Spigelian hernia: current approaches to surgical treatment—a review

Background Spigelian hernias (SpH) belong to the group of eponymous abdominal wall hernias. Major reasons for diagnostic difficulties are its low incidence reaching maximum 2% of abdominal wall hernias, a specific anatomical localization with intact external oblique aponeurosis covering the hernia sac and non-constant clinical presentation. Methods A literature review was completed to summarize current knowledge on surgical treatment options and results. Results SpH presents a high incarceration risk and therefore should be operated upon even if the patient is asymptomatic. Both laparoscopic and open repair approaches are validated by current guidelines with lesser postoperative complications and shorter hospital stay in favour of minimally invasive surgery, regardless of the technique used. Overall recurrence rate is very low. Conclusion All diagnosed SpH should be planned for elective operation to prevent strangulated hernia and, therefore emergency surgery. Both open and laparoscopic SpH treatment can be safely performed, depending on surgeon’s experience. In most cases, a mesh repair is generally advised.

Interparietal Inguinal Hernia with Ectopic Testis – An Uncommon Surgical Emergency

A 46-year-old gentleman presented to casualty with a reducible right groin swelling (Figure 1) present since childhood which had suddenly become painful and irreducible for the past 6 hours. He gives history of absent right testis since childhood. There’s no history of vomiting, abdominal distension or obstipation. He had no surgeries in the past, no testicular disease or infertility problems. Physical examination revealed obstructed inguinal hernia with doubtful strangulation, absent right testis and normal appearing left testis. After evaluation, patient underwent emergency exploration of right inguinal hernia under general anaesthesia which revealed gangrenous small bowel, omentum in between external oblique aponeurosis and skin without a hernia sac (Figure 2) and; ectopic right testis in the superficial inguinal pouch (Figure 3). Segmental resection of gangrenous bowel with primary anastomosis and right orchidectomy performed through the same inguinal approach. Anatomical repair of posterior wall followed by approximation of external oblique aponeurosis was performed. Histopathology report showed gangrenous ileum with patchy necrosis; testis with tubular atrophy and hyalinisation, maturation arrest of spermatogonia and hyperplasia of interstitial Leydig cells. Post-operative recovery was uneventful.

Spigelian hernia with bilateral undescended (impalpable) testis in a child: rare scenario

Spigelain hernia (SH) is rarely seen in children. Various mechanisms has been described for the co-existence with cryptorchidism. A 4 month old boy, a known case of bilateral impalpable testes and intermittent right lower abdominal swelling was brought to paediatric emergency with complaints of excessive cry, poor feeding and irreducible right lower abdominal swelling - the swelling was a little higher than the usual inguinal hernia. On exploration, SH was seen coming off the deep ring then turning around the conjoint tendon and dissecting between internal oblique and external oblique aponeurosis. The hernia contained oedematous but viable gut with compression over the testicular vessels. Gut was viable. The testes was mobilized and fixed into the scrotum. Left testis was impalpable for which nubbin excision was done at a later date. A SH in the lower abdomen may be confused with a high inguinal hernia. In acute obstruction, emergent exploration and reduction is the cornerstone of treatment.

Congenital inguinal hernia repair with and without opening the inguinal canal

Background Elective repair of congenital inguinal hernia is the most common surgery performed by pediatric surgeons and is considered the treatment of choice. The exact technique and steps involved in the repair differs widely among pediatric surgeons, many surgeons open the roof of inguinal canal while preserving the external ring or opening it, this is called the modified Ferguson, s technique. In infants, the inguinal canal is short and virtually the internal and external rings lie over each other so many surgeons also like to perform the whole operation without opening the external oblique aponeurosis distal to the external ring, this technique is called the Mitchell Banks technique. Objective To compare both techniques regarding intraoperative time, incidence of intraoperative and postoperative complications to pass our experience in a trial to reach an ideal surgical technique for congenital inguinal hernia repair. Patients and Methods In this study, 60 cases of congenital inguinal hernia were randomly selected and divided into two equal groups where group A underwent the repair with opening the external oblique aponeurosis and group B underwent the repair without opening the external oblique aponeurosis. Results As regard the postoperative complications, the patients who underwent the Ferguson’s technique experienced more postoperative pain with statistically significant more incidence of postoperative hydrocele than the Mitchell banks technique, no complications occurred postoperatively other than hydrocele in our study. Conclusion Our study results, we can approve that Mitchell Banks technique is easier, consumes less time than Ferguson’s technique with less incidence of postoperative complications and pain which can make this technique better for congenital inguinal hernia repair in children aging 2 years or less.

Nigam’s inverted curtain hernioplasty: a modified lichtenstein tension free hernioplasty for inguinal hernia

Background: It is an open tension-free hernioplasty for primary inguinal hernias using minimal dissection and only 3 sutures to fix the mesh.Methods: A description of operative technique and patient’s demographics are presented.Results: 362 repairs were done with this technique over a period 18 years (March 2000 to March 2018). All were primary uncomplicated inguinal hernias.Conclusions: NICH tackles the both known aetiological factors for recurrence i.e., weakness in inguinal floor and tension at the suture line. It involves minimal tissue dissection and least number of sutures. Two sutures are used to fix the mesh with inguinal ligament. Third suture is used to make an artificial deep inguinal ring in the mesh as well as used to narrow the natural deep inguinal ring to further avoid recurrence. No suture is applied in main body of mesh which remains free like an inverted curtain covering the whole hernia susceptible region of groin. Prolene mesh is used which completely covers the potentially weak area on the floor of inguinal region irrespective of the size of the area in small or big frame persons. Semi double breasting of external oblique aponeurosis avoids displacement of mesh. NICH is associated with least recurrence, less post-operative pain, less post-operative complications and short learning curve.

Study of non-mesh technique of Desarda for inguinal hernia

Background: The tissue based techniques are still acceptable for primary inguinal hernia repair according to the European Hernia Society guidelines. Desarda’s no mesh technique, introduced in 2001, is a hernia repair method using an undetached strip of external oblique aponeurosis. This study compares the results with the studies done worldwide on Desarda’s technique.Methods: A total 120 cases were studied for 2 years (2015-2017), the primary outcomes measured were postoperative pain scores on day 1,7,30 using visual analogue scale, time taken to return to basic activities, time measured from skin incision to skin closer. Complications like cord oedema, seroma, fever, surgical site infection, chronic groin pain and recurrence were evaluated.Results: After a 15-month mean follow up period, 01 (0.83%) case had a recurrence among 120 patients. Mean operative time is 60 min; mean pain score on day-1, 7, 30 are 3.35, 0.9 and 0.008 respectively. Mean time taken to return back to work is 24 hours; complications like chronic groin pain, foreign bodysensation are not seen in single cases. These results are comparable with the studies done worldwide.Conclusions: In Desarda’s technique of inguinal hernia repair does not use mesh, so no complication related with the foreign body are seen and postoperative pain is less, early return to basic activities and Postoperative complications are less.

COMPARISON BETWEEN INGUINAL HERNIOTOMIES WITH AND WITHOUT INCISING EXTERNAL OBLIQUE APONEUROSIS: A RANDOMIZED CLINICAL TRIAL

ABSTRACT Background: Inguinal herniotomy is the most common surgery performed by pediatric surgeons. Aim: To compare the results and complications between two conventional methods of pediatric inguinal herniotomy with and without incising external oblique aponeurosis in terms of recurrence of hernia and other complications. Methods: This one blinded clinical trial study was conducted on 800 patients with indirect inguinal hernia. Inclusion criterion was children with inguinal hernia. The first group underwent herniotomy without incising external oblique aponeurosis and second group herniotomy with incising external oblique aponeurosis. Recurrence of hernia and other complications including ileoinguinal nerve damage, hematoma, testicular atrophy, hydrocele, ischemic orchitis, and testicular ascent were evaluated. Results: Recurrence and other complications with or without incising external oblique aponeurosis had no significant difference, exception made to hydrocele significantly differed between the two groups, higher in the incision group. Conclusion: Herniotomy without incising oblique aponeurosis can be appropriate choice and better than herniotomy with incising oblique aponeurosis. Children with inguinal herniotomy can be benefit without incising oblique aponeurosis, instead of more interventional traditional method.