PROFILE OF THE PATIENTS WHO UNDERWENT PROLENE HERNIA SYSTEM EXTENDED FOR INGUINAL HERNIA IN A TEACHING INSTITUTE IN SUBHIMALAYAN REGION

Introduction: Worldwide, inguinal hernia repair is probably the most commonly performed general surgical procedure. Hence, a slight refinement of surgical repair of inguinal hernia would mean a substantial benefit to the patient. Aim: The study aimed to study profile of the patients who underwent Prolene Hernia System Extended (PHSE) for Inguinal Hernia in a teaching institute in Sub-Himalayan region. Materials and Methods: This was a controlled study conducted over 30 adult patients of both genders admitted at Dr RPGMC Tanda at Kangra from September 2016 to September 2017. Patients clinically diagnosed with inguinal hernias both direct and indirect on examination were enrolled in the trial after their informed consent. Results: Mean age of the patients was 54.9±13.66 years (range 30 to 80 years). 33% of the patients were elderly. All the patients were males. 43% of the patients were smokers and 53% were consuming alcohol. 20% of the patients had associated co-morbidities. 7% patients had previous history of surgery. Fifty percent of the patients had direct hernia while 33% had indirect hernia. Among 10% patients, it was bubonocele type. Seven patients had complications. Scrotal swelling was the most common welling (n=3) followed by inguinodynia (n=2), and seroma formation and urinary retention in one patient each. Conclusion: PHSE for management of inguinal hernia is associated with better outcomes.

Management of patients with suspected COVID-19 who underwent emergency surgery

Background: Since the outbreak of COVID-19, no official guidelines for urgent surgical management of patients with the COVID-19 concern have been recommended. The current study provides our experience about the management for the patients with suspected or confirmed COVID-19 who required urgent surgical intervention.Methods: From February 5, 2019, to May 26, 2020, there were 5 cases of patients with suspected or confirmed COVID-19 infection managed with urgent surgical intervention in two hospitals in Chongqing. Results: The five cases with COVID-19 concern were admitted with different diseases, including acute intussusception, strangulated inguinal indirect hernia, acute purulent appendicitis, femoral fracture and onset to delivery. Finally, four patients obtained negative results afterwards. One pregnant woman with confirmed COVID-19 infection underwent caesarean section. All medical staff involved in the patients management were well, and no in-hospital transmission occurredConclusion:Suspected COVID-19 patients must be managed as positive patients until proven or denied in order to minimize the spread and transmission of infection. The current protocol carried out in our practice might be plausible and technically feasible for hospitals when dealing with COVID-19 infection.

Transverse testicular ectopia: two rare adult cases and a review of literature

The first case is a 45-year-old man who presented with complaints of right-sided indirect hernia. On examination the left hemiscrotum was empty. Open hernioplasty and mesh fixation with orchiopexy of both testes were done in the same hemiscrotum, followed by MRI for further evaluation. The second case is a 26-year-old man who presented with penoscrotal hypospadias and empty left hemiscrotum, with the left testis not palpable in the scrotum or the inguinal region. MRI, karyotyping and laparoscopic orchidectomy were performed, followed by endocrinology work-up. From our experience, preoperative diagnosis with ultrasonography and/or MRI prior to diagnostic laproscopy is benifical when there is a strong suspicion of mullerian duct remnants. In other cases, diagnostic laparoscopy can be useful in diagnosis and management. Placement of both testes in the same hemiscrotum can be considered safe, although not ideal. Also, in cases with partial gonadal dysgenesis, laparoscopic orchidectomy along with excision of the mullerian remnantsis a better approach than orchiopexy.

Conversion of Total Extraperitoneal (TEP) to Transabdominal Preperitoneal (TAPP) for repair of inguinal hernia; Frequency and causes.

Objectives: Our study aims to determine the incidence of and reasons for the conversion of hernia operations from laparoscopic guided total extraperitoneal (TEP) to transabdominal preperitoneal inguinal hernia repair (TEPP). Study Design: Cross-sectional study. Setting: A large tertiary care hospital in Karachi Pakistan. Period: From August 2016 to November 2018. Material & Methods: The sampling technique utilized was consecutive non-probability sampling. The study population consisted of patients between the ages of 22 and 50 years, males, having unilateral inguinal hernia, both direct and indirect presentation. A complete history and physical examination was performed and recorded in a pre-designed proforma for all the patients. Laboratory investigations were performed per routine. The patients underwent laparoscopic total extraperitoneal hernia repair and were noted for complications and conversion to transabdominal preperitoneal inguinal hernia repair. Data was analyzed using IBM SPSS statistics version 20. Chi-square test was used to analyze categorical variables, while mean and percentages were used for numerical data. A p value of less than 0.05 is considered to be statistically significant. Results: The study population was n= 150, mean age of the patients was 36.25 +/- 7.08 with a minimum of 22 and a maximum of 50 years. The direct hernia was present in 47.33% (71 patients) while an indirect hernia was present in 52.67% (79 patients). Out of the total patient population, 21 (14%) of the patients (having a p-value of 0.013) were converted to the TAPP procedure of which 10 (14.08%) has a direct hernia and 11 (13.92%) had an indirect hernia respectively (having a p-value of 0.953). The most common reason for conversion was peritoneal tear, hemorrhage and instrument failure. Conclusion: According to the results of our study, 14% of cases of direct and indirect hernia had to convert from TEP to TAPP procedure, and the main reasons for this conversion were found to be hemorrhage, peritoneal tear and instrument failure.

Insufficiency of prosthetic posterolateral overlap related to recurrence after laparoscopic transabdominal preperitoneal inguinal hernioplasty, as assessed by video review

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.

Insufficiency of prosthetic posterolateral overlap related to recurrence after laparoscopic transabdominal preperitoneal inguinal hernioplasty, as assessed by video review

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.

Historical changes in recurrence forms and their mechanisms after laparoscopic transabdominal preperitoneal inguinal hernioplasty, as assessed by video review

Background: Technical factors leading to hernia recurrence after transabdominal preperitoneal (TAPP) repair include insufficient dissection, inadequate prosthetic overlap and prosthetic size, improper fixation and folding or crinkling of the prosthesis. However, which of these can intraoperatively determine if a case will go on to develop recurrent hernias remains unclear. Methods: We reviewed operation videos for 27 control cases and primary laparoscopic hernioplasty of 13 lesions where the patient suffered recurrence after TAPP repair. Five surgeons blindly reviewed the videos to assess surgical techniques such as adequate dissection, mesh coverage, and folding or crinkling of the mesh. We explored the association of the technique with development of recurrence across our policy change, and hernia type before and after recurrence. Results: After implementing a TAPP repair policy of covering myopectineal orifice (MPO) with sufficiently overlapped mesh, 79% of the rating were satisfactory, whereas 34% were satisfactory prior to the policy. The recurrence rate decreased to 0.7% (5/678) compared with 6.2% (10/161) before the policy ( p <0.001). 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). With univariate analysis, the scores of posterior prosthesis overlap to the MPO in the recurrent cases were significantly lower than controls in the later period ( p =0.019). Conclusions: Fully covering the MPO with mesh is essential for preventing direct type recurrence. Prosthesis overlap posterior to the MPO in a large indirect hernia is important for preventing recurrence.