to the emergency service of Luis Bernaza Hospital in Guayaquil, Ecuador, due to a diffuse abdominal pain, constipation and giant inguinoescrotal mass. The pertinent studies were carried out and a giant inguinoescrotal hernia is diagnosed with home loss, without data of intestinal obstruction. The Goñi Moreno technique was used during 12 days to increase the diameter of the abdominal cavity and return the content from the sack to its place. An exploratory laparotomy and hernioplastia were carried out with satisfactory result and follow up in the outpatient department during 2 months, without alterations.

Tratamiento de la hernia inguinal por cirugía laparoscópica / Inguinal Hernia Treatment through Laparoscopic Surgery

Introducción: En los últimos años, la aplicación de la cirugía laparoscópica ha permitido ofrecer una nueva expectativa en el tratamiento de la hernia inguinal, ya que no solo permite la colocación de una malla sin tensión, sino que además permite colocarla en la auténtica zona débil de la región inguinal: su pared posterior. Objetivo: Mostrar los resultados obtenidos con la implementación de la hernioplastia laparoscópica como tratamiento alternativo en la reparación de las hernias inguinales. Método: Se realizó un estudio cuasi experimental en el servicio de Cirugía General del Hospital General Docente "Comandante Pinares", durante el período comprendido de junio de 2015 hasta mayo de 2017, con una muestra de 27 pacientes. Se controlaron variables como edad, tipo de hernia inguinal, complicaciones del proceder, recidivas del tratamiento, así como la efectividad del proceder en comparación con técnicas convencionales. Resultados: La hernia inguinal unilateral fue la más frecuente tratada, las complicaciones estuvieron dadas por la inguinodinia y rechazo a la malla. Disminuyeron variables como pérdidas sanguíneas, tiempo quirúrgico, la efectividad se consideró buena en la mayoría de los casos. Conclusiones: Se demuestra que la hernioplastia laparoscópica tiene mayores ventajas biológicas, sociales y económicas(AU)

Introduction: In recent years, the usage of laparoscopic surgery has offered new expectations regarding inguinal hernia treatment, since it not only allows the placement of a mesh without tension, but also allows it to be placed in the authentic weak area of the inguinal region, its posterior wall. Objective: To show the outcomes obtained with the implementation of laparoscopic hernioplasty as an alternative treatment in inguinal hernias repair. Method: A quasiexperimental study was carried out, during the period from June 2015 to May 2017, in the general surgery service of Comandante Pinares General Teaching Hospital, with a sample of 27 patients. Variables such as age, type of inguinal hernia, procedural complications, treatment recurrences, as well as the effectiveness of the procedure were controlled in comparison with conventional techniques. Results: Unilateral inguinal hernia was the most frequently treated. Complications were caused by inguinodynia and mesh rejection. Variables such as blood loss and surgical time decreased. Effectiveness was considered good in most cases. Conclusions: Laparoscopic hernioplasty is shown to have greater biological, social and economic advantages(AU)

Hernia útero inguinal derecha atascada en mujer en edad fértil: reporte de un caso / Incarcerated right utero inguinal hernia in a woman of reproductive age: case report

Resumen Introducción: La hernia de pared abdominal es una patología habitual; la presentación más frecuente es de tipo inguinal, cercano a un 70% del total. La incidencia de un saco herniario inguinal conteniendo ovarios y trompas de Falopio, es un hecho reportado en 2,9% de los casos. Caso clínico: Se presenta una paciente, sexo femenino, de 42 años de edad, con historia de hernia inguinal derecha de larga data, ingresa por aumento de volumen doloroso e irreductible, en región inguinal derecha, no impresiona estrangulada; ingresa a pabellón de urgencia. Dentro de los hallazgos quirúrgicos destacan saco herniario que contiene útero y ambos ovarios, sin compromiso vascular. Paciente evoluciona de forma favorable egresando 2 días posterior a la cirugía.

Introduction: Abdominal wall hernia is a frequent pathology, the most frequent hernia are the inguinal type, closed to 70% of all. Although the incidence of inguinal hernial sac containing ovary and Fallopian tubes are reported on a 2.9% of the cases. Case Report: Female patient 42 years old, with a long-term history of right inguinal hernia, with sudden pain and irreducible increase of volume in the correspondent inguinal zone that doesn't look strangled; she was admitted to the emergency operating room. Among surgical findings hernia's sac content was uterus and both ovaries with no signs of vascular compromise. The patient's favorable evolved let her to be discharged from the hospital after 2 days from post operative care

Challenges to the 10 golden rules for a safe minimally invasive surgery (mis) inguinal hernia repair: can we improve? / Desafios para as 10 regras de ouro para o reparo minimamente invasivo seguro das hérnias inguinais: podemos melhorar?

ABSTRACT Background: Since publication of our paper "Ten Golden Rules for a Safe MIS Inguinal Hernia Repair" we have received many questions. As the authors, we feel it is important to address these topics as a follow-up to our paper. Aim: To discuss in more details the main points of controversy, review the rules and update de recommendations. Method: The questions and discussions came mainly over five rules, numbered 3, 5, 6, 7, 10. We analyzed all the comments about recommendations and update some technical principles. Results: Rule 3 - Removing normal fat plugs from the obturator canal is unnecessary and therefore is not recommended; Rule 5 - transection of the uterine round ligament (1 cm proximal to the deep ring) facilitates adequate dissection. When performed in this way it does not appear to be associated with complications; Rule 6 - transection of huge sacs are safer than over-dissection of the cord structures. Whether dissecting completely the sac or abandon the distal part it results in less postoperative seromas is an ongoing debate; Rule 7 - any retroperitoneal structure traversing the internal ring is or play a role like a hernia. Failing to identify and remove the lipoma will ultimately result in the patient experiencing a recurrence; Rule 10 - in TAPP peritoneum should preferably be closed with suture than tackes. Conclusion: 10 Golden Rules emphasize the most important surgical tips and technical steps that allow the safe performance of MIS repairs of inguinal hernias, regardless the technique.

RESUMO Racional: Desde a publicação de nosso artigo "Dez Regras de Ouro para o Reparo Seguro de Hérnia Inguinal MIS", recebemos muitos questionamentos. Como autores, sentimos que é importante abordar esses tópicos como seguimento do artigo Objetivo: Discutir com mais detalhes os principais pontos de controvérsia, revisar as regras e atualizar as recomendações. Método: As dúvidas e discussões surgiram principalmente sobre cinco regras, numeradas 3, 5, 6, 7, 10. Analisamos todos os comentários sobre as recomendações e atualizamos alguns dos princípios técnicos. Resultados: Regra 3 - remoção dos plugs de gordura normais do canal obturador é desnecessária e, portanto, não é recomendada; Regra 5 - transecção do ligamento redondo do útero (1 cm proximal ao anel profundo) facilita a dissecção adequada e quando realizado dessa forma, não parece estar associada com complicações; Regra 6 - transecção de grandes sacos herniários é mais segura do que a dissecção excessiva das estruturas do cordão espermático e, se dissecar completamente o saco ou abandonar a parte distal, resulta em menos seromas pós-operatórios ainda é motivo de debate; Regra 7 - qualquer estrutura retroperitoneal que atravessa o anel interno é ou desempenha o papel como uma hérnia e deixar de identificar e remover o lipoma acabará resultando em recorrência; Regra 10 - na TAPP o peritônio deve ser fechado preferencialmente com sutura do que com tacks. Conclusão: As 10 Regras de Ouro enfatizam as dicas cirúrgicas e etapas técnicas mais importantes que permitem a realização segura de reparos MIS de hérnias inguinais, independentemente da técnica.

Femoral hernia: uncommon, but associated with potentially severe complications / Hérnia femoral: incomum, mas associada a complicações potencialmente graves

ABSTRACT Background: Although the laparoscopic access is becoming the preferable treatment for femoral hernia, there are only few studies on this important subject. Aim: To assess the outcomes of the totally extraperitoneal laparoscopic (TEP) access in the treatment of femoral hernia. Methods: Data of 62 patients with femoral hernia who underwent herniorrhaphy were retrospectively reviewed. The diagnosis of femoral hernia was established by clinical and/or imaging exams in 55 patients and by laparoscopic findings in seven. Results: There were 55 (88.7%) females and 7 (11.3%) males, with female to male ratio of 8:1. The mean age was of 58.9±15.9 years, ranging from 22 to 92 years. Most patients (n=53; 85.5%) had single hernia and the remaining (n=9; 14.5%) bilateral, making a total of 71 hernias operated. Prior lower abdominal operations were recorded in 21 (33.9%) patients. Conversion to laparoscopic transabdominal preperitoneal procedure was performed in four (6.5%). Open herniorrhaphy was needed in two (3.2%), one with spontaneous enterocutaneous fistula in the groin region (Richter's hernia) and the another with incidental perforation of the adjacent small bowel that occurred during dissection of hernia sac. There was no mortality. Conclusion: Femoral hernia is uncommon, and it may be associated with potentially severe complications. Most femoral hernias may be successfully treated with totally extraperitoneal laparoscopic access, with low conversion and complication rates.

RESUMO Racional: Embora o acesso laparoscópico esteja se tornando o tratamento preferencial para a hérnia femoral, poucos são os estudos sobre esse importante assunto. Objetivo: Avaliar os resultados do acesso laparoscópico totalmente extraperitoneal no tratamento da hérnia femoral. Métodos: Os dados de 62 pacientes com hérnia femoral que foram submetidos a herniorrafia foram revisados ​​retrospectivamente. O diagnóstico foi estabelecido por exames clínicos e/ou de imagem em 55 pacientes e por achados laparoscópicos em sete. Resultados: Havia 55 (88,7%) mulheres e 7 (11,3%) homens, com proporção feminino/masculino de 8: 1. A média de idade foi de 58,9±15,9 anos (22-92). A maioria (n=53, 85,5%) apresentava hérnia única e o restante (n=9, 14,5%) bilaterais, perfazendo um total de 71 hérnias femorais operadas. Operações prévias no abdome inferior foram registradas em 21 (33,9%) pacientes. A conversão para procedimento pré-peritoneal transabdominal laparoscópico foi realizada em quatro (6,5%). Herniorrafia aberta foi necessária em dois pacientes (3,2%), um com fístula enterocutânea espontânea na região da virilha (hérnia de Richter) e o outro com perfuração incidental do intestino delgado adjacente que ocorreu durante a dissecção do saco herniário. Não houve mortalidade. Conclusão: A hérnia femoral é incomum e pode estar associada a complicações potencialmente graves. A maioria das hérnias femorais pode ser tratada com sucesso através do acesso laparoscópico totalmente extraperitoneal, com baixas taxas de conversão e complicações.

Simultaneous laparoscopic inguinal hernia repair and cholecystectomy: does it cause mesh infection? / Colecistectomia e herniorrafia inguinal laparoscópica simultâneas: causa infecção de tela?

ABSTRACT Background: Repair of inguinal hernia concomitant with cholecystectomy was rarely performed until more recently when laparoscopic herniorrhaphy gained more adepts. Although it is generally an attractive option for patients, simultaneous performance of both procedures has been questioned by the potential risk of complications related to mesh, mainly infection. Aim: To evaluate a series of patients who underwent simultaneous laparoscopic inguinal hernia repair and cholecystectomy, with emphasis on the risk of complications related to the mesh, especially infection. Methods: Fifty patients underwent simultaneous inguinal repair and cholecystectomy, both by laparoscopy, of which 46 met the inclusion criteria of this study. Results: In all, hernia repair was the first procedure performed. Forty-five (97,9%) were discharged within 24 h after surgery. Total mean cost of the two procedures performed separately ($2,562.45) was 43% higher than the mean cost of both operations done simultaneously ($1,785.11). Up to 30-day postoperative follow-up, seven (15.2%) presented minor complications. No patient required hospital re-admission, percutaneous drainage, antibiotic therapy or presented any other signs of mesh infection after three months. In long-term follow-up, mean of 47,1 months, 38 patients (82,6%) were revaluated. Three (7,8%) reported complications: hernia recurrence; chronic discomfort; reoperation due a non-reabsorbed seroma, one in each. However, none showed any mesh-related complication. Satisfaction questionnaire revealed that 36 (94,7%) were satisfied with the results of surgery. All of them stated that they would opt for simultaneous surgery again if necessary. Conclusion: Combined laparoscopic inguinal hernia repair and cholecystectomy is a safe procedure, with no increase in mesh infection. In addition, it has important advantage of reducing hospital costs and increase patient' satisfaction.

RESUMO Racional: Reparo da hérnia inguinal concomitante à colecistectomia era raramente realizado até mais recentemente, quando a herniorrafia laparoscópica ganhou mais adeptos. Embora geralmente seja opção atraente para pacientes, a realização simultânea tem sido questionada pelo risco potencial de complicações relacionadas à tela, principalmente infecção. Objetivo: Avaliar uma série de pacientes submetidos a colecistectomia e herniorrafia inguinal laparoscópica simultâneas, com ênfase no risco de complicações relacionadas a tela, em especial infecção. Métodos: Cinquenta pacientes foram submetidos a herniorrafia e colecistectomia simultâneas por videolaparoscopia, dos quais 46 atenderam aos critérios de inclusão. Resultados: Em todos, a herniorrafia foi realizada inicialmente. Quarenta e cinco (97,9%) tiveram alta em 24 h. O custo médio total dos dois procedimentos realizados separadamente ($2.562,45) foi 43% maior do que o custo médio das duas operações feitas simultaneamente ($1.785,11). Após 30 dias de acompanhamento pós-operatório, sete (15,2%) apresentaram complicações menores. Após três meses, nenhum necessitou de readmissão hospitalar, drenagem, antibioticoterapia ou sinal de infecção de tela. No seguimento em longo prazo, média de 47,1 meses, 38 (82,6%) foram reavaliados. Três (7,8%) relataram complicações: recorrência de hérnia; desconforto crônico; reoperação por seroma não reabsorvido. No entanto, nenhum apresentou qualquer complicação relacionada à tela. Questionário de satisfação revelou que 36 (94,7%) ficaram satisfeitos com o resultado da operação. Todos afirmaram que optariam pela ela simultânea novamente se necessário. Conclusão: O reparo da hérnia inguinal concomitante com colecistectomia por laparoscopia é procedimento seguro, sem aumento de infecção da tela. Além disso, tem a vantagem importante de reduzir custos hospitalares e aumentar a satisfação do paciente.

Robotic TAPP inguinal hernia repair: lessons learned from 97 cases / Hernioplastia inguinal transabdominal pré-peritoneal (TAPP) robótica: experiência inicial de 97 casos

ABSTRACT Objectives: minimally invasive inguinal hernia repair has proven advantages over open procedures including less pain and earlier return to normal activity. Robotic surgery adds ergonomics, a three-dimensional high definition camera and articulating instruments overcoming some laparoscopic limitations. We aimed to report the outcomes of the early experience of over 97 robotic inguinal hernia repairs performed by a referred surgical group in Brazil. Methods: a review of a prospective mantined database was conducted in patients submitted to robotic transabdominal preperitoneal (TAPP) inguinal hernia repairs between March 2016 and February 2020. Descriptive statistics were performed. Surgical outcomes data and patient follow-ups are reported. Results: retrospective chart review identified 97 patients submitted to robotic TAPP inguinal hernia repair. Mean age was 36.4 years, with median BMI of 26.9 kg/m2. Mean console time was 58 min (range 40-150) and patients were discharged within 24 hours of their stay in a majority of cases. Mesh was placed in all procedures and there were no conversion rates. Complications were low grade and no recurrence was seen after a mean follow-up of 642 days. Conclusion: this study represents to-date the first brazilian case series of robotic TAPP inguinal hernia repair. Our results encourage that robotic assisted TAPP inguinal hernia repair appears to be technically feasible and safe in experienced hands, with good outcomes achieving high health-related quality of life and low recurrence rates in the short and long term.

RESUMO Objetivo: a cirurgia minimamente invasiva das hérnias inguinais apresenta vantagens comprovadas em relação aos procedimentos convencionais, incluindo menos dor e retorno precoce às atividades rotineiras. A cirurgia robótica acrescenta uma melhor ergonomia, ótica estável tridimensional de alta definição e instrumentos articulados, superando algumas limitações laparoscópicas. O objetivo deste estudo é relatar os resultados da experiência inicial de 97 cirurgias de correção de hérnias inguinais robóticas pela técnica transabdominal pré-peritoneal (TAPP) realizadas por um grupo cirúrgico referência no Brasil. Métodos: foi realizada uma revisão de um banco de dados mantido prospectivamente de pacientes submetidos a cirurgias de hérnia inguinal TAPP robótica entre março de 2016 e fevereiro de 2020. Uma análise detalhada dos resultados foi feita e dados dos resultados cirúrgicos e acompanhamento dos pacientes são relatados. Resultados: a revisão retrospectiva do prontuário identificou 97 pacientes submetidos à cirurgia de hérnia inguinal TAPP robótica. A idade média foi de 36,4 anos, com IMC médio de 26,9 kg/m2. O tempo médio de procedimento cirúrgico no console robótico foi de 58 minutos. A colocação de prótese foi realizada em todos os procedimentos e não houve taxas de conversão ou intercorrências. Conclusão: este estudo representa a primeira série de casos de cirurgia robótica de hérnia inguinal pela técnica transabdominal pré-peritoneal no Brasil. Os resultados descritos reforçam que a hernioplastia inguinal robótica apresenta-se como tecnicamente viável e segura em mãos experientes, com bons resultados quanto a qualidade de vida e baixas taxas de recidiva a curto e longo prazo.

Simulated training model in a low cost for laparoscopic inguinal hernioplasty

ABSTRACT Purpose Develop a 3D model for the simulation of laparoscopic inguinal hernioplasty transabdominal preperitoneal (TAPP). Methods This is an experimental study, 18 participants were selected, divided into three groups, experimental (GE) surgeons in training, control (GC) experienced surgeons and Shaw (GS) nonexperienced surgeons. The simulation in the 3D model was carried out in 6 sessions fulfilling the 5 stages. Opening the peritoneum with the creation of the preperitoneal space; identification of important structures; hernia identification and reduction; placement and fixation of the mesh in Cooper's ligament and closure of the peritoneum. Results In the 1st stage, the GE obtained an average of 1.25 ± 0.42 in the 1st session and 3.25 ± 0.62 in the 6th session (p = 0.05) and in the 5th stage 0.91 ± 0.29 in the first session. 1st session and 1.91 ± 0.29 in the 6th session (p = 0.001), with no significant difference between groups. The learning and skill curve in the SG represented 1.08 ± 0.29 1st and 3.50 ± 0.90 6th session (p = 0.001). Conclusions The creation of a systematization of training in simulation applied to the three-dimensional model enabled gain in laparoscopic skills and underpinned its theoretical and practical foundations.

Training model in abdominal wall endoscopic surgery for ventral hernias. Extended totally extra-peritoneal approach (e-tep)

ABSTRACT Purpose: To develop a reproducible training program model covering the steps of the extended totally extraperitoneal approach (e-tep) technique for correction of ventral or incisional hernia repair. Methods: Training sessions with surgeons in the laboratory using both porcine specimens and a new ethylene vinyl acetate (EVA) model simulating the operative steps of the e-tep technique. Students were interviewed and asked to answer a questionnaire pre and post the sessions to assess their performance and evaluated the course and model. Results: A total of 25 trained abdominal wall surgeons was evaluated at the end of the course. It was obtained a 100% satisfaction score of the training, as well as increased confidence levels up to 9 and 10 in all technical aspects of the surgery, having 96% of the surgeons performed a surgery under supervision of the proctors after the course. Conclusions: This training model is simple, effective, low cost, and replicable in guidance on the beginning of e-tep technique adoption, and performance. As a result, surgeons can get more confident and more able to perform surgeries employing this technique.