Tension measurements in abdominal wall hernia repair: Concept and clinical applications Paul L Tenzel, Jordan A Bilezikian, Frederic E Eckhauser, William W Hope International Journal of Abdominal Wall and Hernia Surgery 2019 2(4):119-124 Tension has always been and remains an important concept in hernia repair. Revolutionary techniques in the field of hernia repair have generally aimed to reduce tension and thereby reduce recurrence rates. Despite the uniformly agreed upon idea that tension is an important part of hernia repair, little is known about this subject in ventral and incisional hernias. We reviewed all published journal articles related to abdominal wall tension. Articles were organized into basic science and clinical reports, and results were evaluated for type and technique of tension measurement and implications for clinical practice. Several cadaveric and clinical studies relate to the measurement of abdominal wall tension. Despite similar methods of measuring, there is no uniformly agreed upon device or measurement. Abdominal wall tension has not been correlated with hernia width, and abdominal wall tension measurement has shown to be a useful adjunct intraoperatively. Abdominal wall tension measurements likely have a role in both the research and clinical practice of hernia surgery.

How to teach and learn transabdominal preperitoneal effectively – Experience with introducing transabdominal preperitoneal repair in ten general hospitals in Slovenia (2013–2018) Jurij Gorjanc, Tomaz Jakomin, Andraz Hubad, Katarina Benkovic Golob International Journal of Abdominal Wall and Hernia Surgery 2019 2(4):125-129 INTRODUCTION: Laparoscopic inguinal hernia repair, according to indications, should be offered to every patient in developed countries nowadays. However, in Slovenia, before 2013, only two hospitals (among 13) performed laparoendoscopic procedures routinely for the treatment of inguinal hernias. Besides, until 2016, the Health Insurance Institute of Slovenia (ZZZS) refunded costs according to diagnosis and not procedure and therefore did not stimulate introduction of more costly surgical procedures, such as transabdominal preperitoneal (TAPP) into daily practice. Many hospitals avoided TAPP as a nonprofitable procedure. METHODS: In 2012, the Slovenian Hernia Society hosted Prof. Dr. Reinhard Bittner as invited guest for teaching laparoscopic and open techniques. The symposium was followed by workshops with hands-on possibility in different hospitals. Soon thereafter, many TAPP and other workshops followed in local hospitals, organized by tutors of the Slovenian Hernia Society (about five workshops a year). Official meetings between the Slovenian Hernia Society and the ZZZS were organized. RESULTS: Between the years 2013 and 2018, ten more hospitals (one clinical center and nine general hospitals) started with TAPP procedures on a daily basis after more workshops were organized in their own local surgical department. In every hospital, one or more surgeons were delegated to take responsibility for hernia surgery development in their own department. The health insurance system agreed to raise refund for bilateral inguinal hernia repair. CONCLUSIONS: Availability of laparoscopic inguinal hernia repair in the 3rd millennium should be a must in every EU country. TAPP was successfully introduced and consolidated as inguinal hernia repair technique in ten more hospitals across Slovenia in a relatively short period of 6 years (2013–2018).

Laparoscopic round ligament preserving repair for groin hernia in women: A critical appraisal V Abolmasov Alexey, Badma Bashankaev International Journal of Abdominal Wall and Hernia Surgery 2019 2(4):130-133 BACKGROUND: Our objective was to investigate the clinical characteristics of original laparoscopic round ligament-sparing repair technique for groin hernias in female patients. METHODS: The clinical data of 48 female patients (58 hernias) who underwent laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair using original split mesh technique at Orel Regional Hospital (Russia) between March 2009 and January 2019 were analyzed retrospectively. The aim of the study was to provide an overview about female groin hernias, preferred surgical approach, and the management of round ligament of uterus. RESULTS: There were 58 TAPP repairs in 48 patients. The average follow-up period was 43 months (min. – 3, max. – 122, Mo – 12, and Me – 43). Fifteen femoral hernias were noted in ten patients, of which two femoral hernias were incarcerated. Cysts on the round ligament of the uterus were found in four patients, and most of them underwent laparoscopic resection. Round ligaments of the uterus were preserved in all patients. An average operation time was 56 min (min. – 20, max. – 135, Mo – 40 min, and Me – 50 min). None of the cases was converted to laparotomy. All patients returned to normal activity soon and 1 (1.7%) recurrence was noted during follow-up. CONCLUSION: Laparoscopic inguinal hernia repair is well adopted around the world, but still questions remain which are related to female patients, especially regarding the function and preserving the round ligament. Based on this study, it is possible to preserve the round ligament by using the original laparoscopic TAPP keyhole technique.

Comparison of totally extraperitoneal groin hernia repair with and without mesh fixation Lubov Kupershlyak, Zvi Perry, Boris Kirshtein International Journal of Abdominal Wall and Hernia Surgery 2019 2(4):134-141 INTRODUCTION: Since the introduction of the laparoscopic technique for tension-free inguinal hernia repair, various mesh fixation techniques have been adopted. The need for mesh fixation during the surgery is still under debate. We conducted our study to compare the outcomes of laparoscopic totally extraperitoneal (TEP) inguinal hernia repair with (MF) and without (NMF) mesh fixation. PATIENTS AND METHODS: One hundred and fifty-seven patients underwent laparoscopic inguinal hernia repair without mesh fixation during 2010–2014. Of these, 113 (71.9%) agreed to participate in our trial, underwent physical examination, and filled out a questionnaire regarding their satisfaction with the surgery outcome. The data collected from medical records and results of the examination and the questionnaire were processed statistically and compared to the results of a previous study, which included patients who underwent TEP with mesh fixation. RESULTS: Mean follow-up was about 3 years in both groups. Duration of procedure and length of hospital stay were shorter in the NMF group. Patients without mesh fixation had less pain and earlier return to work and physical activity. There was no significant difference in recurrence rate between NMF and MF groups (5.6% and 4.6%, respectively). The majority of recurrences in the MF group were among patients in whom a nonsplit mesh was used. Surgery satisfaction, however, was significantly higher in the MF group. CONCLUSION: TEP without mesh fixation results in better surgical and postoperative outcome comparing with mesh fixation. Overall hernia recurrence rate was similar in patients with and without mesh fixation. Regular follow-up of at least 18 months is recommended to define true recurrence rate.

Case series of a novel open plication supported by mesh (PSUM) - technique for symptomatic abdominal rectus diastasis repair with or without concomitant midline hernia: Early results and a review of the literature Reetta Tuominen, Jaana Vironen, Tiina Jahkola International Journal of Abdominal Wall and Hernia Surgery 2019 2(4):142-148 BACKGROUND: Abdominal rectus diastasis (ARD), sometimes combined with abdominal wall midline hernia, is a common complaint in women after childbirth. To some individuals, ARD causes functional disability. Convincing data of the long-term results of ARD repair are lacking, especially when ARD is severe, and the optimal technique is undefined. In plastic surgery, the repair is often done with suture alone, but if a concomitant hernia exists, using a mesh is mandatory. This paper reports a novel surgical technique aimed at a reliable and minimally traumatic repair of ARD with or without midline hernia and a review of the literature of ARD repair. PATIENTS AND METHODS: During June 2013–April 2018, 37 consecutive patients with symptomatic ARD with or without concomitant midline hernia were operated on by using a narrow piece of a self-gripping mesh (n = 32) or the tails of the ventral patch (n = 5). The mesh was placed in between the plicated linea alba. The outcome and patient satisfaction in this pilot study were analyzed. RESULTS: A significant subjective improvement in body balance after surgery was reported by 34 patients (92%). During the mean follow-up of 13 months, there was only one partial recurrence of ARD. The complication rate was low, and patient satisfaction was good. CONCLUSION: According to the present study, selected patients with severe lack of muscle control and/or back pain benefit from ARD repair. The minimally traumatic PSUM mesh augmentation seems a promising method for the repair of ARD.

Open mesh repair of interstitial hernia containing small bowel Nisarg Y Mehta, Jesse Casaubon, Ramon Benedicto International Journal of Abdominal Wall and Hernia Surgery 2019 2(4):149-151 Interparietal hernias are rare entities of the anterior abdominal wall in which the hernia sac protrudes between peritoneum, fascia, muscle, or subcutaneous tissue. There are three types of interparietal hernias: interstitial, superficial, and preperitoneal. The interstitial type hernia is rare and involves herniation between the abdominal wall musculature and fascial planes. Diagnosis is rarely made preoperatively, and treatment consists of operative reduction of the hernia sac with primary tissue or mesh repair. Repair of interparietal hernias can be performed open or laparoscopically. We report the case of a 40-year-old male who presented with an incarcerated interstitial hernia which contained small bowel and had developed after open appendectomy performed 20 years prior. The hernia was repaired using the open technique and employed a mesh for reinforcement. The patient tolerated the procedure well and remained free of recurrence.

A case for the laparoscopic approach for rectus-adductor tendonopathy-athletic pubalgia David S Edelman, Harlan Selesnick International Journal of Abdominal Wall and Hernia Surgery 2019 2(4):152-156 Athletes with athletic pubalgia from core muscle injuries have many options available for treatment. Magnetic resonance imaging (MRI) can show pubic bone edema, rectus muscle insertion atrophy, and/or adductor tendonopathy. Our surgical repair using laparoscopically placed biologic mesh placed posteriorly with an open mini-incision to the anterior adductor longus tendon has had excellent results. This presentation will review the injury, a failed open repair followed by a biologic repair involving the rectus-adductor tendon injury onto the pubic bone of a recently treated athlete. A 28-year-old professional athlete presented 4 weeks after an open core muscle injury (CMI) repair. MRI showed disruption of the adductor tendon from the pubis and persistent opposing side rectus abdominis muscle insertion atrophy. After rehabilitation, his complete recovery prompted a retrospective review of all patients with laparoscopic biologic mesh. The laparoscopic, posterior, preperitoneal repair of the rectus-adductor tendon with biologic mesh is effective in treating athletes with athletic pubalgia. The laparoscopic approach to a rectus-adductor tendon injury using biologic mesh has not been well defined. A postoperative MRI found complete regeneration of the rectus and adductor muscles after a failed open CMI surgery (Meyer Repair). The peri-operative MRI shows the surgical progression of this condition.

Amyand's hernia without appendicitis; case report with 4-year follow-up Keerthi Rajapaksha, Samitha Rochana Samaraweera International Journal of Abdominal Wall and Hernia Surgery 2019 2(4):157-158 Amyand's hernia (AH) is a rare condition where the vermiform appendix is present in the inguinal hernia sac. Controversies exist regarding its management, particularly when the appendix is uninflamed. The current case report describes a 76-year-old male patient who was found having AH without appendicitis during the right side inguinal hernia repair. The patient underwent inguinal herniotomy and mesh repair without appendicectomy. There was no appendicitis or recurrence of hernia during the 4-year follow-up. Hence, we conclude that the appendicectomy is not routinely required in AH, if the appendix is uninflamed.