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Laparoscopic recurrent inguinal hernia
Recurrent inguinal hernia? better laparoscopy

Recurrent inguinal hernia: what is it?

L'inguinal hernia belongs to the large family of hernias of the abdominal wall and represents one of the most frequent diseases of surgical interest worldwide: it is estimated that hernias in general affect 5 to 7 percent of the population, and of these about 75 percent are inguinal hernias. In other words, about 2,736,000 people in Italy are affected by inguinal hernias. The majority of these patients end up undergoing surgery, which, in the first instance, is a relatively uncomplicated procedure that is performed under local anesthesia and requires only a few hours of hospitalization. However, in not a small percentage of cases, the repair, for a variety of reasons (ranging from errors in technique to the patient's failure to follow the rules imposed by the surgeon in the postoperative), fails; the hernia reforms: we speak, in this case, of recurrent inguinal hernia.

Recurrence: a frequent problem in inguinal hernias

Modern surgical techniques and the use of prostheses have substantially reduced the rate of recurrence after inguinal hernia surgery; however, a recent study, conducted on more than 46. 000 patients in Denmark, showed that the incidence of inguinal hernia recurrence continues to affect about 4 percent of patients; less than the double-digit percentages observed before the advent of mesh: but, taking into account the numbers reported earlier, theoretically in Italy alone,inguinal herniarecurrence affects more than 100,000 patients-a not a small city!

The problem then facing the Surgeon is: what is the correct treatment of recurrent inguinal hernia?

What is the correct treatment of recurrent inguinal hernia?

Most Surgeons treat therelapsed ing uinal hernia exactly as they had treated the primary inguinal hernia: that is, they operate on it anteriorly, redoing a surgical incision on the previous one, and trying to put a "patch" on it as best they can-very often "inventing" on the spot some variation of the most commonly used surgical techniques (which, in the act, also seems like a good solution). This, unfortunately, is conceptually wrong, as well as going against the indications of the main guidelines available today.

Operating a recurrent hernia with the traditional incision when the primary hernia has already been operated on anteriorly means re-injuring tissue over which the surgeon had already passed during the previous operation, in an area where the anatomy has been profoundly altered by the surgery undergone by the patient anyway, and where there are very intense fibrotic phenomena due to the presence of the mesh: the risk of vascular and nerve injury and postoperative pain increases, and by a great deal; the wall of the inguinal region is further weakened, and the risk of recurrence increases. The patient risks being entangled in an endless and painful odyssey.

Hernia recurrence: better laparoscopy

Le guidelines, in this case drawn up by the European Hernia Society, speak clearly: Recurrent inguinal hernia, guidelines, European Hernia Society

"If previously anterior: consider open preperitoneal mesh or endoscopic approach (if espertise is present)" - i.e., if the patient has previously been operated on anteriorly, open repair with mesh in the preperitoneal position (e.g., Stoppa's or Wantz's techniques) or the endoscopic technique are indicated, provided expertise is present, i.e., there is a Surgeon experienced in this procedure.

In fact, in Italy - for a thousand reasons, which it is not the case to analyze here - there are few Surgeons able to try their hand at inguinal hernia repair laparoscopically, especially if it is arecurrent inguinal hernia (and perhaps even fewer who are able to perform an operation with Stoppa or Wantz technique). These are difficult cases, with altered anatomy in any case (even if, "going from the inside," i.e., from the inner surface of the inguinal region, one is working in seemingly "virgin" territory), which can only be addressed by experienced surgeons. But the advantages are clear: one has the possibility of repairing the herniated defect with a significantly larger mesh than is used in traditional hernia surgery, placed in a "healthy" area than where the surgeon had previously worked; and not infrequently, one may find that one is actually not dealing with arecurring inguinal hernia, but with a new hernia, perhaps unnoticed during the previous surgery, or perhaps formed later; and that, lo and behold, there is also a hernia on the other side, in the other inguinal region, which neither the patient nor the surgeon had noticed, and which can be repaired during the same surgery, before it begins to bother. Not to mention that postoperative pain is significantly less than with traditional surgery, and the patient can return to his or her activities much more quickly.

The video of the surgical technique

And here, finally, is a video of a recent surgery I did for recurrent inguinal hernia, performed laparoscopically (T.A.P.P. technique, Trans Abdominal Pre Peritoneal). This was a utrasectomy patient in his fourth recurrent hernia (!!! That is, three other surgeons had already operated on him by going through the anterior route, evidently without great results). Not an easy surgery, as expected, but successfully concluded to the patient's satisfaction. The mesh, as prescribed by the guidelines, is placed in the preperitoneal space, but without the large incisions required for Stoppa or Wantz techniques (in fact, the patient will be left with three small scars, two 10 mm and one 5 mm...).

The patient was discharged the day after surgery, and had no discomfort or complications in the postoperative period. These results are obtained in the vast majority of cases of patients operated on laparoscopically. But - I repeat - laparoscopic inguinal hernioplasty , especially in cases of recurrent inguinal hernia, is not for everyone, and must be performed by an experienced surgeon.

Enjoy your viewing!

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Dr. Salvatore Cuccomarino
Cuccomarino, MD
Medical Surgeon Specialist in General Surgery
Corso Galileo Ferraris 3
Phone 0110438161
Laparocele, hernia, incisional hernia, abdominal hernia, eventration
And after the surgery, the laparocele

Laparocele, hernia, incisional hernia, abdominal hernia, eventrationAnd after the surgery, the laparocele. It is not so uncommon (indeed!) that after abdominal surgery a "bulge" appears near the surgical scar. It is the laparocele, o incisional hernia: the wall suture has failed ("suture dehiscence"), and now the viscera contained in the abdomen press toward the skin.

A laparocele is a true hernia. The difference is that it appears not at a naturally occurring orifice, but at a surgically created defect. There are many conditions that facilitate the occurrence of a laparocele, ranging from incorrect lifestyles (e.g., smoking), to physiological states (such as advanced age), dysmetabolic (e.g., malnutrition), and pathological (such as tumors).

Treatment of a laparocele is always surgical, and presupposes a careful preoperative study (the dynamic CT scan of the abdominal wall), which must lead to equally careful evaluations of the choice of surgical technique to be adopted.

Repair of a laparocele can in fact be performed either laparoscopically, minimally invasive, or open, but the two access modalities are not interchangeable. Minimally invasive surgery is effective in defects of more modest size, no more than 6-8 cm. In the case of larger defects, in fact, Placement and proper distension of the mesh can be difficult, exposing the patient to an increased risk of recurrence. In addition, a large laparocele also presents other issues that it is crucial to take into account: for example, the volume of the herniated viscera and the residual space of the abdominal cavity, which must be properly calculated: this is to avoid determining, with an incorrect repair, an intra-abdominal pressure increase, which can be a cause of respiratory failure in the patient. In addition, in large laparoceles there is oftenatrophy, associated with retraction, of the muscles of the abdominal wall: this may make it impossible to "reconstruct the midline," as it is called in the jargon, that is, to relocate the muscle-fascial layers of the wall in their correct position so as to repair the abdominal defect. In such cases, anatomical separation of components (SAC), i.e., isolation of the individual layers of the abdominal wall, is necessary: this allows both the muscle-fascial components to be brought closer to the midline and the placement of large meshes, which are essential for reconstructing both the structure and function of the abdominal wall in such cases.

These are very complex and time-consuming operations that can only be performed by highly experienced surgical teams. The most refined anatomical component separation technique is that of Carbonell-Bonafé, two Spanish surgeons who without difficulty can be counted among the great masters of 20th century wall surgery.

I was fortunate to learn the Carbonell-Bonafé technique directly from Professor Fernando Carbonell; currently, my team is among the very few (I think less than 5) in all of Italy performing it. Here is a short film of mine, summarizing in less than 20 minutes a catastrophic laparocele surgery repaired with Carbonell's technique that lasted about 5 hours.

inguinal hernia symptoms, inguinal hernia surgery, scrotal hernia, inguinal hernia symptoms, inguino-scrotal hernia, strangulated hernia, adult umbilical hernia, inguinal hernia surgery, inguinal hernia photo, inguinal hernia surgery, testicular hernia, abdominal laparocele, hernia symptoms, umbilical hernia surgery, inguinal hernia recurrence, crural hernia symptoms, spigastrium hernia, inguinal hernia photos,hernia symptoms, female inguinal hernia, inguinal hernia surgery, umbilical hernia surgery, epigastric hernia symptoms
Abdominal wall surgery in the cancer patient

inguinal hernia symptoms, inguinal hernia surgery, scrotal hernia, inguinal hernia symptoms, inguino-scrotal hernia, strangulated hernia, adult umbilical hernia, inguinal hernia surgery, inguinal hernia photo, inguinal hernia surgery, testicular hernia, abdominal laparocele, hernia symptoms, umbilical hernia surgery, inguinal hernia recurrence, crural hernia symptoms, spigastrium hernia, inguinal hernia photos,hernia symptoms, female inguinal hernia, inguinal hernia surgery, umbilical hernia surgery, epigastric hernia symptoms

Abdominal wall surgery

Abdominal wall surgery is a superspecialty surgery, in many respects more complex than most other abdominal surgeries (except, perhaps, pancreatic surgery and metabolic surgery), requiring years of study and application, and a very detailed knowledge of human anatomy, to be successfully performed. In our unfortunate country, by many of the many, too many big wigs in our own health care, abdominal wall surgery is considered a minor branch of the medical sciences; but one only has to cross the Alps to see how much it is valued, and even feared, in the international surgical environment. And this is well understood when one looks at the disasters, due to surgical unpreparedness, often combined by those who approach the operating table without due respect for the abdominal wall: which, it should be remembered, is one of the load-bearing walls of the "house" in which we live, our body. How would one live in a house with gutted walls? The quality of life would be abysmal; and abysmal is the quality of life of those who are recklessly operated on by those who do not know the laws-often very complex-that dictate that we follow the abdominal wall.

The history of abdominal wall surgery

abdominal wall surgery, inguinal hernia symptoms, inguinal hernia surgery, scrotal hernia, inguinal hernia symptoms, inguino-scrotal hernia, strangulated hernia, adult umbilical hernia, inguinal hernia surgery, inguinal hernia photos, inguinal hernia surgery, testicular hernia, abdominal laparocele, hernia symptoms, umbilical hernia surgery, inguinal hernia recurrence, crural hernia symptoms, spigastrium hernia, inguinal hernia photos,hernia symptoms, female inguinal hernia, inguinal hernia surgery, umbilical hernia surgery, epigastric hernia symptoms,La history of abdominal wall hernia surgery È the History of Surgery: all the greatest Surgeons, all those whose names are remembered, have applied and contributed to it. I have spoken about it at several national and international conferences and courses, because it is a fascinating tale; just as fascinating is the History of the invention of the prostheses we use today in abdominal wall surgery: to the eye, small sheets of plastic, but with extraordinary technological content inside that rests on more than a century of scientific research.

Course on abdominal wall surgery in the cancer patient

It is therefore a great honor for me, and a great pride, to participate, as the ONLY ITALIAN INVITED SPEAKER among dozens of sacred monsters of Spanish (among the best in the world) and Hispanoamerican Surgery, in the International Course of Abdominal Wall Surgery in the Oncological Patient organized by the Sociedad Hispanoamericana de Hernia and by theUniversity of Valencia next October.

The course is sponsored by the Generalitat Valenciana, the Asociación Española de Cirujanos and theInstituto Cervantes, to name but a few of the major Spanish institutions that have shown interest in our work; as well as by numerous international Scientific Societies.

We will hold our country's flag high, and honor our work!

León Herszage died
León Herszage, great Argentine surgeon, has died

León HerszageLeón Herszage, Master of all Argentine Abdominal Wall Surgeons and one of the most eminent personalities of 20th-century surgery, died Jan. 11 in Buenos Aires, where he resided.

I had the privilege of attending one of his lectures in Bilbao, in the Basque Country where I was then residing, in 2011. The occasion was theXI Congreso Nacional de Cirugía de la Pared Abdominal sponsored by the Asociación Española de Cirujanos. I was fascinated by his enthusiasm, despite his advanced age, in recounting the story of his professional life. His cultural achievements, discoveries, even his mistakes, and the devotion he still put into his work then. Unfortunately, on that occasion I was not fortunate enough to meet him personally.

I had, however, later experienced his courtesy and helpfulness. I wanted to buy his texts on Wall Surgery, and since we were part of the same Scientific Society, the SoHAH (Sociedad Hispanoamericana de Hernia, which published these days this nice memory of him) I took the courage in two hands and sent him an email, asking him where I could find them.

He replied back to me in short order, with that ancient courtesy that we have forgotten and that today is found only in habla española countries. He told me that it would be his pleasure to give them to me as a gift, if I had a chance to stop by his consulting room in Buenos Aires.

I had hoped to do so; unfortunately, I could not.

With León Herszage we lose not only a great Colleague, but a fundamental scientific reference of our profession. With him disappears one of the greatest exponents of that cultural aristocracy that was once (now no longer, evidently because of us...) in Europe, and continues to be in many Spanish-speaking countries today, medical thought.

May he rest in peace.



ernie, Panama
Ernie panameñe: chronicle of a success story

And so, I was in Panama. I caught up with old friends, met new ones, but above all I had the joy of operating with them, explaining my techniques, demonstrating and teaching them, and helping a few patients solve their wall problems.
In four days I performed about 20 surgeries, half of them minimally invasive laparoscopic; I was fortunate to have access to ultramodern and super-accessorized operating rooms, and to use very high quality prostheses, such as the Herniamesh Relimesh or the brand new Hybridmesh, a mesh that within two years resorbs 75%, ultimately leaving very little foreign material in the patient. A fantastic mesh for wall repairs, for example, in athletes or adolescents. Nothing to do with the now very scarce resources of the Italian National Health System, destined, moreover, to become even thinner in the coming years.
I have operated on patients with inguinal hernias, crural hernias, epigastric hernias, laparoceles following, above all, gynecological operations or cesarean sections. Operations in some cases very complex, but always completed with excellent results. In short, it was really exhilarating, a complete success. And here is the photo chronicle of those days!

hernias, inguinal hernia, laparocele, Panamá
The operating room staff. I'm the one in the second row, with the colorful beret: local beauties first!


Rather complex case: large abdominal hernia on Pfannestiel incision, the cut normally used by gynecologists for hysterectomies and cesarean deliveries. Here I am drawing the shape of the prosthesis on the patient's abdomen, a prosthesis that will be placed laparoscopically


With my great friend Miguel Aguirre. I am cutting out the mesh, a Relimesh, to be placed minimally invasively laparoscopically


Still with Miguel, as we design the Relimesh net shape for another patient.


Group photo of the surgical team


The magic of lights in laparoscopic surgery!


what is a hernia
I have a hernia-but what is a hernia!!!?

Often, when we talk to our patients, we forget that medical language is a kind of "initiatory" language, little understood by those outside the environment. Therefore, the patient knows he has something but does not always know what.

This is especially true for conditions that are considered "minor" (which they are not): if the person in front of me has a tumor, I spend a lot of time explaining his situation well; but if he has an inguinal hernia, or hemorrhoids, I take it for granted that he already knows what it is, and I don't waste too much time in explanations.
But is it really a matter of wasting time? How many people really know what a hernia is-and, consequently, are able to understand whether and how dangerous it is?

Let's try to get some clarity.

What is a hernia

"A hernia is defined as the exit of a viscera from the cavity that normally contains it, through an orifice, an anatomical channel, or otherwise a continuous solution."

This is the classic definition of hernia, of any hernia, from inguinal hernia to herniated disc; but it is not so readily understood unless one has at least some basic knowledge of anatomy.

So let's try to reason by similarity. If you are of my generation, the generation of kids who when they punctured a bicycle tire did not change it but patched the inner tube, it will come easy to you.

Think precisely of a tire; and imagine that the tire tears, and out of the tear comes the inner tube, as in the photograph below: that's what a hernia is: the tear represents "the orifice, anatomical channel or otherwise continuous solution" of the definition from before; what we surgeons call "the herniated defect."

what is a hernia, abdominal hernia, inguinal hernia

The air chamber that comes out of the tear is the "hernial sac": in the case of the inguinal hernia, it is the peritoneum that used to line the "torn" inguinal wall on the inside and now peeps through the tear itself.

If then the sac contains a "viscera" that has pushed through the "tear"-and which in the case of an abdominal hernia (abdominal hernias are, depending on where in the abdominal wall they occur, inguinal hernia, crural hernia, umbilical hernia, epigastric hernia, Spigelius hernia...) is usually fat (the omentum) or a piece of intestine-these are the "herniary contents." Easy, right?

Now that (I hope) it is clear what a hernia is, let's come to the other question: why can a hernia be dangerous and must be operated on? Well, in abdominal hernias--of which the most common are inguino-crural and umbilical--and particularly, paradoxically, in those in which the defect is small, it is possible, as already mentioned, for the herniated content to be an intestinal loop. Sometimes, it happens that the leaked loop cannot be "reduced," that is, relocated to its natural position inside the abdomen. This is referred to in this case as an incarcerated hernia. The incarcerated loop, because of the compression it undergoes, becomes soaked with fluid and "swells," and this can cause compression of the arteries and veins that supply it. This is strangulated hernia, an extremely life-threatening condition because it is at very high risk of necrosis (i.e., death) of the intestinal loop and its perforation (as in the case of the photo opposite).

That is why all hernias should be referred to a surgeon experienced in abdominal wall surgery, the only specialist who can determine whether to operate, when, and with what technique.