Proposal of set-up standardization for general surgery procedures with the CMR Versius system, a new robotic platform: our initial experience.

BACKGROUND: The article describes our initial experience using CMR Versius platform for several procedures in general surgery. METHODS: Between September 2022 and April 2023, seventy patients underwent robotic surgery in a multi-robotic referral center (San Paolo University Hospital, Milan, Italy). Three surgeons with only laparoscopic experience performed 24 cholecystectomies, 13 inguinal hernia repairs, 9 ventral hernia repairs, 7 right hemicolectomies, 11 left hemicolectomies, 1 sigmoidectomy, 1 ileocecal resection, 1 ventral rectopexy, 1 Nissen fundoplication, 1 total splenectomy, and 1 exploration with multiple biopsies. RESULTS: All surgeries were full-robotic, with only one conversion to laparoscopy. The short length of stay and low rate of severe morbidity are promising findings. Although operative time was lengthened, clinical outcomes were not affected. CONCLUSIONS: Our experience demonstrates that the adoption of Versius system is safe and feasible in general surgery. The standardization of port placement and BSU set-up can certainly reduce the operative time.

Spontaneous bowel evisceration through umbilical hernia in an adult non-cirrhotic patient.

Few cases of spontaneous bowel evisceration (SBE) through umbilical hernias (UHs) in adult patients have been reported in the literature. Interestingly, the spontaneous rupture of the hernia sac is a rare complication usually seen in adult cirrhotic patients with persistent ascites or in patients with congenital wall defects. A man in his early 50s was admitted to our emergency department with SBE through a long-standing acquired UH. He was not clinically cirrhotic, although being HCV positive. Surgeons performed an urgent laparotomy with ileal resection, latero-lateral ileal anastomosis and direct hernioplasty without mesh. Given the rarity of this presentation, we reported it and reviewed the available literature on this subject. Elective hernioplasty is currently suggested to lower the risk of complications. Mesh placement should be preferred, but only if comorbidities and infectious risks do not contraindicate its use. In emergency situations, a direct hernia repair is preferred.

Encountering the corona mortis vessel during laparoscopic totally extraperitoneal mesh hernioplasty and its significance.

Corona mortis (CM) is an anastomotic vessel between the inferior epigastric or external iliac vessels and the obturator or internal iliac vessels. The Latin meaning of it is 'crown of death' which corresponds to massive haemorrhage caused by injury to this vessel during surgery. The incidence of this vessel is around 50% in the hemipelvis. We are presenting an intraoperative video of a right laparoscopic totally extraperitoneal mesh hernioplasty demonstrating a CM artery in the right hemipelvis. Care was taken to prevent injury to this vessel. CO2 insufflation pressure was reduced to less than 10 mm Hg to see any venous variant of this vessel. Carefully, polypropylene mesh was placed without a fixation device. Anatomical knowledge of the CM vessel is therefore essential in preventing injury for surgeons who approach the inguinal and retropubic regions.

¿Es YouTube una herramienta fiable para la enseñanza de cura de hernia inguinal asistida por robot? Una revisión crítica de los recursos disponibles / Is YouTube a reliable tool for approaching robotic assisted transabdominal preperitoneal surgery? A critical review of the available resources

Introducción: La cirugía transabdominal preperitoneal asistida por robot (rTAPP) es una técnica relativamente reciente para el tratamiento de hernia inguinal. Para alcanzar resultados óptimos se deben cumplir las 10 reglas de oro descritas. Los cirujanos en formación suelen revisar vídeos para familiarizarse con nuevas técnicas siendo YouTube una de las plataformas más utilizada. El objetivo de este estudio es realizar una evaluación de los 10 vídeos más vistos en YouTube de reparación de hernia inguinal por rTAPP para determinar si se cumplen las 10 reglas de oro. Métodos: Identificar y evaluar los 10 vídeos con mayor número de visualizaciones relacionados con la rTAPP. Tres Cirujanos con experiencia evaluaron el cumplimiento de las 10 reglas de oro utilizando una escala de Likert. Los datos fueron analizados en Excel (Microsoft) y graficados con Tableau (Tableau Inc). La consistencia entre evaluadores se determinó mediante el alfa de Cronbach, considerándose aceptable un valor > 0,7. Resultados: La evaluación general promedio fue de 3,63 con un rango de 2,6 a 4,9. Las puntuaciones relacionadas con el cumplimiento de las reglas 1, 2, 9, 10 fueron satisfactorias; en cambio, las reglas 3, 4, 5, 7 y 8 fueron débiles, en particular la regla número 7. Se observó consistencia interna entre los evaluadores con un alfa de Cronbach de 0,98. Conclusiones: La falta de cumplimiento con las 10 reglas del oro en la mayoría de los vídeos demuestra que el uso de vídeos (YouTube) no es un adecuado recurso para el aprendizaje de cura de hernia inguinal asistida por robot.(AU)

Introduction: The robotic transabdominal preperitoneal approach (rTAPP) is a relatively recent technique for the treatment of inguinal hernia. To achieve optimal results, the 10 golden rules described must be followed. Surgeons in training often review vídeos to familiarize themselves with new techniques, YouTube being one of the most used platforms. The objective of this study is to carry out an evaluation of the 10 most viewed vídeos on YouTube of inguinal hernia repair by transabdominal preperitoneal approach (rTAPP) to determine if the 10 golden rules are met. Methods: Identify and evaluate the 10 vídeos with the highest number of views related to rTAPP. Three experienced surgeons evaluated compliance with the 10 golden rules using a Likert scale. Data were analyzed in Excel (Microsoft) and plotted with Tableau (Tableau Inc.). The consistency between evaluators was determined using Cronbach's alpha, considering a value >0.7 acceptable. Results: The average overall evaluation was 3.63 with a range of 2.6–4.9. The scores related to compliance with the rules 1, 2, 9 and 10 were satisfactory; on the other hand, rules 3, 4, 5, 7 and 8 were weak, particularly rule number 7. Internal consistency was observed between raters with a Cronbach's alpha of 0.98.Conclusions: The lack of compliance with the 10 golden rules in most of the vídeos demonstrates that the use of vídeos (YouTube) is not an adequate resource for learning robot-assisted inguinal hernia cure.(AU)

Initial experience of a single surgeon for safety and feasibility of the Versius Robotic System in robot-assisted cholecystectomy and hernia repair.

This study aimed to evaluate the feasibility, safety, and perioperative outcomes of cholecystectomy and hernia repair performed with the Versius Robotic System by a surgeon with no prior robotic surgery experience. A retrospective analysis was conducted on adult patients who underwent cholecystectomy, inguinal, or umbilical hernia repair using the Versius Robotic System between August 2021 and June 2023 et al. Zahra Hospital, Dubai, UAE. A total of 105 patients (mean age 38.9 ± 9.2 years) were included. Significant correlations existed between the number of robot-assisted cholecystectomies and the operative metrics. As the number increased, the duration of the total operative (r = - 0.755, p < 0.001), docking (r = - 0.683, p < 0.001), and console (r = - 0.711, p < 0.001) times decreased, indicating improved efficiency with experience. This study demonstrates the safety and feasibility of the Versius Robotic System for cholecystectomy and hernia repair, even for surgeons lacking prior robotic surgery experience.

Approach to concurrent inguinal hernias during laparoscopic appendectomy for early appendicitis.

PURPOSE: Concurrent inguinal hernia can be a challenge for a pediatric surgeon during a laparoscopic appendectomy in children. We aimed to present our approach to inguinal hernias seen during laparoscopic appendectomy. METHODS: In our pediatric surgery clinic between July 2019 and December 2022, the records of patients aged 0-18 who underwent laparoscopic appendectomy were retrospectively investigated. The clinical findings, surgical procedure, and results of intervened inguinal hernia cases during laparoscopic appendectomy were evaluated. RESULTS: Between the study dates, 293 laparoscopic appendectomies were performed in our clinic. Patent processus vaginalis was observed in 5 (1.7%) cases. Laparoscopic hernia repair was performed with the Burnia technique in 2 girls. In one case, the omentum was herniated and adhered to the hernia sac seen during laparoscopy. In another case, swelling in the groin occurred during the introduction of air into the abdomen at the beginning of the operation. Patent processus vaginalis seen in 3 asymptomatic cases was not intervened. There were no postoperative complications or recurrences in the two patients who underwent hernia repair. CONCLUSION: Hernia repair with the Burnia technique might be safely performed in symptomatic inguinal hernia cases seen during laparoscopic appendectomy for early appendicitis.

Efficacy and safety of general anesthesia with caudal block for inguinal hernioplasty in children: a randomized controlled trial.

OBJECTIVE: Caudal block is a type of regional anesthesia suitable for inguinal hernia surgery in children. Our goal was to determine the effectiveness of caudal block combined with general anesthesia in providing intra- and postoperative analgesia and its effect on hemodynamic stability and drug consumption. PATIENTS AND METHODS: Prospective, randomized controlled study included 78 boys, 3-5 years, with an indication for inguinal herniorrhaphy, divided into groups G (general anesthesia, n=39) and G+C (general anesthesia + caudal block, n=39). We monitored hemodynamic parameters intraoperatively, postoperative pain, and total consumption of all medicaments in the perioperative period. The monitoring of complications and side effects of drugs was also carried out. RESULTS: Boys in group G had statistically significantly higher values of heart rate in the 5th minute (p<0.01), in the 25th minute (p<0.01), and after awakening from anesthesia (p<0.01). We obtained similar results with systolic and diastolic pressure values in the 5th minute (p<0.01), 15th minute (p<0.01), 25th minute (p<0.01), before awakening from anesthesia (p<0.01) and after awakening (p<0.01). They also had significantly statistically higher total consumption of propofol, fentanyl, and acetaminophen (p<0.01). Boys in group G+C had significantly lower postoperative pain scores: initially (p<0.01), after 2 hours (p<0.01), and after 5 hours (p<0.01). No complications occurred in this group. CONCLUSIONS: In children, the combination of general anesthesia with caudal block, compared to general anesthesia only, is more efficient in suppressing visceral pain, leading to better hemodynamic stability, and reducing the consumption of medicines in the perioperative period.

Inguinal endometriosis: a case series and review of the literature.

BACKGROUND: Inguinal endometriosis is one of the most common forms of endometriosis. The present study introduces 8 cases of inguinal endometriosis and discusses probable theories of inguinal endometriosis by reviewing the literature. CASE PRESENTATION: 8 Iranian cases of inguinal endometriosis with a mean age of 36 years were presented. Catamenial groin pain and swelling were the most common complications. Also, patients usually had accompanying symptoms such as pelvic pain and dysmenorrhea. One-half of patients had a history of previous abdominal surgery. Ultrasound was diagnostic in 4 patients (50%), and magnetic resonance imaging was used in two patients (25%). Among 6 patients who underwent hormonal therapy, 4 experienced an endometriosis size increase. Inguinal endometriosis was right-sided in 87.5% of patients, and among 4 patients who underwent surgery, 75% had proximal site involvement of the round ligament. CONCLUSION: According to the rarity of inguinal endometriosis, it is more likely to be a misdiagnosis with other inguinal disorders such as inguinal hernia. Inguinal endometriosis should be considered in patients who undergo inguinal herniorrhaphy, with suspected findings such as thickening of the hernia sac wall, bloody fluid inside the sac, or thickening of the extraperitoneal round ligament during the surgery.

Conventional herniorrhaphy followed by laparoscopic appendectomy for a variant of Amyand's hernia: a case report.

BACKGROUND: Amyand's hernia (AH) is an appendix (with or without acute inflammation) trapped within an inguinal hernia. Most AH with acute appendicitis had a preexisting appendix within the hernia sac. We herein report a variant of AH that has never been described before. An inflamed appendix that was managed conservatively was found to have migrated and trapped in the sac of a previously unrecognized right inguinal hernia 6 weeks after the index admission, resulting in a secondary Amyand's hernia. CASE PRESENTATION: A 25-year-old healthy Taiwanese woman had persistent right lower abdominal pain for 1 week and was diagnosed with perforated appendicitis with a localized abscess by abdominal computed tomography (CT). No inguinal hernia was noted at that time. Although the inflamed appendix along with the abscess was deeply surrounded by bowel loops so that percutaneous drainage was not feasible, it was treated successfully with antibiotics. However, she was rehospitalized 6 weeks later for having a painful right inguinal bulging mass for a week. Abdominal CT revealed an inflamed appendix with abscess formation in an indirect inguinal hernia raising the question of a Amyand's hernia with a perforated appendicitis. Via a typical inguinal herniorrhaphy incision, surgical exploration confirmed the diagnosis, and it was managed by opening the hernial sac to drain the abscess and reducing the appendix into the peritoneal cavity, followed by conventional tissue-based herniorrhaphy and a laparoscopic appendectomy. She was then discharged uneventfully and remained well for 11 months. CONCLUSIONS: Unlike the traditional definition of Amyand's hernia, where the appendix is initially in the hernia sac, the current case demonstrated that Amyand's hernia could be a type of delayed presentation following initial medical treatment of acute appendicitis. However, it can still be managed successfully by a conventional tissue-based herniorrhaphy followed by laparoscopic appendectomy.

Effect of Early vs Late Inguinal Hernia Repair on Serious Adverse Event Rates in Preterm Infants: A Randomized Clinical Trial.

Importance: Inguinal hernia repair in preterm infants is common and is associated with considerable morbidity. Whether the inguinal hernia should be repaired prior to or after discharge from the neonatal intensive care unit is controversial. Objective: To evaluate the safety of early vs late surgical repair for preterm infants with an inguinal hernia. Design, Setting, and Participants: A multicenter randomized clinical trial including preterm infants with inguinal hernia diagnosed during initial hospitalization was conducted between September 2013 and April 2021 at 39 US hospitals. Follow-up was completed on January 3, 2023. Interventions: In the early repair strategy, infants underwent inguinal hernia repair before neonatal intensive care unit discharge. In the late repair strategy, hernia repair was planned after discharge from the neonatal intensive care unit and when the infants were older than 55 weeks' postmenstrual age. Main Outcomes and Measures: The primary outcome was occurrence of any prespecified serious adverse event during the 10-month observation period (determined by a blinded adjudication committee). The secondary outcomes included the total number of days in the hospital during the 10-month observation period. Results: Among the 338 randomized infants (172 in the early repair group and 166 in the late repair group), 320 underwent operative repair (86% were male; 2% were Asian, 30% were Black, 16% were Hispanic, 59% were White, and race and ethnicity were unknown in 9% and 4%, respectively; the mean gestational age at birth was 26.6 weeks [SD, 2.8 weeks]; the mean postnatal age at enrollment was 12 weeks [SD, 5 weeks]). Among 308 infants (91%) with complete data (159 in the early repair group and 149 in the late repair group), 44 (28%) in the early repair group vs 27 (18%) in the late repair group had at least 1 serious adverse event (risk difference, -7.9% [95% credible interval, -16.9% to 0%]; 97% bayesian posterior probability of benefit with late repair). The median number of days in the hospital during the 10-month observation period was 19.0 days (IQR, 9.8 to 35.0 days) in the early repair group vs 16.0 days (IQR, 7.0 to 38.0 days) in the late repair group (82% posterior probability of benefit with late repair). In the prespecified subgroup analyses, the probability that late repair reduced the number of infants with at least 1 serious adverse event was higher in infants with a gestational age younger than 28 weeks and in those with bronchopulmonary dysplasia (99% probability of benefit in each subgroup). Conclusions and Relevance: Among preterm infants with inguinal hernia, the late repair strategy resulted in fewer infants having at least 1 serious adverse event. These findings support delaying inguinal hernia repair until after initial discharge from the neonatal intensive care unit. Trial Registration: ClinicalTrials.gov Identifier: NCT01678638.

Safety and feasibility of emergency robot-assisted transabdominal preperitoneal repair for the treatment of incarcerated inguinal hernia: A retrospective study.

BACKGROUND: Few studies assessed robotic in emergency setting and no solid evidence was demonstrated. The aim of this study was to evaluate the feasibility and safety of robot-assisted transabdominal preperitoneal (R-TAPP) repair for the treatment of incarcerated inguinal hernia. METHODS: We retrospectively searched from a prospectively maintained database patients who underwent R-TAPP or open surgery for incarcerated inguinal hernias from January 2018 to March 2023. The primary endpoint was to assess safety and feasibility of the R-TAPP compared to the standard approach. For eligible patients, data was extracted and analyzed using a propensity score-matching (PSM). RESULTS: Thirty-four patients were retrieved from our database, 15 underwent R-TAPP, while 19 underwent open surgery. Mean age was 73.1 ± 14.6 years, 30 patients (88.2%) were male and mean BMI was 23.5 ± 3.2 kg/m2. No intraoperative complication occurred. Three cases requiring small bowel resection were all in the open surgery group (p = 0.112). The operative time was 108 ± 31 min versus 112 ± 31 min in the R-TAPP and open surgery groups (p = 0.716). Seven postoperative complications occurred, only one classified as severe was in the open surgery group. The length of hospital stay was 2.9 ± 1.8 in the R-TAPP versus 4.2 ± 2.3 min in the open surgery group (p = 0.077). PSM analysis showed similar postoperative outcomes and costs in both groups. CONCLUSIONS: Despite its limitations, our study appears to endorse the safety and feasibility of the robotic-assisted treatment for incarcerated inguinal hernia. This approach yielded comparable results to open surgery, albeit in a limited number of patients, suggesting it might be a viable alternative.

[Da Vinci robotic complex in hernia repair surgery]. / Ispol'zovanie roboticheskogo kompleksa Da Vinci v khirurgii gryzh. Opyt kliniki.

OBJECTIVE: To review the first robotic hernia repairs performed at the Ilyinsky Hospital, evolution of this technology, learning curve and early outcomes. MATERIAL AND METHODS: There were 17 procedures at the Ilyinskaya Hospital between 2021 and 2023 (13 men and 4 women). Mean age was 60 years, body mass index 28 kg/m2. ASA grade 1 was observed in 1 patient, grade 2 - 14 ones, grade 3 - 2 patients. Ventral, inguinal and umbilical hernias were diagnosed in 7, 8 and 2 cases, respectively. Ventral hernias required IPOM+ procedure in 3 cases, eTEP-RS procedure in 2 cases and eTEP-RS-TAR procedure in 2 cases. Patients with inguinal hernia underwent transabdominal preperitoneal hernia repair. In case of umbilical hernia, TARUP procedure was performed in 1 case and vTAPP procedure in 1 case. RESULTS: Mean surgery time was 2 hours 38 min (min 1 hour 35 min, max 10 hours 11 min). There was one intraoperative complication (bleeding from epigastric artery). The follow-up period ranged from 3 months to 3 years. There were no recurrent hernias. Postoperative complications were noted in 2 cases. One patient was diagnosed with epididymitis after TAPP, 1 patient - with seroma after eTEP-RS procedure. All complications were relieved by conservative treatment. Bleeding from a. epigastrica inferior was diagnosed after removal of the trocar at the end of surgery. This event required suturing. CONCLUSION: Robotic hernia repair appears to be technically feasible and safe. This approach provides favorable results regarding quality of life and recurrence rate.

Routine closed-suction drainage reduces seromas following totally extraperitoneal (TEP) inguinal hernia repair: A meta-analysis.

BACKGROUND: The value of prophylactic closed-suction drainage in totally extraperitoneal inguinal hernia repair (TEP) is still a matter of controversy. We conducted a meta-analysis of studies examining postoperative seroma rates in patients with or without routine placement of closed-suction drainage tubes. METHODS: A systematic literature search was conducted for trials comparing the outcome of TEP with or without routine drainage placement. Data regarding postoperative outcomes were extracted and compared by meta-analysis. The odds ratio and standardized mean differences with 95% confidence intervals were calculated. RESULTS: Four studies were identified, involving a total of 1626 cases (Drain: n = 1251, no Drain: n = 375). There was a statistically significant difference noted between the 2 groups regarding postoperative seroma formation favoring the Drain group (odds ratio = 0.12; 95% confidence intervals [0.05, 0.29]; P < .001; 4 studies; I2 = 72%). For the remaining secondary endpoints postoperative urinary retention, recurrence, mesh infection and in-hospital length of stay no statistically significant difference was noted between the 2 study groups. CONCLUSION: Current evidence suggests that patients who underwent TEP with routine closed-suction drain placement developed significantly fewer seromas without any additional morbidity or prolongation of in-hospital stay.

The Effectiveness of Cyanoacrylates versus Sutures for Mesh Fixation after Lichtenstein Repair (SCyMeLi STUDY) A Systematic Review and Meta-Analyze of Randomized Controlled Trials.

Background: Chronic postoperative inguinal pain (CPIP) is still the most frequent complication after open Lichtenstein repair and any strategy to reduce its incidence and implications is a step forward to better outcomes. Between the means of mesh fixation atraumatic glue fixation has been explored as such possibility. A meta-analysis of randomized controlled trials comparing the performance of cyanoacrylate glue versus sutures fixation was conducted. Methods: the meta-analysis was conducted according to the PRISMA guidelines. Randomized controlled trials (RCTs) published between January 2000 and December 2021 were searched for in MEDLINE, PubMed, Web of Science, and Google Scholars. The quality of RCTs and the potential risk of bias were assessed using MINORS criteria and the Cochrane risk of bias tool. Results: of 269 papers the meta-analysis was performed on 19 RCTs including 3578 patients. In the glue fixation group, the operation was shorter (mean pooled difference 6 minutes; SE = 0.47; 95% CI = - 6.77 - - 4.92; t test = -12.36; p 0.0001) and immediate postoperative pain was lower (2.37% vs 13.3%OR - 0.158; 95% CI = 0.064 0.386; p = 0.0001). There was no difference in terms of chronic pain, recurrence rate and wound events. Conclusion: glue fixation of mesh in elective Lichtenstein repair of inguinal hernia seems to be a valid choice for a painful and safe procedure without increasing risk of recurrence.

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.

A comparative study between open pre-peritoneal approach versus laparoscopic trans-abdominal pre-peritoneal approach in recurrent inguinal hernia repair: a prospective cohort study.

BACKGROUND: The repair of recurrent inguinal hernias after prosthetic mesh repair is challenging due to the technical complexity and complications associated with it. As well as the increased risk of recurrence due to weakened tissues and distorted anatomy. The Posterior Pre-Peritoneal Approach yields significantly better results than the anterior approach due to its distance from previously scarred tissue. OBJECTIVE: To compare the open pre-peritoneal approach and Laparoscopic trans-abdominal pre-peritoneal approach in the management of recurrent inguinal hernia which was previously managed through an open anterior approach regarding their intra-operative time, the postoperative outcomes in the form of hematoma, wound infection and finally the recurrence within 1-year follow-up. PATIENTS AND METHODS: The current study is a prospective cohort study, a single-center trial conducted from June 2021 to June 2022 in the general surgery department in Ain Shams University Hospitals, which included 74 patients presented with recurrent inguinal hernia who had previous open anterior approach 68(91.8%) males and 6(8.1%) females including a 1-year follow-up postoperative. RESULTS: There were 74 patients in our study with 37 patients in each group. Group (I) underwent an open pre-peritoneal approach and group (II) underwent a Laparoscopic trans-abdominal pre-peritoneal approach. The mean age of the group (I) is 39.51 with a standard deviation of ± 3.49. While in group (II) the mean age is 39.37 with standard deviation ± 3.44 (p = 0.881). From the included 74 patients 67(91.8%) were males and 6(8.1%) were females. As regards the co-morbidities, in group (I) 17(45.9%) patients have no co-morbidities, 11(29.7%) patients have diabetes mellitus, 6(16.2%) patients have hypertension, and 3(8.1%) patients have diabetes and hypertension. Andin group (II) 26(70.3%) patients have no co-morbidities, 6(16.2%) patients have diabetes mellitus, 3(8.1%) patients have hypertension, and 2(5.4%) patients have diabetes and hypertension (p = 0.207). Regarding intra-operative time, the mean time in minutes in the group (I) is 63.33 with a standard deviation of ± 11.95. While in group (II) the mean time in minutes is 81.21 with a standard deviation of ± 18.03 (p = 0.015). The postoperative outcomes were assessed for 1-year follow-up in the form of hematoma, wound infection, and recurrence within 1 year. Regarding the hematoma occurred in 4(10.8%) patients in group (I). While in 2(5.4%) patients in group (II) (p = 0.674). The wound infection was found in 5(13.5%) patients in group(I) and zero patients in group (II) (p = 0.021). Finally, we followed up with the patients for about 1 year to detect the recurrence. Which was found in 3(8.1%) patients in group (I) and 1(2.7%) patient in group (II) (p = 0.615). CONCLUSION: The results of this study demonstrate that both the laparoscopic approach and the open posterior approach are effective for recurrent inguinal hernia following anterior approach mesh hernioplasty, with comparable results. Laparoscopy has been associated with a lower rate of recurrence and overall complications compared to open technique, however, it is difficult to draw definitive conclusions about the preferred option due to its lengthy learning curve and difficulty to perform. Furthermore, the results of this study confirm the previously reported positive results of the posterior pre-peritoneal for recurrent inguinal hernia, particularly when performed by experienced surgeons. Therefore, further prospective randomized population-based trials are necessary to better assess the decision-making for recurrent hernia management and the impact of specialization in abdominal wall surgery in terms of recurrence and complications.

Causes of recurrence of paediatric inguinal hernia after single-port laparoscopic closure.

PURPOSE: This paper explores the causes of paediatric inguinal hernia (PIH) recurrence after single-port laparoscopic percutaneous extraperitoneal closure (SPLPEC). METHOD: From January 2015 to December 2020, the clinical data of 3480 children with PIHs who underwent SPLPEC were retrospectively reviewed, including 644 children who underwent SPLPEC with a homemade single-hook hernia needle from January 2015 to December 2016 and 2836 children who underwent the SPLPEC with a double-hook hernia needle and hydrodissection from January 2017 to December 2020. There were 39 recurrences (including communicating hydrocele) during the 2-5 years of follow-up. The findings of redo-laparoscopy were recorded and correlated with the revised video of the first operation to analyse the causes of recurrence. RESULT: Thirty-three males and 6 females experienced recurrence, and 8 patients had a unilateral communicating hydrocele. The median time to recurrence was 7.1 months (0-38). There were 20 cases (3.11%) in the single-hook group and 19 cases (0.67%) in the double-hook group. Based on laparoscopic findings, recurrence most probably resulted from multiple factors, including uneven tension of the ligation (10 cases), missing part of the peritoneum (14 cases), loose ligation (8 cases), broken knot (5 cases), and knot reaction (2 cases). All children who underwent repeat SPLPEC were cured by double ligations or reinforcement with medial umbilical ligament. CONCLUSION: The main cause of recurrence is improper ligation. Tension-free and complete PIH ligation are critical to the success of surgery, which requires avoiding the peritoneum skip area and the subcutaneous and muscular tissues. Redo-laparoscopic surgery was suitable for the treatment of recurrent inguinal hernia (RIH). For giant hernias, direct ligation of the internal ring incorporating the medial umbilical ligament (DIRIM) may be needed.