Strangulated hernias are described in which the blood supply to the contained part has been impeded, or cut off usually by a constriction, or band intrinsic to the hernia itself. Incarcerated hernia is an irreducible hernia but the blood sup­ply to the contained part is intact [1]. The cause of hernia undergoing strangulation is unknown [1]. Large series [2, 3] of study on strangulated hernia have concluded that pathology intrinsic to the hernia itself or its content is not only the cause of strangulation. Indeed, less than 1% of hernias have a band or other abnormality that can clearly be implicated as causing strangulation.

lation. For inguinal hernia, the neck of the sac is responsible for 80% of obstruction and external ring for 20% [1]. Factors that initiate strangula­tion in a hernia that has been present chronically for many years is poorly understood. Perhaps it is through intestinal odema, or a large bolus passing into the contained intestine, that the rigid con­nes of the hernia itself can now act as a true obstructing mechanism.

laparoscopy as the only means of surgical diag­nostics. Midline laparotomies have showed increased incidence of morbidity, due to possible intestinal resections. Laparoscopy is the choice of procedure for bowel ischaemia diagnosis espe­cially in geriatric patients with comorbidities; thus decreasing both the negative and non­therapeutic laparatomy rates. Romain etal. [11] have studied and demonstrated prognostic factors affecting postoperative morbidity after incarcer­ated groin hernia repair. Midline laparotomy has been established to be an independent prognostic factor for medical and surgical complications. The advanced techniques help in safe assessment of hernia contents during incarcerated and stran­gulated hernia repair and avoiding midline lapa­rotomy. It raises the difculty index for surgeons to evaluate the viability of previously incarcer­ated hernia contents.

• To resect the gangrenous bowel

• To repair the defect

Traditional techniques like Bassini and Shouldice repairs have been preferred choice from contemporary tension free techniques. Hernandez-Irrizary etal. [13] found that 60% of

emergency inguinal hernia repairs used open and non-mesh technique. Literature shows majority of clinicians have preferred open non-mesh tech­nique to decrease the incidence of mesh infection in cases of emergency obstructed, strangulated and inguinal hernias. The standard method of open repair is done via anterior groin incision and repair. The fascia of the external oblique muscle is divided and hernia sac is assessed for contents and inspected for viability. Resection of gangre­nous bowel is performed through the same inci­sion if encountered. Occasionally, it is difcult to reduce the contents through anterior approach. Once the hernia sac is opened, the defect is expanded for reduction of incarcerated contents. In indirect inguinal hernias, the deep inguinal ring is incised medially to avoid injury to the vas deferens. It is important to ensure the inferior epigastric vessels are properly ligated to avoid haemorrhagic complication. For direct hernias, transversalis fascia needs division either medially or laterally. Extensive lateral division demands vigilance of inferior epigastric arteries.

The combination approach TAPP for initial view, reduction of hernia contents and proceed­ing with standard TEP approach has become con­venient approach. The combined laparoscopic approach for incarcerated inguinal hernia takes an advantage of each separate approach. The combined approach was described by Lavonius [29], open anterior approach was used for repair and exploratory laparoscopy was used for reduc­tion and evaluation of bowel viability.

The journey of groin hernia repair is one of the nest examples of evolution of surgical science in the understanding of human anatomy, physiol­ogy and histopathology, to minimize or eliminate the chance of a recurrence. Along a spectrum of continuing evolutionary debates, the current accepted principle of groin hernia repair is a ten­sionless, prosthetic reinforcement of the hernial defect. Surgical repairs based on these principles are anterior repairs like Lichtenstein, anterior preperitoneal repairs like Stoppa’s and posterior endoscopic repairs like total extraperitoneal repair (TEP) and transabdominal preperitoneal repair (TAPP).

Laparoscopic/endoscopic inguinal hernia repair entails placement of the mesh in the poste­rior most potential space of the anterior abdomi­nal wall between the peritoneum and the fascia transversalis. The space is created specically for the repair and allowed to collapse at the end of the procedure. In principle the collapse should grip the mesh and keep it in position thus decreas­ing chances for a recurrence. The success of a surgical procedure for groin hernia is judged by the incidence of recurrence following the repair. Accepted recurrence rates of ~10% for primary repair and 25% for recurrent hernia repair in the pre-prosthetic era have shown a signicant decrease to <5% following tensionless mesh repairs [1]. The risk of recurrence doubles fol­lowing repair for recurrent groin hernia versus primary hernia. The recurrence rates reported for laparoscopic repairs are:

The identied risk factors for recurrence follow­ing an endoscopic repair are primarily technical. Non-controllable patient- or pathology-related risk factors play a small role in recurrences fol­lowing endoscopic repairs.

1. Surgeon’s Expertise: Laparoscopic groin

hernia repair is labelled as a technically

learning curve. The learning curve being

over the rst 100 cases; however, operative

been seen to improve even after 250 cases [7],

implying that factors other than surgical exper-

tise and surgeon’s competence operate in the

institutions’ attaining of adequate competence

(g) Mesh slitting: Slitting a mesh results in a