Predictive factors for the development of surgical site infection in adults undergoing initial open inguinal hernia repair

Infection-Resistant Polypropylene Hernia Mesh: Vision & Innovations

The surgical repair of hernias, a prevalent condition affecting millions worldwide, has traditionally relied on polypropylene (PP) mesh due to its favorable mechanical properties and biocompatibility. However, postoperative infections remain a significant complication, underscoring the need for the development of infection-resistant hernia meshes. This study provides a comprehensive analysis of current advancements and innovative strategies aimed at enhancing the infection resistance of PP mesh. It presents an overview of various research efforts focused on the integration of antimicrobial agents, surface modifications, and the development of bioactive coatings to prevent bacterial colonization and biofilm formation. Additionally, the synergistic effects of novel material designs and the role of nanotechnology in optimizing the anti-infective properties of PP mesh are explored. Recent clinical outcomes and in vitro studies are critically examined, highlighting challenges and potential future directions in the development of next-generation hernia meshes. Emphasis is placed on the importance of interdisciplinary approaches in advancing surgical materials with the ultimate goal of improving patient outcomes in hernia repair.

The impact of smoking on ventral and inguinal hernia repair: a systematic review and meta-analysis

PURPOSE

Individual studies indicate poorer outcomes for smokers after hernia repair. Previous meta-analyses have examined the impact of smoking on specific outcomes such as recurrence and surgical site infection, but there has been a lack of comprehensive consensus or systematic review on this subject. Addressing this gap, our study undertakes a systematic review and meta-analysis to assess the impact of smoking on the outcomes of ventral hernia repair (VHR) and inguinal hernia repair.

SOURCE

A thorough search of Cochrane Central, Scopus, SciELO, and PubMed/MEDLINE, focusing on studies that examined the effect of smoking on inguinal and VHR outcomes was conducted. Key outcomes evaluated included recurrence, reoperation, surgical site occurrences (SSO), surgical site infection (SSI), and seroma.

PRINCIPAL FINDINGS

Out of 3296 screened studies, 42 met the inclusion criteria. These comprised 25 studies (69,295 patients) on VHR and 17 studies (204,337 patients) on inguinal hernia repair. The analysis revealed that smokers had significantly higher rates of recurrence (10.4% vs. 9.1%; RR 1.48; 95% CI [1.15; 1.90]; P < 0.01), SSO (13.6% vs. 12.7%; RR 1.44; 95% CI [1.12; 1.86]; P < 0.01) and SSI (6.6% vs. 4.2%; RR 1.64; 95% CI [1.38; 1.94]; P < 0.01) following VHR. Additionally, smokers undergoing inguinal hernia repair showed higher recurrence (9% vs. 8.7%; RR 1.91; 95% CI [1.21; 3.01]; P < 0.01), SSI (0.6% vs. 0.3%; RR 1.6; 95% CI [1.21; 2.0]; P < 0.001), and chronic pain (9.9% vs. 10%; RR 1.24; 95% CI [1.06; 1.45]; P < 0.01) rates. No significant differences were observed in seroma (RR 2.63; 95% CI [0.88; 7.91]; P = 0.084) and reoperation rates (RR 1.48; 95% CI [0.77; 2.85]; P = 0.236) for VHR, and in reoperation rates (RR 0.99; 95% CI [0.51; 1.91]; P = 0.978) for inguinal hernias between smokers and non-smokers. Analysis using funnel plots and Egger's test showed the absence of publication bias in the study outcomes.

CONCLUSION

This comprehensive meta-analysis found statistically significant increases in recurrence rates, and immediate postoperative complications, such as SSO and SSI following inguinal and VHR. Also, our subgroup analysis suggests that the MIS approach seems to be protective of adverse outcomes in the smokers group. However, our findings suggest that these findings are not of clinical relevance, so our data do not support the necessity of smoking cessation before hernia surgery. More studies are needed to elucidate the specific consequences of smoking in both inguinal and ventral hernia repair.

PROSPERO REGISTRATION

ID CRD42024517640.

Application of machine learning algorithms to predict postoperative surgical site infections and surgical site occurrences following inguinal hernia surgery

PURPOSE

This study aimed to develop, validate, and evaluate machine learning (ML) algorithms for predicting Surgical site infections (SSI) and surgical site occurrences (SSO) after elective open inguinal hernia surgery.

METHODS

A cohort of 491 patients who underwent elective open inguinal hernia surgery at Fudan University Affiliated Huadong Hospital between December 2019 and December 2020 was enrolled. To create a strong prediction model, we employed five ML methods: generalized linear model, random forest (RF), support vector machines, neural network, and gradient boosting machine. Based on the best performing model, we devised online calculators to facilitate clinicians' access to a linear predictor for patients. The receiver operating characteristic curve was utilized to evaluate the model's discriminatory capability and predictive accuracy.

RESULTS

The incidence rates of SSI and SSO were 4.68% and 13.44%, respectively. Four variables (diabetes, recurrence, antibiotic prophylaxis, and duration of surgery) were identified for SSI prediction, while four variables (diabetes, size of hernias, albumin levels, and antibiotic prophylaxis) were included for SSO prediction. In the test set, the RF model showed the best predictive ability (SSI: area under the curve (AUC) = 0.849, sensitivity = 0.769, specificity = 0.769, and accuracy = 0.769; SSO: AUC = 0.740, sensitivity = 0.513, specificity = 0.821, and accuracy = 0.667). Online calculators have been developed to assess patients' risk of SSI ( https://wuqian17.shinyapps.io/predictionSSI/ ) and SSO ( https://wuqian17.shinyapps.io/predictionSSO/ ) after surgery.

CONCLUSIONS

This study developed a prediction model for SSI/SSO using ML methods. It holds the potential to facilitate the selection of appropriate treatment options following elective open inguinal hernia surgery.

Effect of topical gentamicin in preventing surgical site infection in elective incisional hernia repair in a randomized controlled trial

Surgical site infection (SSI) continues to be a common complication of surgery. The real benefit of using topical antibiotics for the prevention of SSI in abdominal hernia repair surgery is still unknown. This study aimed to evaluate the usefulness of topical gentamicin in SSI prophylaxis in incisional hernia repair with mesh. A randomized controlled trial was conducted in patients undergoing open incisional hernia repair. Patients were randomly assigned to one of two groups: in the gentamicin group, each layer of the abdominal wall was irrigated with gentamicin solution before wound closure, and in the saline solution group (placebo), each layer of the abdominal wall was irrigated with normal saline solution. The incidence of SSI and other surgical site complications was compared between both groups, and the presence of adverse effects with the use of topical gentamicin. Data from 146 patients were included for analysis: 74 in the gentamicin group and 72 in the saline solution group. SSI was observed in six patients (8.1%) in the gentamicin group and eight patients (11.1%) in the saline solution group, with no significant differences (p = 0.538) between both groups. No statistically significant differences were observed in the presentation of seroma, hematoma, and surgical wound dehiscence between both groups. No adverse effects were reported from topical application of gentamicin. In this clinical trial, the use of topical gentamicin in incisional hernia repair with mesh did not significantly reduce the incidence of SSI. EU Clinical Trials Register: EudraCT 2018-001860-45 (04/07/2019).

The impact of smoking on inguinal hernia repair outcomes: a meta-analysis of multivariable-adjusted studies

PURPOSE

While the detrimental effects of smoking on postoperative outcomes are recognized, the extent of its risk for inguinal hernia repair remains unclear. Our study aims to assess the influence of smoking on patients who undergo inguinal hernia repair.

METHODS

We systematically reviewed PubMed, Embase, and Cochrane databases. Our goal was to identify studies that compared postoperative outcomes in smoking and non-smoking patients after inguinal hernia repair, and which employed a multivariate analysis to reduce possible confounding factors. Outcomes were recurrence, postoperative complications, and surgical site infection. Odds ratios (ORs) with 95% confidence intervals (CIs) were computed with the use of a random-effects model. Heterogeneity was examined with I2 statistics. This review was prospectively registered in PROSPERO (CRD42023445513).

RESULTS

Our analysis encompassed 11 studies, involving a total of 577,901 patients. Of these, 77,226 (or 13.4%) identified as smokers, with males constituting 90% of the cohort. In terms of surgical approaches, 58% underwent laparoscopic procedures were most common at 58%, followed by open surgeries at 41%, and 1% used robotic techniques. All included studies had a low risk of bias. Smoking was associated with a higher incidence of hernia recurrence (OR 2.95; 95% CI 2.08 to 4.18; p < 0.001; I2 = 0%). No differences were found in postoperative complication (OR 1.15; 95% CI 1.00 to 1.32; p = 0.05; I2 = 56%) or surgical site infection (OR 2.94; 95% CI 0.80 to 10.88; p = 0.11; I2 = 79%).

CONCLUSION

Smoking was associated with a three-fold increase in recurrence. Further studies are needed to evaluate the impact of preoperative smoking cessation on reducing recurrence.

Current trends and outcomes for unilateral groin hernia repairs in the United States using the Abdominal Core Health Quality Collaborative database: A multicenter propensity score matching analysis of 30-day and 1-year outcomes

BACKGROUND

Different unilateral groin hernia repair approaches have been developed in the last 2 decades. The most commonly done approaches are open inguinal hernia repair by the Lichenstein technique, laparoscopic approach by either total extraperitoneal or transabdominal preperitoneal, and robotic transabdominal preperitoneal approach. Hence, this study aimed to compare early and late postoperative outcomes in patients who underwent unilateral robotic transabdominal preperitoneal, laparoscopic transabdominal preperitoneal, and laparoscopic total extraperitoneal, and open groin hernia repair using a United States national hernia database, the Abdominal Core Health Quality Collaborative Database.

METHODS

Prospectively collected data from the Abdominal Core Health Quality Collaborative database was retrospectively reviewed, including all adult patients who underwent elective unilateral groin hernia repair from 2015 to 2022, with a 1:1 propensity score match analysis conducted for balanced groups. The univariate analysis compared the groups across the preoperative, intraoperative, and postoperative timeframes.

RESULTS

The Abdominal Core Health Quality Collaborative database identified 14,320 patients who underwent elective unilateral groin hernia repair and had documented 30 days of follow-up. Propensity score matching stratified 1,598 patients to each group (total of 6,392). The median age was 64 years (interquartile range 53-74) for open groin hernia repair, whereas 60 (interquartile range 47-69) for laparoscopic transabdominal preperitoneal, 62 (interquartile range 48-70) for laparoscopic total extraperitoneal, and 60 (interquartile range 47-70) for robotic transabdominal preperitoneal were noted. Open groin hernia repair had more American Society of Anesthesiologists score 4 (52, 3%) patients (P < .001). A painful bulge was the most common indication (>85%). Operating room time >2 hours was more significant in the robotic transabdominal preperitoneal group (123, 8%; P < .001). Seroma rate was higher in the laparoscopic transabdominal preperitoneal (134, 8%; P < .001). A 1-year analysis had 1,103 patients. Hematoma, surgical site infection, readmission, reoperation, and hernia recurrence at 30 days or 1 year did not differ, with an overall recurrence rate of 6% (n = 67) at 1 year (P = .33). In patients with body mass index ≥30 kg/m2, the robotic approach had lower rates of surgical site occurrence (n = 12, 4%; P = .002) and seroma (n = 5, 2%; P < .001) compared with the other groups. When evaluating recurrence 1 year after surgery, the robotic transabdominal preperitoneal group had 10% versus 18% open groin hernia repair, 11% laparoscopic transabdominal preperitoneal, and 18% laparoscopic total extraperitoneal, but it was not statistically significant (P = .53).

CONCLUSION

There was no difference in readmission, reoperation, and surgical site infection among the surgical techniques at 30 days. However, laparoscopic transabdominal preperitoneal was associated with more seromas. Hernia recurrence at 1 year was similar across groups; the robotic approach had the lowest recurrence rate among all 3 repairs but did not reach statistical significance. The robotic approach performed better in patients with a body mass index of 30 kg/m2 for surgical site occurrence and seroma than in other surgical techniques.

Next generation meshes for hernia repair: Polypropylene meshes coated with antimicrobial benzalkonium chloride induced proliferative activity of fibroblasts

Hernia repair is one of the most frequently performed world-wide surgical procedures in which hernia meshes are becoming increasingly used. Polypropylene (PP) mesh implants reduce the risk of recurrence and post-operative pain, although many other risks are associated with it, such as bacterial infection. In this study we developed PP meshes coated with the well-known antimicrobial compound, benzalkonium chloride (BAK) by dip-coating. Several dilutions (40, 20, 30, 10, 7.5, 5, 2.5, 1, 0.5, 0.1 and 0.05 % v/v) of commercial BAK solution (BAK diluted in 70 % ethyl alcohol at 0.1 % w/v) were used to produce antimicrobial meshes with different amounts of BAK. The dip-coating treatment with low concentrations of BAK (1, 0.5, 0.1 and 0.05 % v/v dilutions) was found to have biocompatible results in fibroblast. The use of 0.1 and 0.05 % v/v dilutions (PP meshes with up to ∼2 % w/w of BAK) showed proliferative activity on fibroblast cells, indicating that these novel antimicrobial meshes show great promise for hernia repair due to their ability to prevent infections while inducing fibroblast proliferation.

Meta‑analysis of single-incision laparoscopic versus multi-trocar laparoscopic totally extraperitoneal inguinal hernia repair

Whether single-incision laparoscopic totally extraperitoneal (SIL-TEP) inguinal hernia repair is similar or superior to multi-trocar laparoscopic totally extraperitoneal (MTL-TEP) inguinal hernia repair is controversial. We conducted this meta-analysis to compare the safety, efficacy and cosmetic effect of the two surgical methods. We systematically searched the Cochrane Library, Embase database and PubMed database for published studies on SIL-TEP and MTL-TEP inguinal hernia repair. The studies were screened and evaluated for quality according to the inclusion and exclusion criteria, and RevMan 5.3 software was used for meta-analysis. Twenty studies were included, including 7 randomized controlled studies and 13 nonrandomized controlled studies. Meta-analysis revealed no significant difference between SIL-TEP and MTL-TEP inguinal hernia repair in terms of unilateral operation time (P = 0.12), bilateral operation time (P = 0.72), pain score on the first day after operation (P = 0.61], chronic pain rate (P = 0.61), total complication rate (P = 0.26), hospital stay (P = 0.72), and recurrence rate (P = 0.83), but the cosmetic effect score (P = 0.002) was higher in the former. These findings demonstrate that SIL-TEP inguinal hernia repair is safe, reliable and feasible. In addition, it can result in a better cosmetic effect of the incision than MTL-TEP inguinal hernia repair. SIL-TEP inguinal hernia repair should be considered for patients with stricter cosmetic requirements.Clinical trial registration: INPLASY2022110085.

The Role of Imaging in the Pre- and Postoperative Evaluation of Inguinal Hernia

Inguinal hernia repair is the most frequently performed surgical procedure. Imaging has a fundamental role in initial assessment and postoperative evaluation of inguinal hernias. Clinical implications of radiology in the preoperative setting include diagnosis of occult/complicated hernias and enhancement of diagnostic certainty. Postoperatively, imaging may assist the detection and characterization of complications. Familiarity with the normal appearance of the postoperative groin area and surgical techniques is required to avoid misinterpretation. This pictorial essay provides an overview of the expected postoperative imaging findings and highlights the role of imaging in the pre- and postoperative evaluation of inguinal hernias, with emphasis on ultrasonography.

Telehealth Follow-Up After Inguinal Hernia Repair in Veterans

INTRODUCTION

Telehealth has been increasingly utilized with a renewed interest by surgical specialties given the COIVD-19 pandemic. Limited data exists evaluating the safety of routine postoperative telehealth follow-up in patients undergoing inguinal hernia repair, especially those who present urgent/emergently. Our study sought to evaluate the safety and efficacy of postoperative telehealth follow-up in veterans undergoing inguinal hernia repair.

METHODS

Retrospective review of all Veterans who underwent inguinal hernia repair at a tertiary Veterans Affairs Medical Center over a 2-year period (9/2019-9/2021). Outcome measures included postoperative complications, emergency department (ED) utilization, 30-day readmission, and missed adverse events (ED utilization or readmission occurring after routine postoperative follow-up). Patients undergoing additional procedure(s) requiring intraoperative drains and/or nonabsorbable sutures were excluded.

RESULTS

Of 338 patients who underwent qualifying procedures, 156 (50.6%) were followed-up by telehealth and 152 (49.4%) followed-up in-person. There were no differences in age, sex, BMI, race, urgency, laterality nor admission status. Patients with higher American Society of Anesthesiologists (ASA) classification [ASA class III 92 (60.5%) versus class II 48 (31.6%), P = 0.019] and open repair [93 (61.2%) versus 67 (42.9%), P = 0.003] were more likely to follow-up in-person. There was no difference in complications, [telehealth 13 (8.3%) versus 20 (13.2%), P = 0.17], ED visits, [telehealth 15 (10%) versus 18 (12%), P = 0.53], 30-day readmission [telehealth 3 (2%) versus 0 (0%), P = 0.09], nor missed adverse events [telehealth 6 (33.3%) versus 5 (27.8%), P = 0.72].

CONCLUSIONS

There were no differences in postoperative complications, ED utilization, 30-day readmission, or missed adverse events for those who followed-up in person versus telehealth after elective or urgent/emergent inguinal hernia repair. Veterans with a higher ASA class and who underwent open repair were more likely to be seen in person. Telehealth follow-up after inguinal hernia repair is safe and effective.

Severe wound infection by MRCNS following bilateral inguinal herniorrhaphy

BACKGROUND

Wound infection after inguinal hernia surgery is not uncommon in the clinical setting. The common microbial aetiology of postoperative inguinal hernia wound infection is Gram-positive bacteria. Staphylococcus aureus is a common pathogen causing wound infection while Staphylococcus epidermidis and Pseudomonas are rare. Staphylococcus epidermidis as a cause of severe wound infection is rarely described in literature. We herein present a case of a 79-year-old man with a rare wound infection after bilateral inguinal herniorrhaphy caused by MRCNS (Methicillin Resistant Coagulase Negative Staphylococcus).

CASE PRESENTATION

We present a case of wound infection accompanied by fever with a temperature of 38.8 °C after bilateral inguinal herniorrhaphy in a 79-year-old man. Bilateral inguinal wounds were marked by redness and swelling, with skin necrosis. In addition, an abscess of approximately 1.5 cm × 1.5 cm was seen on the left wrist. A small amount of gas under the skin in the wound area was observed after pelvic computed tomography (CT) scans. No bacteria were cultured from the inguinal wound discharge, while blood culture detected MRCNS, and Acinetobacter lwoffi was cultured from the pus in the left wrist. We chose appropriate antibiotics based on the results of the bacterial culture and the drug susceptibility results. Vacuum assisted closure (VAC) therapy was used after debridement. The patient was discharged after the wounds improved. He was followed up for ten months and showed no signs of complications. We are sharing our experience along with literature review.

CONCLUSIONS

We are presenting a rare case of MRCNS wound infection following open inguinal hernia surgery. Although a rarity, clinicians performing inguinal hernia surgery must consider this entity in an infected wound and follow up the patient for complications of MRCNS.

Treatment of mesh infection after inguinal hernia repair: 3-year experience with 120 patients

PURPOSE

Mesh infection is a devastating complication of sterile hernia repair surgery. This study was performed to assess the short- and long-term outcomes following treatment for mesh infection after inguinal hernia repair.

METHODS

This single-center retrospective study included all patients who developed mesh infection after inguinal hernia repair from January 2018 to December 2020. Patient demographics, mesh infection characteristics, microbiology, features of surgery, short- and long-term outcomes, and follow-up data were analyzed.

RESULTS

In total, 120 patients (8 women, 112 men; mean age, 54.4 years; mean body mass index, 24.8 kg/m²) were treated for mesh infection. The cultures were positive in 88 patients; 62.5% of these were positive for Staphylococcus aureus. Laparoscopic exploration was performed in 108 patients. Seventy patients underwent complete removal of infected mesh, and 50 underwent partial removal. During the short-term follow-up, 11 patients developed a minor wound infection and were treated with dressings and antibiotics, 1 developed a wound infection requiring debridement, 30 developed seromas, and 3 developed hematomas that did not require surgical intervention. During the mean follow-up of 39.1 months, 4 patients developed hernia recurrence, 2 experienced chronic pain, and 23 developed recurrent infection requiring reoperation in the partial mesh removal group (in contrast, only 4 patients in the complete mesh removal group developed recurrent infection, with a statistically significant difference).

CONCLUSION

The outcome of mesh infection after inguinal hernia repair treated by mesh removal is satisfactory. Systematic individualized treatment by experienced experts based on the patient's previous repair technique, implanted mesh, and physical condition is recommended.

Evaluating the Role of Glove Changing Before Mesh Application During Herniorrhaphy Surgery to Reduce Surgical Site Infections

Background: Prevention of surgical site infection (SSI) in hernia repair with mesh remains the main concern. Many risk factors have been proposed; however, the role of changing the glove remains to be elucidated. Methods: This longitudinal study was conducted on adult inguinal hernia cases referred to elective repair using mesh reconstruction. Two hundred cases were enrolled and classified into two groups, including the group that surgeon and his assistants changed the glove and the group in which the gloves remained unchanged. Age, gender, surgery duration, and the side of hernia were compared between those who developed SSI and those without this complication. Moreover, the infection rate was compared between the two study groups. Results: One hundred and two males (51.0%) and 98 females (49.0%) with a mean age of 42.60 ± 15.79 years old were enrolled in the study. None of the variables showed a significant difference between SSI cases and non-SSI cases. Moreover, the rate of infection was not significantly different between the two study groups. Conclusions: Glove changing before mesh application indicates no considerable role in reducing SSI rate; however, further studies are needed to confirm these findings.

Risk Factors for Surgical Site Infection in the Undeserved Population After Ventral Hernia Repair: A 3936 Patient Single-Center Study Using National Surgical Quality Improvement Project

Background: Ventral hernia repair (VHR) is one of the most common surgical procedures performed in the United States. Surgical site infections (SSI) carry significant morbidity for the patient and pose a very challenging problem for the surgeon, associated with up to 6.6% of cases. Thus, surgeons should be well versed in the risk factors implicated in SSI after VHR. Given the high burden of diabetes, obesity, and smoking in our patient population, we sought to study the rate of SSI and the risk factors that led to SSI in our population. Study Design: This is a retrospective study using the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) database for the years 2014-2019. We identified patients who underwent VHR at a single institution in the Bronx, New York. The rate of SSI was calculated, and then, risk factors for SSI were identified using logistic regression analysis. Results: A total of 3936 patients underwent VHR. Incisional hernias made up 41% of the cohort, and there were 37.4% laparoscopic repairs. During the 30-day follow-up, SSI was identified in 101 patients (2.6%). Factors associated with SSI include emergent surgery (adjusted odds ratio [aOR] = 2.57), body mass index >35 kg/m² (aOR = 2.38), insulin-dependent diabetes mellitus (aOR = 2.36), and incisional hernia (aOR = 1.81). In addition, a laparoscopic approach was found to be a protective factor (aOR = 0.43, 95% confidence interval 0.25-0.75). Surprisingly, different from other studies, smoking cigarettes was not associated with SSI in our cohort. Conclusions: The rate of SSI after VHR in our institution is 2.6%, which is within that reported in the literature. Most of the variables associated with SSI are modifiable and are similar to those previously reported. Laparoscopic repairs appear to be protective for its occurrence.

Comparative benefits of local anesthesia and spinal anesthesia in adult open inguinal hernia: a meta-analysis of clinical randomized controlled trials

INTRODUCTION

To systematically evaluate the clinical effects of local anesthesia and spinal anesthesia in the treatment of open inguinal hernia in adults, and provide theoretical evidence for clinical choice.

EVIDENCE ACQUISITION

We searched the PubMed, Embase and The Cochrane Library, and collected published clinical randomized controlled trials (RCTs) on the efficacy and safety of local anesthesia and spinal anesthesia for open inguinal hernia surgery in adults. According to the inclusion and exclusion criteria, the literature was screened and the data was analyzed by using Review Manager.

EVIDENCE SYNTHESIS

A total of 11 RCT studies were included in the meta-analysis, with 591 cases in the local anesthesia group and 584 cases in the spinal anesthesia group. Our results showed that compared with the spinal hernia repair group, the hernia repair group under local anesthesia had a lower incidence of headache (RR=0.11, 95% CI (0.03, 0.46)) , urinary retention (RR=0.13, 95% CI（0.05,0.32)) and postoperative pain score at 12 hours (SMD=-1.09, 95% CI (-1.41, -0.76)), and a higher anesthesia efficiency (RR=1.09, 95% CI （1.03,1.16)) and satisfaction rate (RR=1.12, 95% CI (1.01, 1.24)). There was no statistically significant difference between the two groups in operation time, the incidence of intraoperative pain, hematoma, infection, postoperative chronic pain in the groin area, and testicular pain/swelling.

CONCLUSIONS

In open inguinal hernia surgery for adults, local anesthesia is better than spinal anesthesia with lower incidence of adverse events, higher efficacy and satisfaction.

Risks and Prevention of Surgical Site Infection After Hernia Mesh Repair and the Predictive Utility of ACS-NSQIP

AIM

The aim of this paper was to provide a narrative review of surgical site infection after hernia surgery and the influence of perioperative preventative interventions.

METHODS

The review was based on current national and international guidelines and a literature search.

RESULTS

Mesh infection is a highly morbid complication after hernia surgery, and is associated with hospital re-admission, increased health care costs, re-operation, hernia recurrence, impaired quality of life and plaintiff litigation. The American College of Surgeons National Surgical Quality Improvement Program is a particularly useful resource for the study and evidence-based practise of abdominal wall hernia repair.

DISCUSSION

The three major modifiable patient comorbidities significantly associated with postoperative surgical site infection in hernia surgery are obesity, tobacco smoking and diabetes mellitus. Preoperative optimization includes weight loss, cessation of smoking, and control of diabetes. Intraoperative interventions relate, in particular, to the control of fomite mediated transmission in the operating theatre and prevention of mesh contamination with S. aureus CFUs. Risk management strategies should also target the niche ecological conditions which enable bacterial survival and subsequent biofilm formation on an implanted mesh. Outcomes of mesh infection after hernia surgery are closely related to mesh type and porosity, patient smoking status, presence of MRSA, bacterial adhesion and biofilm production. The use of suction drains and the timing of drain removal are controversial and discussed in detail. Finally, the utility of the ACS-NSQIP Surgical Risk Calculator in predicting complications and outcomes in individual patients and the importance of quality improvement initiatives in surgical units are emphasized.

Smoking, Obesity, and the Elective Operation

Smoking and obesity are commonly encountered problems in the elective, perioperative setting. This article reviews the risks posed by smoking and diabetes and explores way to mitigate such risks. Other means of perioperative optimization are also discussed in an effort to describe perioperative strategies that can improve patient outcomes.

Risk factors for surgical site infection after groin hernia repair: does the mesh or technique matter?

INTRODUCTION

Surgical site infections (SSIs) following groin hernia repair (GHR) are getting rarer in high income countries despite a wider use of meshes. Among the risk factors for SSIs, those related to the mesh and the surgical technique have rarely been described.

METHODS

A registry-based multicenter study using prospectively collected data, including SSIs and their potential risk factors, was conducted in the French Hernia-Club.

RESULTS

Between 2012 and 2019, 21,976 consecutive unselected adult patients aged 64.8  ±  15.4 years old (88.9% male) underwent GHR (83.5% unilateral). Fifty four percent were laparoscopic; 97.6% used mesh. The overall incidence of SSI was 0.26%. The incidence of SSI was respectively, 0.24% and 0.19% (p  =  0.420) in open vs laparoscopic repairs; 0.19% and 0.25% (p  =  0.638) for polyester vs polypropylene mesh; In adjusted multivariate analysis focusing on macroporous meshes (which were the most implanted meshes: 23,148 out of 24,099), there were no differences in terms of SSIs' rates regarding the technique: open versus laparoscopy (p  =  0.762) nor the type of mesh used: polypropylene versus polyester (p  =  0.557).

CONCLUSION

The rate of SSI following GHR was low in this large registry study. Mesh type and surgical technique did not affect SSIs rates. Caution is advised when interpreting these data due to this very low rate of SSI and the potential for a type II error.

Analysis of risk factors for surgical site infection and postoperative recurrence following inguinal and femoral hernia surgery in adults

OBJECTIVE

We aimed to evaluate the causes of complications following surgery for inguinal and femoral hernia, using surgical site infection (SSI) and recurrence rate as indicators of outcomes to consider appropriate treatments.

METHODS

We retrospectively assessed the medical histories of 1,098 patients with adult inguinal and femoral hernias who underwent herniorrhaphy between July 2010 and March 2019. Using SSI and recurrence rate as indicators of outcomes, we statistically assessed the influence of preoperative and operative conditions on surgical outcomes.

RESULTS

The occurrence of postoperative SSI was significantly more frequent in patients who experienced a long surgical duration, excessive blood loss, and incarceration; underwent emergency surgery and bowel resection; and in whom no mesh sheet insertion was performed. There was no correlation between mesh use and SSI in cases that did not require emergency incarceration repair. For cases involving hernia incarceration, the use of a mesh sheet was avoided to prevent potential infection, which could explain the high incidence of SSI in cases where mesh was not used. The hernia may have recurred due to technical issues during the procedure, as well as failure to ligate the hernia sac.

CONCLUSIONS

Selecting the appropriate surgical method for hernia repair may reduce the incidence of SSI. If manual reduction of inguinal hernias is not possible, an appropriate surgical procedure should be determined based on laparoscopic findings in facilities where laparoscopic hernia surgeries are frequently performed. Moreover, in cases without infection and bowel resection, mesh use may be beneficial. Recurrence can be prevented by ligating the hernia sac during surgery and solving relevant technical problems.

Simulated training model in a low cost for laparoscopic inguinal hernioplasty

Purpose

Develop a 3D model for the simulation of laparoscopic inguinal hernioplasty transabdominal preperitoneal (TAPP).

Methods

This is an experimental study, 18 participants were selected, divided into three groups, experimental (GE) surgeons in training, control (GC) experienced surgeons and Shaw (GS) nonexperienced surgeons. The simulation in the 3D model was carried out in 6 sessions fulfilling the 5 stages. Opening the peritoneum with the creation of the preperitoneal space; identification of important structures; hernia identification and reduction; placement and fixation of the mesh in Cooper’s ligament and closure of the peritoneum.

Results

In the 1st stage, the GE obtained an average of 1.25 ± 0.42 in the 1st session and 3.25 ± 0.62 in the 6th session (p = 0.05) and in the 5th stage 0.91 ± 0.29 in the first session. 1st session and 1.91 ± 0.29 in the 6th session (p = 0.001), with no significant difference between groups. The learning and skill curve in the SG represented 1.08 ± 0.29 1st and 3.50 ± 0.90 6th session (p = 0.001).

Conclusions

The creation of a systematization of training in simulation applied to the three-dimensional model enabled gain in laparoscopic skills and underpinned its theoretical and practical foundations.