Surgical Technique and Chronic Postoperative Inguinal Pain in Patients Undergoing Open Inguinal Hernioplasty in Portugal: A Prospective Multicentric Cohort Study.

INTRODUCTION: Evidence about the advantage of Lichtenstein's repair, the guidelines' recommended technique, is scarce regarding postoperative chronic inguinal pain (CPIP). The primary aim of this study was to compare CPIP in patients undergoing Lichtenstein versus other techniques. METHODS: Prospective multicentric cohort study including consecutive adults undergoing elective inguinal hernia repair in Portuguese hospitals (October - December 2019). Laparoscopic and mesh-free hernia repairs were excluded. The primary outcome was postoperative pain at three months, defined as a score of ≥ 3/10 in the European Hernia Society Quality of Life score pain domain. The secondary outcome was 30-day postoperative complications. RESULTS: Eight hundred and sixty-nine patients from 33 hospitals were included. Most were men (90.4%) and had unilateral hernias (88.6%). Overall, 53.6% (466/869) underwent Lichtenstein's repair, and 46.4% (403/869) were treated with other techniques, of which 83.9% (338/403) were plug and patch. The overall rate of CPIP was 16.6% and 12.2% of patients had surgical complications. The unadjusted risk was similar for CPIP (OR 0.76, p = 0.166, CI 0.51 - 1.12) and postoperative complications (OR 1.06, p = 0.801, CI 0.69 - 1.60) between Lichtenstein and other techniques. After adjustment, the risk was also similar for CPIP (OR 0.83, p = 0.455, CI 0.51 - 1.34) and postoperative complications (OR 1.14, p = 0.584, CI 0.71 - 1.84). CONCLUSION: The Lichtenstein technique was not associated with lower CPIP and showed comparable surgical complications. Further investigation as- sessing long term outcomes is necessary to fully assess the benefits of the Lichtenstein technique regarding CPIP.

Comparative analysis of different surgical approaches for recurrent inguinal hernia: a single-center observational study.

Purpose: Managing recurrent inguinal hernias is complex, and choosing the right surgical approach (laparoscopic vs. open) is vital for patient outcomes. This study compared the outcomes of using the same vs. different surgical approaches for initial and subsequent hernia repairs. Methods: We retrospectively analyzed patients who underwent recurrent inguinal hernia repair at Seoul National University Bundang Hospital between January 2014 and May 2023. Patients were divided into the "concordant" and "discordant" groups, comprising patients who underwent same and different approaches in both surgeries, respectively. Preoperative baseline characteristics, index surgery data, postoperative outcomes, and recurrence rates were analyzed and compared. Results: In total, 131 patients were enrolled; the concordant and discordant groups comprised 31 (open, n = 19; laparoscopic, n = 12) and 100 patients (open to laparoscopic, n = 68; laparoscopic to open, n = 32), respectively. No significant differences were observed in the mean operation time (50.5 ± 21.7 minutes vs. 50.2 ± 20.0 minutes, P = 0.979), complication rates (6.5% vs. 14.0%, P = 0.356), or 36-month cumulative recurrence rates (9.8% vs. 9.8%; P = 0.865). The mean postoperative hospital stay was significantly shorter in the discordant than in the concordant group (1.8 ± 0.7 vs. 1.4 ± 0.6, P = 0.003). Conclusion: Most recurrent inguinal hernia repairs were performed using the discordant surgical approach. Overall, concordance in the surgical approach did not significantly affect postoperative outcomes. Therefore, the selection of the surgical approach based on the patient's condition and surgeon's preference may be advisable.

Proposal for encoding the surgical treatment in abdominal wall pathology based on a multidimensional analysis of history.

OBJECTIVE: To develop a multidimensional method that allows to identify different treatment concepts, techniques, protagonists, and their connections in surgical pathology of the abdominal wall throughout its historical development, serving as a basis or guide for the future. METHOD: First, an extensive and rigorous review of the literature was conducted to search for and group the different treatments described in the most common abdominal wall pathologies, including both groin and ventral hernias. Then, all treatment approaches were chronologically ordered and grouped according to their author, surgical approach, and method of approach. With all the information gathered, a table was created following a rational and multidimensional criterion that allows for the encoding of the set. RESULTS: 21 treatment modalities were identified and distributed into 8 groups. Additionally, 3 types of authors were detected: the creator, the innovator, and the popularizer. The assignment of values to different dimensions allowed us to obtain an alphanumeric code representative of the set. CONCLUSION: Multidimensional historical analysis allows analytical objectivity and set encoding. Its practical scope should be investigated.

A retrospective noninferiority study of laparoscopic inguinal hernia repair feasibility for recently graduated surgeons in Thailand.

Purpose: The feasibility of starting laparoscopic surgery among newly graduated surgeons lacking extensive experience in open approaches remains a topic of interest. We aimed to evaluate the safety and efficacy of laparoscopic inguinal hernia repair (LHR) compared to open inguinal hernia repair (OHR) in this population. Methods: This retrospective cohort study was conducted on inguinal hernia surgeries performed by a single recently graduated surgeon during the learning phase. Patient data were collected from July 2021 to November 2022 with a focus on demographics, intraoperative details, and 1-year postoperative outcomes. Noninferiority testing was employed with a predetermined margin of 15% to compare the complication rates, recurrence rates, and other secondary outcomes between LHR and OHR. Results: The study cohort comprised 66 patients (OHR group, n = 45 and LHR group, n = 21). Patient characteristics were similar between groups. No significant differences were observed in the complication rates (OHR, 26.7% and LHR, 19.0%; p = 0.50) or recurrence rates (OHR, 2.2% and LHR, 4.8%; p = 0.54). The LHR group demonstrated noninferior outcomes compared with the OHR group in terms of complication, recurrence, readmission, and reoperation rates. Except for the operative time, secondary outcomes did not differ significantly between the groups. Conclusion: LHR is a feasible initiation for recently graduated surgeons, demonstrating noninferior outcomes compared with open repair. Therefore, the belief that one must master open surgery before beginning laparoscopy may be untrue.

Totally extraperitoneal laparoscopy-assisted microsurgical vasovasostomy for the treatment of obstructive azoospermia caused by pediatric bilateral inguinal herniorrhaphy.

BACKGROUND: Pediatric inguinal hernia repair (IHR) is a common cause of obstructive azoospermia (OA). Yet, the surgical treatment for this kind of OA remains difficult with poor fertility outcome. OBJECTIVES: To evaluate the safety and effectiveness of totally extraperitoneal laparoscopy-assisted microsurgical vasovasostomy (VV) in the treatment of OA caused by pediatric bilateral IHR. MATERIALS AND METHODS: Totally, 37 patients with OA caused by pediatric bilateral IHR were enrolled in this study from March 2015 to December 2020 in Shanghai General Hospital. The clinical data and fertility outcomes were collected and analyzed. RESULTS: All patients enrolled had a history of bilateral IHR at the age of 1-10 years old. The mean age of patients was 27 ± 4.31 (range: 18-35) years. Totally extraperitoneal laparoscopy (TEP) was applied in 31 patients for the exploration and retrieval of pelvic vas deferens end, and 30 of them underwent microsurgical VV successfully. Among the six cases where TEP was not applied, five cases underwent microsurgical anastomosis. Intraoperative exploration revealed that the location of vas deferens injuries included scrotum (2.70%, 1/37), inguinal canal (5.41%, 2/37), pelvic cavity (78.37%, 29/37), and multiple sites (13.51%, 5/37). The mean operation time was 339 ± 96.73 min (range: 130-510 min). There were no surgical complications. Thirty-three cases were followed up for 5-48 months with four cases lost to follow-up. The overall patency rate, pregnancy rate, and natural pregnancy rate were 75.86% (22/29), 46.67% (14/30), and 36.84% (7/19, 3 patients without family planning), respectively. And seven couples conceived through the assisted reproductive technique, two of which using fresh sperm in the ejaculate. CONCLUSION: TEP laparoscopy-assisted microscopic VV is an effective treatment for patients with OA caused by pediatric bilateral IHR.

Association of Metabolic Derangement and Postoperative Outcomes in Hernia Repair With Component Separation: A Propensity Score-matched Nationwide Analysis.

INTRODUCTION: Metabolic syndrome (MetS) is characterized by cardiometabolic abnormalities such as hypertension, obesity, diabetes, or dyslipidemia. This study aims to evaluate the association of MetS on the postoperative outcomes of ventral, umbilical, and epigastric hernia repair using component separation. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent ventral, umbilical, and epigastric hernia repair with component separation between 2015 and 2021. MetS status was defined as patients receiving medical treatment for diabetes mellitus and hypertension, with a body mass index greater than 30 kg/m2. Propensity matching was performed to generate two balanced cohorts with and without MetS. T-tests and Fisher's Exact tests assessed group differences. Logistic regression models evaluated complications between the groups. RESULTS: After propensity score matching, 3930 patients were included in the analysis, with 1965 in each group (MetS versus non-MetS). Significant differences were observed in the severity and clinical presentation of hernias between the groups. The MetS cohort had higher rates of incarcerated hernia (39.1% versus 33.2%; P < 0.001), and recurrent ventral hernia (42.7% versus 36.5%; P < 0.001) compared to the non-MetS cohort. The MetS group demonstrated significantly increased rates of renal insufficiency (P = 0.026), unplanned intubation (P = 0.003), cardiac arrest (P = 0.005), and reoperation rates (P = 0.002) than the non-MetS cohort. Logistic regression models demonstrated higher likelihood of postoperative complications in the MetS group, including mild systemic complications (OR 1.25; 95%CI 1.030-1.518; P = 0.024), severe systemic complications (OR 1.63; 95%CI 1.248-2.120; P < 0.001), and reoperation (OR 1.47; 95%CI 1.158-1.866; P = 0.002). There were no significant differences in the rates of 30-d wound complications between groups. CONCLUSIONS: The presence of metabolic derangement appears to be associated with adverse postoperative medical outcomes and increased reoperation rates after hernia repair with component separation. These findings highlight the importance of optimizing preoperative comorbidities as surgeons counsel patients with MetS.

High ligation with posterior wall repair for inguinal hernia repair in young adults: a nationwide cohort study.

Purpose: This study evaluated the difference in the recurrence of inguinal hernia in young adult patients who underwent either high ligation alone or high ligation with posterior wall repair using nationwide data. Methods: This retrospective study included young adult patients (aged 16-30 years) who underwent surgery for inguinal hernia between June 1, 2013 and December 31, 2020. Data from the National Health Information Database from the Korea Health Insurance Service were used for this study. Patients were divided into 2 groups (high ligation alone and posterior wall repair). The primary outcome was the difference in recurrent inguinal hernia surgeries between the 2 groups. Results: Among the 10,803 patients included in the study, 947 underwent high ligation alone, and 9,856 underwent high ligation with posterior wall repair. Recurrence was observed in 18 patients (1.9%) in the high ligation only group and 84 (0.85%) in the high ligation with posterior wall repair group. Log-rank test findings revealed that recurrence was less frequent in the high ligation with posterior wall repair group than in the high ligation only group (P = 0.003). In the multivariate analysis of factors influencing recurrence, posterior wall repair (hazard ratio, 0.241; P = 0.001) was shown to significantly lower the recurrence. Conclusion: Posterior wall repair might be necessary for inguinal hernia repair in young adults.

Amyand's Hernia With Sliding Component: A Case Report.

Amyand's hernia (AH) occurs when the appendix becomes part of an inguinal hernia. Amyand's hernias are typically discovered incidentally during surgery due to their variable clinical manifestations and features, such as caecum and appendix forming the sliding component in the present case. Claudius Amyand operated it for the first time in 1735. Due to the simple presentations that these patients typically exhibit, the diagnosis is extremely challenging. The choice between surgical modalities is influenced by the numerous, logically accepted advantages and disadvantages of management modalities, which are subject to debate. That being said, we believe that, in the absence of sepsis or inflammation, open repair using mesh - as long as a clean operating room and competent surgical skill are available - should be the gold standard approach.

Two cases of intraoperative diagnosed Amyand hernia: Case report and literature review.

INTRODUCTION: Amyand hernia is the presence of an incarcerated vermiform appendix (either inflamed or not) within the hernia sac. This type of hernia is very rare with an incidence reported to be 0.5 to 1 % and even rarer in adults. CASES PRESENTATION: We present here two cases of male patients found the have an Amyand Hernia diagnosed incidentally intraoperatively, and managed with appendectomy and mesh herniorrhaphy. CLINICAL DISCUSSION: For the management of this type of hernia, in general, the surgeon should perform an appendectomy with the repair to prevent future herniation or appendicitis, but some opinions differ, and state that when there are no signs of inflammation, it is not required to perform a preventative appendectomy. CONCLUSION: The decision on how to manage depends on multiple factors including inflammation of the appendix, the possibility of abdominal sepsis, and the patient comorbidities. The status of the appendix determines whether to undergo hernia repair with or without mesh.

Toxina botulínica y neumoperitoneo secuencial en el manejo de hernia inguinoescrotal gigante: Reporte de caso / Botulinum toxin and sequential pneumoperitoneum in the management of giant inguinoscrotal hernia: Case report

Introducción. Las hernias gigantes con pérdida de domicilio son aquellas cuyo saco herniario alcanza el punto medio del muslo en bipedestación y su contenido excede el volumen de la cavidad abdominal. Estas hernias son un reto quirúrgico dada la difícil reducción de su contenido y del cierre primario de la fascia. Tienen mayor riesgo de complicaciones asociadas al síndrome compartimental abdominal, así como mayor tasa de recurrencia y morbilidad en los pacientes. Caso clínico. Paciente masculino de 81 años, reconsultante por hernia inguinoescrotal derecha gigante, de dos años de evolución, sintomática, con índice de Tanaka de 24 %. Se decidió aplicar el protocolo de neumoperitoneo secuencial (hasta 11.000 ml en total en cavidad) además de toxina botulínica en pared abdominal (dos sesiones). Resultados. Se logró la corrección exitosa de la hernia inguinoescrotal gigante, sin recaídas de su patología abdomino-inguinal. El paciente manifestó satisfacción con el tratamiento un año después del procedimiento. Conclusiones. El protocolo de neumoperitoneo secuencial es una alternativa en casos de hernias complejas, con alto riesgo de complicaciones, que requieren técnicas reconstructivas adicionales. La aplicación previa de toxina botulínica es un adyuvante considerable para aumentar la probabilidad de resultados favorables. Sin embargo, debe incentivarse la investigación en esta área para evaluar su efectividad.

Introduction. Giant hernias with loss of domain are those whose hernial sac reaches the midpoint of the thigh in standing position and whose content exceeds the volume of the abdominal cavity. These hernias are a surgical challenge given the difficult reduction of their contents and the primary fascial closure, with a higher risk of complications associated with abdominal compartment syndrome, as well as a higher rate of recurrence and morbidity in patients. Clinical case. A 81-year-old male patient with comorbidity, reconsulting due to a symptomatic giant right inguinoscrotal hernia of two years of evolution, with a Tanaka index of 24%, eligible for a sequential pneumoperitoneum protocol (up to a total of 11,000 cc in cavity) plus application of botulinum toxin (two sessions) in the abdominal wall. Results. Successful correction of the patient's giant inguinoscrotal hernia was achieved using this protocol, without recurrence of his abdomino-inguinal pathology and satisfaction with the procedure after one year. Conclusion. The sequential pneumoperitoneum protocol continues to be an important alternative in cases with a high risk of complications that require additional reconstructive techniques, while the previous application of botulinum toxin is a considerable adjuvant to further increase the rate of favorable results. However, research in the area should be encouraged to reaffirm its effectiveness.

Amyand's hernia with concurrent appendicitis: A case of interval laparoscopic herniorrhaphy and literature review.

INTRODUCTION AND IMPORTANCE: Amyand's hernia with concurrent appendicitis is rare, with a reported incidence of 0.13 % of all inguinal hernias. This condition is challenging to diagnose and manage and no optimal treatment has been established. CASE PRESENTATION: A 71-year-old man presented with an acutely painful, tender, and irreducible right inguinal hernia. He had a history of a right inguinal hernia for several months and had undergone open left inguinal hernia repair. The patient had no other medical comorbidities. Blood test results were nonspecific, with a C-reactive protein of 90 mg/L. Ultrasound scan suggested a strangulated right inguinal hernia. Laparoscopy revealed an Amyand's hernia with concurrent appendicitis and a pus-filled right inguinal hernia sac. The patient underwent laparoscopic appendicectomy, followed by staged laparoscopic transabdominal preperitoneal right inguinal hernia repair with mesh after eight weeks to reduce mesh infection. Histopathological examination confirmed acute uncomplicated appendicitis without perforation or malignancy. The patient had an unremarkable post-operative recovery. DISCUSSION: This case highlights the diagnostic challenges associated with Amyand's hernia and concurrent appendicitis. Laparoscopy provides both diagnostic and therapeutic opportunities. In this case, laparoscopic mesh herniorrhaphy was delayed and staged until local hernia sac inflammation resolved following appendicectomy. CONCLUSION: Surgeons should have an index of suspicion for Amyand's hernia given the heterogeneity of presentations. A case-by-case approach is required to prevent post-operative complications and determine the safe timing of definitive hernia repair when the inguinal hernial sac is inflamed. Further research is required to provide surgeons with evidence-based approaches for this unique condition.

Robotic transabdominal preperitoneal repair for bilateral obturator hernia: a video vignette.

Obturator hernias (OHs) are a rare cause of bowel obstruction that requires immediate surgical intervention to prevent morbidity and mortality. Patients with OHs present with acute intestinal obstruction secondary to incarceration, with a high morbidity and mortality rate due to delayed diagnosis and treatment. Although several surgical approaches have been reported, a standard approach for OH treatment has not yet been established. Here, we report the case of a 74-year-old woman who presented with bilateral OHs. The patient presented at our institution with pain in the left lower quadrant. Computed tomography revealed preperitoneal fat in both obturator foramen. Robotic transabdominal preperitoneal (R-TAPP) bilateral OH repair was performed, and a mesh was placed over both obturator foramen. The patient recovered without postoperative complications and was discharged on postoperative day 2. This suggests that the R-TAPP approach is safe for OH repair without incarceration.

Treatment of canine perineal hernia with a fascia lata graft is noninferior to the elevation of the internal obturator muscle: a prospective randomized trial of 66 dogs.

OBJECTIVE: To compare the recurrence rate after herniorrhaphy of canine perineal hernia (PH) using elevation of the internal obturator muscle (EIOM) or fascia lata graft (FLG) and assess how clinical signs related to defecation evolve during 12 months postoperatively. ANIMALS: 66 client-owned male dogs undergoing PH surgery between March 1, 2017, and December 31, 2020. METHODS: Dogs were randomized into 2 groups (EIOM = 36; FLG = 30) applying 2 stratification factors: preoperative bladder location and the defecation signs score (DSS). Follow-up visits were at 2 weeks and 3, 6, and 12 months postoperatively. The main outcome, the recurrence of PH was evaluated by rectal examination. We evaluated the noninferiority of FLG to EIOM from the difference in recurrence proportions between the techniques (95% CI), comparing the CI with a pre-defined noninferiority margin (15%). To evaluate defecation signs, the DSS was calculated from the owner questionnaire and assessed with a linear mixed model (P < .05 significant). RESULTS: In 63 dogs attending the 12-month follow-up, the recurrence rate was 8.8% (3/34) in the EIOM and 10.3% (3/29) in the FLG group. The CI (-11.94% to 14.99%) was below the pre-defined margin, indicating the noninferiority of FLG. After surgery, the DSS decreased (P < .001), remaining low during the follow-up. CLINICAL RELEVANCE: FLG was non-inferior to EIOM when considering recurrence. The DSS decreased postoperatively and complications were uncommon. FLG is a useful alternative for the treatment of canine PH.

Safety and efficacy revisited: a systematic review and meta-analysis of glue versus tack mesh fixation in laparoscopic inguinal herniorrhaphy.

Background: This analysis addresses the uncertainty surrounding the efficacy of glue mesh fixation (GMF) compared with tack mesh fixation (TMF) in laparoscopic herniorrhaphy. Our meta-analysis incorporates recently conducted randomized controlled trials (RCTs) to enhance the reference for assessing the efficacy and safety of GMF. Methods: PubMed Central, Google Scholar, Science Direct, and Cochrane Library were extensively reviewed for articles in the English language performed from inception to May 2023 using the keywords "Glue mesh repair," "Tack mesh repair," "Inguinal Hernia," "Herniorrhaphy," "Laparoscopic," "Mesh Fixation," and "Randomized controlled trials." Results: In this meta-analysis, we incorporated a total of 20 randomized controlled trials, evaluating each article individually using quality ratings. Compared with TMF, GMF demonstrated a significant reduction in the incidence of chronic pain [RR: 0.40, (0.23, 0.68)] and pain scores on postoperative day 1 [MD: -1.07, (-1.90, -0.25)]. We also used funnel plots and Egger's regression to test for publication bias. Conclusion: In summary, this meta-analysis establishes the significance of GMF in reducing chronic pain and postoperative day 1 pain compared with TMF. However, no statistically significant difference was noted between the GMF and TMF groups concerning hematoma, seroma, operation time, recurrence rate, and total complications. Nonetheless, given the small number of cases in this study, the findings must be validated in the future by multicenter, large-sample, high-quality RCTs.

Non-mesh inguinal hernia repair with early resumption of peritoneal dialysis in patients on continuous ambulatory peritoneal dialysis.

PURPOSE: Inguinal hernia is a common complication of peritoneal dialysis (PD). Although tension-free mesh repair is a leading option for inguinal hernia repair, concerns over serious mesh-related complications may indicate a role for non-mesh inguinal hernia repair. In addition, there is no consensus on the perioperative dialysis regimen. Early resumption of PD may avoid the additional risks associated with hemodialysis. We report on the outcomes of non-mesh inguinal hernia repair in patients on continuous ambulatory PD (CAPD) and provide a perioperative dialysis protocol that aims to guide early resumption of PD. METHODS: Between May 2019 and September 2023, thirty CAPD patients with 43 inguinal hernias who underwent non-mesh inguinal hernia repair were retrospectively analyzed. Data on the patient characteristics, perioperative dialysis regimen, perioperative features, complications, and hernia recurrence were collected and assessed. RESULTS: Thirty patients with a total of 43 inguinal hernia repairs were included in this study. The median age was 53 years. 23 patients were male and 7 were female. Non-mesh inguinal repair was performed for all patients. PD was resumed at a median of 2 days after the surgery. Five patients received interim hemodialysis. There were no postoperative surgical or uremic complications and no recurrence after a median follow-up of 31.5 months. CONCLUSION: Our study demonstrates the effectiveness and safety of non-mesh repair with early resumption of PD in patients on CAPD. Interim HD is unnecessary in selected patients. Choosing the optimal perioperative dialysis regimen is essential to managing inguinal hernias in CAPD patients.

Comparison of the analgesic efficacy of the ultrasound-guided transversalis fascia plane block and erector spinae plane block in patients undergoing open inguinal hernia repair under spinal anesthesia.

BACKGROUND: Open inguinal hernia repair (OIHR) surgery is a common surgical procedure, and ultrasound guided interfascial plane blocks can also be included in current approaches to postoperative multimodal analgesia regimens. This study aimed to compare the postoperative analgesic efficacy of the erector spinae plane block (ESPB) and transversalis fascia plane block (TFPB) in patients undergoing OIHR. METHODS: This prospective, randomized, assessor-blinded comparative study was conducted in the postoperative recovery room and ward of a tertiary hospital. A total of 80 patients with American Society of Anesthesiologists physical status I-III were enrolled and allocated equally to either the ESPB or TFPB group. The patients received standard multimodal analgesia in addition to an ultrasound-guided ESPB or TFPB. During the first 24 h postoperatively, tramadol consumption was assessed and pain levels at rest and during movement were compared using numeric rating scale (NRS) scores at 1, 3, 6, 9, 12, 18, and 24 h postoperatively. RESULTS: The results showed no difference in NRS scores at any time point between the groups, except for NRS at rest in the third hour. However, tramadol consumption was lower in the TFPB group than in the ESPB group overall (88 ± 75.2 vs. 131 ± 93.7 mg, respectively; P = 0.027, mean difference: -43, 95% CI [-80.82, -5.18]). CONCLUSIONS: The TFPB leads to lower tramadol requirements in the first 24 h postoperatively than the ESPB in patients undergoing OIHR.

Clinical application of the modified neck-shoulder technique based on membrane autopsy to laparoscopic totally extraperitoneal prosthesis for indirect inguinal hernia.

OBJECTIVE: To investigate the anatomical basis and clinical application value of the modified neck-shoulder technique based on membrane autopsy in laparoscopic totally extraperitoneal prosthesis (TEP) for tension-free repairs of indirect inguinal hernia. METHODS: In this retrospective cohort study, we analyzed the clinical data of 136 patients with indirect inguinal hernia who underwent laparoscopic TEP for tension-free repairs at the Department of Gastroenterological Surgery Unit 1, the First Hospital of Putian City, Fujian Province from June 2017 to June 2020. The patients were divided into the modified neck-shoulder technique group (68 cases) and the traditional surgery group (68 cases), according to the different surgical methods. The intraoperative and postoperative conditions of the two groups were compared. RESULTS: Both the modified neck-shoulder technique group and the traditional surgery group completed the herniorrhaphy. Compared with the traditional surgery group, the modified neck-shoulder technique group had a shorter operation time [(37.15 ± 5.320) min vs. (54.04 ± 5.202) min, t = 18.472, p < 0.001], less intraoperative blood loss [(5.53 ± 1.634) ml vs. (16.21 ± 3.375) ml, t = 23.544, p < 0.001], lower incidence of intraoperative peritoneal injury [3 cases (4.41%) vs. 9 cases (13.26%), χ2 = 3.29, p = 0.07], lower intraoperative conversion rate [1 case (1.47%) vs. 8 cases (11.76%), χ2 = 5.83, p = 0.016], and lower incidence of postoperative chronic pain [1 case (1.47%) vs. 12 cases (17.65%), χ2 = 10.291, p = 0.001], all of which were statistically significant (p < 0.05). Both groups were followed up for 12 months after surgery. Relapse was not observed in any case. CONCLUSION: Drawing upon the surgical principles of the open neck-shoulder technique and the understanding of the membrane autopsy in the inguinal region, our center has summarized a set of operation procedures called the "modified neck-shoulder technique" for laparoscopic TEP in the tension-free repairs of indirect inguinal hernias. This new surgical technique could expeditiously and precisely navigate the interlayer gap in the preperitoneal space under the enlarged view of the laparoscope. It facilitated the high ligation, disconnection, or repositioning of the hernia sac, enhancing the reliability of patch placement while minimizing collateral damage, reducing postoperative complications, and shortening operation time.

Twelve-year outcomes of watchful waiting versus surgery of mildly symptomatic or asymptomatic inguinal hernia in men aged 50 years and older: a randomised controlled trial.

Background: Inguinal hernia belongs to the most common surgical pathology worldwide. Approximately, one third is asymptomatic. The value of watchful waiting (WW) in patients with asymptomatic or mildly symptomatic inguinal hernia has been established in a few randomised controlled trials (RCTs). The aim of this study was to assess long-term outcomes of a RCT comparing WW and elective surgery. Methods: In the original study, men aged ≥50 years with an asymptomatic or mildly symptomatic inguinal hernia were randomly assigned to WW or elective repair. In the present study, the primary outcome was the 12-year crossover rate to surgery, secondary outcomes were time-to-crossover, patient regret, pain, quality of life and incarceration. Dutch Trial Registry: NTR629. Findings: Out of 496 originally analysed patients, 488 (98.4%) were evaluable for chart review (WW: n = 258, surgery: n = 230), and 200 (41.0%) for telephone contact (WW: n = 106, surgery: n = 94) between November 2021 and March 2022 with a median 12 years follow-up (IQR 9-14). After 12 years, the estimated cumulative crossover rate to surgery was 64.2%, which was higher in mildly symptomatic than in asymptomatic patients (71.7% versus 60.4%, HR 1.451, 95% CI: 1.064-1.979). Time-to-crossover was longer in asymptomatic patients (50% after 6.0 years versus 2.0 years, p = 0.019). Patient regret was higher in the WW group (37.7 versus 18.0%, p = 0.002), as well as pain/discomfort (p = 0.031). Quality of life did not differ (p = 0.737). In the WW group, incarceration occurred in 10/255 patients (3.9%). Interpretation: During 12-year follow-up, most WW patients crossed over to surgery, significantly earlier with mildly symptomatic hernia. Considering the relatively low incarceration rate, WW might still be an option in asymptomatic patients with a clear preference and being well-informed about pros and cons. Funding: The initial trial was funded by the Netherlands Organisation for Health Research and Development (ZonMW). This long-term study did not receive funding.