Diagnostic Laparoscopy as Decision Tool for Re-recurrent Inguinal Hernia Treatment Following Open Anterior and Laparo-Endoscopic Posterior Repair

IntroductionThe guidelines of the international hernia societies recommend posterior repair in laparo-endoscopic technique for recurrent inguinal hernia after open anterior mesh repair and, conversely, open anterior repair for recurrence after laparo-endoscopic primary repair. Even when these guidelines are followed, already 1 year after repair a re-recurrence rate of 1–2% must be expected, with that rate rising further in the subsequent years. Accordingly, increasingly more patients with re-recurrence after anterior and posterior mesh implantation must be treated, which constitutes a problem that to date has been investigated in only very few studies. Hence, there are no well-founded recommendations. This paper now presents a number of case reports aimed at identifying the role of explorative laparoscopy as decision tool for re-recurrent inguinal hernia treatment.Patients and methodsBased on three case reports the role of explorative laparoscopy as decision tool for re-recurrent inguinal hernia treatment is presented below.ResultsIn all the three cases described explorative laparoscopy played a key role as decision tool when deciding how best to treat re-recurrence after anterior and posterior inguinal hernia repair. In one case severe adhesions after robotic prostatectomy and in another case correct placement of the mesh in the posterior plane, adhesions from the cecum to the groin region and no definitive finding of a re-recurrence resulted in an open repair. In the third case, an insufficient laparoscopic posterior mesh placement made the re-recurrent TAPP procedure relatively easy.ConclusionExplorative laparoscopy is an important decision tool for re-recurrent inguinal hernia treatment to minimize the risks of the procedure for the patients

Early Surgical Intervention following Inguinal Hernia Repair with Severe Postoperative Pain

IntroductionSevere postoperative pain is an important risk factor for onset of chronic inguinal pain following inguinal hernia repair. All measures must be taken to eliminate postoperative pain.Materials and methodsThis case report highlights the problems of severe postoperative pain following transabdominal preperitoneal patch plasty (TAPP) inguinal hernia repair and describes a systematic treatment path that may include surgical intervention.ResultsFollowing TAPP operation for lateral inguinal hernia, this patient who had been operated on in an external hospital still experienced intense, stabbing inguinal pain on postoperative day 7 during movement, despite optimal pain treatment. Diagnostic examination did not reveal any findings of note. The surgical report documented that the surgeon had used metallic tacks for mesh fixation, i.e., at the pectineal line of the pubic bone, pubic symphysis, upper margin of the mesh, and for closure of the peritoneum. During surgical revision on postoperative day 7, eight tacks and the mesh were removed and, following further dissection, a new mesh was placed and fixed with glue. The patient’s intense stabbing pain resolved immediately after surgery.ConclusionSince the results of late intervention for chronic inguinal pain are anything but satisfactory, early surgical intervention should be considered for patients with severe postoperative pain >3 days of suspected surgical origin

Treatment of Large Incisional Hernias in Sandwich Technique - A Review of the Literature

IntroductionIn a systematic review of the surgical treatment of large incisional hernia sublay repair, the sandwich technique and aponeuroplasty with intraperitoneal mesh displayed the best results. In this systematic review only the sandwich technique, which used the hernia sac as an extension of the posterior and anterior rectus sheath and placement of a non-absorbable mesh in the sublay position, was included. Other modifications of the sandwich technique are published in the literature and were also analyzed in this literature review.MethodsA systematic search of the available literature was performed in November 2017 using Medline, PubMed, and the Cochrane Library using the terms “sandwich technique”, “double prosthetic repair”, “double mesh intraperitoneal repair”, and “component separation technique with double mesh”. This review is based on 24 relevant publications. Unfortunately, the evidence of the available studies is not very high since only prospective and retrospective case series have been published. There are no comparative studies at all. Therefore, the findings of the published case series must be viewed in a critical light.ResultsThe published studies report a remarkably low recurrence rate of 0-13% with a follow-up of 1–7 years. One limitation that must be mentioned here is that in around half of the studies the method of follow-up was not specified and in the remaining cases this was based on clinical examination by the surgical team. This puts into perspective the reported results, which appear to be too favorable given the complex nature of the hernias involved.The major disadvantage of the sandwich technique is a very high rate of wound complications of up to 68%, mainly induced by creation of large skin and subcutaneous cellular tissue flaps.ConclusionIt is difficult to evaluate the significance of the various modifications of the “sandwich technique” based on the available literature since it includes only case series and no comparative studies. The techniques used are associated with very high wound complication rates but with only relatively low recurrence rates despite the complexity of the cases involved. This must be verified in studies with a well-designed methodology

What Do We Know About Component Separation Techniques for Abdominal Wall Hernia Repair?

IntroductionThe component separation technique (CST) was introduced to abdominal wall reconstruction to treat large, complex hernias. It is very difficult to compare the published findings because of the vast number of technical modifications to CST as well as the heterogeneity of the patient population operated on with this technique.Material and MethodsThe main focus of the literature search conducted up to August 2017 in Medline and PubMed was on publications reporting comparative findings as well as on systematic reviews in order to formulate statements regarding the various CSTs.ResultsCST without mesh should no longer be performed because of too high recurrence rates. Open anterior CST has too high a surgical site occurrence rate and henceforth should only be conducted as endoscopic and perforator sparing anterior CST. Open posterior CST and posterior CST with transversus abdominis release (TAR) produce better results than open anterior CST. To date, no significant differences have been found between endoscopic anterior, perforator sparing anterior CST and posterior CST with transversus abdominis release. Robot-assisted posterior CST with TAR is the latest, very promising alternative. The systematic use of biologic meshes cannot be recommended for CST.ConclusionCST should always be performed with mesh as endoscopic or perforator sparing anterior or posterior CST. Robot-assisted posterior CST with TAR is the latest development