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Cir Cir 2012;80:331-341

Strangulated inguinal hernia

Ernesto Manuel Gngora-Gmez

Background: Strangulated inguinal hernia (SIH) has an overall prevalence of 1.3% in adults, affecting mainly senile patients, with a high incidence of morbidity and mortality. There are more than 13different surgical techniques for treatment, but none has proven to be more effective than the others. Methods: The present observational, longitudinal and prospective study carried out at Hospital General, Centro Medico La Raza in Mexico City proposes a new surgical technique to treat SIH. Between December 2000 and August 2010, 43adult patients with SIH were consecutively subjected to preperitoneal mesh repair and exploratory laparotomy (PPMR and ELAP), a personal modification by the author to the Stoppa-Rives technique. Several variables were studied. Results: There was zero mortality. There were no cases of inguinal recurrence or reintervention. Onepatient developed a granuloma at the surgical site. There were threecases of superficial wound infection, sixcases of inguinoscrotal seroma, and onecase of incisional hernia. Discussion: There is no international consensus on the treatment of SIH although it is interesting to analyze the studies published during the last two decades and to observe the results. Studies that propose a preperitoneal approach with mesh demonstrate the best results by reducing morbidity and mortality. Conclusions: Preperitoneal mesh repair and exploratory laparotomy reduce the rate of morbidity and mortality in the treatment of SIH. Inguinal hernias must be repaired at the time of diagnosis to avoid strangulation. Key words: strangulated inguinal hernia, preperitoneal mesh repair, exploratory laparotomy

The worldwide prevalence of strangulated inguinal hernia (SIH) is 0.32.9% of all inguinal hernias in adults.1-3 Primary hernias strangulate more than recurrent and small hernias more than large hernias at a ratio of 5:1.4 The risk of hernia strangulation is greatest during the first 3 months of its appearance5 and occurs at an average age of 69 years with no difference between genders. The right side is most affected (2:1). Indirect hernias become strangulated more

Departamento de Ciruga General, Hospital General Gaudencio Gonzlez Garza, Centro Mdico la Raza, Instituto Mexicano del Seguro Social, Mexico, D.F., Mexico

Correspondence: Ernesto Manuel Gngora-Gmez Quertaro 144-412, Col. Roma, Deleg. Cuauhtmoc CP 06700, Mexico, D.F., Mexico Tel: (0155) 10844747 Ext. 7401 E-mail: Received for publication: 9-14-2011 Accepted for publication: 3-28-2012

than direct and femoral hernias; the latter are more frequent in females.6 Before the use of mesh in inguinal hernia surgery there were no reports on morbidity of SIH because there was practically no short- or long-term follow-up on management of these cases. However, there were reports on mortality as follows: in 1959, Rogers7 reported 26%, in 1960 Nyhus et al.8 reported 33%, in 1975 Read9 reported 25%, in 1994 Pans and Jacquet10 reported 17%, in 2000 Steinke and Zellweger11 reported 25% and Harouna et al.12 reported 40%. After the advent of mesh, the mortality index has been reduced to 13%, whereas the reported incidence of recurrence is 04%, surgical wound infection 521%, and seroma 315%.13-15 Some femoral, and mainly the obturator, hernias become chronically sporadically trapped (especially in females). Isolated reports exist on the morbidity and mortality index of the latter when they cause acute episodes of occlusion and constitute a surgical emergency. From the time that plastic prostheses began to be used in the management of abdominal wall hernia, mainly inguinal, a revolution in surgical techniques began and thereby its terminology, coining new concepts such as with tension to refer to the traditional techniques by Bassinni, McVay, Halsted, and Shouldice and tension free to refer to the

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new techniques that used prosthetic mesh such as Lichtenstein, Stoppa, Mesh-Plug, PHS, etc. With the advent of the mesh, a revolution in the management of hernias began, mainly in the groin. Prior to these changes there were at least nine procedures with tension suggested for management of SIH. After the onset of mesh prostheses, new tension free techniques have been incorporated, with application of the mesh anteriorly, preperitoneally,21-23 or with laparoscopic techniques.24-28 Currently, there are more than 13 procedures recommended for management of SIH. This study once again proposes the preperitoneal repair with mesh and exploratory laparotomy, confirming its advantages and favorable results because it resolves the hernia as well as the damage caused by the ensuing strangulation by achieving the following: a) Access to both inguinal regions by the Cheatle-Henry technique b) Reduction of the sac and its contents c) Application of the prosthetic material and of a drainage system in the preperitoneal region d) Wide approach of the abdominal cavity that allows assessment of the damage, observation of the existence of unsuspected concomitant hernias, identification of the number and degree of lesions in the internal organs, facilitation of intestinal decompression, performance of the pertinent enterostomy and anastomosis or bowel rest if required and, finally, for washing and draining the cavity in case of intestinal leak and generalized peritonitis e) One sole repair technique for all types of inguinal hernias by the application of mesh in the preperitoneal space, which allows for correction of all hernia defects in the inguinocrural region, eliminating the need to apply a different technique for each hernia type f) No specialized training necessary because all surgeons can perform the procedure and the use of sophisticated equipment is not required (such as the laparoscope) or a long learning curve g) The only option for advanced cases (gangrene of the soft tissues or great intestinal dilation) that require debridement, orchiectomy, bowel decompression, and relaxing incisions to enlarge the orifice and free the trapped organ Early diagnosis, overall evaluation of the patients status and timely treatment are the keys for prognosis as well as intensive fluid replacement, adequate antibiotic use, nasogastric decompression of the abdomen, kidney monitoring and correction of coagulation parameters and other existing health issues due to the multipathological nature of these patients. These objectives must be met promptly, during the first 24 h prior to the surgical event.

Details of the surgical technique: preperitoneal mesh repair and exploratory laparotomy (Figure 1) A midline infraumbilical incision was made close to the symphysis pubis and after dissection by planes the preperitoneal space was entered without opening the peritoneum. Ipsilateral traction was carried out over the muscular wall to expose by blunt dissection the posterior wall of the affected groin (the surgeon has the option to primarily explore the contralateral groin in search of suspected or unidentified concomitant hernias)29 and the site of hernia strangulation was located to manually reduce it with traction and internal and external gentle countertraction. If such a reduction is not possible, relaxing incisions should be made to widen the neck of the hernia. In case of indirect hernia, the epigastric vessels should be cut and ligated, protecting the sac and its contents so as to not open it. A cut is made in the internal ring between 11 and 12 oclock in an oblique superomedial direction, resecting the fibers of the ligament of Hesselbach and the conjoined tendon (Figure 2). In the direct hernia the cut is made between 10 and 11 oclock and over the posterior fascia of the union of the rectus and transverse muscles (posterior face of the conjoined tendon or ligament of Henle) (Figure 3). If the hernia is femoral, the cut will be oblique in the iliopubic tract at its insertion at the ligament of Cooper (Gimbernat ligament) medially. It should be noted that the femoral vessels are found adjacent in the external lateral sense and in the lateral superior direction the epigastrics emerge. Exposure and cutting maneuvers should be done gently and precisely (Figure 4). If an obturator hernia is found, the cut should be made in the endopelvic fascia below the ligament of Cooper medially and inferior to avoid the obturator vessels and nerves (Figure 5). Once the sac and its contents are freed, it is retracted towards the abdomen without opening it, in order to avoid contamination. If reduction of the sac is impossible (because it is intimately adhered) it can be ligated and cut at the level of the neck avoiding as much as possible escape of the contents to the preperitoneal space, leaving the inguinoscrotal remnant of the sac attached. This will be exhaustively washed and will allow exteriorization of one of the drainage tubes closed to suction (in case a perforated sac is found, with evident contamination due to the presence of an abscess and/or intestinal leak, a mesh should not be applied and Nyhus type fascial repair will be done). A piece of polypropylene mesh not less than 1012cm should be placed before parietalization of the spermatic cord, suturing it with nonabsorbable monofilament material to the pubic tubercle, Coopers ligament, iliopsoas fascia and conjoined

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Midline incision

Contralateral preperitoneal exploration

Presence of hernia Unilateral prosthesis Absence of hernia

Preperitoneal exploration Groin pathology

Reduction of sac Not opened

Integral sac Perforated sac Abscess and intestinal leak in inguinal region. Do not apply Apply polypropylene mesh parietalization of the cord Adherence of sac section at the level of the neck; avoid leaks

Fascial type Nyhus repair

Installation of closed drainage

Leave residual sac in situ

Approach abdominal cavity according to midline,not

Exploration and evaluation of damage

Resection and intestinal anastomosis, closed technique

Solution for other damages lavage?/cavity drainage?

Closure of wall with aseptic technique

Figure 1. Algorithm of surgical technique: preperitoneal repair with mesh and exploratory laparotomy.

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Figure 2. Incision in ligament of Hesselbach.

tendon. A closed drain is then installed, which is exteriorized from below and inside the anterior superior iliac spine (the surgeon decides on the exit site according to the type of case). This type of drainage has decreased the number of hematomas reported in other studies. We now proceed (but not earlier) to opening the peritoneum via the midline to complete the approach by means of a laparotomy. Using this route, the cavity is explored to evaluate the damage and its repair. Resection of the affected organs is performed and anastomosis, if the damage is intestinal. This exposure will allow washing of the cavity and draining, if necessary. In some cases decompression of the dilated intestine is obligatory because if not done it imposes closure under tension of the cavity. The surgeon will manually decompress in retrograde manner or aspiration through enterotomy. The wall closure should be completed using aseptic technique. Also, the skin edges and epidermis will be left open in case of peritonitis and according to the surgeons judgment. Emphasis is given to proceed with careful handling of tissues, judicious use of cautery and suture materials, shorter operative times, removal of devitalized tissue, use of efficient drainage and aseptic closure of the cavity. General

Figure 3. Incision in ligament of Henle.

anesthesia is ideal for this surgery because it provides adequate intraoperative relaxation.

Patients and Methods

From December 1, 2000 to August 31, 2010, 43 adult patients with SIH underwent emergency surgery consecutively with preperitoneal repair with mesh and exploratory laparotomy. Patients were all seen in the Emergency Department of the General Hospital Medical Center La Raza in Mexico City. All patients underwent routine screening studies: blood count, blood chemistry, serum electrolytes, blood amylase, prothrombin time, partial thromboplastin time, abdominal x-rays standing and supine and chest xray. All patients were assessed primarily by an emergency physician who initiated rehydration therapy, analgesia and antibiotics. The Department of General Surgery was then contacted for interconsultation.

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Figure 4. Incision in ligament of Gimbernat.

Average age of the patients was 71 years (range: 2692 years). There were 18 females and 25 males. There were 33 patients with comorbidities with the following being predominant: hypertension (19 patients), obesity (16 patients), type 2 diabetes mellitus (8 patients), prostatism (6 patients), lung disease (6 patients), heart disease (5 patients), and renal disease (3 patients). There were 33 cases of primary hernia and 10 cases of recurrent hernia (three with more than two recurrences). Small hernias (<8 cm) strangulated more often (34 cases) than those >8 cm (9 cases). The right side was most affected (24 cases) than the left (19 cases). The time of evolution since the first symptoms appeared until the time of surgery was 46.2 h (990 h); 39 patients had signs of intestinal obstruction and 24 patients had signs of peritoneal irritation. There were 19 cases of dehydration. Leukocytosis >10,000 was demonstrated in 28patients and bandemia in 12 patients. Dermoepidermal changes were present in five cases (one with scrotal gangrene). X-rays of the abdomen showed air fluid levels in 36 patients, bowel loop dilation in 39 patients, free fluid in the cavity in eight patients, and intestinal wall edema in 28 cases. All patients were subjected to preperitoneal surgical repair with mesh

Figure 5. Incision in the endopelvic fascia below Coopers ligament.

and exploratory laparotomy. We chose the Gilbert-Rutkow classification (because it was the most practical and complete in our estimation) to group the hernias of our patients: type II (8cases); type III (14cases); type IV (6 cases), type V (1 case), type VI (5 cases) and type VII [9 cases (female predominance with 7 cases and 2 cases of males)]. There were also concomitant hernias found: six contralateral, one ipsilateral, two umbilical and two postincisional. There were four Richter hernias identified and one Amyand.30 Resection was carried out on 34 patients due to necrosis, although in some cases there was compromise of more than one organ: small intestine in 18 cases (all with involvement of some segment of the ileum and that was resolved with end-to-end anastomosis in two planes), hernia lipoma in 13 cases, hernia sac in 19 cases, omentum in eight cases, epiploic appendix in four cases, testicle in three cases, colon in two cases (the cecum in one case that required an ileostomy and sigmoid in the second case that required colostomy of

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the descending colon); the cecal appendix of the Amyand case was excised despite vascular recuperation. There were nine cases without resection because the trapped organs recovered their viability. There was also more than one organ found trapped: small intestine 6, colon 5 (two of the cecum and three of sigmoid), and omentum 5 (Table 1). Peritonitis due to intestinal leakage occurred in four cases, all of which were managed with scrupulous washing of the cavity, application of Saratoga-type drains in both parietocolic gutters and management with double or triple antibiotic. One case of intestinal leak was due to cecal perforation (the case that required ileostomy) and the other three were leaks from the small intestine. After segmental bowel resection, anastomosis with aseptic technique was performed in two planes. A preperitoneal inguinal drain was placed in 24 patients and intraabdominal in ten patients (four of these patients experienced intestinal leak). A relaxing incision was done in the constricting hernia ring because it was impossible to free up the hernia sac and its contents with simple maneuvers in 18 cases: ten indirect hernias, four indirect hernias and four femoral hernias. The characteristics of the mesh installed were Dacron2, polypropylene (PPL) 37, light mesh 3, and composite (polypropylene + Teflon) 1. General anesthesia was administered in all cases because of the requirement of adequate intraabdominal relaxation. Average surgical time was 142 min (75260 min) (Table 2). Antibiotic therapy was administered with one or more drugs: two cases without antibiotics, monotherapy in 21 cases, two antibiotics in 15 cases, and three antibiotics in five cases. Average hospital stay was 7.1 days (225 days). Follow-up of 1118 months was reported in 21 patients; 13 patients died during the course of the study due to non-

Table 2. Surgical findings for SIH

Peritonitis* Drainage Relaxing incision (18) Type of mesh 4 Inguinal** Abdominal Indirect opening Direct opening Femoral opening Polypropylene Light Dacron Bilayer Type of anesthesia Surgical Time (min)
*Intestinal leak due to perforation. **Closed drainage. SIH, strangulated inguinal hernia.

24 10 10 4 4 37 3 2 1 43 142


Table 1. Resection due to necrosis or vascular repair

Resection for necrosis* 34 Small intestine Hernia sac Hernia lipoma Omentum Epiploic appendix Testicle Colon Without resection for vascular recuperation ** 9 Small intestine Colon Omentum Cecal appendix
* Various cases with more than one necrosed organ. ** Various cases with more than one incarcerated organ.

18 19 13 8 4 3 2 6 5 5 1

surgical-related causes. Nine patients were lost to followup. No deaths occurred during surgical management or during the postoperative period. Deaths occurred during a 10year period due to various diseases unrelated to the surgery. There were zero recurrences during the follow-up period. There were no re-operations. No case had to be reoperated during the immediate postoperative period. There was an infected granuloma in one patient; 2 months after surgery an area of swelling was demonstrated in the interior commissure of the scar that finally revealed three knots of suture material and remained oozing until we opened to 3 cm and washed the area intensively for 12 days until control was obtained. Closure was done by secondary intent without requiring re-exploration or removal of the mesh. Incisional hernia was done in one patient detected 1 month after surgery in the mid-third portion of the scar. The patient underwent conventional open herniorraphy during the second month without incident. Infection occurred in three patients. The wound was left open due to development of peritonitis and the infection was controlled with exhaustive lavage, without mesh infection. In two patients we reapproximated the wound margins with sutures, and in the third patient closure was done by secondary intent. There were six cases of seroma, four were noted among the first 10 cases reported. We did not leave a preperitoneal drain as routinely done and the other two occurred with cases of giant inguinoscrotal hernias. All resolved with one and three evacuation punctures performed aseptically during office consultation (Figure 6).

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Results 7 6 5 4 3 2 1 0 Seroma Surgical wound infection Incisional Granuloma hernia

Figure 6. Results of morbidity with the surgical technique for strangulated inguinal hernia.

Management of the complicated inguinal hernia requires a precise diagnosis. It is important to define the degree of involvement of its contents. In the case of SIH, all intervening aggravating factors should be analyzed. Selection of the operative technique is still controversial; however, each day there is further proof of the benefits derived from wide abdominal cavity exploration and hernia repair with preperitoneal prosthesis during the same surgical event. Another reason for the controversy is the use of mesh in areas potentially contaminated; however, various reports confirm that its use in such situations is not contraindicated.31-34 Approaching a strangulated inguinal hernia via an inguinal incision without exploration of the abdominal cavity carries distinct risks: Missing inadvertent unsuspected concomitant hernias Totally missing intraabdominal lesions that cannot be identified through a limited hernia orifice such as perforation and intestinal leak, severe ischemia and/or necrosis of the small or large intestine, of the omentum, epiploic appendix or cecal appendix, bladder or the testicle Not identifying chronic constrictions in the intestine when strangulated, provoked by the tight neck of the hernia that in the future will stenose and cause difficult to diagnose intestinal occlusions35 Ignoring the presence of unsuspected purulent or intestinal blood collections that warrant drainage High degree of difficulty for intestinal resection and anastomosis as well as placing the surgical procedure at risk when performing a contaminated procedure in the inguinal region

Postponing the surgery for a second surgical time gives priority to the resection, maintaining the latent risk of a second strangulation in the short term. In the past decade, various types of light mesh prostheses associated with polyglactine or polyglecaprone to reduce regional inflammatory reaction of index of seroma began to be used. We used three types of these mesh prostheses and no cases of seroma were presented. However, it should be mentioned that this complication may be due to a number of associated factors such as the size of the hernia and, therefore, the extension of the regional surgical dissection, size and characteristics of the prosthesis (heavy or light), resection or not of the hernia sac, use of a delayed surgery and installation of a good closed drainage. In other reports on seromas, minor complications have been reported after use of heavy Dacron or polypropylene mesh, but these reports did not mention if drains were used. In our series the largest number of seromas occurred when a closed drain was not installed. We also point out that the closed drain decreases the possibility of exterior contamination as may occur with open drains. Since 1994, various studies reporting the use of mesh for management of SIH have been published with good shortand long-term results; however, some of these studies do not distinguish, with certainty, incarcerated from SIH and both concepts were managed in an indistinct manner. Some are reports of individual cases and other report on larger series. Up to now there have been no comparative and randomized studies that individually confront the different techniques. The studies that report the use of open techniques with mesh and those that use laparoscopic techniques report a substantial decrease in morbidity and mortality. In 1994, Henry and Randriamanantsoa22 proposed the use of prostheses in surgical emergencies. They applied 15 mesh plugs, 32 Mersiline meshes and 7 Vicryl meshes, mainly through an inguinal approach. Resection was carried out in five cases, reporting only one wall abscess as a complication. In 1996, Gavioli et al.32 presented their work with 31 cases subjected to the application of a polypropylene mesh (29 cases) and Dacron (2 cases) preperitoneally or retromuscularly. They performed intestinal resection in three patients and omentum in 13 due to necrosis. There were no infections or recurrences. These authors proposed the use of mesh in SIH, excluding the case with severe infection due to gangrenous intestine, perforation and peritonitis as well as in those in whom colonic resection is performed. In 1997 Pans et al.21 published a retrospective study suggesting the use of a preperitoneal prosthesis using a midline abdominal approach. They presented a series of 35 cases in which 13 resections were performed, although the degree of vascular involvement in the unresected cases was not speci-

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fied. Complications included two infections of the surgical wound that did not require mesh removal, six hematomas, one seroma, one recurrence 46 months later and a death unrelated to the surgery. No drains were left. Follow-up was 4.2 years. In 2000, Mauch et al.23 studied 44patients: 32 with incarcerated inguinal hernia and 12 with SIH. These authors proposed a midline posterior approach and repair with mesh in all cases. Resection was done in 12 cases and the results included eight cases of wound infection, two recurrences and no deaths. The first reports of transabdominal preperitoneal laparoscopic management management (TAPP) combined with assisted intestinal resection were published by Tschudi et al.16 and Watson et al.24 in 1993 (report of isolated cases). Since then, other reports have been published such as the one from Leibl et al.28 in 2001 that consisted of a retrospective study of 194cases of incarcerated inguinal hernias. These authors introduced the terms chronic incarcerated and acute incarcerated, and performed resection in only six cases, reporting a morbidity of 6.6% without deaths or recurrences during a 26-month follow-up. In 2004, Ferzli et al.27 proposed the total extraperitoneal (TEP) laparoscopic approach in a retrospective study of 16 patients, of whom five were managed via a conventional anterior approach (type of technique was unspecified) because of intestinal gangrene and inflammation of the inguinal wall. Eleven patients began with TEP and three patients were converted to an open procedure, but the technique was not specified. A morbidity of 25% was reported and included a mesh infection resolved with local hygiene and a wound infection. These authors introduced the term acutely incarcerated. In 2005, Gongora4 reported on a comparative study presenting 38 cases of SIH divided into two groups: group A with 20 cases operated with different open techniques and group B with 18 cases operated with preperitoneal repair with mesh and exploratory laparotomy. Eighteen cases in group A required resection of some intraabdominal organ and 16 cases in group B. Results on morbidity and mortality show important differences between groups. In group A there were three deaths, five recurrences, five wound infections, two granulomas, and four re-operations. In group B there were no cases of recurrences, death or re-operation. There were two wound infections, one granuloma, one seroma and one case of incisional hernia. It is notable that the index of recurrence has statistical significance (p<0.05) when applying Fisher exact test, affirming the reduction of recurrences when preperitoneal repair with mesh is done and exploratory laparotomy in the management of SIH. In 2005, Papaziogas et al.34 carried out a retrospective study comparing the tension-free repair with the modified

Bassini technique (Andrews) in 75cases (33 and 42 cases, respectively). They performed intestinal resection in 14 cases, distinguishing the terms of complicated hernia requiring resection and those not requiring resection. These authors concluded that the presence of SIH does not contraindicate the use of mesh. In 2006, Rebuffat et al.6 presented a retrospective study on laparoscopic repair of SIH in 43 hernia emergencies. Fifteen were operated with conventional anterior approach techniques (the type of technique was not specified), 28 were operated on via a transabdominal preperitoneal approach (TAPP), three were converted, nine were subjected to intestinal resection and 16 cases did not undergo resection. Morbidity demonstrated a case of wound hematoma. It should be noted that these authors detailed some of the contraindications of TAPP for SIH: scrotal hernias, pelvic or extensive surgery, abdominal surgery, severe cardiopulmonary problems, signs of intestinal gangrene, severe infection of the inguinal wall and a prior elective TAPP. Other reports of laparoscopic management of femoral and obturator hernias provide information of isolated cases with good results. In 2006, Wysocky et al.14 reported in a retrospective study the results after comparison of 77 patients undergoing the Lichtenstein technique and the Bassini technique (56 and 21 cases, respectively). They performed eight resections in patients subjected to the Lichtenstein technique and five resections in patients undergoing Bassini technique. There were no significant differences found between these procedures and concluded that the use of PPL mesh for SIH is safe and with a low risk of infection. In 2007, Bessa et al.15 in a prospective study reported on the results of a Lichtenstein repair of a SIH. The study was composed of two groups of patients, one with 25 patients who had SIH and another 25 patients with nonstrangulated hernia operated electively. In the first group, intestinal resection was performed in only four patients with a 20-month follow-up. The authors reported a scrotal hematoma, no recurrences, no infection and no mesh removal. They concluded that the technique can be successfully applied in SIH. In 2008, Dieng et al.36 in a retrospective study from 1997 to 2002 included 228 patients diagnosed with SIH. The Bassini technique was used on 158 patients and McVay technique on 70 patients. Only 16 bowel resections were performed. They reported one death, eight recurrences, five wound infections, and three scrotal hematomas. There was a 42-month follow-up of 108 patients. They concluded that the traditional procedures, Bassini in particular, offer good results with acceptable medium-term recurrence rates. Also in 2008, Legnani et al.,37 in their article reporting TAPP plasty for the acute management of inguinocrural hernias, described nine cases (four were excluded due to

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anesthetic contraindications or due to the large size of the hernias.) Two cases required resection and one case had postincisional herniorrhaphy performed without recurrence after an 18-month follow-up. They concluded that TAPP can be proposed for management of SIH allowing the correction of the hernia and the resolution of the damage as well as visual control of the type of vascular injury of the trapped organ and its possible recovery. In 2009, Deeba et al.38 presented a review paper on seven references captured from Medline, Ovid, Cochrane, Embase and Google on the laparoscopic management of SIH. They analyzed 328 cases reporting six conversions, 17 bowel resections resolved laparoscopically or by minilaparotomy and 34 complications (25 classified as minor). No mention was made of recurrence or mortality. Table 3 provides a review of all the authors mentioned above, emphasizing that there is statistical significance with p <0.05 for the largest number of resections from the author in relation to all other investigators. Most of these studies do not specify the differences between incarcerated and strangulated hernias. In fact, some authors use terms such as acute incarcerated, chronic incarcerated, acutely incarcerated, emergency hernia,

complicated hernias that require resection and those that do not. The cases of all the above references add up to 1157 with a percentage of resections of 20%, whereas the percentage in the background of this article is 79%. It is not possible to document the reasons for these discrepancies because inclusion criteria in each of the studies are not well defined and, therefore, we consider it pertinent to make some considerations in this regard. According to the findings and results of this study, it is possible to infer that only cases in which the following variables are documented should be included: bulging hernia sac (and contents), tense, painful, irreducible, with >12 h of evolution intestinal occlusive syndrome with gastrointestinal vomiting, bloating and diffuse colic systemic inflammatory response syndrome (tachycardia, dehydration, leukocytosis, etc.) signs of peritoneal irritation radiological changes with bowel loop distention, air fluid levels, free fluid and/or intra-abdominal collections, etc. Given these signs and symptoms, we may ascertain that it is possible to establish the definitive diagnosis of SIH

Table 3. Historical analysis of cases

Year 1994 1996 1997 2000 2001 2005 2006 2006 2007 2008 2008 2009 2010 Author Henry22 Gavioli

Technique Inguinal approach Preperitoneal mesh Preperitoneal mesh Preperitoneal mesh Tapp** Lichtenstein Bassini Tapp Lichtenstein Bassini Lichtenstein Bassini-McVay Tapp Tapp-Tep*** RPPM and LAPE****

n 54 31 35 44 194 33 42 28 56 21 25 228 9 328 43

Resection 5 16 13 12 6 4 10 9 8 5 4 16 2 17 34

% 9 51 37 27 3 12 23 32 14 23 16 7 22 5 79

Years of follow-up 4.2 2 2 9 9 1 3 3 1 3.5 1.5 10

Pans21 Mauch23 Leibl28 Papaziogas34 Rebuffat


Wisocky14 Bessa15 Dieng36 Legnani


Deeba38 * Gngora

*Review articles from 19892008: COCHRANE, OVID, MEDLINE, EMBASE, GOOGLE (seven articles chosen among 43). **Intraabdominal preperitoneal technique. ***Total extraperitoneal technique. ****Preperitoneal repair with mesh and exploratory laparotomy.

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from the preoperative period. Therefore, that this set of syndromes should be considered as inclusion criteria to qualify specific cases of SIH and to clearly differentiate incarcerated inguinal hernias or reduced hernias. The latter do not suffer vascular damage and, therefore, constitute a bias by their imprecise inclusion in the case series. After emphasis on vascular damage and its impact from SIH, treatment should be considered mandatory, whereas an elective procedure may be used for reduced or incarcerated hernias. In conclusion: The operative technique of preperitoneal mesh repair and exploratory laparotomy has reduced morbidity and mortality in the management of SIH. Proceeding with preperitoneal mesh repair and exploratory laparotomy would allow for resolution of all cases of SIH, regardless of the complications that arise and type of existing hernia, including more advanced cases. Preperitoneal mesh repair and exploratory laparotomy is accessible to any surgeon because it requires no additional technology than what is available in any operating room. The use of mesh in hernias and/or in potentially contaminated areas should not be considered a contraindication. All inguinal hernias must undergo a tension-free plasty in the shortest time possible, especially in the case of patients >60 years of age. References
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Volume 80, No. 4, July-August 2012