Worldwide, over 20 million patients undergo inguinal hernia repair annually [1]. The feasibility of laparoscopic treatment for inguinal hernias and its advantages over open techniques have already been demonstrated [2, 3]. Laparoscopic inguinal hernia repair (LIHR) was associated with earlier discharge from hospital, quicker return to normal activity and work and significantly fewer postoperative complications than open inguinal hernia repair [4]. In experienced centers, LIHR has become the standard of care due to reported benefits such as reduced pain and rapid postoperative recovery [5].

Nonetheless, there is no sufficient literature regarding laparoscopic approach for the treatment of complicated inguinocrural hernias in the emergency setting. Incarcerated or strangulated inguinocrural hernias are a common pathology for general surgeons [6]. These were classically treated by open surgery but with the development of laparoscopy, the question remains if the benefits of this minimally invasive technique could be transferred to patients with complicated inguinocrural hernias. Actual guidelines report that due to the lack of evidence of benefits of one technique over the other, in the case of complicated hernias in the emergency setting an individualized approach is preferred [5].

Our primary outcome was to evaluate the feasibility and safety of the laparoscopic approach for complicated inguinocrural hernias by comparing outcomes to the open surgery approach.

During the study period a total of 8782 inguinocrural hernia repairs were performed, of which 166 were classified as complicated due to incarceration or strangulation. Of these, 83 were treated by OS, while 79 underwent LS. A total of 4 patients were converted from laparoscopic to open surgery and were excluded from this study; causes of conversion included failure to reduce the herniated bowel, lack of space in the abdominal cavity during laparoscopy due to significant bowel distension and abdominal adhesions. The distribution of patients between groups through the years is shown in Figure 3. The mean age of patients was 65.6 years (±15.6), the average body mass index (BMI) was 26.2 kg/m2 (±4.1) and 69.7% of patients (113) were male, with no statistically significant differences between groups. Although a higher percentage of patients with ASA (American Society of Anesthesiologists) Score III/IV and a history of previous abdominal surgeries were approached via OS, no statistically significant differences were found between the groups. Patient’s characteristics are detailed in Table 1.

A total of 19 complicated femoral hernias were treated, accounting for 11.7% of the series. In the OS group 11 patients had femoral hernias, while in the LS group, 8 patients had femoral hernias. Hernia’s characteristics are detailed in Table 1.

Bowel resection was required in 11 patients (13.2%) in OS group and in 9 patients (11.3%) in LS group (p 0.8). The median operative time was 117 min (IQR 100–120) in OS group and 70 min (IQR 60–103) in LS group, showing a statistically significant reduction of surgical time for LS group (p 0.03). See Table 1.

The mean length of stay for the OS group was 2.96 (±3.1) days and 1.9 (±1.4) in LS group with a statistically significant difference between groups (p 0.01). See Table 2.

The recurrence rate of the series was 0.6% (2 cases), with 1 recurrence in OS group and 1 recurrence in LS group, with a mean follow-up of 19.2 (±4.7) months in OS group and 20.3 (2.5) in LS group. There were 19 (11.7%) morbidities recorded, 14 in the OS group (16.8%) and 5 (6.3%) in the LS group, with a statistically significant difference between groups (p 0.04). See Table 2.

The feasibility of laparoscopic treatment for inguinal hernias and its advantages over open techniques have already been demonstrated [2–4]. However, despite the known benefits of laparoscopy, there is no sufficient literature regarding laparoscopic approach for the treatment of complicated inguinocrural hernias and there is no consensus on management of complicated abdominal hernias [5–8].

Currently, laparoscopy is considered the standard procedure for managing acute abdomen in the emergency settings [9]. In addition to its therapeutic utility, laparoscopy offers diagnostic value by allowing assessment of the entire abdominal cavity, thereby facilitating the exclusion of associated pathologies and differential diagnosis [10].

Since the introduction of laparoscopy to the management of the acute abdomen, it has gained widespread acceptance due to several advantages, including: a comprehensive 360° evaluation of the abdominal cavity, the ability to identify other pathologies, pneumoperitoneum´s contribution to the reduction of herniated bowel, sometimes even allowing for spontaneous reduction due to carbon dioxide pressure, the opportunity to perform hernia repair while simultaneously assessing visceral involvement and a thorough evaluation of the need for bowel resection and its extent [11–13].

Conventional open surgery is still recommended for patients with contraindications to laparoscopic surgery or in centers with limited experience in laparoscopy [14]. However, one of its drawbacks is that, in cases with visceral involvement, bowel resection and anastomosis must be performed before the hernia repair, potentially increasing the rate of segmental bowel resections. Laparoscopic surgery offers all the benefits of a minimally invasive approach, including the potential to monitor the affected bowel while performing the repair, allowing time for potential recovery without the need for resection [11]. This approach enables a complete evaluation of the abdominal cavity, favors the reduction of herniated contents through pneumoperitoneum, and reduces the rate and extent of bowel resections [15].

Actual guidelines report that due to the lack of evidence of benefits of one technique over the other, in the case of complicated hernias in the emergency setting an individualized approach is preferred [5].

In our retrospective study, we can see how through the years, the percentage of patients treated by LS increased year by year (Figure 3), showing how the surgical team gained confidence and skill in the management of complicated inguinocrural hernias by laparoscopy. To date, patients with a history of severe respiratory conditions, previous abdominal surgeries, or significant abdominal distension are eligible for a preferred OS approach. These conditions hinder laparoscopic surgery due to pneumoperitoneum intolerance, difficulty accessing the abdominal cavity, and reduced intra-abdominal space during laparoscopy, respectively.

In our series, by comparing the LS and OS group, the benefits of laparoscopy were demonstrated, showing a reduction in surgical time (p 0.03), length of stay (p 0.01) and total morbidities (p 0.04), with a similar recurrence rate (p 1).