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.

Effect of neuromuscular blockade reversal on post-operative urinary retention following inguinal herniorrhaphy.

PURPOSE: This study aims to define the risk of post-operative urinary retention (POUR) following inguinal hernia repair in those that received sugammadex compared to anticholinesterase. METHODS: Adults undergoing inguinal herniorrhaphy from January 2019 to July 2022 with at least 30-day follow-up receiving rocuronium or edrophonium and reversed with an anticholinesterase or sugammadex were included. 1-to-2 propensity score matched models were fitted to evaluate the treatment of effect of sugammadex vs. anticholinesterase on POUR, adjusting for patient comorbidities, ASA class, wound class, operative laterality, urgency of case, and open versus minimally invasive repair. RESULTS: 3345 patients were included in this study with 1101 (32.9%) receiving sugammadex for neuromuscular blockade reversal. The 30-day rate of POUR was 2.8%; 1.4% in the sugammadex and 4.4% in the anticholinesterase group. After propensity score matching, patients receiving sugammadex had significantly lower risk of POUR compared to anticholinesterase overall (OR 0.340, p < 0.001, 95% CI 0.198-0.585), in open (OR 0.296, p = 0.013, 95% CI 0.113-0.775) and minimally invasive cases (OR 0.36, p = 0.002, 95% CI 0.188-0.693), unilateral (OR 0.371, p = 0.001, 95% CI 0.203-0.681) and bilateral repairs (OR 0.25, p = 0.025, 95% CI 0.074-0.838), elective (OR 0.329, p < 0.001, 95% CI 0.185-0.584) and clean cases (OR 0.312, p < 0.001, 95% CI 0.176-0.553). CONCLUSIONS: The incidence of 30-day new onset POUR was 2.8%. Sugammadex was associated with significantly lower risk of POUR after inguinal herniorrhaphy compared to anticholinesterase overall and when stratifying by operative modality, laterality, and wound class.

Outcomes Of Mesh Fixation Versus Non Fixation In Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair: A Randomized Clinical Study.

Objectives: The present study aimed to compare the results of laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair with and without mesh fixation regarding postoperative pain, recurrence, operative time, and complications. METHODS: This randomized controlled clinical trial included 100 patients who underwent TAPP inguinal hernia with mesh fixation (group A) or a fixation-free procedure (group B) for early onset inguinal hernia at the General Surgery Department, Kafrelsheikh University Hospital, from January 2021 to June 2022. RESULTS: The parameters for pain assessment (NRS) in the first week (mean 7 (5 - 8)), the first month (mean 3 (1 - 5)), and after three months(mean 0 - (70% of patients), (mean 1- (30% of patients) were significantly higher in the fixation group (p<0.001). The fixation group had significantly more operative time than non fixation, with a mean (69.34±13.55, 60.92±10.18) respectively. Recurrence rate and postoperative complications did not show any significant difference between the studied groups. CONCLUSIONS: Mesh non-fixation for laparoscopic TAPP hernia repair is safe, practical, and effective with minimal postoperative pain and no increased risk of recurrence.

Enfermedad de Mondor del pene en un paciente joven / Mondor disease of the penis in a young patient

Se presenta el caso clínico de un paciente de 21 años de edad, con antecedente de herniorrafia inguinal derecha, quien asistió a consulta de control y refirió presentar una induración y dolor en la región dorsal del pene con 4 días de evolución, que había comenzado después de una relación sexual en la cual consumió marihuana. En el examen físico se encontró la vena dorsal del pene engrosada, dura y dolorosa a la palpación. Se le diagnosticó una enfermedad de Mondor del pene. La ecografía Doppler confirmó la tromboflebitis de esta vena. El paciente recibió tratamiento médico y evolucionó satisfactoriamente.

The case report of a 21 years patient with history of right inguinal herniorrhaphy is presented, who attended control visit and he made reference to an induration and pain in the dorsal region of the penis with 4 days of evolution that had begun after a sexual relationship in which he consumed marihuana. In the physical exam the penis dorsal vein was found thicken, hard and painful to the palpation. He was diagnosed a Mondor disease of the penis. The Doppler scanning confirmed the thrombophlebitis of this vein. The patient received medical treatment and had a favorable clinical course.

Analgesic and hemodynamic effects of intravenous infusion of magnesium sulphate versus dexmedetomidine in patients undergoing bilateral inguinal hernial surgeries under spinal anesthesia: a randomized controlled study.

BACKGROUND: Spinal anesthesia is commonly employed during inguinal hernial surgeries. Its short duration may, however, be considered a limitation, especially for bilateral hernial repair. The aim of this research is to investigate the analgesic and hemodynamic effects of intravenous infusion of both MgSO4 and dexmedetomidine on patients undergoing bilateral inguinal hernia surgeries under spinal anesthesia. METHODS: This study was a prospective, randomized, double-blinded controlled trail. It included 60 male patients who had been scheduled for bilateral elective inguinal hernia surgery under spinal anesthesia at Kasr Al-Aini hospital. Patients were randomly allocated to one of three groups (n = 20 each) to receive 50 mL of 0.9% saline intravenous infusion of either dexmedetomidine 0.5 µg.kg-1. h-1 (Group D) or magnesium sulphate 15 mg.kg-1. h-1 (Group M) or normal saline (Group S). The primary outcome of this study was set as the total duration of analgesia. Secondary outcomes were set as the onset and duration of sensory and motor blockade, perioperative hemodynamics, and the total 24-hour postoperative morphine consumption. RESULTS: Durations of sensory and motor blockades as well as durations of analgesia were all significantly longer among patients in Group D (mean 2.2, 3.5, 5.8 hours respectively) and Group M (mean 2.2, 3.3, 5.2 hours respectively), in comparison to Group S (mean 1.5, 2.7, 3.9 hours respectively). No significant differences were found in systolic or diastolic arterial blood pressure, heart rate oxygen saturation, cardiac output, or stroke volume among the study groups. Seven patients in Group D and four patients in Groups M and S developed hypotension. CONCLUSION: Intravenous infusion of either dexmedetomidine or MgSO4 with spinal anesthesia effectively improves the quality of spinal anesthesia and prolongs the duration of postoperative analgesia and decreases the 24-hour postoperative morphine consumption. Results also demonstrated that the use of dexmedetomidine resulted in a slightly longer duration of analgesia, whilst the use of MgSO4 resulted in slightly better hemodynamic stability.

Comparison of Three Different Doses of Dexmedetomidine Added to Bupivacaine in Ultrasound-Guided Transversus Abdominis Plane Block; A Randomized Clinical Trial.

BACKGROUND: Adding dexmedetomidine to bupivacaine has been shown to prolong the analgesic effects of the transversus abdominis plane (TAP) block. However, the optimal dose of this adjuvant drug is unclear. OBJECTIVES: Identifying optimal doses of dexmedetomidine added to bupivacaine in the TAP block. METHODS: In this randomized controlled trial, 86 patients candidate for elective open inguinal herniorrhaphy under spinal anesthesia were divided randomly into three groups; low (L), medium (M), and high (H) dose of dexmedetomidine, that finally 80 cases ended the study and were analyzed. At the end of the surgery, the patients underwent ultrasound-guided TAP block. In all patients of the three groups, the analgesic base of the block was 20 mL bupivacaine 0.125% that was supplemented with 0.5, 1, or 1.5 µ/kg of dexmedetomidine in groups L, M, and H, respectively. RESULTS: The maximum duration of the block was 4 hours in group L and 8 hours in groups M and H. None of the patients needed to receive analgesic at 0, 2, and 24 hours after the block. The dose of analgesic required in the first 8 hours of the block in groups M and H was less than in group L (P < 0.02). Patients in groups H and M were more satisfied with the block (P < 0.01) and experienced less pain compared with group L (P < 0.01). Drowsiness and sedation were observed in patients up to 4 hours after the TAP block, which was dependent on the dexmedetomidine dose (P < 0.01). CONCLUSIONS: Based on our results, the optimal dose of supplemental dexmedetomidine could be 1 µ/kg in the TAP block.

Resultados clínicos del tratamiento de pacientes con hernia inguinal unilateral mediante cirugía ambulatoria

Objetivo: Describir los resultados clínicos del tratamiento de pacientes con hernia inguinal unilateral (HIU) realizados en una unidad de cirugía mayor ambulatoria de un hospital de nivel III. Material y métodos: Se revisaron las historias clínicas de los pacientes operados de HIU en la Unidad de Cirugía Mayor ambulatoria (UCMA) del Hospital Cayetano Heredia (HCH) entre julio del 2013 y junio del 2016. Resultados: El número final de pacientes incluidos fue 154. La edad promedio fue 43 años; 101 (65,6%) fueron varones; 104 (67,5%) tenían riesgo quirúrgico ASA I; 12 (7,8%) tenían enfermedades asociadas; 94 (61,0%) se operaron con la técnica abierta, y 60 (39,0%) por la vía laparoscópica. La cirugía laparoscópica fue usada con más frecuencia en las mujeres (p=0.037). El tiempo operatorio fue mayor en la cirugía laparoscópica (p=0.033). No hubo diferencia significativa con respecto a la edad, riesgo quirúrgico, complicaciones anestésicas y complicaciones quirúrgicas entre pacientes operados con cirugía abierta y con cirugía laparoscópica. En total 34 (22%) pacientes no salieron de alta el mismo día de la cirugía: Ocho (5,2%) pacientes por presentar complicaciones y 26 (16,8%) pacientes por razones administrativas/ sociales. Conclusión: La cirugía ambulatoria de HIU en adultos realizada por la técnica abierta o laparoscópica, es un procedimiento seguro que permite el alta del paciente el mismo día de la cirugía.

SUMMARY Objective: To describe the clinical outcomes of patients with unilateral inguinal hernia (UIH) treated in an ambulatory surgical unit (ASU) of a level III hospital. Methods: The clinical charts of patients treated at the ASU of Cayetano Heredia Hospital from July 2013 to June 2016 were reviewed. Results: 154 patients were included, mean age was 43 years; 101 (65.6%) were males; 104 (67.5%) had ASA I risk; 12 (7.8%) had underlying diseases; 94 (61.0%) undergone the open technique and 60 (39.0%) undergone laparoscopy. Laparoscopy was most frequently applied in women (p=0.037). Surgical time was higher in laparoscopic procedures (p=0.033). No significant differences were observed in variables such as age, surgical risk, anesthetic and surgical complications between open and laparoscopic procedures. Thirty-four (22%) patients were not discharged the day of the procedure: 8 (5.2%) presented complications and 26 (16.8%) had administrative or social reasons. Conclusion : Ambulatory surgery of UIH in adults either by open or laparoscopic procedures is safe and allows discharging patients the day of the procedure.

Better timing of ultrasound-guided transversus abdominis plane block for early recovery after open inguinal herniorrhaphy: A prospective randomised controlled study.

BACKGROUND: This study investigated the optimal timing of analgesic transversus abdominis plane (TAP) block in the operating room for better recovery quality using the Korean version of the Quality of Recovery-40 (QoR-40K) questionnaire in patients who had undergone open inguinal herniorrhaphy. METHODS: This single-centre, prospective randomised controlled study included adult male patients who had an ASA physical status of I-II. A total of 80 patients were analysed. The patients were randomly assigned and classified into pre-incisional TAP (pre-TAP) block (n = 40) and post-incisional TAP (post-TAP) block (n = 40) groups. The quality of postoperative functional recovery and complications were compared between the two groups during 24 h postoperatively. RESULTS: Preoperative findings of the two groups were comparable. The global QoR-40K score was higher in the pre-TAP group than in the post-TAP group. Among sub-dimensions, scores of physical comfort and pain were higher in the pre-TAP group than in the post-TAP group. In the post-anaesthesia care unit, the pre-TAP group showed lower pain scores than the post-TAP block group. There was no severe pain in the pre-TAP group, but two patients (5.0%) in the post-TAP block group suffered severe pain. The pre-TAP group required lower doses of IV rescue opioid in the PACU than the post-TAP group. All patients were discharged from hospital on postoperative day 1 without surgical complications. CONCLUSIONS: The timing of analgesic TAP block may be of clinical importance to prevent postoperative pain and to improve the quality of early patient recovery following open inguinal herniorrhaphy.

[Factors influencing recovery from childhood inguinal herniorrhaphy-induced vas deferens obstruction after microscopic vasovasostomy].

OBJECTIVE: To investigate the factors influencing the recovery from childhood inguinal herniorrhaphy (IH)-induced vas deferens obstruction following microscopic vasovasostomy. METHODS: We retrospectively analyzed the clinical data on 41 cases of microscopic vasovasostomy for obstructive azoospermia in our hospital from July 2015 to September 2018. All the patients had a history of inguinal hernia treated by IH in the childhood. We performed scrotal ultrasonography, semen analysis and seminal plasma biochemistry to confirm vas deferens obstruction preoperatively. If sperm was observed for ≥2 times in semen examination after vasovasostomy, we considered the vas deferens successfully unobstructed. RESULTS: Microscopic vasovasostomy was successfully completed in 39 of the cases, of which2 were lost to follow-up, with a follow-up rate of 94.8% (37/39). The patients, at the mean age of (25.54 ± 2.85) years and with body mass index (BMI) of (24.92 ± 2.79) kg/m2 and post-IH time of (18.97 ± 2.58) years, were followed up for (13.05 ± 3.74) months. Successful recovery from vas deferens obstruction was observed in 78.4% (29/37) of the patients after IH, 80.0% (16/20) in the < 26-year-olds, 76.5% (13/17) in the ≥26-year-olds (P = 0.795), 75.0% (12/16) in those with BMI < 24.92 kg/m2 , 81.0% (17/21) in those with BMI ≥24.92 kg/m2 (P = 0.807), 78.6% (11/14) in those with post-IH time of < 19 years, 18.3% (18/23) in those with post-IH time of ≥19 years (P = 0.982), 60.0% (12/20) in those with sperm and 82.4% (14/17) in those without sperm found intraoperatively (P = 0.428), 42.9% (3/7) in those treated by unilateral and 82.4% (26/30) in those by bilateral vasovasostomy (P = 0.027). Multivariate logistic regression analysis showed a close correlation between the operation side and postoperative recovery from vas deferens obstruction (P = 0.022). CONCLUSIONS: For male patients undergoing microscopic vasovasostomy for childhood IH-induced vas deferens obstruction, the operation side is an independent factor influencing postoperative recovery, while age, BMI, post-IH time, and intraoperative presence or absence of sperm are not significantly correlated with it.

Open tensionless repair techniques for inguinal hernia: a meta-analysis of randomized controlled trials.

BACKGROUND: Lichtenstein repair (LR), mesh-plug repair (MPR), and prolene hernia system (PHS) are three common open tensionless repair techniques for inguinal hernia (IH); each technique has its supporters and controversies never stop. It is necessary to perform a meta-analysis to evaluate the clinical efficacy of these three open tensionless repair techniques. METHODS: RCTs comparing at least any two of the three open tensionless repair techniques for IH were searched in online databases. Literature screening and quality assessment were carried out basing on the established inclusion criteria and exclusion criteria. Statistical analyses were carried out using RevMan software 5.3. The primary outcomes were recurrence, chronic pain and time to return to work. Secondary outcomes were inguinal paresthesia, testicular and scrotal problems, hematoma, seroma and wound infection. RESULTS: Twenty-two references on fifteen RCTs involving a total of 3716 hernias were selected for the meta-analysis. In these trials, seven comparing LR and MPR, five comparing LR and PHS, and three comparing LR, MPR and PHS. All primary and secondary outcomes could be pooled analyzed in comparison of MPR and PHS with LR, while only two primary outcomes (recurrence and chronic pain) and one secondary outcome (wound infection) could be pooled analyzed in comparison of MPR with PHS. Results of this meta-analysis demonstrated that MPR and PHS were comparable to LR in all primary and secondary outcomes, and MPR and PHS were comparable in terms of recurrence, chronic pain and wound infection. CONCLUSIONS: This meta-analysis indicates that MPR and PHS seem comparable to LR in terms of recurrence, chronic pain, time to return to work, inguinal paresthesia, testicular and scrotal problems, hematoma, seroma and wound infection. MPR and PHS seem comparable in terms of recurrence, chronic pain and wound infection.

Multimodal analgesia for treatment of allodynia and hyperalgesia after major trauma in a cat.

CASE SUMMARY: A 2-year-old polytraumatized male cat was admitted to a teaching hospital for correction of a defective inguinal herniorrhaphy. Upon arrival, the cat showed signs of neuropathic pain, including allodynia and hyperalgesia. Analgesic therapy was initiated with methadone and metamizole; however, 24 h later, the signs of pain continued. Reparative surgery was performed, and a multimodal analgesic regimen was administered (methadone, ketamine, wound catheter and epidural anesthesia). Postoperatively, the cat showed signs of severe pain, assessed using the UNESP-Botucatu multidimensional composite pain scale. Rescue analgesia was initiated, which included methadone, bupivacaine (subcutaneous wound-diffusion catheter) and transversus abdominis plane block. Because the response was incomplete, co-adjuvant therapy (pregabalin and electroacupuncture) was then implemented. Fourteen days after admission, the patient was discharged with oral tramadol and pregabalin for at-home treatment. RELEVANCE AND NOVEL INFORMATION: Neuropathic pain is caused by a primary lesion or dysfunction in the nervous system and is a well-described complication following trauma, surgical procedures such as hernia repair, and inadequate analgesia. The aims of this report are to: (1) describe a presentation of neuropathic pain to highlight the recognition of clinical signs such as allodynia and hyperalgesia in cats; and (2) describe treatment of multi-origin, severe, long-standing, 'mixed' pain (acute inflammatory with a neuropathic component). The patient was managed using multiple analgesic strategies (multimodal analgesia), including opioids, non-steroidal anti-inflammatory drugs, locoregional anesthesia, co-adjuvant drugs and non-pharmacological therapy (electroacupuncture).

Pure tissue repairs: a timely and critical revival.

"The majority of hernias can be satisfactorily repaired by using the tissues at hand. The use of mesh prosthesis should be restricted to those few hernias in which tension or lack of good fascial structures prevents a secure primary repair. This group includes large direct inguinal hernias and incisional hernias in which the defect is too large to close primarily without undue tension. Most recurrent hernias, because of this factor are best repaired with mesh prosthesis". These words, penned in 1960 by Francis Usher have reconfirmed what had been a mantra of the Shouldice Hospital (Usher in 81:847-854, 1960). The Shouldice Hospital has specialized in the treatment of abdominal wall hernias since 1945. It has, since its beginning, insisted on the fact that a thorough knowledge of anatomy coupled with large volumes of surgical cases would lead to unparalleled expertise. It was Cicero who taught us that "Practice, not intelligence or dexterity, will win the day"! Since the seminal contribution of Bassini (1844-1924), there have been no less than 80 procedures imitating his inguinal herniorrhaphy and much more since the introduction of mesh and mesh devices (Iason in Hernia. The Blakiston Company, Philadelphia, pp 475-604, 1940). All have failed to some extent and it appears that the common denominator for these failures was the inability to understand the importance of entering the preperitoneal space. Only Shouldice and McVay (Lotheissen, Narath) realized the shortcoming and have continued to thrive as a successful procedure. Entering the preperitoneal space eliminates any temptation to plicate the posterior inguinal wall, a layer normally deficient in direct inguinal hernias, but it also allows the identification of muscle layers rectus, transversus and internal oblique muscles which will go to reconstruct the posterior inguinal wall, without tension as reported by Schumpelick (Junge in 7(1):17-20, 2003).

[Laparoscopic repair of inguinal hernia and communicating hydrocele in children. Our experience in the last years]. / Reparación laparoscópica de la hernia inguinal e hidrocele en edad pediátrica. Nuestra experiencia en los últimos años.

INTRODUCTION: Laparoscopic inguinal hernia and hydrocele repair has become an alternative to the more frequently used inguinal approach. We describe our experience with the laparoscopic technique. MATERIAL AND METHODS: Retrospective study of laparoscopic inguinal hernia and hydrocele repair performed during the period between 2003-2016. We included patients < 14 years, with communicating hydrocele and/or indirect inguinal hernia diagnosis (N = 39). We have studied two cohorts; group A patients with indirect inguinal hernia (N = 31) and group B patients with communicating hydrocele (N = 8). We used intraperitoneal laparoscopic approach, performing herniorrhaphy of the internal inguinal orifice without resection of the hernial sac. The main outcome measurements were surgical indication and postoperative complications. RESULTS: The indication for laparoscopic repair was bilateral defects (46.2%), unilateral defects (28.2%), defects associated with umbilical hernia (23.1%) and associated with another pathology (2.6%). In group A the rate of complications that required new admission was 3.2% and the recurrence rate was 9.7%. In group B, was 12.5% ​​and 12.5% respectively. We have not observed a significant relationship with respect to patient age, laterality or suture used and the rate of complications in any of the groups. CONCLUSIONS: Despite the limitations of our study given the small sample size and retrospective nature, the complication rate (15%) is higher than that published in the literature. This makes us take a step back to reassess our indications and technique, and not forget that the laparoscopic approach is not a technique without risks and requires a learning curve.

OBJETIVOS: La reparación laparoscópica de la hernia inguinal e hidroceles en la edad pediátrica, se ha convertido en una alternativa a la herniorrafia inguinal clásica. Describimos nuestra experiencia en las intervenciones realizadas con dicha técnica. MATERIAL Y METODOS: Estudio retrospectivo de las reparaciones laparoscópicas de hernia inguinal e hidrocele realizadas en el periodo 2003-2016. Se han incluido pacientes <14 años, diagnosticados de hidrocele comunicante y/o de hernia inguinal indirecta (N=39), divididos en dos cohortes: grupo A pacientes con hernia inguinal indirecta y grupo B pacientes con hidrocele comunicante. Se ha empleado el abordaje laparoscópico intraperitoneal, y anillorrafia del orificio inguinal interno sin resección del saco herniario. Las variables principales estudiadas han sido la indicación quirúrgica y las complicaciones postquirúrgicas. RESULTADOS: Las indicaciones quirúrgicas han sido los defectos bilaterales (46,2%), defectos unilaterales (28,2%), defectos asociados a hernia umbilical (23,1%) y asociados a otra patología (2,6%). En el grupo A la tasa de complicaciones que precisaron de ingreso fue de 3,2% y la tasa de recurrencias fue de 9,7%; mientras que en el B han sido del 12,5% y del 12,5% respectivamente. No hay una relación significativa respecto a la edad, la lateralidad o la sutura utilizada y la tasa de complicaciones en ninguno de los grupos. CONCLUSIONES: A pesar de las limitaciones del estudio, el porcentaje total de complicaciones (15,3%) es más elevado que el publicado en la literatura. Esto nos hace reflexionar y no olvidar que el abordaje laparoscópico no es una técnica exenta de riesgos y requiere de una curva de aprendizaje.

Ultrasonography in diagnosis and analysis of chronic pain following anterior open inguinal herniorrhaphy.

BACKGROUND: Chronic pain as a complication following inguinal herniorrhaphy has attracted increasing attention in recent years. There is evidence that the chronic pain seriously affects patients' quality of life. However, there are few imaging studies and diagnostic techniques of the chronic pain. The aim of this study is to explore the etiology and to analysis ultrasonographic imaging description of chronic pain following anterior open inguinal herniorrhaphy. METHODS: One hundred fifty two patients with the chronic pain following anterior open inguinal herniorrhaphy were performed by ultrasonography to identify the main causes of postoperative chronic pain. Positive ultrasonic diagnoses were confirmed to be correct by the pain relieved when the patients underwent re-operation and other clinical operations. Positive diagnoses which appeared simultaneously were grouped for pairwise comparisons. RESULTS: Two hundred sixteen positive ultrasonic diagnoses, 12 categories of postoperative chronic pain were found. They were encapsulated effusion, scrotal wall edema, testitis, hydrocele testis, restricted motion of spermatic cord at the reconstructed deep inguinal ring, varicocele, scar sutured into pubic tubercle, shrinking mesh, accumulational mesh or mesh plug, recurrent hernia, cyst of spermatic cord and epididymal cyst. In the pairwise comparison groups, encapsulated effusion with scrotal wall edema, varicocele with restricted motion of spermatic cord at the reconstructed deep inguinal ring, and shrinking mesh with recurrent hernia had significant differences in each intragroup comparisons(P < 0.05). CONCLUSIONS: Ultrasonography provieds important value in the diagnosis of chronic pain following anterior open inguinal herniorrhaphy. Some positive diagnoses occur simultaneously, which is necessary for doctors to consider comprehensively.

Inguinal Hernia: Mastering the Anatomy.

The success of an inguinal hernia repair is defined by the permanence of the operation while creating the fewest complications at minimal cost and allowing patients an early return to activity. This success relies and depends on the surgeon's knowledge and understanding of groin anatomy and physiology. This article reviews relevant anatomy to inguinal hernia repair and technical steps to open tissue and mesh repairs as well as minimally invasive approaches.

Transient obturator nerve block with fascia iliaca compartment block following local infiltration for open inguinal herniorrhaphy.

BACKGROUND: Ilioinguinal nerve block is effective for analgesia after open inguinal herniorrhaphy. However, transient femoral nerve palsy can happen after the block. The ambulatory patients sometimes cannot discharge from the hospital with the motor deficiency. Here is described a case of fascia iliaca compartment block with complete obturator nerve block after surgical infiltration analgesia for open inguinal herniorrhaphy. CASE PRESENTATION: An ambulatory open inguinal herniorrhaphy was performed for a 63-year-old male under general anesthesia. The mixture of short-/long-acting local anesthetics was injected by the surgeon into the subcutaneous tissue, between the Camper's and Scarpa's fasciae, into the inguinal canal, and between the internal oblique and transversus abdominis muscles. The patient could not adduct his ipsilateral hip joint at all 1 h after emergence. The flexion of the hip joint was weakened two more hours later, and numbness of the lateral thigh emerged. The complications completely resolved 7 h after surgery. CONCLUSIONS: Surgical infiltration analgesia as well as percutaneous ilioinguinal nerve block can cause both fascia iliaca plane block and obturator nerve block. Analgesia regimen should be carefully built for ambulatory surgery.

Comparison of efficacy of transversus abdominis plane block and iliohypogastric/ilioinguinal nerve block for postoperative pain management in patients undergoing inguinal herniorrhaphy with spinal anesthesia: a prospective randomized controlled open-label study.

PURPOSES: The purpose of this study was to compare the effects of lateral abdominal transversus abdominis plane block (TAP block) and iliohypogastric/ilioinguinal nerve block (IHINB) under ultrasound guidance for postoperative pain management of inguinal hernia repair. Secondary purposes were to compare the complication rates of the two techniques and to examine the effects of TAP block and IHINB on chronic postoperative pain. METHODS: This was a prospective randomized controlled open-label study. After approval of the Research Ethics Board, a total of 90 patients were allocated to three groups of 30 by simple randomized sampling as determined with a priori power analysis. Peripheral nerve blocks (TAP block or IHINB) were administered to patients following subarachnoid block according to their allocated group. Patient pain scores, additional analgesic requirements and complication rates were recorded periodically and compared. RESULTS: Pain scores were significantly lower in the study groups (p < 0.001, p < 0.001, p < 0.001, p = 0.002, p < 0.001, p < 0.001 for 1, 2, 4, 6, 24, and 48 h and at 1 and 6 months, respectively). First pain declaration times were significantly longer in the study groups (TAP block group [GT] 266.6 ± 119.7 min; IHINB group [GI] 247.2 ± 128.7 min; and control group [GC] 79.1 ± 66.2 min; p < 0.001). At 24 h, the numeric rating scale scores of GT were significantly lower than GI (p = 0.048). Additional analgesic requirements of GT and GI patients were found to be significantly lower than GC patients (p = 0.001, p < 0.001, p = 0.006, p = 0.002, p = 0.001, p < 0.001 for 1, 2, 4, 6, 24, and 48 h, respectively). CONCLUSION: We conclude that administration of TAP block or IHINB for patients undergoing inguinal herniorrhaphy reduces the intensity of both acute and chronic postoperative pain and additional analgesic requirements.

"Scarless" Inguinal Herniorrhaphy.

INTRODUCTION: Laparoscopic inguinal herniorrhaphy is widely accepted. Robotic-assisted surgery provides improved 3-dimensional visualization and enhanced dexterity. The purpose of this case series was to demonstrate the feasibility of a modified, robotic, single-site, unilateral inguinal herniorrhaphy. TECHNIQUE: Six patients 18 years of age or older with a body mass index <35 provided informed consent and underwent hernia repair with a modified herniorrhaphy technique from January to July 2014. Eight patients were screened and six case experiences are described in this series. The da Vinci Si robot, gel port, and instruments (Intuitive Surgical, Sunnyvale, California, USA) were used. With the patient in Trendelenburg position, a 25-mm incision was made within the umbilicus. The fascia was incised, and the peritoneal cavity was entered. A robotic cholecystectomy gel port was placed. Robotic instruments were inserted, and the robot was docked. A preperitoneal flap was raised on the affected side with the robotic instruments used interchangeably. The hernia sac was identified and reduced, and the mesh was tacked in place. The preperitoneal flap was tacked back in place. The robot was undocked, the abdomen was desufflated, and the fascia was closed. DISCUSSION: Single-site unilateral inguinal herniorrhaphy was performed for 6 patients. All patients were discharged the same day, had good aesthetic results, and experienced no hernia recurrence. Robotic single-site gel port inguinal herniorrhaphy is feasible and appears as safe and time efficient as laparoscopic herniorrhaphy in this small group.