title: The combined laparoscopic approach for the treatment of incarcerated inguinal hernia.
abstract: BACKGROUND
  The traditional open approach to incarcerated inguinal hernia has several drawbacks including difficulty avoiding tension in the swollen and edematous tissues leading to a higher recurrence rate, possible contamination of the mesh if it is implanted in an area of bowel strangulation, and proper evaluation of whether ischemic bowel requires resection or not, which may mandate laparotomy. This study aimed to evaluate an approach that combines intraperitoneal laparoscopic exploration with hernia reduction and total extraperitoneal (TEP) repair of the hernia.
  
  
  METHODS
  An exploratory laparoscopy is performed. The incarcerated content is gently retracted into the abdominal cavity and inspected. If no resection is needed, the gas is deflated, the umbilical trocar is removed, and the preperitoneal space is accessed with a Hasson trocar inserted behind the rectus muscle toward the pelvis. Two additional 5-mm trocars are inserted into the preperitoneal space in the lower midline. A standard TEP repair with mesh is performed.
  
  
  RESULTS
  Between 2005 and 2008, 15 patients underwent laparoscopic exploration for incarcerated inguinal hernia followed by TEP repair. Of the 15 patients, 8 had acute incarceration and 7 had chronic irreducible hernia. Reduction of the incarcerated content was straightforward, and no bowel resection was needed. No major complications or wound or mesh infections occurred.
  
  
  CONCLUSIONS
  The combined laparoscopic approach offers a solution to incarceration of inguinal hernias while taking advantage of each separate approach. The first part of the procedure enables easy reduction of the incarcerated content and assessment of its viability. The second part enables a simple and standard repair, similar to that for an elective case. If bowel necrosis is suspected preoperatively, an open anterior approach should be taken to avoid possible intraabdominal contamination.
authors.affiliation: Department of General Surgery and Transplantation, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, 52621 Tel-Hashomer, Israel. aviad.hoffman@gmail.com
authors.forename: Aviad
authors.initials: A
authors.lastname: Hoffman
authors.forename: Eyal
authors.initials: E
authors.lastname: Leshem
authors.forename: Oded
authors.initials: O
authors.lastname: Zmora
authors.forename: Orit
authors.initials: O
authors.lastname: Nachtomi
authors.forename: Moshe
authors.initials: M
authors.lastname: Shabtai
authors.forename: Amram
authors.initials: A
authors.lastname: Ayalon
authors.forename: Danny
authors.initials: D
authors.lastname: Rosin
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006552:Hernia, Inguinal / Q000150:complications / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies