Ultrasound diagnosis of congenital Morgagni hernias: Ten years of experience at two Chinese centers

BACKGROUND Morgagni hernias are rare anomalies that are easily misdiagnosed or missed.AIM To summarize the ultrasound(US)imaging characteristics of Morgagni hernias through a comparison of imaging and surgical results.METHODS The records of children with Morgagni hernias who were hospitalized at two hospitals between January 2013 and November 2023 were retrospectively re-viewed in terms of clinical findings,US features,and operative details.RESULTS Between 2013 and 2023,we observed nine(five male and four female)children with Morgagni hernias.Upper abdominal scanning revealed a widening of the prehepatic space,with an abnormal channel extending from the xiphoid process to the right or left side of the thoracic cavity.The channel had intestinal duct and intestinal gas echoes.Hernia contents were found in the transverse colon(n=6),the colon and small intestine(n=2),and the colon and stomach(n=1).Among the patients,seven had a right-sided lesion,two had a left-sided lesion,and all of them had hernial sacs.CONCLUSION US imaging can accurately determine the location,extent,and content of Morgagni hernias.For suspected Mor-gagni hernias,we recommend performing sonographic screening first.

Robotic-assisted versus laparoscopic repair of type II, III and IV hiatal hernias: A retrospective study comparing adverse outcomes

Objective:Robotic-assisted surgery(RAS)is continuing to expand in use in surgical specialties,including foregut surgery.The available data on its use in large hiatal hernia(HH)repair are limited and conflicting.This study sought to determine whether there are significant differences in adverse outcomes following HH repair performed with a robotic approach vs.a laparoscopic approach.This study was limited to outcomes in patients with type II,III,and IV HHs,as these hernias are typically more challenging to repair.Methods:A retrospective analysis was performed from data obtained from TriNetX,a large deidentified clinical database,over a 10-year period.Adult patients who underwent type II,III,or IV HH repair were included in the study.HH with robotic repair was compared to laparoscopic repair.Cohorts were propensity score matched for demographic information and comorbidities.Risk ratios,risk differences(RDs)with 95%confidence intervals(CIs),and t test for each examined adverse outcome were used to estimate the effects of robotic repair vs.laparoscopic repair.Results:In total,20,016 patients who met the inclusion criteria were identified;1,515 patients utilized RAS,and 18,501 used laparoscopy.Prior to matching,there were significant differences in age,sex,comorbidity,and BMI between the two cohorts.After 1:1 propensity score matching,analyses of 1,514 well-matched patient pairs revealed no significant differences in demographics or comorbidities.Patients who underwent robotic repair were more likely to experience major complications,including venous thromboembolism(RD:0.007,95%CI:0.003,0.011;p?0.002),critical care(RD:0.023,95%CI:0.007,0.039;p?0.004),urinary/renal complications(RD:0.027,95%CI:0.014,0.041;p<0.001),and respiratory complications(RD:0.046,95%CI:0.028,0.064;p<0.001).RAS was associated with a significantly shorter length of stay(32.4±27.5 h vs.35.7±50.1 h,p?0.031),although this finding indicated a reduction in the length of stay of less than 4 hours.No statistically significant differences in risk of esophageal perforation,infection,postprocedural shock,bleeding,mortality,additional emergency room visits,cardiac complications,or wound disruption were found.Conclusions:Patients who undergo robotic-assisted large HH repair are at increased risk of venous thromboembolism,need critical care,urinary or renal complications and respiratory complications.Due to variations in RAS technique,experience,and surgical volumes,further study of this surgical approach and complication rates is warranted.

Reinforced tissue matrix to strengthen the abdominal wall following reversal of temporary ostomies or to treat incisional hernias

BACKGROUND Abdominal wall deficiencies or weakness are a common complication of tem-porary ostomies,and incisional hernias frequently develop after colostomy or ileostomy takedown.The use of synthetic meshes to reinforce the abdominal wall has reduced hernia occurrence.Biologic meshes have also been used to enhance healing,particularly in contaminated conditions.Reinforced tissue matrices(R-TMs),which include a biologic scaffold of native extracellular matrix and a syn-thetic component for added strength/durability,are designed to take advantage of aspects of both synthetic and biologic materials.To date,RTMs have not been reported to reinforce the abdominal wall following stoma reversal.METHODS Twenty-eight patients were selected with a parastomal and/or incisional hernia who had received a temporary ileostomy or colostomy for fecal diversion after rectal cancer treatment or trauma.Following hernia repair and proximal stoma closure,RTM(OviTex®1S permanent or OviTex®LPR)was placed to reinforce the abdominal wall using a laparoscopic,robotic,or open surgical approach.Post-operative follow-up was performed at 1 month and 1 year.Hernia recurrence was determined by physical examination and,when necessary,via computed tomo-graphy scan.Secondary endpoints included length of hospital stay,time to return to work,and hospital readmissions.Evaluated complications of the wound/repair site included presence of surgical site infection,seroma,hematoma,wound dehiscence,or fistula formation.RESULTS The observational study cohort included 16 male and 12 female patients with average age of 58.5 years±16.3 years and average body mass index of 26.2 kg/m^(2)±4.1 kg/m^(2).Patients presented with a parastomal hernia(75.0%),in-cisional hernia(14.3%),or combined parastomal/incisional hernia(10.7%).Using a laparoscopic(53.6%),robotic(35.7%),or open(10.7%)technique,RTMs(OviTex®LPR:82.1%,OviTex®1S:17.9%)were placed using sublay(82.1%)or intraperitoneal onlay(IPOM;17.9%)mesh positioning.At 1-month and 1-year follow-ups,there were no hernia recurrences(0%).Average hospital stays were 2.1 d±1.2 d and return to work occurred at 8.3 post-operative days±3.0 post-operative days.Three patients(10.7%)were readmitted before the 1-month follow up due to mesh infection and/or gastrointestinal issues.Fistula and mesh infection were observed in two patients each(7.1%),leading to partial mesh removal in one patient(3.6%).There were no complications between 1 month and 1 year(0%).CONCLUSION RTMs were used successfully to treat parastomal and incisional hernias at ileostomy reversal,with no hernia recurrences and favorable outcomes after 1-month and 1-year.

Role of botulinum toxin a in the management of complex incisional hernias

Despite the technological breakthroughs and discover of abdominal meshes, ventral hernia has always been challenging in therapeutic strategies by the surgeons, with high recurrence rates. The use of botulinum toxin A (BTA) for the management of ventral and incisional hernia (IH) poses an increasingly interesting practice, especially for the intimidating complex one. The preoperative administration of the toxin to the lateral abdominal muscles by use of Ultra-Sound guidance causes muscle paralysis and a reduction of intraabdominal pressure. Thus, the hernia defect can be primarily closed without tension, if the length of the defect is up to 10 cm. In larger hernia, this method can be combined with component separation techniques or the use of a mesh. The mesh placement seems to be better by laparoscopy. The site of injection and the dosage of BTA are still under discussion amongst authors. The optimal administration is proposed by some authors to be at least 2 weeks before repair. There is also an analgesic effect of BTA to the patients that underwent hernia reconstruction. Ultimately, the role of BTA in the reconstruction of ventral hernia seems to be promising, but there is a necessity for several randomized clinical trials.

Crucial anatomy and technical cues for laparoscopic transabdominal preperitoneal repair: Advanced manipulation for groin hernias in adults

Groin hernias include indirect inguinal, direct inguinal, and femoral hernias. Obturator and supravesical hernias appear very close to the groin. High-quality repairs are required for groin hernias. The concept of "tension-free repair" is generally accepted, and surgical repairs with mesh are categorized as "hernioplasties". Surgeons should have good knowledge of the relevant anatomy. Physicians generally focus on the preperitoneal space, myopectineal orifice, topographic nerves, and regional vessels. Currently, laparoscopic surgery has therapeutic potential in the surgical setting for hernioplasty, with laparoscopic transabdominal preperitoneal(TAPP) repair appearing to be a powerful tool for use in adult hernia patients. TAPP offers the advantages of accurate diagnoses, repair of bilateral and recurrent hernias, less postoperative pain, early recovery allowing work and activities, tension-free repair of the preperitoneal(posterior) space, ability to cover obturator hernias, and avoidance of potential injury to the spermatic cord. The disadvantages of TAPP are the need for general anesthesia, adhering to a learning curve, higher cost, unexpected complications related to abdominal organs, adhesion to the mesh, unexpected injuries to vessels, prolonged operative time, and as-yet-unknown long-term outcomes. Both technical skill and anatomical familiarity are important for safe, reliable surgery. With increasing awareness of the importance of anatomy during TAPP repair, we address the skills and pitfalls during laparoscopic TAPP repair in adult patients using illustrations and schemas. We also address debatable points on this subject.

Successful surgical management of ruptured umbilical hernias in cirrhotic patients

Acute umbilical hernia rupture in patients with hepatic cirrhosis and ascites is an unusual,but potentially lifethreatening complication,with postoperative morbidity about 70% and mortality between 60%-80% after supportive care and 6%-20% after urgent surgical repair.Management options include primary surgical repair with or without concomitant portal venous system decompression for the control of the ascites.We present a retrospective analysis of our centre's experience over the last 6 years.Our cohort consisted of 11 consecutive patients(median age:53 years,range:36-63 years) with advanced hepatic cirrhosis and refractory ascites.Appropriate patient resuscitation and optimisation with intravenous fluids,prophylactic antibiotics and local measures was instituted.One failed attempt for conservative management was followed by a successful primary repair.In all cases,with one exception,a primary repair with non-absorbable Nylon,interrupted sutures,without mesh,was performed.The perioperative complication rate was 25% and the recurrence rate 8.3%.No mortality was recorded.Median length of hospital stay was 14 d(range:4-31 d).Based on our experience,the management of ruptured umbilical hernias in patients with advanced hepatic cirrhosis and refractory ascites is feasible without the use of transjugular intrahepatic portosystemic shunt routinely in the preoperative period,provided that meticulous patient optimisation is performed.

Abdominal hernias:Radiological features

Abdominal wall hernias are common diseases of the abdomen with a global incidence approximately 4%-5%. They are distinguished in external,diaphragmatic and internal hernias on the basis of their localisation.Groin hernias are the most common with a prevalence of 75%, followed by femoral(15%)and umbilical(8%).There is a higher prevalence in males(M:F,8:1).Diagnosis is usually made on physical examination.However,clinical diagnosis may be difficult,especially in patients with obesity,pain or abdominal wall scarring.In these cases, abdominal imaging may be the first clue to the correct diagnosis and to confirm suspected complications. Different imaging modalities are used:conventional radiographs or barium studies,ultrasonography and Computed Tomography.Imaging modalities can aid in the differential diagnosis of palpable abdominal wall masses and can help to define hernial contents suchas fatty tissue,bowel,other organs or fluid.This work focuses on the main radiological findings of abdominal herniations.

Modified rives-stoppa repair for abdominal incisional hernias

Incisional hernias are a prevalent problem in abdominal surgery and occur in 11% of patients who undergo laparotomy. Primary suture clo-sure of incisional hernias results in a 31%-58% chance of recurrence. The addition of a pros-thetic mesh implant decreases recurrence rates to 8%-10%. Popularized in Europe by Rives and Stoppa, the sublay technique has proven to be very effective, with low recurrence rates (0%-23%) and minimal complications. The pur-pose of the study was to evaluate the experi-ence of a single surgeon at a large tertiary care center performing a modified Rives-Stoppa re-pair for abdominal incisional hernias. To do this, the records of all patients undergoing a modi-fied Rives-Stoppa incisional hernia repair be-tween January 2000 and August 2003 were ret-rospectively reviewed. Outpatient clinic notes, discharge summaries, operative reports, and laboratory data were reviewed for patient demographics, surgical data and postoperative complications. Univariate analysis was per-formed in order to identify predictors for recur-rence. During the study period, 83 patients un-derwent a modified Rives-Stoppa incisional hernia repair. Nineteen patients were excluded due to incomplete medical records. No patients required postoperative exploration for an in-tra-abdominal catastrophe. Twenty-five percent (n=16) of patients had a complication as a result of the hernia repair. Only two patients (3.1%) developed recurrent incisional hernias. History of diabetes (p=0.007) and benign prostatic hy-perplasia (p=0.000) were the only significant predictors for recurrence. The results presented here confirm that the modified Rives-Stoppa retromuscular repair is an effective method for the repair of incisional hernias. The complica-tion and recurrence rates compare favorably to results for currently popular alternative tech-niques.

Fascinating history of groin hernias:Comprehensive recognition of anatomy,classic considerations for herniorrhaphy,and current controversies in hernioplasty

Groin hernias include indirect inguinal,direct inguinal,femoral,obturator,and supravesical hernias.Here,we summarize historical turning points,anatomical recognition and surgical repairs.Groin hernias have a fascinating history in the fields of anatomy and surgery.The concept of tension-free repair is generally accepted among clinicians.Surgical repair with mesh is categorized as hernioplasty,while classic repair without mesh is considered herniorrhaphy.Although various surgical approaches have been developed,the surgical technique should be carefully chosen for each patient.Regarding as interesting history,crucial anatomy and important surgeries in the field of groin hernia,we here summarized them in detail,respectively.Points of debate are also reviewed;important points are shown using illustrations and schemas.We hope this systematic review is surgical guide for general surgeons including residents.Both a skillful technique and anatomical knowledge are indispensable for successful hernia surgery in the groin.

Incisional Hernias: Risk Factors and Treatment in a Context of Limited Resources

Background: The purpose of this study was to describe the etiologic factors and therapeutic modalities of incisional hernias in the department of surgery at the regional hospital of Tenkodogo, in Burkina Faso. Methods: It is a cross sectional study covering the period from 2010 to 2012. Sampling was comprehensive, including all the patients operated for incisional hernias during this period. Results: Fifty-four patients were included. Their average age was 22.3 years. There were 35 (64.8%) males and 19 (35.2%) female patients. We counted 28 large-size incisional hernias, 14 medium-size incisional hernias and 12 incisional hernias of small size. The average time from the first surgery to the diagnosis of incisional hernias was 8 months. Generalized acute peritonitis (44.4%) and acute intestinal obstructions (22.2%) were the main indications of initial surgical interventions. Vertical midline incisions have been involved in 37 cases (68.5%). Therapeutically, two surgical techniques have been used: open suture repair and open mesh repair. Forty-two patients (77.8%) were treated by open suture repair. Twelve patients (22.2%) benefited from open mesh repair. Post-operative complications were noted in 2 patients. Nine patients (16.7%) presented a recurrence after 12 months. Conclusion: In the rural area of Burkina Faso, incisional hernias occur in young patients. Emergencies with abdominal Infections are the main operative indications. Prostheses are relatively high cost and less accessible. The recidivism rate is high.

Primary parahiatal hernias:A case report and review of the literature

BACKGROUND Parahiatal hernias(PHHs)are rare occurring disease,with a reported incidence of 0.2%-0.35%in patients undergoing surgery for hiatal hernia.We found only a handful of cases of primary PHHs in the literature.The aim of this paper is to present a case of a primary PHH and perform a systematic review of the literature.CASE SUMMARY We report the case of a 60-year-old Caucasian woman with no history of thoracoabdominal surgery or trauma,which accused epigastric pain,starting 2 years prior,pseudo-angina and bloating.Based on imagistic findings the patient was diagnosed with a PHH and an associated type I hiatal hernia.Patient underwent laparoscopic surgery and we found an opening in the diaphragm of 7 cm diameter,lateral to the left crus,through which 40%-50% of the stomach had herniated in the thorax,and a small sliding hiatal hernia with an anatomically intact hiatal orifice but slightly enlarged.We performed closure of the defect,suture hiatoplasty and a“floppy”Nissen fundoplication.Postoperative outcome was uneventful,with the patient discharged on the fifth postoperative day.We performed a review of the literature and identified eight articles regarding primary PHH.All data was compiled into one tabled and analyzed.CONCLUSION Primary PHHs are rare entities,with similar clinical and imagistic findings with paraesophageal hernias.Treatment usually includes laparoscopic approach with closure of the defect and the esophageal hiatus should be dissected and analyzed.Postoperative outcome is favorable in all cases reviewed and no recurrence is cited in the literature.

Cardiovascular Complications of Large Hiatal Hernias: Expanding the Indications for Robotic Surgical Anatomic and Physiologic Repair: A Review

Background: Historically, the pathophysiology of Hiatal Hernias (HH) has not been fully understood. As a result, the surgical therapy of HH has focused primarily on gastrointestinal symptoms and Gastroesophageal Reflux (GERD). This treatment strategy has been associated with poor relief of symptoms and poor long-term outcomes. In fact, until recently, most patients with HH have been watched and referred for surgery as a last resort. Recent experience has shown that a large (giant) Hiatal Hernia (GHH) is a common problem known to impact adjacent organs such as the hearts and lungs. Those referred for surgical repair often complain of dyspnea, which is erroneously attributed to pulmonary compression or aspiration, but has been shown to be from tamponade caused from compression of the heart by herniated abdominal contents. This article reviews the present understanding of GHH, the cardiac complications which result from GHH, and the most advanced robotic minimally invasive surgical approach to the anatomic and physiologic repair of GHH. Methods: In a prospective cohort study, we evaluated patients undergoing RRHH with at least a 2-year follow-up. All patients undergoing elective (RRHH) were identified preoperatively and enrolled prospectively in this study. Preoperative characteristics, medical comorbidities, and clinical information were all recorded prospectively and recorded into a secure surgical outcomes database. All patients received the previously validated Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire preoperatively and at postoperative time points of 1 month, 1 year, and 2 years. Patients routinely had a barium swallow postoperatively before discharge but did not undergo a barium swallow, an endoscopy, or a CT scan study at the 1-month time point unless indicated by symptoms. At 6 months, 1 year, and yearly intervals thereafter, all patients received an endoscopy study to ascertain the presence of a recurrence, regardless of symptoms. Recurrence was defined as over 2 cm or 10% of the stomach above the diaphragm detected by CT, esophagogram or endoscopy. In addition, an extensive search was conducted using Pub Med in order to extract references to the cardiovascular complications of HH. Results: 423 patients underwent RRHH. With a long-term follow-up, there was a significant decrease in the Median Symptom Severity Score from 42.0 preoperatively, to 3.0 postoperatively. Recurrence was seen in 5 patients (5/423) for a recurrence rate of 1.1%. Conclusion: This experience has been the basis of two important realizations: 1) all patients with GHH have at least some degrees of clinically relevant compression of the inferior vena cava and the left atrium which causes tamponade and cardiogenic dyspnea which completely resolves after successful surgical repair;and 2) primary care providers and gastroenterologists who usually treat patients for GHH repair rarely recognize cardiac compression and tamponade as the cause of the shortness of breath and gradual increase in dyspnea on exertion and progressive fatigability in these patients. This article reviews the present understanding of GHH, the cardiac complications which result from GHH and the most advanced robotic minimally invasive surgical approach to the anatomic and physiologic repair of GHH.

Parietal Hernias in Adults at Bouaké University Hospital: Epidemiological and Diagnostic Aspects

Introduction: A hernia of the abdominal wall is defined as the externalization of a viscera of the abdominal cavity in relation to a deficiency of the components of the wall. Topographies are diverse and diagnosis is based on clinical practice. The objective of this study was to describe the epidemiological and diagnostic aspects of abdominal wall hernias at the University Hospital of Bouaké, C&#244te d’Ivoire. Patients and Methods: This was a descriptive retrospective study that ran from January 2010 to December 2022. It concerned all patients admitted for abdominal wall hernias. Results: We collected 497 records of patients admitted for abdominal wall hernia. Abdominal wall hernias accounted for 7.6% of patients admitted to the ward (n = 6512) and were the fourth most common patient. These were males (79%;n = 392) and females (21%;n = 105). The mean age was 43 years [range: 17 and 70 years]. The occupation was dominated by forced labourers with 73% (n = 372) more specifically farmers (42%;n = 209). The average consultation time was 2 days (extreme 1 and 8 days). The main clinical signs were abdominal pain for strangulated hernias with or without occlusive signs (n = 397;79.8%) and reducible bothersome swelling with intermittent pain (n = 100;20.2%) for non-strangulated hernias. Hernias of the groin (inguinal and femoral hernia) were the most frequent with 85% (n = 422) followed by hernias of the white line (epigastric, umbilical and hypogastric) with 14% (n = 71) and lumbar hernias (Spiegel, Jean-Louis Petit and Grynfeltt) with 1% (n = 4), we did not note any cases of pelvic hernia (obturator and ischiatic). Conclusion: Parietal hernias are a common surgical condition at the Ivory Coast University Hospital, particularly in Bouaké. Groin hernia is the most common topographic variety. Strangulation is the main complication.

Robotic Laparoscopic Transdiaphragmatic Repair of Large Hiatal Hernias

Introduction: Although laparoscopic Nissen fundoplication is the most common procedure for the repair for hiatal hernia (HH) repair, HH recurrence due to breakdown of the hiatoplasty has been reported as a common mechanism of failure after primary repair. Left transthoracic anatomic and physiologic repair (AFR) of HH is associated with lower incidence of leak and reoperation but greater morbidity. Adopting the transthoracic approach to a robotic laparoscopic platform may represent the ideal approach to the repair of HH. This study reviews the results of this technique. Methods: A retrospective review was performed on patients who had robotic AFR (RAFR) of large HH. All patients received the previously validated Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire preoperatively and postoperatively. Objectively, symptoms were graded using the Visick Scale. Recurrence was defined as greater than 2 cm or 10% of the stomach above the diaphragm detected by either CT, esophagogram or endoscopy. The preoperative data was compared to the results at 2 years. Results: 396 patients underwent RAPR. The Median GERD-HRQL score was 42 (range 38 - 45) preoperatively and 6 (range 0 - 14) at two years (p < 0.05). Preoperatively 87% of patients were graded as Visick IV. At two years, 95% were graded as Visick I. HH recurrence occurred in 4/396 patients (1%). Conclusion: RAFR of HH is associated with excellent symptom relief and low recurrence rate. RAFR should be considered when deciding on what operation to perform in patients with large paraesophageal hiatal hernias.

Alternative to mesh repair for ventral hernias: Modified rectus muscle repair

BACKGROUND Mesh utilization for ventral hernia repair is associated with potential complications such as mesh infections,adhesions,seromas,fistula formation and significant postoperative pain.The modified rectus muscle repair(RMR)is as an option to repair midline ventral hernias without mesh.AIM To evaluate the short term outcomes when the modified RMR was used to repair ventral hernias.METHODS This was a 5-year prospective study that examined the outcome of all consecutive patients with ventral abdominal wall hernias>5 cm in maximal diameter who underwent repair using the modified RMR technique in a single surgeon unit.Patients were reviewed in an outpatient clinic at 3,6 and 12 mo and evaluated for hernia recurrence on clinical examination.Each patient’s abdominal wall was also assessed with using ultrasonography at 24 mo to detect recurrences.All data were examined with SPSS ver 18.0.RESULTS Over the 5-year study period,there were 52 patients treated for ventral hernias at this institution.Four patients were excluded and there were 48 in the final study sample,at a mean age of 56 years(range 28-80).The mean maximal diameter of the hernia defect was 7 cm(range 5-12 cm).There were 5(10.4%)seromas and 1 recurrence(2.1%)at a mean of 36 mo follow-up.CONCLUSION The authors recommend the modified RMR as an acceptable alternative to mesh repair of ventral hernias.The seroma rate can be further reduced with routine use of drains.The modified RMR also has the benefit of eliminating all mesh-specific complications.

The Technique of Shouldice in the Treatment of the Inguinal Hernias at the Hospital Somine Dolo of Mopti(Mali)Subject of 675 Cases

The objective was to study epidemiological and therapeutic aspects of the inguinal hernia according to the technique of Shouldice. Methodology: we realized a retrospective study, concerning the patients operated for inguinal hernia according to the technique of Shouldice in the service of general surgery of the hospital Sominé Dolo of Mopti, Mali. All the patients operated during the period of study for inguinal hernia according to the technique of Shouldice were included. The patients operated for hernia by other technique than that of Shouldice were not included. Results: The study has been realized in the service of general surgery of the hospital Sominé Dolo of Mopti (Mali). It was about a retrospective study which concerned 25 years from January, 1987 till December, 2012. 675 patients operated according to the technique of Shouldice were registered. The average age was of 49 years +/&minus;17.7. There were 90.7% (612) men. The sex-ratio is 9.7. The farmers, the housewives and the workers represented 51.1% (115). In 75.2% (508) the patients consulted for inguinal tumefaction. In operating meadow, the hernia was complicated to 246 (36.4%) patients among whom 72 cases were of recurrence. The hernia constriction was the main complication operating meadow 58.5% (48/82). The operating suites in one year were simple at 94.2% (636) of the patients;they were marked by 24 cases of recurrence, 12 cases of neuralgia, 6 cases of testicular atrophy, and 3 cases of keloid. Conclusion: The technique of Shouldice is the technique of choice for the cure of the inguinal hernia in developing countries because of the good result and its little expensive cost with compared with the other techniques using medical devices.

Activity of metalloproteinases and adiponectin in obese patients——a possible factor of incisional hernias after bariatric procedures

Purpose： Metalloproteinases are a key component of the pathogenesis of abdominal hernias. Obesity is considered a risk factor in herniogenesis and hernia recurrence. The aim of this study was to evaluate the serum concentrations of metalloproteinase-2（MMP-2）, MMP-9, MMP-13, and adiponectin in morbidly obese and nonoverweight controls. Materials and methods： The participants were recruited from among patients undergoing bariatric and non-bariatric surgery and divided into two groups： I（body mass index（BMI）≥35 kg/m^2, n=40） and II（BMI〈25 kg/m^2, n=30）. Serum concentrations of MMP-2, MMP-9, MMP-13, and adiponectin were measured using enzyme-linked immunosorbent assay（ELISA）. Results： A statistically significant difference between groups was observed for MMP-2 concentration. The median MMP-9 concentration was higher in the obese group, but the difference was not statistically significant. Median MMP-13 concentrations did not differ between groups. Serum adiponectin concentration was insignificantly higher in the non-obese group. Conclusions： The elevated serum MMP-2 and MMP-9 concentrations in obese individuals may be related to the higher incidence of incisional hernias in this population.

Hybrid IPOM: A Novel Technique for the Management of Incisional Hernia

Background and Aim: The incidence of incisional hernias has been reported to be around 15%. In the present scenario, a wide array of surgical procedures are available for their better management. In this study, we intend to share our experience with one novel technique, “Hybrid IPOM (Intraperitoneal onlay meshplasty)” as a management option for a selected cohort of patients. Methods: This prospective study was undertaken during January 2019 to July 2023 at King Abdullah medical city, Makkah. A total of 51 cases were selected for Hybrid IPOM repair as per inclusion criteria;medium sized (4 - 10 cm) hernia defects;uncomplicated hernias;age more than 18 years. The follow-up period of the patients varied from 6 months to 4 years. The operation commenced with open hernia dissection, mesh deployment into abdomen, defect closure and then conversion to laparoscopy for the posterior mesh placement. Results: A total of 51 cases were repaired successfully with this technique. 48 out of 51 cases were incisional hernias secondary to some primary procedure done either for hernias itself or some other intra-abdominal pathology. The three cases were primary hernias falling in medium to large category with unaesthetic overlying skin. The age range was 19 to 72 years. The mean (range) operative time was 135 (90 - 240) min, and the average blood loss was 70 ml. The mean (range) hospital stay was 3 (2 - 11) days. All patients returned to routine work within 2 - 3 weeks of surgery. The median follow-up was 15 (6 - 48) months. Of the 51 cases, 3 patients developed seroma (managed conservatively), 1 patient developed a large hematoma (needed evacuation), and 1 patient developed superficial wound infection (managed with antibiotics). Two patients had recurrences;one patient had previously failed multiple repairs, and the other developed a postoperative hematoma. None of our patients had an iatrogenic bowel injury. Conclusion: Hybrid IPOM technique is a safe, feasible and easily reproducible technique. It may prove easier especially for beginners in laparoscopy, as it achieves faster and easy adhesiolysis thereby reducing operative time and easier establishment of the pneumoperitoneum. Besides, it gives the chance to excise ugly scars and improve the cosmesis.

Clinical observation of extraction-site incisional hernia after laparoscopic colorectal surgery

BACKGROUND Laparoscopic colorectal cancer surgery increases the risk of incisional hernia(IH)at the tumor extraction site.AIM To investigate the incidence of IH at extraction sites following laparoscopic colo-rectal cancer surgery and identify the risk factors for IH incidence.METHODS This study retrospectively analyzed the data of 1614 patients who underwent la-paroscopic radical colorectal cancer surgery with tumor extraction through the abdominal wall at our center between January 2017 and December 2022.Diffe-rences in the incidence of postoperative IH at different extraction sites and the risk factors for IH incidence were investigated.RESULTS Among the 1614 patients who underwent laparoscopic radical colorectal cancer surgery,303(18.8%),923(57.2%),171(10.6%),and 217(13.4%)tumors were ex-tracted through supraumbilical midline,infraumbilical midline,umbilical,and off-midline incisions.Of these,52 patients developed IH in the abdominal wall,with an incidence of 3.2%.The incidence of postoperative IH was significantly higher in the off-midline incision group(8.8%)than in the middle incision groups[the supraumbilical midline(2.6%),infraumbilical midline(2.2%),and umbilical incision(2.9%)groups](χ^(2)=24.985;P<0.05).Univariate analysis showed that IH occurrence was associated with age,obesity,sex,chronic cough,incision infection,and combined diabetes,anemia,and hypopro-teinemia(P<0.05).Similarly,multivariate analysis showed that off-midline incision,age,sex(female),obesity,incision infection,combined chronic cough,and hypoproteinemia were independent risk factors for IH at the site of laparoscopic colorectal cancer surgery(P<0.05).CONCLUSION The incidence of postoperative IH differs between extraction sites for laparoscopic colorectal cancer surgery.The infraumbilical midline incision is associated with a lower hernia rate and is thus a suitable tumor extraction site.

Omental fibroma combined with right indirect inguinal hernia masquerades as a scrotal tumor: A case report

BACKGROUND The most common causes of scrotal enlargement in patients include primary tumor of the scrotum,inflammation,hydrocele of the tunica vaginalis,and indirect inguinal hernia;scrotal enlargement caused by external tumors of the scrotum is rare.The patient had both a greater omentum tumor and an inguinal hernia,and the tumor protruded into the scrotum through the hernia sac,which is even rarer.Moreover,omental tumors are mostly metastatic,and primary omental fibroma is rare.CASE SUMMARY Here,we report a rare case of a 25-year-old young man with scrotal enlargement and pain for 3 months.Preoperative examination and multidisciplinary discu-ssions considered intra-abdominal tumor displacement and inguinal hernia,and intraoperative exploration confirmed that the greater omentum tumor protruded into the scrotum.Therefore,tumor resection and tension-free inguinal hernia repair were performed.The final diagnosis was benign fibroma of the greater omentum accompanied by an indirect inguinal hernia.CONCLUSION This unusual presentation of a common inguinal hernia disease illustrates the necessity of performing detailed history taking,physical examination,and imaging before surgery.