Laparoscopic Management of Strangulated Recurrent Inguinal Hernia With Tackling of Intraop Unusual Defect Closure Troubleshooting

Abstract 65/male Presented in casualty with pain in the abdomen, vomiting, distension, constipation, and irreducible swelling in the right inguinal region. Since 3 days. Ultrasonography – acute intestinal obstruction. X ray of abdomen- air-fluid levels. Plan – diagnostic laparoscopy. Procedure – Under GA. 3 ports 1–10 mm umbilical- camera port. 2–5 mm left midclavicular line below 2 cm umbilicus. 3–5 mm right midclavicular at the level of the umbilicus. Dilated bowel loops. Hernia defect identified with bowel. Loops going into defect. Difficult to reduce bowel loop. The decision was taken to enlarge the defect. Previously put mesh identified. Mesh cut in neck of the sack reached with a monopolar hook. Strangulated bowel loops delivered into peritoneum. Defect closure started with 1 number nonabsorbable barbed suture. While suturing needle broke. As the patient is not much afforded, we decided to go ahead with the same suture. 1 mm skin incision with stab knife on the inguinal region. Suture passer needle introduced. But the suture passer needle broke while inserting. Next plan – prolene loop with veress needle. Veress needle introduced from same stab incision. Barbed suture introduced into prolene loop n removed outside. Now, the same barbed suture has to go into the abdomen from the opposite side of the defect. But there is difficulty in putting barbed suture into abdomen with a prolene loop and vereses needle. 3 attempts done. Not successful. After thinking for 2–3 minutes, the decision was taken to introduce suture with a Rhoeders knot pusher. The same stab knife incision is used in the different directions. Defect closure completed with Rhoeders knot pusher. Gangrenous bowel resection and anastomosis were done through a 4 cm laparotomy incision.