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Groin node dissection was done in an 80-year-old woman who had bilateral groin metastasis from squamous cell carcinoma of the vulva. After this procedure, laparoscopic pelvic lymphadenectomy was performed because of bilaterally positive groin nodes. Postoperatively, a strangulated femoral hernia occurred.
INTRODUCTION: An obturator hernia is a rare hernia that is bilateral in about 6% of patients. Most patients present with chronic pelvic pain although a few patients may present with features of intestinal obstruction. Only about 10% of obturator hernias are diagnosed preoperatively. METHODS: A 65-year-old female patient with chronic obstructive pulmonary disease presented with bilateral groin swellings associated with local pain and heaviness. She also suffered from recurrent episodes of abdominal distension. She was diagnosed to have bilateral direct inguinal hernias and a left femoral hernia. At endoscopy under epidural anesthesia she was found to have a direct inguinal, an indirect inguinal, and a femoral hernia on the left side and an indirect inguinal hernia on the right side. Additionally, the endoscopic totally extraperitoneal approach to inguinal hernias identified hitherto undiagnosed bilateral obturator hernias. The hernias were reduced and polypropylene mesh was placed bilaterally covering the myopectineal orifice and pelvic floor bilaterally. RESULTS: The patient was discharged the next day and is symptom-free on followup at eight months. CONCLUSION: Endoscopic repair of groin hernias allows the surgeon not only to diagnose and treat unsuspected groin hernias but also allows identification, dissection, and repair of coincidental occult pelvic hernias like obturator hernias at the same time.
BACKGROUND: Both the PROLENE Polypropylene Hernia System (Ethicon, Johnson & Johnson, Cincinnati, OH) and plug-and-patch devices including the Bard PerFix Plug repair (C.R. Bard. Inc., Murray Hill, NJ) are currently used in open groin herniorrhaphy. These systems rely on incorporating two mesh prostheses of different designs. In this animal study, early results for the two types of device were compared laparoscopically. MATERIALS AND METHODS: Twenty-four uncastrated male pigs (average weight, 25 kg) were randomized into two groups of 12 each for repair of unilateral groin hernia defects with the PROLENE Hernia System (Prolene) or the PerFix Plug (PerFix). Laparoscopic examination was performed immediately after the surgery to check the configuration and coverage area of the preperitoneally positioned mesh devices, with stress-loading tests to compare their primary efficiency. RESULTS: By contrast to the PerFix prostheses, in which the preperitoneal cone-shaped mesh only obliterated the primary fascial defect, in two-thirds of the Prolene repairs the flat and widely deployed underlay patch not only overlapped the defect but also covered the entire myopectineal orifice. Under heavy stress loading (25 newtons), the Prolene group also had a significantly lower incidence of fascial defect exposure in comparison to the PerFix counterparts (P = 0.003). In the stress-loading tests, four Prolene and eight PerFix plugs failed (P >0.005), mainly due to tissue disruption. CONCLUSION: Properly implanted Prolene devices have a wider coverage area and lower risk of fascial defect exposure and thus should be the treatment of choice for large groin hernia defects where the inguinal floor is attenuated. Where the PerFix devices are used under these conditions, they must be adequately secured to a healthy fascial edge, with onlay coverage patches to eliminate any weak points that might cause early recurrence.
Seven patients with extensive loss of soft tissue, extensor tendon, and exposure of bone and joint of dorsum of hand and foot were treated with free composite flaps from the groin area. To retard the adhesion by scarring, membrane interposition between tendon and bone was recommended. The groin flap, based on superficial circumflex iliac vessels, was combined with a well-vascularized external oblique aponeurosis. The groin skin flap provided skin coverage, and the aponeurosis was used simultaneously to create a gliding surface for reconstructed tendons in a single one-stage procedure. All composite free-tissue transfers were successful. The advantages of this technique are: (1) a single, one-stage procedure; (2) fewer adhesions of reconstructed tendons, and no need of secondary tenolysis; and (3) good cosmesis and minimal morbidity at donor site.
BACKGROUND: Complications that develop in groin hernias, such as irreducibility and obstruction, with or without strangulation may make an easily treatable condition a life-threatening one. Identification of risk factors that may predict development would help place the patient in a high-risk group. Priority admission and early elective surgery for such a patient would avoid significant mortality and morbidity. METHODS: This is a 10-year combined prospective and retrospective study of children and adults. Records of complicated groin hernias were identified from July 1985 to July 1995 from the outpatient department and available inpatient medical records. The same number of controls of simple uncomplicated hernias were then chosen using random number tables from among the large number belonging to the same time period. These two groups were then compared and analysed using statistical methods for age, sex, side of hernia, site of hernia (inguinal/femoral), duration of hernia, length of the waiting list for elective surgery, and contents of the hernial sac along with some other parameters to identify patients with high-risk factors. RESULTS: Age was found to be a significant risk factor and predicted complications in both elderly adults and very young children. Sex of the patient (male) and side of hernia (right) were significant risk factors in children only. Site of hernia was an important risk factor and adults with femoral hernia were most likely to experience complications. Duration of hernia for less than a year proved to be the most important risk factor for both children and adults. The majority of patients with complicated hernias had not presented earlier in the outpatient department, which implies that most hernias that become complicated do so within a very short time before patient referral. Mortality was high in patients with coexisting diseases, while morbidity was affected by viability of contents of the hernial sac which in turn was directly affected by duration of irreducibility or delay in presentation. CONCLUSIONS: The risk factors useful in predicting complications in an adult patient with groin hernia were age (older age group), duration of hernia (short duration), type of hernia (femoral more than inguinal) and coexisting medical illness. In children, the risk factors were age (very young), gender (male), short duration of hernia and side (right side).
The groin region is subdivided into two distinct anatomic areas: the inguinal canal and the femoral triangle. A series of cross-sectional imaging cases illustrate that a good understanding of the local anatomic characteristics of the groin allows confident characterization of groin pathologic conditions. Such conditions can be classified into five major groups: congenital abnormalities, noncongenital hernias, vascular conditions, infectious or inflammatory processes, and neoplasms. Congenital entities include hernias, cysts, undescended testis, and retractile testes. Ultrasound (US) is useful in depicting these conditions. In the second group, noncongenital hernias, US allows visualization of bowel loops in peristalsis within the hernia. Herniography, computed tomography (CT), and magnetic resonance (MR) imaging are also helpful in diagnosis. Among vascular conditions, false aneurysms may be detected from the turbulent flow through the tract at Doppler US. The characteristic venous flow of varicoceles is best diagnosed with US during the Valsalva maneuver. Infectious or inflammatory conditions include, among others, hematomas, which appear hyperattenuating at CT and have variable appearances, depending on the age of the blood products, at MR imaging. The origins of neoplasms may be assessed at CT and MR imaging, although appearances of solid tumors are relatively nonspecific.
Recurrent groin hernia is not uncommon in Taiwan. Subsequent surgical repairs are difficult, due to cicartrization and deterioration of the inguinal floor. In this report, the intermediate and long-term outcomes of 212 patients with recurrent groin hernias who underwent surgical repair within a 10-year period were analyzed in order to assess the effectiveness of two modified repair techniques. Patients with unilateral first-time recurrent hernia (UR; n = 87) were treated by a modified Shouldice technique using an inguinal approach. Those with bilateral or multiple recurrences (MRs; n = 125) were treated with giant prosthetic reinforcement of the visceral sac (GPRVS, Stoppa operation) using a midline preperitoneal approach. Complete exploration of the groin floor on the side of recurrence revealed a high rate of direct space defects (UR, 41.5%; MR, 65%) and multiple posterior wall defects (UR, 29.9%; MR, 30%). In the UR group, a 4 x 10-cm preperitoneal prosthetic mesh was incorporated to reinforce the repair. For MR patients, I reduced the transverse dimension of the mesh prosthesis by 2 cm compared with the original Stoppa protocol; to reduce crinkling, the average dimensions were 23 x 14 cm. Complications in the UR group included testicular atrophy (3 patients) and femoral vein thrombosis (1). Complications in the MR group were transient scrotal fluid accumulation (9 patients), fatal perioperative acute myocardial infarction (1), and failure of the peritoneum to grow over the mesh (1). The average hospital stay was 3 days in the UR group and 6 days in the MR group. The long-term follow-up (1-9 years) revealed a 5.7% re-recurrence rate with an 86.2% follow-up rate in the UR group, and a 1.9% re-recurrence rate with an 86.6% follow-up rate in the UR group. I conclude that GPRVS is an excellent treatment for URs, but the transverse dimension of the prosthetic mesh should be reduced for Taiwanese subjects. However, for first-time MRs, a modified Shouldice technique with incorporation of a preperitoneal prosthetic mesh is still recommended. The surgical dissection is less extensive and the hospital stay is shorter, while the re-recurrence rate is acceptably low.
BACKGROUND: Groin surgery for recurrent varicose veins can be technically difficult due to scarring from previous surgery. Access to the sapheno-femoral junction (SFJ) can be facilitated by approaching the veins indirectly (subfascially) by first exposing the common femoral artery. The aim of this paper was to document experience with both direct and indirect approaches to the SFJ for recurrent varicose veins. METHOD: A retrospective analysis of all patients having groin surgery for recurrent varicose veins. RESULTS: Of 128 legs having surgery, the approach to the SFJ was direct in 46%, indirect in 53% and unknown in one leg. Complications occurred after 40% of all procedures but were significantly more common following indirect surgery (57% versus 20%, P < 0.001), of which the most frequent were of a lymphatic nature (26% versus 5%, P < 0.001) or wound infection (16% versus 7%, P = 0.05). CONCLUSION: Wound complications are common following groin surgery for recurrent varicose veins especially after an indirect approach to the SFJ.
The "Tension free" and TEP (total preperitoneal repair) of groin hernia gained more popularity in surgical practice in the last five years. The aim of the study was to reveal our experience with these two surgical techniques. The TEP procedure was done in 29 cases, till "Tension free" herniorraphy was performed at 32 cases. Postoperative complications in the group with TEP hernia repair were found in 1 case. Two complications were observed in the "Tension free" group. The follow up of the patients revealed I recurrence in the group of TEP herniorraphy and no recurrence in "Tension free" group. These two techniques for repair of groin hernias had several advantages and in spite of increased operating theater costs should be adopted on a routine basis in some cases than conventional techniques for repair of groin hernia.
Using their experience the authors analyze the surgical methods of repair of groin hernias of McVay, Kukudjanov and Shouldice as a method of choice for combined groin hernias. Using their own anatomical researches, the authors prove that it is possible to explore and using Cooper's ligament extrafascially. The combination of duplication of the transversal fascia (as in Shouldice repair) and moderate change of the medial insertion point of the internal oblique abdominal muscle and the transversal abdominal muscle and suturing the Cooper ligament (as in Kukudjanov repair method), but extrafascially, a new repair method evolve, which strengthens the three weak points in the area. This method would meet to the highest extend the requirements for a correct anatomo-physiological strength of the groin area.
A series of 93 patients operated on for groin hernias by applying the preperitoneal approach is reported (89 bilateral and four unilateral). The patients were divided into two groups. Group one included 24 patients without prosthetic repair. Group two included 65 patients who had undergone repair with Ampoxen mesh. Some untraditional methods are reported, such as interparietal repair, rotative transposition of external oblique muscle aponeurosis, etc. As far recurrences are concerned, no differences were recorded between the two groups (Pt greater than 0.05). Of all 193 groin hernias 81% were followed up and the total percentage of recurrences was 4.5%. Slight testicular and neuralgic postoperative complications were reported (three and two patients respectively). The advantages of biomaterials were confirmed by ultrasound examinations of ten patients from both groups. A conclusion is made that hernia repair strategy should be based on natural groin tissue resources.
Since March 1983, the authors have applied three types of lateral groin flap to reconstruct the external genitals and to repair skin defects in the perineal region in 16 cases. (1) A single lateral groin flap was used to construct vagina in two patients; (2) A composite flap containing iliac crest bone was applied to reconstruct penis in 11 cases; (3) A coaxial pedicle flap of the lateral groin and lower abdominal area was used to repair skin defects of the penis and scrotum in two cases, and to relieve postburn scar contracture in the perineal region in another. 14 flaps survive completely with satisfactory results. 70 per cent of 1 composite flap was lost because of hematoma. The distal portion (3 x 5 cm) of 1 single flap necrosed due to injury of the deep branch of SCIA during operation and resurfaced with a free skin graft, final result is fair.
In order to determine the value of the pelvic part of the radical dissection of the groin, the histories of 23 patients with Stage II (UICC) melanoma with histologically proved metastases of the iliac or obturator lymph nodes, or both, were studied. Histologically proved primary melanomas were found in 19 patients, 18 were localized on the leg and one on the trunk. In four patients, the primary melanoma was unknown. Seven patients had received adjuvant radiotherapy. The time between node dissection and the moment of analysis was two years for 17 patients, five years for 11 patients and ten years for ten patients. Calculated actuarially, 42 per cent of the patients were still without distant metastasis after two years and 32 per cent after five and ten years. At the time of the analysis, ten patients were alive, nine without evidence of disease and three having survived for more than five years. Remarkably, the primary tumor of all three patients was "unknown" and they had all had adjuvant radiotherapy. In pooling the data of this series with those from the literature, it appears that, of 78 patients with Stage II melanoma and deep node involvement, 12 had a disease-free survival time of more than five years after therapeutic radical groin dissection. Involvement of deep nodes does not always seem to equate with systemic disease. We think that, when there is an indication for a therapeutic groin dissection, an en bloc superficial and deep lymph node dissection is warranted.
In the belief that recurrences will be lower if all defects are repaired at the original operation, I performed a Cooper's ligament repair on all groin hernias in adult patients between 1959 and 1984, regardless of the hernia type. This series includes 1142 repairs in 942 patients. Follow-up has been 97%, with 80% of the patients being personally examined by the author. Excluding late deaths, 906 repairs in 747 patients have been followed up for an average of 9 years. There have been 18 recurrences, for a recurrence rate of 2% of live repairs. This breaks down to 1.9% for 779 primary hernias and 2.4% for 127 recurrent hernias. In primary hernias only the recurrence rates are 3.5% for 289 direct hernias, 1.1% for 459 indirect hernias, and 0% for 31 femoral hernias. Seventeen of the 18 recurrences have been indirect along the cord in a subgroup of 147 repairs done with a subcutaneously transplanted cord and followed for an average of 17.4 years (recurrence rate, 11.6%). This method was discarded in 1972. There has been only one recurrence in 572 repairs with the cord left in the natural position and followed for an average of 7.1 years (recurrence rate, 0.2%). This shows the value of not superimposing the internal and external rings (90% confidence limits that the recurrence rate is less than 0.7%). There has been no recurrence in 154 repairs in female patients or 33 repairs with orchiectomy followed for 8.1 and 8.8 years, respectively. A Cooper's ligament repair gives a strong posterior wall and repairs all the defects that can occur in the groin. It can be done safely on all adult groin hernia patients, with a recurrence rate lower than those reported for selective methods of repair.
BACKGROUND: Prostheses are widely used in the elective treatment of adult groin hernias. Their use for strangulated hernias remains controversial because of the potential risk of sepsis. METHODS: Thirty-five patients with a strangulated groin hernia were treated by insertion of a prosthetic mesh via a midline preperitoneal approach. Nine patients needed an intestinal resection for irreversible necrosis without peritonitis, and an appendicectomy was carried out in three others. RESULTS: There were two postoperative wound infections, neither in patients who had an intestinal resection. No mesh had to be removed. The recurrence rate was one of 35 after mean follow-up of 4.2 years. CONCLUSION: A strangulated groin hernia can be repaired safely with prosthetic mesh. When an intestinal resection is carried out with sufficient care to minimize infective complications, the use of mesh is not contraindicated.
In 1994 we have started the Stoppa technique which was only used for the recurrent groin hernia repair, when Mersilene mesh was implanted in preperitoneal position from a lower midline incision. From March, 1994 to March, 1996 seventeen Stoppa procedures were performed in our department (14 men, 3 women, mean age of 66 years). Type of hernias: 13 unilaterale, 3 bilaterale recurrent groin hernias and 1 primary bilaterale groin hernia combined with a lower midline incisional hernia. Operations were performed by 7 surgeons. The mean time of the surgery was 85 min. (35-165). The mean postoperative stay in the hospital was 9 days (7-19). The Stoppa technique could be performed in all patients. Serious early postoperative complications didn't occur. The two late recurrences were observed amongst the first five patients. All implanted mesh were well tolerated by the patients. Author believe, this procedure has some advantages: the site of the incision is located in a new place from where the dissection is easier than in the previous incision, the stich fistulas from the previous operation can be avoided, furthermore this method could be applicated for combined hernias located in the lower part of abdomen and it is cheaper than the laparoscopic hernioplasty.
With the laparoscopic approach, bilateral and complex groin defects can be corrected simultaneously by applying a preperitoneal mesh that covers the entire posterior wall of the groin, using a technique similar to the one described by Stoppa. We present our series of hernias repaired by the transabdominal preperitoneal laparoscopic approach with the Stoppa-type technique. The report consists of 78 cases of bilateral defects, of which 60% were indirect bilateral hernias, 23% direct bilateral, and 17% combined defects; 28.5% were recurrent hernias. Only minor complications were observed (hematomas and urinary retention) in some patients, but all resolved spontaneously. Three recurrences (0.7%) have been seen to this date. This method is recommended as the method of choice for complex groin defects.
The free compound groin flap has been used to reconstruct anterior mandibular defects in four patients. The bone grafts have remained viable despite being placed in irradiated and contaminated fields. Partial intraoral exposure of two of the bone grafts did not interfere with their viability. Positive technetium Tc 99m pyrophosphate scanning, histology, and tetracycline labeling of the bony part of the composite flap indicate the maintenance of osseous viability without a transitory substitution phase for bone remodeling as seen in conventional bone grafts. Bone viability as it relates to blood supply of the free osteocutaneous groin flap is discussed.