Laparoscopic Inguinal Hernia Repair for Female Patients: Experience from a High-volume Center in 20 years.

BACKGROUND: Although laparoscopic inguinal hernia repair (LIHR) is widely performed worldwide, few studies have focused on the procedure in female patients. This study investigated the characteristics and outcomes of female patients with inguinal hernias who underwent LIHR. MATERIALS AND METHODS: This study retrospectively analyzed the data of 7380 patients with inguinal hernia admitted to the General Surgery Department of Ruijin Hospital and underwent LIHR from January 2001 to December 2020. The clinical characteristics, surgical outcomes, and complications were assessed. RESULTS: In total, 572 female patients were enrolled in this study. The proportion of femoral hernias in female patients was higher in women than in male patients (17.4% vs. 0.3%, respectively). Mesothelial cysts of the round uterine ligament (MCURL) were noted in 74 patients. The mean age of patients with MCURL was lower than that of patients without MCURL (46.4 vs. 55.6, P =0.018). Seventy cases (93.3%) of MCURL were resected laparoscopically, and 5 cases were resected through an auxiliary small incision. The round ligament was cut off in 335 patients and preserved in 237. No significant differences were observed in the number of hospitalization days, recurrence rates, or complications between the transection and preservation groups. None of the cases were converted to laparotomy, and no recurrence was noted during follow-up. CONCLUSION: LIHR is safe and feasible in female patients. Treatment of femoral hernia, MCURL, and the round ligament of the uterus should be carefully considered during LIHR in female patients.

Hip synovial cyst presenting as femoral hernia - case report.

We are pleased to introduce this interesting case report. A female patient presented to emergency department with a new lump in her right groin. Although there was quite convincing history for femoral hernia, the clinical findings were not correlating with this completely. The patient underwent ultrasound examination which showed synovial cyst originating from the right hip. This is a rare presentation of hip synovial cyst and we have therefore decided to publish this case report.

Femoral Hernias: Analysis of Preoperative Risk Factors and 30-Day Outcomes of Initial Groin Hernias Using ACS-NSQIP.

Femoral hernias are infrequently encountered groin hernias. The purpose of this study was to describe the natural history of femoral hernias by evaluating patient demographics, comorbidities, operative details, 30-day mortality, and risk factors for postoperative complications compared with inguinal hernias and in reducible versus incarcerated hernias. Overall 5360 femoral hernia repairs and 183,173 inguinal hernia repairs were identified using the 2005 to 2015 American College of Surgeon-National Surgical Quality Improvement Program's database. Univariate analysis was used to compare patient characteristics between femoral and inguinal hernias and between reducible and nonreducible femoral hernias. Multivariable logistic regression analyses were used to identify risk factors for 30-day postoperative complications after repair. Femoral hernias accounted for 2.8 per cent of initial groin hernias and 18.9 per cent of all groin hernias in females. A total of 56.5 per cent of initial femoral hernias were nonreducible and these patients were significantly older. Rates of small bowel resection (5.7 vs 0.3%, P < 0.0001), exploratory laparotomy (2.5% vs 0.4%, P < 0.0001), and diagnostic laparoscopy (2.0% vs 0.7%, P < 0.0001) were significantly higher in incarcerated femoral hernias compared with reducible femoral hernias. There were significantly higher rates of unplanned return to the OR, postoperative sepsis, and 30-day mortality in incarcerated femoral hernias versus reducible femoral hernias. Most femoral hernias present incarcerated in older, female patients. Femoral hernias present more commonly incarcerated in patients with significant comorbid diseases and are associated with significantly increased rates of systemic, local, major, and minor complications, return to OR, and mortality. Careful consideration should be given for the evaluation of intestinal viability in the acute setting.

Combined Littre and Richter's femoral hernia: an extremely rare intra-operative finding.

Littre hernia is defined as the herniation of a Meckel's diverticulum, while Richter's hernia is the herniation of a portion of the bowel wall. An extremely rare case of a combined Littre and Richter's femoral hernia is reported. An 82-year-old male presented at the emergency department with a painful golf ball-like mass at the right inguinofemoral region. With the diagnosis of incarcerated femoral hernia, he was urgently taken to the operating room. Intraoperatively, an incarcerated Littre, as well as a Richter's hernia were revealed. Enterectomy and side-to-side small bowel anastomosis were performed. The patient made an uneventful recovery. To the best of our knowledge, the present is the first report of a combined Littre and Richter's femoral hernia. Such findings should be reported to raise the awareness of surgeons for complicated cases. It is of utmost importance to have a high suspicion index for strangulated hernias, to minimize the time between admission and surgery.

De Garengeot hernia: an uncommon presentation of acute appendicitis.

We present a case of a 78-year-old female patient with an uncommon presentation of acute appendicitis. She was found to have a perforated appendicitis which developed in a femoral hernia sack. An appendix present in a femoral hernia is called a De Garengeot Hernia, which is a rare form of femoral hernia. Clinical presentation, diagnosis and management are discussed.

Parietal Strangulation Of Small Intestine In Femoral Hernia Site With Symptoms Of Intestinal Obstruction In Patient With Incidentally Found Small Intestine Tumor--A Case Report.

Richter's hernia (partial enterocele) is the strangulation/entrapment of only part of the circumference of the intestinal wall. It is relatively rare, and presents without mechanical obstruction - giving vague, non-specific symptoms and signs, and a threat of intestinal necrosis, gangrene, followed by perforation. A report of a case of entrapment of the jejunum in the femoral ring, which did not cause the gangrene, but symptoms of mechanical obstruction, is presented. Further inspection of the small bowel in this case revealed an extra-luminal tumour, which appeared to be a GIST. The entrapped part of the jejunum has been released and the tumour has been resected.

Increasing Body Mass Index Is Inversely Related to Groin Hernias.

Few studies describe the relationship between obesity and groin hernias. Our objective was to investigate the correlation between body mass index (BMI) and groin hernias in a large population. Patients with the diagnosis of inguinal or femoral hernia with and without incarceration or strangulation were identified using the Kaiser Permanente Southern California regional database including 14 hospitals over a 7-year period. Patients were stratified by BMI. There were 47,950 patients with a diagnosis of a groin hernia--a prevalence of 2.28 per cent. Relative to normal BMI (20-24.9 kg/m(2)), lower BMI was associated with an increased risk for hernia diagnosis. With increasing BMI, the risk of incarceration or strangulation increased. Additionally, increasing age, male gender, white race, history of hernia, tobacco use history, alcohol use, and higher comorbidity index increased the chance of a groin hernia diagnosis. Complications were higher for women, patients with comorbidities, black race, and alcohol users. Our study is the largest to date correlating obesity and groin hernias in a diverse United States population. Obesity (BMI ≥ 30 kg/m(2)) is associated with a lower risk of groin hernia diagnosis, but an increased risk of complications. This inverse relationship may be due to limitations of physical exam in obese patients.

Femoral hernia, a rare complication following deep inguinal lymph node dissection.

A 72-year-old woman underwent complete deep inguinal lymph node dissection on her right side subsequent to metastasis from malignant melanoma. On the second postoperative day, the patient reported of nausea and vomiting. She presented with a mass in the resected area that gradually increased in size to approximately 15×20 cm. The wound was opened a few hours after onset of symptoms and a large femoral hernia with 40 cm of small intestine was immediately revealed protruding in the groin. Prophylactic suturing of the inguinal ligament and Coopers ligament can reduce the risk of postoperative femoral hernia. Further, the authors argue that drainage for seroma and haematoma should be performed with utmost care, considering other possible causes and, if necessary, guided by ultrasonography.

Groin defects seen at extra-peritoneal laparoscopic dissection during surgical treatment of athletic pubalgia.

BACKGROUND: Recently new disease process, often referred to as athletic pubalgia (AP), has been acknowledged by the medical community. The patients suffering from this ailment present with unilateral or bilateral chronic groin pain associated with physical activity without a clear diagnosis of a groin hernia. Though physical therapy and medical treatments are considered first line remedies, some believe that surgical treatment may have better, quicker, and more durable outcomes and procedures aimed at groin reinforcement seem to relieve most of symptoms in the majority of the patients. Despite many surgeons consistently noting rectus insertion or adductor thinning, multiple hernia defects are often seen during dissections and the clinical significance of these findings is still not known. MATERIALS AND METHODS: Between 2007 and 2011, 40 patients underwent an extra-peritoneal laparoscopic reinforcement of rectus abdominals and insertion of adductor muscles for AP. All patients underwent wide and bilateral groin dissection and the findings were cataloged. RESULTS: All of the patients presented with groin defects upon wide dissection. Thirty-four patients (85%) presented with small bilateral indirect inguinal defects and 28 (70%) of these patients did not have any additional defects. Five patients (12.5%) were found to have only unilateral inguinal hernia defects. One patient presented with a small direct defect. In addition to these defects, five patients (12.5%) had additional unilateral femoral hernias, whereas no patient had solitary femoral hernia defects. CONCLUSION: AP is a new diagnostic entity with poorly understood etiology. It mostly affects young active adults, often involved in competitive sports and surgical methods may be most effective at achieving the cure. In our experience all of the patients presented with groin defects, though not all were the same. It is our belief that these defects, although likely not the only component, play a significant role in the pathophysiology of AP.

[Connective tissue dysplasia as a reason of recurrent inguinal hernia].

The examination results of 78 patients with recurrent inguinal hernia revealed presence of systemic connective tissue abnormalities in addition to dysplasia of posterior wall of inguinal canal in 48 (61.6%) patients. Hernial disease was observed in 37 (47.4%) patients including umbilical hernia in 12 cases, femoral hernia in 8 patients, hiatal hernia in 3 patients and bilateral inguinal hernia in 14 cases. Group of other diseases included varicose veins of lower limbs in 15 (19.2%) patients, mitral valve prolapse in 3 (3.8%) patients, violation of skin elasticity (striae) in 6 (7.7%) cases, diverticulum of bladder in 2 (2.6%) patients, diverticulum of esophagus in 1 (1.3%) patient, diverticulosis of small intestine in 2 (2.6%) cases. Our data prove that inguinal hernia is local manifestation of systemic disease.

Hernia emergencies.

Hernia emergencies are commonly encountered by the acute care surgeon. Although the location and contents may vary, the basic principles are constant: address the life-threatening problem first, then perform the safest and most durable hernia repair possible. Mesh reinforcement provides the most durable long-term results. Underlay positioning is associated with the best outcomes. Components separation is a useful technique to achieve tension-free primary fascial reapproximation. The choice of mesh is dictated by the degree of contamination. Internal herniation is rare, and preoperative diagnosis remains difficult. In all hernia emergencies, morbidity is high, and postoperative wound complications should be anticipated.

A novel laparoscopic-assisted approach to the repair of pediatric femoral hernias.

BACKGROUND: Femoral hernias in young children are relatively rare and can be difficult to diagnose as they are often mistaken for inguinal hernias. Although a few reports have described laparoscopic techniques, most traditional repair methods still focus on an open approach using either an inguinal or crural incision. Here we describe a laparoscopic-assisted technique that is buttressed by a cigarette of mesh for the repair of this uncommon pediatric entity. SUBJECTS AND METHODS: We report three consecutive cases of children with femoral hernias repaired with only two small incisions: a 5-mm umbilical incision for a 30° camera and a 1-cm groin incision for dissection and ligation of the hernia sac. After sac ligation, the repair was buttressed with a small mesh cigarette. RESULTS: Using this approach, right femoral hernias were repaired without complication in three children, between 8 and 9 years of age. Two patients had ipsilateral indirect inguinal hernias. No contralateral groin hernias were identified in any of the patients. Operative time averaged 40 minutes, recovery time was quick, and follow-up at 6 months revealed good cosmesis. CONCLUSIONS: This laparoscopic-assisted approach to pediatric femoral hernia repair with a small mesh plug is a safe, effective, and efficient technique. Because only two incisions are required, postoperative pain is minimal, and cosmesis is excellent. Nonetheless, more patients and longer follow-up will be required to accurately judge the long-term implications of this novel technique.

Pediatric abdominal wall defects.

This article reviews the incidence, presentation, anatomy, and surgical management of abdominal wall defects found in the pediatric population. Defects such as inguinal hernia and umbilical hernia are common and are encountered frequently by the pediatric surgeon. Recently developed techniques for repairing these hernias are aimed at improving cosmesis and decreasing pain while maintaining acceptably low recurrence rates. Less common conditions such as femoral hernia, Spigelian hernia, epigastric hernia, lumbar hernia, gastroschisis, and omphalocele are also discussed. The surgical treatment of gastroschisis and omphalocele has undergone some advancement with the use of various silos and meshes.

Aetiology of femoral hernias revisited: bilateral femoral hernia in a young male (two cases).

Bilateral femoral hernias are less common in men than in women and rare in young adults. Only one case of a bilateral femoral hernia in a young man has been reported in the literature before. Three main theories have been postulated for femoral hernias. The theory that they are an acquired disease is the most accepted due to the common occurrence of such hernias in multiparous women but the theory lacks enough evidence. We report two cases in young men. Anatomical variations in the femoral canal could be the primary aetiological factor in these patients. A unilateral femoral hernia in young men with acquired aetiological factors requires a clinical examination of the opposite side.

Recurrent femoral hernia and associated ovarian pathology.

The following case describes an ovarian tumour presenting in a highly unusual manner-in the form of a recurrent femoral hernia. Recurrent femoral herniae are unusual and should prompt awareness of underlying pathology causing increased intra-abdominal pressure.

[Inguinal and femoral hernia repair]. / Chirurgie der Leisten- und Schenkelhernien.

With an incidence of 200,000 new cases per year in Germany, inguinal hernia has a significant socioeconomic impact. The 2009 guidelines from the European Hernia Society established treatment recommendations. Hernia repair is based on reinforcing the posterior wall of the inguinal canal by suture or mesh repair by an anterior or posterior approach. Lightweight mesh reduces recurrence rates and is the treatment of choice even in primary hernias. Laparoscopic hernia repair is associated with specific risks but is superior in postoperative pain and earlier return to work.

The time profile of groin hernia recurrences.

PURPOSE: If the pathogeneses of the development of a recurrence varies following the different methods of hernia repair, the time required to develop a recurrence could be expected to vary. The aim of the study was to identify risk factors affecting the time interval between the primary repair and the reoperation. METHODS: Data from the Swedish Hernia Register were used. Each year of the 5-year follow-up period was treated as a separate subgroup and merged together into one large group. For each risk factor, we performed a Cox proportional hazard analysis, testing for interactions between the year and the risk factor, with reoperation as the endpoint. RESULTS: Altogether, 142,578 repairs were recorded, of which 7.7% were performed on women. The mean age of the cohort was 59 years. The overall recurrence rate in the 5-year period was 4.3%. Multivariate analysis showed that recurrence following surgery for recurrent hernia occurred relatively early (P < 0.05).Recurrence also appeared early if postoperative complications were registered (P < 0.05). Recurrence after suture repair or laparoscopic repair appeared relatively early compared to recurrence following open mesh repair (P < 0.05). In a separate analysis, a relatively higher risk for early recurrence was seen for all sutured repairs compared to all mesh repairs (P < 0.05). CONCLUSIONS: The pathogenesis behind the development of recurrence probably differs depending on the technique applied during the hernia repair. The higher proportion of early recurrences following laparoscopic repair, suture repair and recurrent repair may be explained by the high proportion of technical failures.

Anatomical changes after inguinal hernia treatment: a reason for chronic pain and recurrent hernia?

BACKGROUND: Chronic pain and hernia recurrence are the most frequent long-term complications of treating inguinal hernia. One reason may be postsurgical changes in the anatomy of the groin. METHODS: In a retrospective investigation from 1994 to 2008, 1,194 patients undergoing 1,421 laparoscopic transabdominal preperitoneal (TAPP) herniorrhaphies were studied. Anatomical structures in the groin, seen in 1,214 primary and 207 recurrent hernias, were charted by means of video analysis. Hernia orifices, myopectineal orifice (MPO), and Hesselbach's and Hessert's triangles were measured in their respective vertical and horizontal diameters in order to calculate the surface area. Other anatomical changes were also recorded. RESULTS: The mean surface area of hernial orifices was 3.00 +/- 2.01 cm(2) in primary hernias and 3.60 +/- 3.81 cm(2) in recurrent hernias. The mean surface area of Hesselbach's triangle was 4.23 +/- 2.21 cm(2) in the former group and 2.09 +/- 2.10 cm(2) in the latter (p < 0.0001). The mean surface area of Hessert's triangle in primary hernias (9.03 +/- 6.17 cm(2)) was significantly larger than that in recurrent hernias (3.11 +/- 3.67 cm(2); p < 0.0001). Further anatomical changes in suture-treated recurrent hernias included a dislocated spermatic cord, a raised inguinal ligament, and asymmetry in the region. CONCLUSION: The treatment of inguinal hernia by the suture technique is followed by significant anatomical changes such as reduction of the surface area and a subsequent increase of tension in the inguinal region. This could be one of the main reasons for chronic pain and hernia recurrence.