The optimal surgical approach of incarcerated and strangulated inguinal hernia is controversial. Retrospective studies showed that surgical approaches through lower abdominal median incision or laparoscopic are superior to the oblique inguinal incision, respectively. Whether transabdominal laparoscopic approach is superior to the lower abdominal median incision approach needs prospective research.Prospective comparative study of patients with incarcerated and strangulated groin hernia admitted to Jinshan hospital for emergency surgery from January 2018 to June 2022. They were divided into two groups according to different surgical approach. The open preperitoneal repair group (OPR) was operated through the lower abdominal median incision. Laparoscopic preperitoneal repair group (TAPP) was completed under transabdominal laparoscope. The perioperative complications and long-term results of the two groups were compared and analyzed. Eighty-two patients met the inclusion criteria, 40 in OPR group and 42 in TAPP group. Baseline data of the two groups were comparable. Thirteen cases (15.9%) of the two groups underwent intestinal resection and anastomosis. Seventy cases (90.2%) underwent the 1st stage mesh repair, including 5 cases of preperitoneal hernioplasty after intestinal resection. The average operation time of TAPP group was 13 min longer (60.7 ± 13.7 min vs 47.8 ± 19.8 min P < 0.001), and the visual analogue scale pain score at 24 h after operation was lower (3.5 ± 1.2 vs 4.4 ± 1.7 P = 0.019) than that of OPR group. There was 1 case of bladder injury (2.5%) in OPR group and 1 case of inferior abdominal artery injury (2.4%) in TAPP group. There was no difference in the rate of the 1st stage hernioplasty between the two groups. In OPR group, 2 cases (5%) extended the incision for more than 2 cm, while in TAPP group, 1 case (2.4%) converted to laparotomy. The time of hospital stay (3.2 ± 1.8 d vs 4.3 ± 2.7 d, P = 0.036) and return to normal activities (7.9 ± 2.7 d vs 11.0 ± 4.4 d, P < 0.001) were shorter in TAPP group. The rate of total postoperative complications including chronic pain, surgical-site infection, seroma, hernia recurrence and so on was 11.9% in TAPP group, which was not significantly different from 25% in OPR group (P = 0.212). There were no cases of mesh related infection and death within 30 days in both groups.TAPP is safe and feasible for the operation of acute incarcerated inguinal hernia. TAPP had better comfort and faster recovery over open preperitoneal repair for the appropriate patients with incarcerated/strangulated inguinal hernia, which can reduce acute pain, shorten hospital stay and return to normal activities earlier.

OBJECTIVE: Despite the widespread of ventral hernia repairs globally, the approach method, dissection planes, defect closure, and the choice and placement layer of mesh are an ongoing debate. We reported the details of surgical techniques, safety and feasibility for robot-assisted transabdominal transversalis fascial and preperitoneal repair (R-TATFPP) for small ventral hernia.
METHODS: This study included 5 cases of R-TATFPP repair among 22 cases performed by robot-assisted ventral hernia repair from 2018 to 2023 with the approval of the Institutional Review Board at St. Luke\'s International University and clinical ethical committee at St. Luke\'s International Hospital (19-R147, 22-012).
RESULTS: There were four males and one female, with mean age of 64.4 ± 10.0 years, inclusive of two umbilical and three incisional hernias. Mean height, weight, body mass index (BMI), hernia defect length, width, operation time, console time, and hospital stay were 171.2 ± 11.8 cm, 82.4 ± 13.4 kg, 28.0 ± 2.1 kg/m2, 2.8 ± 1.4 cm, 3.0 ± 1.3 cm, 180 min, 133.8 min, and 2.4 days, respectively. No conversion nor complication was observed except for one acute urinary retention.
CONCLUSIONS: Robot-assisted transversalis fascial and preperitoneal repair was safe and feasible for small ventral hernia with the minimal disruption to the abdominal wall architecture and structures.

BACKGROUND: The Shouldice method for inguinal hernia repair remains the gold standard for prosthesis-free repairs. Nonetheless, international guidelines have favored posterior mesh reinforcement as the standard of care for inguinal hernia repair due to lower risk of recurrence and chronic pain, avoidance of general anesthesia, and favorable biomechanical properties. Recent publications have shown the benefits of an open approach to posterior repairs. Herein, we use the Abdominal Core Health Quality Collaborative (ACHQC) registry to compare patient-reported outcomes after a Shouldice no-mesh repair versus open preperitoneal (OPP) mesh repair.
METHODS: We performed a propensity score matched analysis to compare patient-reported quality of life (QoL) and peri/postoperative outcomes after a Shouldice repair versus OPP. Data from 2012 to 2022 were obtained from the ACHQC, and 1:1 optimal matching was performed. EuraHS scores were used to estimate QoL, and further analysis on the EuraHS domains of pain, aesthetics, and activity restriction were performed between the two cohorts.
RESULTS: Matching resulted in 257 participants in each, Shouldice and OPP cohorts. OPP was associated with a better QoL score compared to Shouldice at 30 days after surgery (Median (IQR) 7.75 (2.0-17.0) vs 13.0 (4.0-26.1); OR 0.559 [0.37, 0.84]; p = 0.003). This difference persisted at 6 months and 1 year postoperatively (OR 0.447 [0.26, 0.75] and 0.492 [0.26, 0.93], respectively). We did not observe any significant differences in hernia recurrence risk at 1-year, or rates of 30-day SSOs/SSIs, postoperative bleeding, peripheral nerve injury, DVTs, or UTIs.
CONCLUSIONS: Our data suggest that OPP is associated with significantly better patient-reported QoL, in the first month after surgery and up to 1 year postoperatively, especially with respect to lesser pain, when compared to the Shouldice repair. In specialized inguinal hernia practices, open posterior mesh repairs may lead to better outcomes than non-mesh repairs. We encourage more training in both repairs to facilitate larger prospective studies and evaluation of the generalizability of these results to all surgeons performing IHR.

The Lichtenstein repair has been synonymous with \"open\" inguinal hernia repair (IHR) for 40 years. However, international guidelines have suggested that posterior mesh placement results in advantageous biomechanics and reduced risk of nerve-related chronic pain. Additionally, the use of local anesthetics has been shown to reduce postoperative pain and complication risks. An open transrectus preperitoneal/open preperitoneal (TREPP/OPP) repair combines posterior mesh placement with the use of local anesthetic and as such could be the ideal repair for primary inguinal hernia. Using the Abdominal Core Health Quality Collaborative (ACHQC) registry, we compared open anterior mesh with open posterior mesh repairs.
We performed a propensity score matched analysis of patients undergoing open IHR between 2012 and 2022 in the ACHQC. After 1:1 optimal matching, both the TREPP/OPP and Lichtenstein cohorts were balanced with 451 participants in each group. Outcomes included patient-reported quality of life (QoL), hernia recurrence, and postoperative opioid use.
Improvement was seen after TREPP/OPP in EuraHS QoL score at 30 days (OR 0.558 [0.408, 0.761]; p = 0.001), and the difference persisted at 1 year (OR 0.588 [0.346, 0.994]; p = 0.047). Patient-reported opioid use at 30-day follow-up was significantly lower in the TREPP/OPP cohort (OR 0.31 [0.20, 0.48]; p < 0.001). 30-day frequency of surgical-site occurrences was significantly higher in the Lichtenstein repair cohort (OR 0.22 [0.06-0.61]; p = 0.007). There were no statistically significant differences in hernia recurrence risk at 1 year, or rates of postoperative bleeding, peripheral nerve injury, DVTs, or UTIs.
Our analysis demonstrates a benefit of posterior mesh placement (TREPP/OPP) over anterior mesh placement (Lichtenstein) in open inguinal hernia repair in patient-reported QoL and reduced opioid use.

OBJECTIVE: The totally extraperitoneal repair (TEP) technique has been widely performed, and compared with open surgery, TEP results in less postoperative pain and similar surgical outcomes in the treatment of inguinal hernias. However, TEP has a longer learning curve than does conventional surgery.
METHODS: The data for patients who underwent TEP for inguinal hernias by a single surgeon between April 2017 and July 2019 were analyzed retrospectively. The cumulative summation (CUSUM) method and the following two variables were used to analyze the learning curve: (1) the operation event (OE), including intraoperative complications and conversion to open surgery; and (2) the operation score (OS), as calculated by the operation time, patient body mass index, and disease characteristics.
RESULTS: The CUSUM chart showed three phases for both the OE and OS. The former reached a first inflection point after the 85th case and decreased after the 200th case, and the latter reached a plateau after the 101st case and decreased after the 203rd case. The operation time was longer in phases 1 and 2 than in phase 3 (64.2 min versus 47.9 min versus 31.1 min; p < 0.001), and the OS was lower in phase 3 than in the other phases (71.9 points versus 106.4 points versus 142.7 points; p < 0.001). Ten cases of intraoperative complications were observed, all in the first and second phases (p = 0.011).
CONCLUSIONS: At least approximately 100 cases are required for the initial learning period, and an additional 103 cases are required for the accumulation of additional experience. Surgical competency can be gained after 203 TEPs are performed.

UNASSIGNED: The aim of this study was to compare minimally invasive preperitoneal (MIP) single layer mesh repair with total extraperitoneal (TEP) inguinal hernia repair in terms of complications, recurrence, and chronic pain.
UNASSIGNED: A total of 240 patients who underwent elective, primary, unilateral inguinal hernia operation between April 2011 and September 2012 were divided into two randomized groups. The first group underwent MIP repair and the second group underwent TEP repair. Visual Analogue Scale (VAS) and Sheffield Scale (SS) were used to evaluate chronic pain.
UNASSIGNED: In all, 225 (95%) of the patients completed follow-up and were included in analyses. A significant difference was not detected between groups in terms of demographics, operative time, or intraoperative, early, or late complications. Length of time before return to work was significantly shorter in the TEP group (p <0.001). Recurrence was seen in 1 (0.88%) patient in the MIP group and 1 (0.89%) patient in the TEP group (p= 0.993). Evaluation of chronic pain revealed no significant difference between groups in VAS and SS values at postoperative 6th, 12th, and 24th months.
UNASSIGNED: In conclusion, it was observed that MIP repair for inguinal hernia has all of the advantages of preperitoneal repair and eliminates disadvantages of TEP repair. MIP technique is as safe as TEP repair and has similar qualities in terms of chronic pain, even though it is an open intervention.

Femoral hernias constantly present as incarceration or strangulation and require emergency surgery. Incarcerated and strangulated femoral hernia repair remains challenging and controversial. The aim of our study was to analyze the efficacy of preperitoneal tension-free hernioplasty via lower abdominal midline incision for incarcerated and strangulated femoral hernia.
Data of 47 patients who underwent emergency surgery for incarcerated or strangulated femoral hernias from January 2009 to December 2017 were retrospectively analyzed. According to the surgical incisions, they were divided into two groups: the observation group (21 cases) had a lower abdominal midline incision, and the control group (26 cases) had a traditional inguinal incision. General data of patients, intraoperative findings, operative time and postoperative complications were compared.
Patient characteristics showed that the two groups were comparable.15 cases (31.9%) underwent intestinal resection, and 32 cases (68.1%) underwent first-stage tension-free repair in total. The rate of first-stage tension-free hernioplasty was significantly higher in the observation group (18/21, 85.7% vs 14/26 53.8%, P = 0.020). No additional incision was required in the observation group, while six cases of the control group (23.1%) had an additional incision for intestinal resection and anastomosis (P = 0.026). Mean operative time (53.6 ± 24.7 min vs 77.9 ± 36.5 min, P = 0.012) and the length of hospital stay (6.3 ± 4.2 days vs 10.3 ± 6.9 days, P = 0.020) were significantly shorter in the observation group. The time of return to normal physical activity resulted significantly reduced compared to the control group (9.2 ± 4.1 days vs 13.3 ± 6.6 days, P = 0.017). The total incidence of postoperative complication (including chronic pain, foreign body sensation, hernia recurrence, wound infection and seroma/hematomas) in the observation group was lower (14.3% vs 42.3% P = 0.037). There were two recurrences in the control group. No mesh-related infection and no mortalities in two groups.
Midline preperitoneal approach for incarcerated and strangulated femoral hernia is a convenient and effective technique. It can improve the rate of first-stage tension-free repair of incarcerated femoral hernia and allow intestinal resection through the same incision, and with lower rate of postoperative complications.

BACKGROUND: Many surgical techniques have been used to repair abdominal wall defects in the inguinal region based on the anatomic characteristics of this region and can be categorised as \'tension\' repair or \'tension-free\' repair. Tension-free repair is the preferred technique for inguinal hernia repair. Tension-free repair of inguinal hernia can be performed through either the anterior transversalis fascia approach or the preperitoneal space approach. There are few large sample, randomised controlled trials investigating the curative effects of the anterior transversalis fascia approach versus the preperitoneal space approach for inguinal hernia repair in patients in northern China.
METHODS: This will be a prospective, large sample, multicentre, randomised, controlled trial. Registration date is 1 December 2016. Actual study start date is 6 February 2017. Estimated study completion date is June 2020. A cohort of over 720 patients with inguinal hernias will be recruited from nine institutions in Liaoning Province, China. Patient randomisation will be stratified by centre to undergo inguinal hernia repair via the anterior transversalis fascia approach or the preperitoneal approach. Primary and secondary outcome assessments will be performed at baseline (prior to surgery), predischarge and at postoperative 1 week, 1 month, 3 months, 1 year and 2 years. The primary outcome is the incidence of postoperative chronic inguinal pain. The secondary outcome is postoperative complications (including rates of wound infection, haematoma, seroma and hernia recurrence).
BACKGROUND: This trial will be conducted in accordance with the Declaration of Helsinki and supervised by the institutional review board of the Fourth Affiliated Hospital of China Medical University (approval number 2015-027). All patients will receive information about the trial in verbal and written forms and will give informed consent before enrolment. The results will be published in peer-reviewed journals or disseminated through conference presentations.
BACKGROUND: NCT02984917; preresults.

OBJECTIVE: In Japan, transabdominal preperitoneal (TAPP) inguinal hernia repair is performed by firmly pulling the peritoneum inwards to lift it from the underlying deep layer of subperitoneal fascia. It decreases the postoperative pain and discomfort in the inguinal area. The aim of this study was to evaluate the feasibility of the sandwich approach, which is a new technique for creating a preperitoneal space.
METHODS: The operation was performed via the sandwich approach. We made sure to protect the preperitoneal fascia areolar layer when making the preperitoneal space.
RESULTS: We performed TAPP in 745 patients (876 hernias) treated between October 2006 and April 2015 at Himeji Medical Center and Kurashiki Central Hospital. Before October 2010, we did not use the sandwich approach, and recurrence was observed in three patients. From October 2010, we always used the sandwich approach and never experienced any cases of recurrence. Clavien-Dindo classification Grade 3 or higher postoperative complications occurred in 6 patients (0.8%) between October 2006 and April 2015. Mesh-related ileus was the most frequently observed morbidity. There were no cases of vas differentia or spermatic vessel injury, postoperative chronic pain, or urinary retention.
CONCLUSIONS: The sandwich approach is feasible as another standard dissective procedure for TAPP.

A case of a 78-year-old female with bilateral groin prevascular herniae following an emergency aorto-uniiliac EVAR and femoro-femoral bypass for a ruptured abdominal aortic aneurysm is presented. Primary repair of the herniae was achieved using a preperitoneal approach. The case emphasises a safe approach to dealing with this rare complication.