We report a case of an 80-year-old man who presented with a right inguinal hernia that appeared incarcerated. On exploration a sausage shaped mass was found in the sac, which was debulked and histologically shown to be a well differentiated malignant peritoneal mesothelioma. Rare tumours may present as inguinal hernias and palliative debulking may be effective when they present in inguinal hernia sacs.

Since the first true herniorrhaphy was performed by Bassini over 100 years ago, all modifications and surgical techniques have shared a common disadvantage: suture line tension. The anatomic, physiologic, and pathologic characteristics of hernia recurrence are examined. The prime etiologic factor behind most herniorrhaphy failures is the suturing together, under tension, of structures that are not normally in apposition. With the use of modern mesh prosthetics, it is now possible to repair all hernias without distortion of the normal anatomy and with no suture line tension. The technique is simple, rapid, less painful, and effective, allowing prompt resumption of unrestricted physical activity.

Laparoscopic herniorrhaphy is compared with conventional herniorrhaphy in 20 patients, who underwent laparoscopic herniorrhaphy utilizing a Mersilene plug and patch graft, and high ligation of the neck of the sac with an Endo-GIA. Patients were pain-free and returned to normal activity the first postoperative day. There was one recurrent direct inguinal hernia in an indirect repair. Laparoscopic herniorrhaphy appears to be a safe, effective way to repair indirect inguinal hernias and certain direct inguinal hernias. There is a marked reduction of pain and rapid return to normal activity. The disadvantage of this procedure is the lack of long-term follow-up.

OBJECTIVE To compare results and outcomes following laparoscopic and tension-free open inguinal herniorrhaphy. DESIGN A prospective, nonrandomized trial of a single surgeon's experience. SETTING A large university hospital. PATIENTS The study included 100 patients with 116 hernias. Patients were offered open hernia repair or, if medically suitable for general anesthesia, a laparoscopic hernia repair. Fifty-seven patients underwent open repair and 43 patients underwent laparoscopic repair. INTERVENTION Laparoscopic repair was performed using a transabdominal preperitoneal mesh technique. Open hernia repair was performed using a mesh-plug technique in which the hernia sac was reduced and held in place by a cone of mesh. The floor was covered with a second piece of mesh that encircled the cord and was sutured at the internal ring; it was held in place under the external oblique without sutures. RESULTS Patients undergoing open repair were older than those undergoing laparoscopic repair. The distribution of hernia types was similar. The laparoscopic operation took longer than the open operation (mean [+/- SD], 1.9 +/- 0.4 hours vs 1.6 +/- 0.4 hours; P <.05), was more expensive ($4165 +/-$1154 vs $2985 +/-$1682; P <.05), and required more postoperative admissions (28% vs 3.5%). There were three recurrences in the laparoscopic group and none in the open group. Patients undergoing laparoscopic repair consumed the same amount of narcotic analgesics as did the group undergoing open repair and had discomfort for the same amount of time. Patients undergoing laparoscopic repair returned to work sooner than did patients undergoing open repair (5.6 days vs 10.3 days; P <.05). CONCLUSIONS Laparoscopic hernia repair returns patients to the workplace faster than open hernia repair despite a similar analgesic requirement. The laparoscopic repair costs more and has a higher recurrence rate than open repair. Laparoscopic repair is most suitable for bilateral hernias. Further investigation of this technique is required before its wide-scale application can be recommended.

The results of 6,321 consecutive herniorrhaphies have been reported. Over 20 percent of the cases were referred recurrences when first seen. Ninety-one percent of the patients were followed from 2 to 14 years, with an overall recurrence rate of 0.7 percent. A low recurrence rate was not unfavorably affected by the prompt resumption of activity postoperatively. Some recurrences are unavoidable; however, it is essential to accept the dictum that all hernias can be cured.

One hundred and seventy-nine patients with 237 hernias of the groin who were at high risk for recurrence after classic hernioplasty were operated upon; the procedure of giant prosthetic reinforcement of the visceral sac (GPRVS) was used. The patients in this series had predominantly recurrent and re-recurrent hernias. However, a few were obese with bilateral primary direct hernias and some had associated connective tissue disorders, such as Marfan and Ehlers-Danlos syndromes. GPRVS eliminates hernias of the groin by rendering the peritoneum inextensible by placing, in the preperitoneal space, a large prosthesis that extends far beyond the borders of the myopectineal orifice. The myopectineal orifice is the weak spot at which all hernias of the groin begin and is bounded by the rectus, oblique abdominal and iliopsoas muscles and the pectin of the pubis. In bilateral GPRVS, the peritoneum of both groins is reinforced with a single prosthesis inserted in the preperitoneal space through the midline. In unilateral GPRVS, the mesh envelops the peritoneum of a single groin. This simplifies the operation and makes it suitable for surgical centers that perform outpatient operations. The prosthesis with the best physical characteristics for GPRVS is Mersilene (polyester fiber). Unsutured prostheses of polypropylene and Teflon (polytetrafluoroethylene) may not adhere at the far edges, leading to a failure and recurrence. The over-all recurrence rate in this series of problem hernias was 3.7 per cent, which is extremely good. However, the rate becomes outstanding if recurrences resulting from meshes unsuitable for GPRVS are excluded.

Although the elective repair of groin hernias is advised to prevent strangulation, the likelihood of this complication occurring is unknown. To quantify this risk, the cumulative probability of strangulation in relation to the length of history has been calculated for inguinal and femoral hernias presenting to this hospital between 1987 and 1989. Of 476 hernias (439 inguinal, 37 femoral), there were 34 strangulations (22 inguinal, 12 femoral). After 3 months the cumulative probability of strangulation for inguinal hernias was 2.8 per cent, rising to 4.5 per cent after 2 years. For femoral hernias the cumulative probability of strangulation was 22 per cent at 3 months and 45 per cent at 21 months. The rate at which the cumulative probability of strangulation increased was in both cases greatest in the first 3 months, suggesting that patients with a short history of herniation should be referred urgently to hospital and given priority on the waiting list.

Laparoscopic hernia repair offers the potential for more rapid recovery in patients compared with standard anterior herniorrhaphy. Whether the procedure can be performed safely and effectively has yet to be determined. Long-term success will depend on the ability to adhere to the basic principles of traditional hernia repair, maintain low recurrence rates, and achieve rapid return of the patient to work. Inguinal anatomy as viewed through the laparoscope is unfamiliar to most surgeons. The potential for complications requiring laparotomy is increased with laparoscopic hernia repair and dissection in this region requires precise knowledge of the anatomic relationships. Photographic representations of cadaver dissections of the intra-abdominal inguinal region are displayed, and detailed descriptions applicable anatomic structures are presented. A laparoscopic approach for the repair of inguinal and femoral hernia is provided, based on sound comprehension of anatomic relationships.

Laparoscopic inguinal "exploration" was undertaken in 22 consecutive pediatric patients to assess the value of this technique in detecting the presence or absence of occult inguinal hernias on the asymptomatic side of patients with unilateral disease. After a CO2 pneumoperitoneum was established using a Veress needle, a 2 mm 0 degree laparoscope was passed via a 3 mm cannula and both inguinal rings were inspected. Eleven cases (50%) had previously unsuspected bilateral disease diagnosed at laparoscopy and had bilateral inguinal hernias confirmed at exploration. Nine cases, in which the asymptomatic side was assessed as being negative at laparoscopy, were confirmed negative by open exploration. In one misdiagnosed case of bilateral hernias, no hernias were found at laparoscopy and one side had a non-communicating hydrocele at exploration. There was one failure, an infant less than 2 months of age, in whom the inguinal anatomy could not be adequately visualized at laparoscopy and a hernia was found at exploration. There were no complications. Thus, laparoscopic inguinal "exploration" was 96% accurate in this initial evaluation. The adoption of this approach to the assessment of the asymptomatic contralateral side in infants with unilateral hernias would eliminate many inguinal operations and the complications associated with unnecessarily manipulating the delicate cord structures.