OBJECTIVE: Seroma formation is the most common cause of morbidity associated with laparoscopic inguinal hernia repair. This study aimed to examine the relationship between the thickness of subcutaneous fat (TSF) and the risk of postoperative seroma.
METHODS: We reviewed data from a prospective cohort of 229 male patients who underwent laparoscopic total extra-peritoneal (TEP) hernioplasty for indirect inguinal hernia between August 2018 and July 2021. The TSF was assessed using preoperative ultrasound images. The risk factors for postoperative seroma were determined using univariate and multivariate logistic regression models.
RESULTS: Postoperative seromas occurred in 26 patients (11.4%). The factors associated with postoperative seroma included longer hernia duration, larger hernia defects, extension into the scrotum, and greater TSF (P < 0.05). In multivariate analysis, a greater TSF was independently associated with a greater risk of postoperative seroma (per 1 mm: odd ratio [OR] 1.105, 95% confidence interval [CI] 1.048-1.165, P < 0.001; TSF ≥ 26.0 mm: OR 7.033, 95% CI 2.485-19.901, P < 0.001). Similar results were obtained in the subgroup analysis. The area under the curve of TSF for predicting seroma formation was 0.703 (95% CI 0.601-0.806).
CONCLUSIONS: Ultrasound-derived TSF may be a promising prognostic factor for postoperative seroma in patients undergoing laparoscopic TEP repair. Further validation is required and then this parameter can be used to improve decision-making process.

OBJECTIVE: Seroma represents the most prevalent postoperative complication following laparoscopic inguinal hernia repair, particularly in the case of large inguinoscrotal hernias. This randomized controlled trial was undertaken with the objective of assessing the effects of internal orifice narrowing achieved by suturing the divided distal hernia sac in laparoscopic repair of indirect inguinoscrotal hernias.
METHODS: A total of 58 patients aged 18 years or older, were randomized into two groups: Group I, which underwent internal orifice narrowing, and Group II, which served as the control without narrowing. The study\'s primary endpoint was the incidence and volume of seroma in the inguinal region on postoperative days 1 and 7, as well as at 1, 3, and 6 months following the procedure. Secondary outcomes encompassed metrics like total operative time, acute and chronic pain levels, duration of hospital stay, recurrence rates, and the occurrence of any additional complications.
RESULTS: In comparison to the control group, the experimental group exhibited a significantly lower incidence of seroma formation at 7 days (P = 0.001). Furthermore, the ultrasonic assessment indicated a reduced seroma volume in the operative group on postoperative day 7 (8.84 ± 17.71 vs. 52.39 ± 70.78 mL; P < 0.001). Acute pain levels and hospital stay were similar between the two groups (1.22 ± 0.76 vs. 1.04 ± 0.53, P = 0.073; 1.22 ± 0.07 vs. 1.19 ± 0.08, P = 0.627, respectively). Notably, neither chronic pain nor early recurrence, nor any other postoperative complications were observed in either group throughout the follow-up period, which extended for at least 6 months (range: 6-18 months).
CONCLUSIONS: In the context of laparoscopic inguinoscrotal hernia repair, the incidence and volume of seroma can be significantly reduced through the implementation of internal orifice narrowing achieved by suturing the divided distal hernia sac. And, this reduction in seroma formation was not associated elevation in postoperative pain levels or recurrence rates.

Introduction and importance: More than 600 cases of De Garengeot\'s hernia, characterized by a femoral hernia containing the vermiform appendix, have been reported. The surgical method of choice has been an appendectomy and a primary hernia repair. Since the emergence of laparoscopy, this is undoubtedly an option. However, the treatment of the appendix remains in most reports as an appendectomy. Successful appendix-sparing treatment of De Garengeot\'s hernia via laparotomy or laparoscopy has been described, mainly since the COVID-19 pandemic. Case presentation: We report a new case of an 80-year-old woman with an incarcerated De Garengeot\'s appendiceal femoral-crural hernia, successfully treated entirely laparoscopically. She had noticed the protrusion of a lump in her right inguinal region for two months. Radiological studies, ultrasonography (US), and computed tomography (CT) were inconclusive. Due to the failure in the preoperative diagnosis, a minimally invasive endoscopic approach was performed. Although the distal appendix appeared incarcerated in the femoral ring, there was no evidence of appendicitis. Thus, a fully laparoscopic appendix-sparing transabdominal preperitoneal (TAPP) hernioplasty procedure was undertaken. The patient made an uninterrupted recovery. She did well postoperatively with no complications, left the hospital the same day in a stable condition, returned to complete activities, and has enjoyed good health since. Clinical Discussion: Our literature review shows that in selected cases an appendectomy may be safely avoided, eliminating appendectomy-associated morbidity, and could be considered the first-line alternative when expertise is available. Conclusion: A fully laparoscopic appendix-sparing TAPP approach seems safe and feasible to treat this entity.

OBJECTIVE: To find the superiority of extended total extraperitoneal (E-TEP) repair and trans-abdominal pre-peritoneal (TAPP) mesh repair in inguinal hernia repair.
METHODS: A total of 30 patients with a unilateral or bilateral inguinal hernia (IH), and recurrent IH, following open repair were studied. Out of 30 patients, laparoscopic TAPP or E-TEP mesh repair was performed in an equal number of inguinal hernia patients. The patient\'s demographic parameters, duration of surgery, postoperative hospital stay, and complications were compared.
RESULTS:  In the E-TEP group, 33.33% of patients had left inguinal hernia (LIH), 60% of patients were diagnosed with right inguinal hernia (RIH) and 6.67% of patients had right inguinal and right direct hernia (RDH). In the TAPP group, 33.33% of patients had LIH and 53.33% of patients were suffering from RIH. Moreover, 6.67% of patients were diagnosed with a left inguinal direct hernia, and a similar proportion of patients had a right inguinal direct hernia. The mean duration of surgery was found to be significantly higher in the TAPP group (P<0.0000). The mean postoperative hospital stay was 2.07±0.59 and 2.80±1.32 days in E-TEP and TAPP groups, respectively (P=0.044).
CONCLUSIONS: In the present study, E-TEP mesh repair is a superior technique in the management of inguinal hernia as compared with TAPP repair.

OBJECTIVE: Less than 450 cases of femoral hernias containing the vermiform appendix have been published since De Garengeot\'s first description. A laparoscopic treatment option opened 15 years ago seems reliable and safe. A literature review of all the patients who have benefited from this new therapeutic alternative is presented.
METHODS: A systematic review using the German Society of Surgery\'s recommendations was performed for De Garengeot\'s hernias totally treated laparoscopically. Keywords searched included \"De Garengeot hernia\" OR \"femoral hernia appendix\" OR \"crural hernia appendix.\"
RESULTS: Only 29 out of 225 De Garengeot hernia\'s manuscripts were identified describing patients entirely treated laparoscopically: 25 patients by a transabdominal preperitoneal hernia repair (TAPP) and 4 patients by a total extraperitoneal (TEP) procedure; 85.1% were females. The mean age was 71 years. Twenty-two patients had pre-operative imaging tests, sonography (2), computed tomography (14), or both (6). Nevertheless, only 56% had a preoperative diagnosis. Twenty-one cases required urgent treatment, while programmed surgery was possible in 7 instances. An appendix-sparing procedure could be done in 16% of the TAPPs. No postoperative complications occurred. The median hospital stay was 2.5 days.
CONCLUSIONS: The best surgical approach for a De Garengeot\'s hernia is not defined, and many critical questions remain unanswered. A better understanding of the diagnosis and treatment of this peculiar hernia will supply guidelines for clinicians who may encounter it hereafter. A fully laparoscopic approach seems perfectly safe and feasible for this entity, and it could be considered the first-line alternative if enough expertise is available.

Background and Objectives: Less than 300 cases of a De Garengeot\'s hernia have been published. This rare femoral hernia with the vermiform appendix included appears almost exclusively on the right side, mainly in females, and it generally debuts as an incarcerated femoral hernia. Although most of the times there is a concomitant appendicitis, clinical signs of peritonitis are absent. The wide use of radiologic exams has not favored its preoperative diagnosis, but been usually found incidentally during a surgical emergency. The best surgical approach to a De Garengeot\'s hernia is not totally defined and many critical questions still remain unanswered. Open surgery is considered the standard treatment procedure, but since the emergence of laparoscopy for incarcerated hernias, this is certainly an option. Methods: We report the successful laparoscopic management of an 83-year-old woman who had been operated on her right inguinal hernia, with a Rutkow-Robbins\' technique, 4 months earlier. She had noticed the protrusion of a lump in her right inguinal region for 2 months. Radiological studies were not conclusive. With a miss diagnosis of a recurrent incarcerated inguinal hernia, a minimal invasive endoscopic approach was performed. A representative case of this fully laparoscopic TAPP procedure is presented. Results: The patient made an uninterrupted recovery. She left the hospital the day after in a stable condition and has enjoyed good health since. Conclusion: A fully laparoscopic TAPP approach seems perfectly safe and feasible to treat this entity, and could be considered the first line alternative when enough expertise is available.

OBJECTIVE: The best way to reduce seroma formation after laparoscopic indirect hernia repair is debated. We noticed that internal ring defect closure in laparoscopic mesh hernioplasty could provide promising outcomes with an effect on diminishing seroma formation. We introduce our closure technique and report our experience.
METHODS: This prospective study was conducted from May 2019 to May 2021. Patients with European Hernia Society classification L3 indirect or scrotal hernia were recruited and underwent laparoscopic transabdominal patch plasty (TAPP). Hernia defect closure was performed before mesh deployment. The primary outcomes were seroma formation, postoperative pain, and hernia recurrence. Perioperative data and postoperative complications were also recorded.
RESULTS: Consecutive 77 patients with 89 indirect hernias (including 51 scrotal hernias) were recruited in two regional tertiary hospitals. All operations were successful without open conversion. The mean size of the hernia defect was 3.7 ± 0.5 cm (range, 2.5-5.0 cm). The mean operative time for each hernia repair (peritoneum to peritoneum) was 48.3 ± 10.8 min (range, 33-72 min), and the mean time required for internal ring closure was 6.7 ± 2.2 min (range, 4-10 min). Intraoperative bleeding was minimal. The mean visual analog scale pain score at rest on the first postoperative day was 2.2 (range, 1-4). The average postoperative length of hospital stay was 18 h (range, 14-46 h). During a mean follow-up period of 9.4 months (range, 3-23 months), no hernia recurrence or chronic pain were noted. Seroma formation was detected on six sides of unilateral hernias (6.7%) on postoperative day 7, with a mean volume of 45.8 ml (range, 24-80 ml). All seromas were mild and resolved spontaneously within 3 months, with no need for evacuation or other treatment and without major impact on the final outcome.
CONCLUSIONS: Defect closure in laparoscopic mesh hernioplasty for large indirect hernias is safe and feasible and can significantly reduce postoperative seroma formation and relative complications. This approach is recommended in large indirect or scrotal hernia repair.

OBJECTIVE: To evaluate the results of using titanium thread mesh implants in the treatment of anterior abdominal wall hernias.
METHODS: This article evaluates the titanium thread mesh implant used by us in the treatment of 240 patients with anterior abdominal wall hernias; describes the features of this type of implants and the technical features of various types of operations using them.
RESULTS: The overall rate of postoperative complications was 2.9%. Hernia recurrence was observed in 2.4% of patients after laparoscopic transabdominal preperitoneal hernioplasty.
CONCLUSIONS: The use of a mesh implant made of titanium thread did not reveal any specific complications for this implant. At the stage of gaining experience with a mesh implant made of titanium thread, technical difficulties may occur when placing and fixing it, which increases the duration of surgery.
UNASSIGNED: Оценка результатов использования сетчатых имплантатов из титановой нити при лечении грыж передней брюшной стенки.
UNASSIGNED: Наблюдали 240 больных с грыжами передней брюшной стенки, которым было проведено лечение с применением сетчатого имплантата из титановой нити. Выявляли особенности применения имплантатов этого типа и технические особенности выполнения разных видов операций с их использованием.
UNASSIGNED: Общая частота послеоперационных осложнений составила 2,9%. Рецидив грыжи отмечали у 2,4% больных после лапароскопической трансабдоминальной предбрюшинной герниопластики.
UNASSIGNED: Использование сетчатого имплантата из титановой нити не выявило специфических осложнений. На этапе приобретения опыта работы с сетчатым имплантатом из титановой нити возможны технические сложности при его размещении и фиксации, что увеличивает продолжительность оперативного вмешательства.

UNASSIGNED: Posterior rectus canal assumed immense importance with newer laparoscopic technique of total extra-peritoneal pre-peritoneal (TEPP/TEP) hernioplasty for inguinal hernia. However, scientific study of live surgical anatomy of posterior rectus canal is almost totally lacking in the English literature, and hence the present study was conducted.
UNASSIGNED: 3-midline-port technique through posterior rectus sheath approach; Initial telescopic dissection under direct CO2 insufflation followed by instrument dissection.
UNASSIGNED: 68 TEPP hernioplasties were successful in 60 patients with mean age of 50.1 ± 17.2 years (range 18-80) and mean BMI of 22.6 ± 2.0 kg/m2 (range 19.5-31.2). Rectusial fascia was a definite anatomical entity, dividing traditional posterior rectus canal into two channels, namely, true retromuscular space and true posterior rectus canal (T-PRC). Rectusial fascia was variable, i.e., thick diaphanous (n= 47), thick membranous (n= 13), thin membranous (n= 3) and thin flimsy (n= 5). Posterior rectus sheath (PRS) was also variable, incomplete (n= 54) and complete (n= 14). Incomplete PRS showed seven variations in both extent and/or morphology. Complete PRS show five morphological variations. Transversalis fascia demonstrated three morphological variations, namely, single diaphanous (n= 41), single membranous (= 10) and thin flimsy (n= 3). TEPP hernioplasty was readily feasible through avascular true posterior rectus canal.
UNASSIGNED: Posterior rectus canal is divided by \'rectusial fascia\' into two channels, namely, true retromuscular space and true posterior rectus canal, latter being proper avascular plane of dissection for TEPP hernioplasty. Rectusial fascia, posterior rectus sheath and transversalis fascia showed morphological variations. Timely recognition of variable real-time anatomy is recommended to perform adequate proper surgical dissection for seamless TEPP hernioplasty with ease, rapidity and safety.

BACKGROUND: Technical factors leading to hernia recurrence after transabdominal preperitoneal repair include insufficient dissection, inadequate prosthetic overlap and prosthetic size, improper fixation and folding, or crinkling of the prosthesis. However, determining intraoperatively if a case will develop recurrent hernias due to these factors remains unclear.
METHODS: Five surgeons blind-reviewed operation videos of primary laparoscopic hernioplasty in 13 lesions that went on to develop recurrent hernias (i.e., future recurrence), as well as 28 control lesions, to assess twelve items of surgical techniques. Since we changed a surgical policy of covering myopectineal orifice (MPO) in April 2003, we analyzed the data for the earlier and later periods. The data was analyzed with hierarchical clustering to obtain a gross grouping. The differences of the ratings between the future recurrent and control lesions were then analyzed and the association of the techniques with the hernia recurrence rate, the size of the prosthesis, and the hernia type across hernia recurrence were explored.
RESULTS: The lesions were grouped based on the time series, and its boundary was approximated when we changed our surgical policy. This policy change caused ratings to progress from 34% satisfactory, to 79% satisfactory. The recurrence rate decreased to 0.7% (5/678), compared with 6.2% (10/161) before the policy was implemented (p < 0.001). With univariate analysis, the ratings of posterior prosthesis overlap to the MPO in the recurrent lesions were significantly lower than controls in the later period (p = 0.019). Although various types of recurrences were noted in the earlier period, only primary indirect and recurrent indirect hernias were observed in the later period (p = 0.006).
CONCLUSIONS: Fully covering the MPO with mesh is essential for preventing direct recurrence hernias. Additional hernia recurrence prevention can be obtained by giving appropriate attention to prosthesis overlap posterior to the MPO in a large indirect hernia.