Feasibility and safety of redo laparoscopic repair of recurrent inguinal hernia following previous endolaparoscopic repair.

BACKGROUND: Laparoscopic redo inguinal hernia (LRIH) repairs are fraught with challenges as the pre-peritoneal space is violated due to previous surgery and the presence of mesh. The purpose of this study was to present the feasibility and safety of LRIH in a series of patients with recurrent inguinal hernia following previous endolaparoscopic repair and present technical experiences and clinical outcomes in this subset of patients. PATIENTS AND METHODS: This was a retrospective study from a prospective database of 16 patients who underwent LRIH between March 2014 and December 2020. The decision to do a redo laparoscopic surgery was undertaken after a detailed discussion with the patient. The operative details, challenges faced and tips to overcome difficulties have been explained in detail. RESULTS: Out of 16 patients (mean age 49.5 years, all men), 15 underwent laparoscopic redo trans-abdominal pre-peritoneal (TAPP) mesh repair and 1 underwent laparoscopic enhanced-view totally extra-peritoneal (eTEP) mesh repair. The mean operating time was 68.5 min for unilateral, 115 min for bilateral TAPP and 90 min for eTEP. The main contributing factors for recurrences were mesh migration, insufficient size of the mesh and inadequate fixation. There was no conversion to open repair. The duration of stay was 1-2 days. There was no documented re-recurrence during the follow-up period of 2-9 years. CONCLUSION: Based on our experience, redo laparoscopic inguinal hernia mesh repair after previous endolaparoscopic repair is feasible, effective and safe in experienced hands.

Novel laparo-endoscopic hybrid technique of management of a rare case of duodeno-duodenal intussusception.

We herein report a rare case of duodeno-duodenal intussusception (IS) presenting with obstruction caused by tubulovillous adenoma in an adult with malrotation that was managed by a novel laparoendoscopic hybrid technique. This was done by passing transjejunal nasogastric tube (NG) through one of the ports and manoeuvring it towards the IS. Two hundred and fifty millilitre of saline was flushed by aseptosyringe with pressure connected to the NG. This hydrostatic reduction technique resulted in distension of the jejunal and duodenal loop achieving reduction of IS. Intraoperative endoscopy was performed to exactly localise the mass lesion. The duodenum was kocherised and was delivered through a 4-cm transverse incision. Anterior duodenotomy was performed; the mass was excised; and duodenotomy was closed transversely. An extensive literature search did not show any case report of duodenoduodenal IS being managed by this technique. The combination of novel retrograde decompression and intraoperative endoscopy helped us to manage this rare case by this novel technique.

Enhanced view totally extraperitoneal approach: A better alternative to transabdominal preperitoneal approach for irreducible inguinoscrotal and giant inguinal hernias!

The advantages of enhanced view totally extraperitoneal (eTEP) over TEP approach are well established in large inguinoscrotal, recurrent inguinal, patients with short pubis to umbilicus distance and in obese patients. Irreducible inguinoscrotal hernias (IISHs) and giant inguinal hernias (GIHs) pose a great challenge. GIHs are hernias which extend below the midpoint of the inner thigh with the patient in the standing position. Majority of these hernias are managed by open, hybrid or by transabdominal pre-peritoneal (TAPP) approach. TAPP was considered the optimal minimally invasive approach for these hernias as it provides a large working space and reduction of contents under vision. My practice of eTEP has been limited to IISH and GIH. I would like to share some technical tips to manage these cases by eTEP approach.

Persistent Müllerian duct syndrome: A surgical surprise and management during laparoscopic transabdominal pre-peritoneal repair.

Persistent Müllerian duct syndrome is an intersex disorder which occurs due to the failure of regression of Müllerian structures in genotypical and phenotypical males. It is a rare disorder of male internal pseudohermaphroditism with normal secondary sexual characters and XY karyotype. We report a male patient with the diagnosis of bilateral inguinoscrotal hernia with cryptorchidism scheduled for laparoscopic bilateral transabdominal pre-peritoneal (TAPP) mesh repair with bilateral orchidopexy. Intra-operatively, there was a rudimentary uterus with tubes on both sides. Bilateral testicular biopsy was taken to confirm the presence of testicular tissue and to exclude malignancy and ovarian tissue. Hernia surgery was deferred in the first stage. After 2 weeks, he underwent laparoscopic bilateral orchidopexy with TAPP mesh repair. At 6-year follow-up, there is no recurrence of hernia or features of malignancy in the retained testis.