Primary abandon of hernia sac for inguinoscrotal hernias: a safe way to cut corners.

INTRODUCTION: Inguinoscrotal hernias (ISH) pose a challenge to surgeons with consistently higher rates of postoperative complications and recurrence rates. The aim of this study is to report our initial experience and early results with a new technique for inguinoscrotal hernia repair. METHODS: A review of a prospectively maintained multi-center database was conducted in patients who underwent minimally invasive repair using the "primary abandon-of-the-sac" (PAS) technique for inguinoscrotal hernias from March 2021 to July 2022. Demographics and outcomes were analyzed. Univariate analysis and multivariate logistic regression were performed. RESULTS: A total of 76 minimally invasive inguinal hernia repairs were performed. In 70 patients (92%) C-PAS was used as the technique to abandon the sac while in the remaining 6 patients, "pirate-eye-patch" technique was used. Median hernia ring was 3 (IQR 2.5-3.5) cm and median hernia sac was 9.5 (8-10.8) cm. Median operative time was 70 min (IQR 56-96). Seroma was present in 22 (28.9%) patients 7 days after surgery. Most had seroma only in the inguinal area (n = 19; 25%). Thirty days after surgery, 12 (15.8%) patients still had seroma in the inguinal area and 6 (7.9%) in the inguinoscrotal area. Ninety days after surgery, four (5.3%) patients had inguinal seroma, 2 (2.6%) scrotal seromas and 3 (3.9%) inguinoscrotal seromas. The size of the hernia sac was not associated with seroma formation 7 days after surgery (OR 1.06; 95% CI 0.89-1.2; P = 0.461) in the multivariate logistic regression. BMI was also not associated with seroma formation (OR 0.8; 95% CI 0.74-1.06; P = 0.2). CONCLUSIONS: Planned abandon of the hernia sac is an interesting alternative and is associated with a low rate of complications and acceptable seroma formation rates.

Endoscopic onlay repair for ventral hernia and rectus abdominis diastasis repair: Why so many different names for the same procedure? A qualitative systematic review.

BACKGROUND: A subcutaneous endoscopic onlay repair for ventral hernia with an anterior plication of diastasis recti (DR) has been published under different names in different countries. The aim of this systematic review is to assess the safety and feasibility of different named techniques with the same surgical concept. METHODS: The PRISMA guidelines were followed during all stages of this systematic review. The MINORS score system was used to perform qualitative assessment of all studies included in this review. Recommendations were then summarized for the following pre-defined key items: protocol, research question, search strategy, study eligibility, data extraction, study designs, risk of bias, publication bias, heterogeneity, and statistical analysis. RESULTS: The systematic literature search found 2548 articles, 317 of which were duplicates and excluded from analysis. The titles and abstracts from the remaining 2231 articles were assessed. After careful evaluation, 2125 articles were determined to be unrelated to our study and subsequently excluded. The full text of the remaining 106 articles was thoroughly assessed. Case reports, editorials, letters to the editor, and general reviews were then excluded. A total of 13 articles were ultimately included for this review, describing a similar subcutaneous endoscopic approach for repair of concomitant ventral hernias and rectus diastasis defined under nine different named techniques on 716 patients. The number of patients in those studies varied from 10 to 201. The mean operative time varied from 68.5 to 195 min. The most common complication was seroma, followed by pain requiring intervention, hematoma, and surgical site infection. CONCLUSIONS: There are a few technique variations described in different studies, but with no significant differences in outcomes. We, therefore, propose to unify these procedures under one term, ENDoscopic Onlay Repair (ENDOR). This technique has shown to be effective and safe, with seroma being the most common complication.

Ten golden rules for a safe MIS inguinal hernia repair using a new anatomical concept as a guide.

BACKGROUND: Although laparoscopic inguinal hernia repair was described about 30 years ago and advantages of the technique have been demonstrated, the utilization of this approach has not been what we would expect. Some reasons may be the need for surgeons to understand the posterior anatomy of the groin from a new vantage point, as well as to acquire advanced laparoscopic skills. Recently, however, the introduction of a robotic approach has dramatically increased the adoption of minimally invasive techniques for inguinal hernia repair. METHODS: Important recent contributions to this evolution have been the establishment of a new concept known as the critical view of the Myopectineal Orifice (MPO) and the description of a new way of understanding the posterior view of the antomy of the groin (inverted Y and the five triangles). In this paper, we describe 10 rules for a safe MIS inguinal hernia repair (TAPP, TEP, ETEP, RTAPP) that combines these two new concepts in a unique way. CONCLUSIONS: As the critical view of safety has made laparoscopic cholecystectomy safer, we feel that following our ten rules based on understanding the anatomy of the posterior groin as defined by zones and essential triangles and the technical steps to achieve the critical view of the MPO will foster the goal of safe MIS hernia repair, no matter which minimally invasive technique is employed.

Laparoscopic treatment of celiac axis compression by the median arcuate ligament and endovascular repair of a pancreaticoduodenal artery aneurysm: case report.

Compression of the celiac axis by the median arcuate ligament of the diaphragm can cause nonspecific symptoms such as abdominal pain, vomiting, and weight loss. There is a known association between stenosis or occlusion of the celiac trunk and aneurysms of the pancreaticoduodenal artery. Treatment strategies for patients who have this association should be selected on a case-by-case basis. We describe the case of a patient with pancreaticoduodenal artery aneurysm associated with compression of the celiac trunk by the arcuate ligament, which were managed with endovascular and laparoscopic techniques, respectively.

Retention of laparoscopic skills in naive medical students who underwent short training.

BACKGROUND: Simulators are useful tools in the development of laparoscopic skills. However, little is known about the effectiveness of short laparoscopic training sessions and how retention of skills occurs in surgical trainees who are naïve to laparoscopy. This study analyses the retention of laparoscopic surgical skills in medical students without prior surgical training. METHODS: A group of first- and second-year medical students (n = 68), without prior experience in surgery or laparoscopy, answered a demographic questionnaire and had their laparoscopic skills assessed by the Fundamentals of Laparoscopic Surgery (FLS) training protocol. Subsequently, they underwent a 150-minute training course after which they were re-tested. One year after the training, the medical students' performance in the simulator was re-evaluated in order to analyse retention. RESULTS: Of the initial 68 students, a total of 36 participated throughout the entire study, giving a final participation rate of 52 %. Thirty-six medical students with no gender predominance and an average age of 20 years were evaluated. One year after the short training programme, retention was 69.3 % in the peg transfer (p < 0.05) and 64.2 % in ligature (p < 0.05) compared with immediate post-training evaluation. There was no significant difference in suturing. The average sample score in the baseline test was 8.3, in the post-training test it was 89.7, and in the retention test it was 84.2, which corresponded to a skill retention equivalence of 93 %. CONCLUSIONS: There was a significant retention of the laparoscopic surgical skills developed. Even 1 year after a short training session, medical students without previous surgical experience showed that they have retained a great part of the skills acquired through training.

Appropriateness of Online Chat-Based Artificial Intelligence (ChatGPT) Answers to Common Questions on Inguinal Hernia Repair.

ChatGPT is a conversational AI model developed by OpenAI designed to generate human-like text based on the input it receives. ChatGPT has become increasingly popular, and the general public may use this tool to ask questions about different medical conditions. There is a lack of data showing if ChatGPT is able to provide reliable information on medical conditions to the general public. The aim of our study is to assess the accuracy and appropriateness of ChatGPT answers to questions on inguinal hernia management.

How Appropriate Are Recommendations of Online Chat-Based Artificial Intelligence (ChatGPT) to Common Questions on Ventral Hernia Repair?

ChatGPT is a conversational AI model developed by OpenAI to generate human-like text based on the input it receives. ChatGPT has become increasingly popular, and the general public may use this tool to ask questions about different medical conditions. There is a lack of data to demonstrate ChatGPT is able to provide reliable information on medical conditions. The aim of our study is to assess the accuracy and appropriateness of ChatGPT answers to questions on ventral hernia management.

Minimally invasive lipoabdominoplasty (MILA) tactic.

While diastasis recti (DR) was long neglected by general surgeons, plastic surgeons considered conventional abdominoplasty as the only repair option. However, this scenario has changed recently, either due to a better understanding of the correlation between DR and abdominal wall function and greater risk of recurrence in abdominal hernia repairs, or due to the development of new minimally invasive techniques for repairing DR. One of these surgical procedures consists of the concept of an abdominoplasty, that is, supra-aponeurotic dissection and plication of the DR (with or without abdominal hernia) but performed through three small supra-pubic incisions by laparoscopy or robotic approach. More recently, this procedure has gained new stages. Liposuction and skin retraction technology have been associated with MIS plication of DR, which increases the indications for the technique and potentially improves results. For the first time in the literature, we describe these steps and the synergy between them.

Effect of laparoscopic handle size on surgical performance: A randomized crossover trial.

Laparoscopic instrument handles design and dimensions are crucial to determine the configuration of surgeons' hand grip and, therefore, can have a deleterious effect on overall surgical efficiency and surgeons' comfort. The aim of this study is to investigate the impact of laparoscopic handle size and hand surface area on surgical task performance. A single-blind, randomized crossover trial was carried out with 29 novice medical students. Participants performed three simulated tasks in "black box" simulators using two scissor-type handles of different sizes. Surgical performance was assessed by the number of errors and time required to complete each task. Hand anthropometric data were measured using a 3D scanner. Execution time was significantly higher when cutting and suturing tasks were performed with the smaller handle. In addition, hand surface area was positively correlated with peg transfer task time when performed with the standard handle and was correlated with cutting task time in small and standard handle groups. We also found positive correlations between execution time and the number of errors executed by larger-handed participants. Our findings indicate that laparoscopic handle size and hand area influence surgical performance, highlighting the importance of considering hand anthropometry variances in surgical instrument design.

BRAZILIAN HERNIA AND ABDOMINAL WALL SOCIETY STATEMENT ON LARGE HIATAL HERNIAS MANAGEMENT.

Large hiatal hernias, besides being more prevalent in the elderly, have a different clinical presentation: less reflux, more mechanical symptoms, and a greater possibility of acute, life-threatening complications such as gastric volvulus, ischemia, and visceral mediastinal perforation. Thus, surgical indications are distinct from gastroesophageal reflux disease-related sliding hiatal hernias. Heartburn tends to be less intense, while symptoms of chest pain, cough, discomfort, and tiredness are reported more frequently. Complaints of vomiting and dysphagia may suggest the presence of associated gastric volvulus. Signs of iron deficiency and anemia are found. Surgical indication is still controversial and was previously based on high mortality reported in emergency surgeries for gastric volvulus. Postoperative mortality is especially related to three factors: body mass index above 35, age over 70 years, and the presence of comorbidities. Minimally invasive elective surgery should be offered to symptomatic individuals with good or reasonable performance status, regardless of age group. In asymptomatic and oligosymptomatic patients, besides obviously identifying the patient's desire, a case-by-case analysis of surgical risk factors such as age, obesity, and comorbidities should be taken into consideration. Attention should also be paid to situations with greater technical difficulty and risks of acute migration due to increased abdominal pressure (abdominoplasty, manual labor, spastic diseases). Technical alternatives such as partial fundoplication and anterior gastropexy can be considered. We emphasize the importance of performing surgical procedures in cases of large hiatal hernias in high-volume centers, with experienced surgeons.

Evaluation of bacterial contamination after "pure" (totally) transvaginal NOTES diagnostic peritoneoscopy with biopsies in swine: a comparative study with laparoscopy.

INTRODUCTION: Bacterial contamination from viscerotomy is a barrier to natural orifice translumenal endoscopic surgery (NOTES). The aim of this survival study is to evaluate pure (totally) transvaginal NOTES bacterial contamination compared with laparoscopy in pigs. METHODS: Twelve adult female pigs underwent peritoneoscopy with liver and peritoneal biopsies, using either laparoscopy (Glap, six animals) or pure transvaginal (GNOTES) access, and were maintained alive for 7 days. In all animals, blood cultures were taken at baseline, and after 24 h and 7 days postoperatively. Swab cultures from vagina (GNOTES) and skin (Glap) were obtained pre- and post-antisepsis. Peritoneal fluid culture was obtained at necropsy. For statistical analysis, Glap and GNOTES were compared for presence of positive bacterial cultures (qualitative bacterial analysis) using Fisher's test, with level of significance set at p < 0.05. RESULTS: All animals had good postoperative outcome. One animal had transient perioperative bleeding from a transvaginal access. Two animals in Glap and one in GNOTES had positive blood cultures after the procedure. All animals from GNOTES and Glap presented with mixed flora pre-antisepsis. After antisepsis, one animal (GNOTES) presented with a positive vaginal swab culture (a single bacterial strain was identified). There was no positive skin swab culture in Glap. There were no signs of intra-abdominal infection at necropsy. In two animals, one from Glap and another from GNOTES, intra-abdominal culture was positive for Corynebacterium spp. and Escherichia coli, respectively. There was no correlation between the bacterial flora found at the access site and in the peritoneal cultures. CONCLUSIONS: Pure transvaginal peritoneoscopy with liver and peritoneal biopsy in swine is feasible and associated with bacterial contamination comparable to laparoscopy. Peritoneal bacterial contamination was clinically insignificant after 1 week postoperatively. Preoperative antisepsis provided significant reduction of bacterial load prior to transvaginal and laparoscopic procedures.

Minilaparoscopic technique for inguinal hernia repair combining transabdominal pre-peritoneal and totally extraperitoneal approaches.

INTRODUCTION: Endoscopic surgical repair of inguinal hernia is currently conducted using 2 techniques: the totally extraperitoneal (TEP) and the transabdominal (TAPP) hernia repair. The TEP procedure is technically advantageous, because of the use of no mesh fixation and the elimination of the peritoneal flap, leading to less postoperative pain and faster recovery. The drawback is that TEP is not performed as frequently, because of its complexity and longer learning curve. In this study, we propose a hybrid technique that could potentially become the gold standard of minimally invasive inguinal hernia surgery. This will be achieved by combining established advantages of TEP and TAPP associated with the precision and cosmetics of minilaparoscopy (MINI). MATERIALS AND SURGICAL TECHNIQUE: Between January and July 2011, 22 patients were admitted for endoscopic inguinal hernia repair. The combined technique was initiated with TAPP inspection and direct visualization of a minilaparoscopic trocar dissection of the preperitoneum space. A10-mm trocar was then placed inside the previously dissected preperitoneal space, using the same umbilical TAPP skin incision. Minilaparoscopic retroperitoneal dissection was completed by TEP, and the surgical procedure was finalized with intraperitoneal review and correction of the preperitoneal work. DISCUSSION: The minilaparoscopic TEP-TAPP combined approach for inguinal hernia is feasible, safe, and allows a simple endoscopic repair. This is achieved by combining features and advantages of both TAPP and TEP techniques using precise and sophisticated MINI instruments. Minilaparoscopic preperitoneal dissection allows a faster and easier creation of the preperitoneal space for the TEP component of the procedure.

DECOMP Report: Answers surgeons expect from an abdominal wall imaging exam.

Abdominal wall (AW) hernias are a common problem faced by general surgeons. With an essentially clinical diagnosis, abdominal hernias have been considered a simple problem to be repaired. However, long-term follow-up of patients has shown disappointing results, both in terms of complications and recurrence. In this context, preoperative planning with control of comorbidities and full knowledge of the hernia and its anatomical relationships with the AW has gained increasing attention. Computed tomography (CT) appears to be the best option to determine the precise size and location of abdominal hernias, presence of rectus diastase and/or associated muscle atrophy, as well as the proportion of the hernia in relation to the AW itself. This information might help the surgeon to choose the best surgical technique (open vs MIS), positioning and fixation of the meshes, and eventual need for application of botulinum toxin, preoperative pneumoperitoneum or component separation techniques. Despite the relevance of the findings, they are rarely described in CT scans as radiologists are not used to report findings of the AW as well as to know what information is really needed. For these reasons, we gathered a group of surgeons and radiologists to establish which information about the AW is important in a CT. Finally, a structured report is proposed to facilitate the description of the findings and their interpretation.

Is Minimally Invasive Repair the New Gold Standard for Primary Unilateral Inguinal Hernias? Results of an International Survey of Surgeons.

Background: The Lichtenstein repair has long been heralded as the gold standard for unilateral primary inguinal hernias. However, minimally invasive surgery (MIS) repairs have gained popularity over the past decades given its advantages in recurrent, bilateral, and now even in primary inguinal hernias. We aim to further explore the perception of different techniques among surgeons internationally. Methods: A questionnaire was posted in three closed groups for surgeons and residents on Facebook® and surgical groups on WhatsApp®. It was also e-mailed to members of the following surgical societies: Mexican Society of Surgery, Brazilian Hernia Society, Asia Pacific Hernia Society, and European Hernia Society. Descriptive and basic comparative statistical analyses were performed. Results: In total, 874 surgeons answered the survey: 759 (86.9%) were male and 418 (47.8%) were from North America, 735 (84.1%) had completed training and 605 (69.2%) considered themselves hernia specialists. If safety profiles of inguinal herniorrhaphy were equal, 533 (61%) would choose MIS. Laparoscopic transabdominal preperitoneal ranked first among preferred techniques if the cost of all techniques was the same. Safety of the procedure followed by experience of the surgeon is the most influential factors. Lastly, hernia specialists were more likely to choose an MIS technique (P < .0001). Conclusion: When an international sample of 874 attending and trainee surgeons were surveyed about what technique they would prefer to repair their own uncomplicated unilateral inguinal hernia, most chose MIS. Safety of the procedure and the surgeon's experience were the most important factors in choosing a surgical technique.

CHALLENGES TO THE 10 GOLDEN RULES FOR A SAFE MINIMALLY INVASIVE SURGERY (MIS) INGUINAL HERNIA REPAIR: CAN WE IMPROVE?

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.

Groin Hernia in Females Routinely Treated by Totally Extraperitoneal Laparoscopic Approach.

BACKGROUND AND OBJECTIVES: There is a dearth of studies on laparoscopic treatment of female groin hernia. Our study assessed the outcome of groin hernia repair in females employing the totally extraperitoneal laparoscopic (TEP) access. METHODS: Data of all females who were subjected to laparoscopic groin herniorrhaphy, from August 1998 to February 2020 were retrospectively obtained. Groin hernia repair was routinely started with TEP access. RESULTS: A total of 2,399 patients who underwent laparoscopic groin herniorrhaphy, 254 (10.6%), were females. Most females (n = 191; 75.2%) had single hernia and the remaining (n = 63; 24.8%) had bilateral hernias, making a total of 317 hernias operated. Indirect inguinal hernia was the most common hernia type (72.5%), followed by femoral hernia (17.4%) and direct hernia (10.1%). Prior lower abdominal operations were recorded in 97 (38.2%) patients. Conversion to a laparoscopic transabdominal preperitoneal procedure was performed due to technical difficulties to dissect the preperitoneal space in 17 patients (6.7%) and to open procedure in only one patient (0.4%) with incarcerated femoral hernia in whom an incidental perforation of the small bowel occurred. Intra- and postoperative complications occurred in 12 (4.7%) and 15 (5.9%) patients, respectively. There was no mortality. Most patients (n = 221; 87%) were discharged on the same day of the operation. Hernia recurrence was diagnosed in 6 patients (2.4%). CONCLUSION: It is concluded that females with groin hernia may be successfully treated with totally extraperitoneal laparoscopic access, with low conversion and complication rates.

SIMULTANEOUS LAPAROSCOPIC INGUINAL HERNIA REPAIR AND CHOLECYSTECTOMY: DOES IT CAUSE MESH INFECTION?

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.

FEMORAL HERNIA: UNCOMMON, BUT ASSOCIATED WITH POTENTIALLY SEVERE COMPLICATIONS.

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.