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BACKGROUND: The incidence of direct inguinal hernia in the pediatric population is relatively low and is usually discovered intraoperatively, rendering it unfamiliar to most pediatric surgeons. The traditional approach involves directly addressing the peritoneal defect, which includes dissecting the sac and repairing the peritoneum, reinforced with the umbilical ligament. In this paper, we present our experience with a novel approach to anatomical repair utilizing a non-mesh transabdominal preperitoneal (TAPP) approach. METHODS: This a retrospective case series of direct inguinal hernia that were operated laparoscopically using the novel approach of repair from January 2018 to January 2024. Data were analyzed for demographics, presentation, type of defect, operative time, complications, and recurrence. The new approach utilizes the pre-peritoneal approach to delineate the exact facial defect then, primary anatomical repair is established using 2/0 non-absorbable braided sutures. Finally, closure of the peritoneum was performed using running 4/0 absorbable sutures. This is a retrospective case series of direct inguinal hernias that were operated on laparoscopically using the novel repair approach from January 2018 to January 2024. Data were analyzed for demographics, presentation, type of defect, operative time, complications, and recurrence. The new approach employs the pre-peritoneal approach to accurately delineate the fascial defect, followed by primary anatomical repair using 2/0 non-absorbable braided sutures. Finally, the peritoneum is closed using running 4/0 absorbable sutures. RESULTS: Data from nine cases were included. Six cases were on right side, and three cases were on left side. Patients were predominantly boys (8 boys and 1 girl). The mean age at operation was 25.1 months (range:11 month to 5 years). Four patients had previous indirect inguinal hernia repair on the same side. The mean operative time was 34 ± 9 min. No intraoperative complications occurred. The median follow up period was 24 months with no recurrence was detected in any of the cases. CONCLUSION: The non-mesh TAPP approach offers excellent exposure of the fascial structures, facilitating accurate identification and repair of the defect. Despite being technically demanding, it allows for the establishment of a robust anatomical repair. No recurrences occurred in the study group; however, a longer follow up and a larger sample are needed to provide more reliable evaluation. LEVEL OF EVIDENCE: III.

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Here, we report a case of laparoscopic trans-inguinal hernia repair (transabdominal preperitoneal repair or TAPP) for a recurrent inguinal hernia following direct Kugel surgery. A 71-year-old man underwent direct Kugel hernioplasty for a right inguinal hernia at another hospital 4 years prior to presentation. The patient subsequently underwent laparoscopic surgery using the TAPP technique, during which the abdominal cavity was visualized with a laparoscope, revealing a tubular mesh protruding towards the abdominal cavity with a direct and indirect hernia ring. Three months post-surgery, no recurrence was observed.

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We present a case of a recurrent inguinal bladder hernia that was previously unsuccessfully operated on three times and was repaired using totally extraperitoneal repair (TEP). A 79-year-old man presented with a right inguinal swelling that had been treated three times on the same side with anterior approaches. Computed tomography confirmed a recurrent inguinal bladder hernia. TEP was performed after identifying the bladder hernia preoperatively, with previous surgeries that used a plug-and-patch technique through an anterior approach. The extraperitoneal approach allowed the bladder to be reduced without injury and the hernia to be safely repaired using a 3D Max® Light Mesh. The postoperative recovery was uneventful, with no recurrence after 1 year. TEP facilitates the diagnosis and repair of bladder hernias, emphasizing the importance of preoperative diagnosis and the efficacy of endoscopic procedures in bladder hernia repair, even in recurrent cases.

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Inguinal hernias are among the most common cases presented to a surgeon. In spite of extensive research and clinical experience over centuries, inguinal hernias still pose anatomical challenges for operating surgeons, especially with a propensity for recurrence. One such complicated entity is the Amyand's hernia - defined as an inguinal hernia contained within the hernial sac - the vermiform appendix - as the herniated content. It is a rare clinical presentation and carries with it certain complexities with regard to operative decisions and clinical management. We present a case of a 71-year-old male presenting with a recurrent inguinal hernia, with an incarcerated, inflamed appendix as the content; managed surgically with appendicectomy and herniorraphy, without the use of a prosthetic mesh.

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INTRODUCTION: The utilization of laparoscopic techniques in the management of inguinal hernias among pediatric patients has seen a rising trend. We aimed to assess the efficacy of laparoscopic excision of the hernial sac as a suitable approach for managing inguinal hernias specifically in female patients and conducted a prospective study to investigate this hypothesis. METHODS: Over a comprehensive four-year period, a total of 99 hernias in 69 female patients were surgically addressed using laparoscopic methods. The surgical procedure primarily involved the laparoscopic inversion and excision of the hernial sac without subsequent distal suturing. RESULTS: During the initial phase of the study, two cases encountered recurrences within 48 hours post-operation, potentially attributed to incomplete excision. However, in the subsequent period, no further recurrences were recorded. CONCLUSION: Our study findings support the contention that laparoscopic excision of the sac, without adjunctive closure of the peritoneum, suffices as an effective approach for managing inguinal hernias in female pediatric patients.

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OBJECTIVE: The aim: To improve the efficiency of treatment of recurrent abdominal wall hernia associated with ligature fistula. PATIENTS AND METHODS: Materials and methods: We analysed the results of treatment of recurrent hernias with ligature fistula in 86 patients. 44 patients of group 1 were treated according to the developed algorithm (fistula and mesh explantation, wound debridement, mesh fixation and wound closure with antiseptic-containing polyurethane composite), 42 patient (group 2) were treated according to the traditional one. RESULTS: Results: Decreased rate of seroma formation in group 1 if compared to group 2 was observed up to 6,7% against 23,8% (OR=0,23; 95%CI=0,06-0,92; р=0,038). Wound infection occurred in 1 (2,3%) case of group 1 against 7 (16,7%) of group 2 (OR= 0,12; 95% CI =0,01-0,99; р=0,027). 4 (9,5%) patients from group 2 developed recurrent ligature fistula (OR= 0,10; 95%CI= 0,01-1,90). Recurrence of hernia was observed in 1 (2,9%) patient of group 1 against 6 (17,7%) patients of group 2 (OR=0,14; 0,01-1,21; р=0,048). CONCLUSION: Conclusions: Surgical treatment optimisation of recurrent abdominal wall hernia associated with ligature fistula improved the efficiency of treatment, which was proven by the obtained outcomes and relative risk of complications.

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Introduction: Inguinal hernia repair is one of the most commonly performed surgical procedures in general surgery. Despite surgical advances, recurrence and chronic pain are still major issues after this intervention. Aim of our study was to retrospectively assess and compare outcomes of robotic versus laparoscopic repair of recurrent inguinal hernia. Methods: All patients who underwent recurrent inguinal hernia repair between 2014 and 2021 in five different institutions were included in our study. Baseline data on age, gender, body mass index, comorbidities, smoking habit, and anticoagulant therapy were retrospectively collected from prospectively maintained databases. Operative time, length of stay, and early and late complications were compared between the robotic and the laparoscopic approach. Results: Forty-eight patients underwent recurrent inguinal hernia repair between January 2014 and December 2021. Twenty-three patients underwent a robotic procedure, whereas 25 were submitted to the laparoscopic intervention. Overall mean follow-up was 26.2 months. There was no significant difference in the baseline characteristics of the two groups. Acceptable and comparable rates of peri- and postoperative outcomes were recorded. However, postoperative visual analog scale score and incidence of chronic pain were lower after the robotic rather than after the laparoscopic approach. (2.9 versus 3.8 P = .002; 20% versus 0%; P = .02, respectively). Conclusions: Minimally invasive repair of recurrent inguinal hernia is safe and feasible; robotic surgery is associated with low rate of postoperative and chronic pain without a significant increase in operative time.

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INTRODUCTION: Amyand's hernia (AH)-where the appendix becomes incarcerated within the inguinal hernia (IH) sac-is rare, particularly if detected and operated concurrent with a contralateral recurrent IH. PRESENTATION OF CASE: A 65-year-old man presented with symptomatic bilateral IH; the left IH was recurrent. Abdominopelvic computed tomography (CT) revealed a right IH with appendiceal herniation and left recurrent IH with omental fat. Using the prolene hernia system (PHS) mesh, the left recurrent IH underwent operation, followed by the right AH. The patient was in a good state with no recurrence 16 months postsurgery. DISCUSSION: If AH is accidentally encountered during surgery, the procedure should differ depending on the inflammatory state of the appendix. Simultaneously operating AH and contralateral recurrent IH is complicated; it is necessary to preoperatively decide which side to operate on first and whether to use an anterior or laparoscopic posterior surgical approach. If the planned operation is unattainable, alternative surgery should be considered. Fortunately, herein CT was performed prior to surgery, and the surgical plan was properly established. CONCLUSION: Prior to simultaneous AH and contralateral recurrent IH surgery, the surgical plan should be established. If the planned surgical technique for recurrent hernia repair is not feasible, an alternative should be performed. In AH repair, different surgical methods are required depending on the presence and severity of inflammation of the appendix.

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INTRODUCTION AND IMPORTANCE: The literature regarding size descriptions for spermatic cord lipomas is limited. The term "giant" is utilized loosely and seen on case reports for masses as small as 6 cm. Here we present a case of a giant left sided spermatic cord lipoma, found incidentally during a recurrent inguinal hernia repair, that measured 18 × 14 × 10 cm on final pathologic examination. CASE PRESENTATION: A 59 year old male, with a history of morbid obesity and surgical history of prior bilateral inguinal hernia repair, presented with recurrent left sided groin and scrotal bulging with associated discomfort several months after the initial hernia repair. Following imaging performed on preoperative work up, the patient was brought to the operating room for a robotic inguinal hernia repair. CLINICAL DISCUSSION: Preoperative physical examination was limited due to the patient's body habitus which precluded a definitive diagnosis of inguinal hernia based on physical examination. Computed tomography of the abdomen and pelvis was performed with findings consistent with bilateral recurrent inguinal hernias. A bilateral robotic inguinal hernia repair was attempted. The procedure was converted to open via a groin incision when an incidental 18 cm left sided spermatic cord lipoma was discovered. An orchiectomy was ultimately performed as the mass was intimately intertwined with the spermatic cord. CONCLUSION: In our case, the patient had a recurrent inguinal hernia and an incidental finding of an 18 cm spermatic cord lipoma which warranted a left orchiectomy followed by open inguinal hernia repair. We propose standardizing the term "giant" to include spermatic cord lipomas >15 cm.

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Introduction Surgery for complex inguinal hernia (IH) (recurrent IH or IH after radical prostatectomy (RP)) may be difficult because of the presumed scar or adhesion in the retropubic space. A hybrid method combining the laparoscopic and anterior approaches (HLAA) in a bidirectional surgical technique may be an option in complex IH cases. Methods Patients at our institution who underwent IH repair for complex IH using HLAA from April 2018 to November 2019 were included. We retrospectively evaluated the patient characteristics, IH diagnosis, intraoperative variables, complications, and hernia recurrence during the follow-up period. Results Twenty patients were involved in this study. Seven patients underwent hLAA for recurrent IH, whereas the remaining 13 underwent hLAA for IH after RP. Five patients had bilateral IH, all of whom had IH after RP. The type of IH was lateral in 21 patients, medial in six patients, and lateral and medial in two patients. Hernia repair was performed using a patch alone in two patients and a plug and patch in 18 patients. Seroma or hematoma was observed in five patients, and one patient experienced chronic pain. No hernia recurrence was observed during the median follow-up period of 24 months. Conclusion hLAA could facilitate precise diagnosis and intraoperative confirmation of repair for recurrent IH and IH after RP. The intraoperative findings and the cause of recurrence can be easily shared among surgeons in hLAA. Further investigations are necessary to determine the long-term efficacy of hLAA in a larger cohort.

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The Kugel procedure resulted in extensive adhesion in the preperitoneal space. Performing a transabdominal preperitoneal repair (TAPP) for recurrent hernia after Kugel procedure is extremely difficult. In this case report, we present the case of a 81-year-old male who presented with recurrent inguinal hernia after Kugel procedure 8 years ago. Transabdominal laparoscopy was performed first. Indirect hernia formed inferior to the lateral edge of the previous mesh was diagnosed under laparoscopy. The patient's medial umbilical ligament (MUL) was big enough and could be completely released by separating the Retzius space. Finally, TAPP was successfully performed by using the MUL to create and close the preperitoneal space. No perioperative complications or hernia recurrence was observed 1 year after the surgery. Using the MUL to deal with preperitoneal problems was practical and feasible.

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PURPOSE: The objective of this study was to assess data on inguinal hernia repairs (IHR) performed for recurrence over a 16 year period (2004-2019) in Spain. METHODS: A retrospective cohort study of 1,302,788 patients who underwent IHR from January 2004 to December 2019 was conducted. Data were extracted from the Spanish Minimum Basic Data Set (MBDS) of the Health Ministry database. The primary objective was to analyse the proportion of IHR performed by recurrence. As secondary objectives, we evaluated factors related to recurrent hernia (analysed by univariate analysis and multivariable logistic regression analysis) and trends in the recurrent case rate over the 16 year period. RESULTS: We identified 95,025 patients (7.3% of all IHR) who underwent surgery for recurrent inguinal hernia. Patients undergoing recurrent IHR were more likely to be male (OR 1.687, 95% CI 1.645-1.730), elderly (age > 74 years), and more complicated when they arrived in the operating room (gangrene OR 3.951, 95% CI 3.734-4.180; occlusion OR 1.905, 95% CI 1.853-1.960), and thus had more surgical site occurrences and related mortality. The proportion of IHR performed for recurrence has been dropping over the years (8.7% in 2004 vs. 6.5% in 2019, p < 0.005). CONCLUSION: The rate of recurrent IHR in Spain (2004-2019) is 7.3%. Recurrent IHR correlates to emergent and complicated surgery and thus to a worst outcome. The trend of this 16 year period is of decreasing operated recurrent inguinal hernia. This is good news even though the improvement is slight and certainly insufficient. Establishing and optimising the rate of hernia recurrence is important for patients and for the health-care system.

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PURPOSE: The open posterior approach in the form of either a Stoppa or Wantz operation may be a good alternative technique particularly in the repair of complex inguinal hernias. The term "complex inguinal hernia" designates hernias with a combination of arduous features including large hernia defects, large to giant hernia sacs, multiple recurrences, and bilaterality. In this retrospective analysis, we investigated our results of open posterior repair in view of its feasibility in patients with complex inguinoscrotal hernias. METHODS: From a series of 845 inguinal hernia patients, we retrospectively reviewed the records of 60 patients with complex inguinal hernias whom were directed to open preperitoneal repair by either a Stoppa or Wantz procedure. RESULTS: More than 80% of cases were males with large to giant inguinoscrotal hernias. One half of patients had bilateral hernias, and one fourth had recurrent hernias. Early postoperative complications occurred in almost half of patients; however, most of them were minor. The most important early complication in this series was the full recurrences we encountered in the very next morning in two patients. Eighty-three percent of patients left hospital in the first 2 days averaging 1.8 days of hospital stay. The mesh:defect area ratio is < 7 in recurrent hernias while it is > 9 in nonrecurrent cases. CONCLUSION: The open posterior approach to complex inguinal hernias facilitated both handling and repair of difficult hernias. It was very well tolerated by the patients, and yielded favorable postoperative results. We think the open posterior repair may be a method of choice in the repair of complex inguinal hernias.

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BACKGROUND/AIM: Currently, there is no classification system specializing in recurrent inguinal hernia (RIH) after open-surgery. For this reason, in this study we proposed one so as to understand the causes of RIH. PATIENTS AND METHODS: Recurrence of IH after suture-repair was classified either as the tissue-loosening (TL) or the tissue-disruption (TD) type. Recurrence after open-mesh-repair was classified according to the locational relation between the hernia-defect and the mesh, as follows: i) mesh-distant (MD), ii) para-mesh (PM), iii) mesh-migration (MM), and iv) unclassifiable (UC). Fifty-two RIHs in 48 patients were classified, using this system, and analyzed. RESULTS: This system-based classification led to the identification of: i) MM in 11 lesions, ii) PM in 11, iii) MD in 10, iv) TL in 7, v) TD in 5, and vi) UC in 8 lesions. The median time to recurrence (MTR) was significantly shorter in patients who had previously undergone a mesh-repair (n=34) compared to those who had undergone a suture-repair (n=13) [Mesh-repair vs. suture-repair MTR: 1.6 years (0.1-20) vs. 30 years (15-72), p<0.001]. MTR was significantly shorter in the following order: i) MM [0.5(0.1-2.0)]), ii) PM [2.6(0.2-15)]), iii) MD [11(0.5-20)], iv) TD [20(15-30)], and v) TL [40(30-72)] (p<0.001). CONCLUSION: This classification system helps understand the causes of RIH, leading to improved outcomes following open-surgery in the future.

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Introduction Inguinal hernia is the most common hernia among the abdominal wall hernias. This study aims to estimate the long-term recurrence rate and laparoscopy-related risk factors for inguinal hernia at King Fahad Specialist Hospital in Buraidah, Al Qassim region, Saudi Arabia. Methods A single-center retrospective study of all laparoscopic hernia repair patients admitted in the surgical department of King Fahad Specialist Hospital in Buraidah, Al Qassim region, Saudi Arabia from January 2016 to July 2020. Results A total of 64 patients were included in the present study. All patients were male with a mean age 42.27±15.79 years. Out of 64 patients, 71.9% were married and 11 (17.2%) were smokers. Most patients were found to be in the elective priority (89.1%) and the emergency cases were 10.1%. A total of 6.3% had a recurrent hernia and 93.7% had a primary hernia. After testing the association of hernia repair and the patient-related factors, it was observed that there is no significant association between recurrent hernia repair and the mean age (p=0.072), body mass index (BMI) (p=0.962), smoking (p=0.347), married patients (p=0.196), and diabetes (p=0.446). Conclusion A total of 6.3 % of patients developed a recurrent inguinal hernia after laparoscopic repair. In contrast to the literature, this study showed that patient-related risk factors were not statically significant among our patients. However, the reasons behind the recurrence rate tend to be multifactorial, including surgical, technical, hospital capability, and patients factors. Therefore, early recognization and management of these risk factors are essential to prevent further cases.

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BACKGROUND: For recurrent incarcerated and strangulated hernias, the optimal treatment strategy for each case is needed. CASE PRESENTATION: The study patient was a 70-year-old man. TAPP repair was performed for a left inguinal hernia (JHS Classification II-1) 7 years earlier. The patient experienced transient pain and swelling of the left inguinal region for 5 months and visited our emergency department for abdominal pain and vomiting. A CT scan showed a recurrent left inguinal hernia and small bowel incarceration, and emergency surgery was performed. Laparoscopic observation of the abdominal cavity revealed recurrent left inguinal hernia (Rec II-1) with small bowel incarceration. The small bowel was reduced after pneumoperitoneum, and no findings suggested intestinal tract necrosis. Adhesions around the herniated sac were dissected using an extraperitoneal approach and then shifted to mesh plug repair. No perioperative complications or hernia recurrence were observed in the 10 months after the surgery. CONCLUSIONS: This report describes a novel, successful surgical treatment for a recurrent incarcerated hernia. In our patient, we could easily perform dissection and understand the positional relationship by hybrid surgery using the TEP method. Additionally, in patients with incarcerated hernias, we believe that performing hybrid surgery by combining the TEP method would be useful because bowel dilation caused by intestinal obstruction would not disturb the operative field.

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An inguinal hernia involving the ureter is extremely rare and even rarer in patients with native kidneys. It can occur with or without obstructive uropathy and as such, a high index of suspicion should be held for patients with urinary symptoms and concurrent inguinal hernia. Additionally, iatrogenic ureter injury can occur if surgeons are unaware of ureteral involvement pre-operatively. We present a case of a patient with a known ureteroinguinal hernia who proceeded to have an elective hernia repair with ureteral protection.

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INTRODUCTION: As patients with recurrent inguinal hernia (RIH) are at a higher risk of perioperative complications, international guidelines have been developed to mitigate these risks by recommending the reverse approach for repair. We aim to study the characteristics of RIH, compliance to guidelines-based repair (GR) and determine factors influencing compliance to guidelines. METHODS: A retrospective study of patients with RIH was carried out at two tertiary institutions in Singapore, over 10 years from January 2010 to 2020. RESULTS: There were 16 patients with bilateral recurrences and 214 patients with unilateral recurrences. The characteristics of patients with non-guidelines-based repair (NGR) versus GR were similar, p > 0.05. GR was performed for 128 (52.1%) hernias as compared to NGR for 118 (47.9%) hernias. The open approach was more common in NGR than GR, 115/118 (89.8%) versus 58/128 (45.3%), p < 0.001. Forty (n = 40, 16.3%) RIH presented emergently, of which 37 underwent NGR while 3 underwent GR, p < 0.0001. More consultants were present during GR 103/128 (80.5%) as compared to NGR 78/118 (66.1%), p = 0.018. Emergency presentation of hernia recurrence, OR 7.74 (CI 6.11-9.20), p = 0.005, and open repair during the index repair were significantly associated with NGR, OR 6.63 (CI 4.42-8.84), p = 0.01. Median length of stay was shorter in the GR 1 day (IQR 1-2 days) versus 2 days (IQR 2-5 days) in the NGR group, p = 0.02. CONCLUSION: The compliance rate of GR for RIH is 52%. NGR for RIH had acceptable short-term outcomes. For elective presentation of RIH, GR should be encouraged given a shorter length of hospital stay.

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OBJECTIVE: Open repair of recurrent inguinal hernias has been shown to result in significantly poorer perioperative outcomes when compared to open primary hernia repair. However, limited data exist comparing primary and recurrent laparoscopic inguinal hernia repair (LIHR). The aim of our study was to compare quality of life and clinical outcomes between these two groups. METHODS: Patients undergoing LIHR at a single institution from 2012 to 2018 were reviewed from a prospectively managed quality database. Quality of life outcomes were measured using the surgical outcomes measurement system and Carolinas Comfort Scale surveys administered preoperatively and at 3 weeks, 6 months, 1 year, and 2 years postoperatively. RESULTS: A total of 1298 patients undergoing LIHR were analyzed (1139 primary, 159 recurrent). There were older and more male patients in the recurrent group. There were no major complications, and recurrence rates were not significantly different between primary and recurrent groups (1.3% vs 2.4% p = 0.56), while hematoma occurred more commonly in the recurrent group (1.5% vs 4.4% p = 0.0205). Short- and long-term quality of life were similar between the groups except lower (worse) physical function at 3 weeks (32.9 ± 4.2 vs 31.9 ± 4.4: p = 0.0186) and 6 months (34.6 ± 2.8 vs 33.8 ± 3.0: p = 0.0175) and increased sensation of mesh (3 weeks) in the recurrent group (2.3 ± 5.4 vs 3.3 ± 5.3: p = 0.0160). CONCLUSION: Recurrent inguinal hernia repair using laparoscopic totally extraperitoneal approach is as safe and effective as primary repair with similar quality of life.

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BACKGROUND: Inguinal hernia repair is a common surgical procedure; however, the effects of laparoscopic and open mesh repair in the treatment of recurrent inguinal hernia are unclear. This study aimed to evaluate the effects of laparoscopic and open mesh repair in the treatment of recurrent inguinal hernia by conducting a meta-analysis of randomized controlled trials (RCTs). METHODS: A comprehensive, meta-analysis of RCTs on the effects of laparoscopic and open mesh repair in the treatment of recurrent inguinal hernia was performed. English- and Chinese-language studies published up to December 30, 2017 were identified via a systematic search of the PubMed, Embase, Science Direct, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure (CNKI), and Wanfang databases. Summary odd ratios or weighted mean differences (MDs) with 95% confidence intervals (CIs) were adopted to calculate each outcome using a fixed or random effects model. RESULTS: Ten RCTs involving a total of 1,017 patients were included. There was no statistically significant difference in the rate of recurrence (P=0.23; OR: 0.74, 95% CI: 0.45-1.21), hematoma (P=0.47; OR: 0.71, 95% CI: 0.28-1.79), urinary retention (P=0.94; OR: 0.97, 95% CI: 0.46-2.07) and acute pain (P=0.71; OR: 0.74, 95% CI: 0.14-3.76) between the laparoscopic and open mesh repair groups. The incision infection rate (P=0.02; OR: 0.28, 95% CI: 0.10-0.81) of the laparoscopic group was lower and the length of hospital stay (P<0.0001; MD: -3.65, 95% CI: -4.76 to -2.53) was significantly shorter than those of the open repair group. However, the laparoscopic group had a longer operative time (P=0.0002; MD: 20.30, 95% CI: 9.60-31.01). CONCLUSIONS: The laparoscopic approach is superior to the open mesh approach for the repair of recurrent inguinal hernia in some aspects, including the incision infection rate and length of hospital stay. However, more high-quality studies on the effects of laparoscopic and open mesh repair for the treatment of recurrent inguinal hernia are warranted.

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