Recurrence after groin hernia repair-revisited

Transabdominal Preperitoneal Repair for an External Supravesical Hernia With an Incarcerated Ovary: A Case Report

External supravesical hernias with ovarian incarceration have not been reported previously. Here, we describe transabdominal preperitoneal (TAPP) repair of an external supravesical hernia with ovarian incarceration. A 68-year-old woman presented to our outpatient clinic with the chief complaint of right inguinal swelling and pain. A 3-cm-diameter mass in the right inguinal region that was difficult to reduce was palpable, and computed tomography (CT) revealed a suspicious lesion of the right hydrocele of the canal of Nuck. Hydrocelectomy was performed through an inguinal incision, and the external inguinal ring was repaired using the Marcy method. The histopathological examination confirmed the diagnosis of the canal of Nuck. Three months postoperatively, the patient again presented with right inguinal pain, and CT revealed a right femoral hernia requiring surgical repair. Intraoperative findings revealed a right external supravesical hernia with an incarcerated ovary, which was laparoscopically reduced and repaired with a mesh. At the three-month follow-up, there were no postoperative complications or recurrences. Incarcerated ovaries with inguinal hernias have been reported in girls; however, incarcerated ovaries with external supravesical hernias have not been reported in women. Although the preoperative diagnosis was difficult to make in this case, the laparoscopic approach led to the diagnosis and successful mesh repair. Although optimal mesh repair of external supravesical hernias using TAPP has not been established, we believe that 2-5 cm around the hernial orifice, the Hesselbach triangle, and the lateral triangle should be covered with mesh.

Round ligament management during minimally invasive groin hernia repair in women: a systematic review and meta-analysis

BACKGROUND

Female sex has been associated with worse outcomes after groin hernia repair (GHR), including a higher rate of chronic pain and recurrence. Most of the studies in GHR are performed in males, and the recommendations for females extrapolate from these studies, even though females have anatomy intricacies. The round ligament of the uterus (RLU) is associated with pelvic stabilization and plays a role in sensory function. Transection of the RLU during GHR is controversial as it can allow easier mesh placement but can favor genitourinary complications and chronic pain. As no previous meta-analysis compared preserving versus transecting the RLU during minimally invasive (MIS) GHR, we aim to perform a systematic review and meta-analysis evaluating surgical outcomes comparing the approaches.

METHODS

Cochrane Central, Embase, and PubMed databases were systematically searched for studies comparing transection versus preservation of the RLU in MIS groin hernia surgeries. Outcomes assessed were operative time, bleeding, surgical site events, hospital stay, chronic pain, paresthesia, recurrence rates, and genital prolapse rates. Statistical analysis was performed using RevMan 5.4.1. Heterogeneity was assessed with I2 statistics. A review protocol for this meta-analysis was registered at PROSPERO (CRD 42023467146).

RESULTS

1738 studies were screened. A total of six studies, comprising 1131 women, were included, of whom 652 (57.6%) had preservation of the RLU during MIS groin hernia repair. We found no statistical difference regarding chronic pain, paresthesia, recurrence rates, and postoperative complications. We found a longer operative time for the preservation group (MD 6.84 min; 95% CI 3.0-10.68; P = 0.0005; I2 = 74%).

CONCLUSION

Transecting the RLU reduces the operative time during MIS GHR with no difference regarding postoperative complication rates. Although transection appears safe, further prospective randomized studies with long-term follow-up and patient-reported outcomes are necessary to define the optimal management of RLU during MIS GHR.

The Lichtenstein technique is being used adequately in inguinal hernia repair: national analysis and review of the surgical technique

INTRODUCTION

it is estimated that approximately 20 million people undergo inguinal hernia surgery annually in the world, with the Lichtenstein technique being the most performed surgical procedure. The objective of this study is to analyze the knowledge of the technical principles used in the Lichtenstein technique.

METHOD

Survey-type intersectional study approved by the research ethics committee of São Camilo University Center (CAAE: 70036523.1.0000.0062). During the research period, 11,622 e-mails were sent to members of the main national surgical societies with research on the technical principles of Lichtenstein surgery. The survey was carried out using an electronic form with 10 multiple-choice questions. The form was answered anonymously on the SurveyMonkey and Google Forms platforms.

RESULT

744 responses were received to the electronic form. Based on this number of respondents, our survey has a confidence level of 95% with a margin of error of 3.5%. It was observed that there is no standardization of the technique among the majority of responders (53.4%). Many surgeons still perform digital dissection of the spermatic cord (47%). A small number of interviewees (15.2%) performed sutures with absorbable thread in the region of the internal oblique aponeurosis, while more than half (55.2%) continued to perform sutures with non-absorbable thread. Most surgeons use a small overlap or fix the mesh juxtaposed to the pubic symphysis (51%).

CONCLUSION

Our research identified that a small percentage of respondents adequately know the technical principles of Lichtenstein surgery. The result brings us new insights into the need to review Lichtenstein technique.

Muscular groin hernias: an anatomical variation as a cause of recurrence

PURPOSE

The objective of this study was to understand our center's experience with the rare entity of muscular groin hernias. Specifically, to determine this hernia's incidence and characteristics and provide valuable information to surgeons that can be utilized at the time of a hernia repair regardless of modality used.

METHODS

This was a retrospective chart review between 2005 and 2019. Patients who had a primary or recurrent groin hernia operation for an atypically located hernia (other than direct, indirect, or femoral) were included. Descriptive statistics were utilized to present the hernia and patient data as median (interquartile range, range).

RESULTS

There were 152 patients with 155 muscular hernias identified in primary operations and 41 patients with 41 muscular hernias identified in recurrent operations. In both primary and recurrent groups there were more males, and the males were on average younger with a higher body mass index (BMI) than females. Most muscular hernias were located lateral (76) or lateral/superior (33) to the internal ring with a median distance between 2 and 3 cm (1, 0.3-5; 2.8,2-5) from the internal ring. A concurrent ipsilateral inguinal hernia was found and repaired in 42.3% of left and 46.8% of right sided primary muscular hernia operations. A concurrent ipsilateral inguinal hernia was noted in 5% of left and 14.3% of right sided recurrent muscular operations. In left sided recurrent operations for a muscular hernia, 68.9% had a previous ipsilateral inguinal hernia repair and in right sided recurrent operations, 67.7% had a previous ipsilateral inguinal hernia repair.

CONCLUSION

This study describes a previously unidentified groin muscular hernia in both primary and recurrent hernia operations as a potential cause of hernia recurrence and identifies muscular hernia locations. This information can be utilized at the time of surgery to identify and subsequently repair these defects, leading to improved patient and hernia outcomes.

Mesh repair versus non-mesh repair for incarcerated and strangulated groin hernia: an updated systematic review and meta-analysis

BACKGROUND

Mesh repair in incarcerated or strangulated groin hernia is controversial, especially when bowel resection is required. We aimed to perform a meta-analysis comparing mesh and non-mesh repair in patients undergoing emergency groin hernia repair.

METHODS

We performed a literature search of databases to identify studies comparing mesh and primary suture repair of patients with incarcerated or strangulated inguinal or femoral hernias who underwent emergency surgery. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics.

RESULTS

1095 studies were screened and 101 were thoroughly reviewed. Twenty observational studies and four randomized controlled trials comprising 12,402 patients were included. We found that mesh-based repair had reduced recurrence (OR 0.36; 95% CI 0.19, 0.67; P = 0.001; I2 = 35%), length of hospital stay (OR - 1.02; 95% CI - 1.87, - 0.17; P = 0.02; I2 = 94%) and operative time (OR - 9.21; 95% CI - 16.82, - 1.61; P = 0.02; I2 = 95%) without increasing surgical site infection, mortality or postoperative complications such as seroma, chronic, ileus or urinary retention. In the subgroup analysis of patients that underwent bowel resection, we found that mesh repair was associated with an increased risk of surgical site infection (OR 1.74; 95% CI 1.04, 2.91; P = 0.04; I2 = 9%).

CONCLUSIONS

Mesh repair for incarcerated and strangulated groin hernias reduces recurrence without an increase in postoperative complications and should be considered in clean cases. However, in the setting of bowel resection, mesh repair might increase the incidence of surgical site infection.

Diagnostic performance of CT with Valsalva maneuver for the diagnosis and characterization of inguinal hernias

PURPOSE

Inguinal hernias are mainly diagnosed clinically, but imaging can aid in equivocal cases or for treatment planning. The purpose of this study was to evaluate the diagnostic performance of CT with Valsalva maneuver for the diagnosis and characterization of inguinal hernias.

METHODS

This single-center retrospective study reviewed all consecutive Valsalva-CT studies between 2018 and 2019. A composite clinical reference standard including surgery was used. Three blinded, independent readers (readers 1-3) reviewed the CT images and scored the presence and type of inguinal hernia. A fourth reader measured hernia size. Interreader agreement was quantified with Krippendorff's α coefficients. Sensitivity, specificity, and accuracy of Valsalva-CT for the detection of inguinal hernias was computed for each reader.

RESULTS

The final study population included 351 patients (99 women) with median age 52.2 years (interquartile range (IQR), 47.2, 68.9). A total of 381 inguinal hernias were present in 221 patients. Sensitivity, specificity, and accuracy were 85.8%, 98.1%, and 91.5% for reader 1, 72.7%, 92.5%, and 81.8% for reader 2, and 68.2%, 96.3%, and 81.1% for reader 3. Hernia neck size was significantly larger in cases correctly detected by all three readers (19.0 mm, IQR 13, 25), compared to those missed by all readers (7.0 mm, IQR, 5, 9; p < 0.001). Interreader agreement was substantial (α = 0.723) for the diagnosis of hernia and moderate (α = 0.522) for the type of hernia.

CONCLUSION

Valsalva-CT shows very high specificity and high accuracy for the diagnosis of inguinal hernia. Sensitivity is only moderate which is associated with missed smaller hernias.

Comparison of glue versus suture mesh fixation for primary open inguinal hernia mesh repair by Lichtenstein technique: a systematic review and meta-analysis

BACKGROUND

The use of glue as a mesh fixator in open Lichtenstein inguinal hernia repair (IHR) has gained popularity to reduce recurrence and postoperative complications. This meta-analysis aims to provide an up-to-date review to compare glue versus suture fixation in primary open Lichtenstein IHR.

METHODS

PubMed, Embase, The Cochrane Library, Web of Science, and Springer were systematically searched till June 2021 for randomized controlled trials (RCTs) comparing glue versus suture fixation in open Lichtenstein IHR. Primary outcomes were early (at 1 year) and late recurrence (5 years or more). Secondary outcomes were the length of operation, postoperative haematoma and seroma, and chronic pain at 1 year.

RESULTS

A total of 17 RCTs with 3150 hernias (glue n = 1582, suture n = 1568) were included. Only three studies reported late recurrence. Glue fixation was associated with shorter operative duration (MD - 4.17, 95% CI - 4.82, - 3.52; p < 0.001 and a lower incidence of haematoma formation (OR 0.51, 95% CI 0.32, 0.81; p = 0.004). There was no significant difference in postoperative seroma (OR 0.72, 95% CI 0.35, 1.49; p = 0.38), chronic pain after 1 year (OR 1.10, 95% CI 0.73, 1.65; p = 0.65), early recurrence (OR 1.11, 95% CI 0.45, 2.76; p = 0.81, I² = 0%), and late recurrence (OR 1.23, 95% CI 0.59, 2.59; p = 0.59, I² = 0%).

CONCLUSION

Early and late recurrence were comparable between glue and suture fixation in open Lichtenstein IHR patients. Glue fixation had shorter operating time and lower haematoma formation than suture fixation. Chronic pain and seroma formation were comparable. More RCTs should report long-term outcomes.

Incarcerated multiple recurrent inguinal hernia with incidental finding of textiloma in the abdominal wall from previous hernia repair

Multiple recurrent inguinal hernia is a diagnostic and surgical challenge. In terms of additional incarceration of the recurrent hernia, few options for the surgeon are available. We present a case of multiple recurrent left sided inguinal hernia in female patient presented with clinical signs of mechanical bowel obstruction. Preoperative computed tomography of the abdomen presented the hernia defect and also revealed the presence of textiloma in the abdominal wall from previous hernia repair. Intraoperatively there were no signs of bowel ischemia. Hernia defect was closed with resorbable mesh (bridging “in – lay” repair). Postoperative surgical site infection of the wound occurred. Patient was discharged from hospital on day 17.

A study of the effectiveness of the bilateral and contralateral occult inguinal hernia repair by total extraperitoneal repair with intraperitoneal examination

PURPOSE

Of the various methods used, the laparoscopic surgical repair of inguinal hernias is widely performed. We aimed to estimate the incidence of bilateral and contralateral occult inguinal hernias in our surgical population and to compare the results of total extraperitoneal repair (TEP) for bilateral and unilateral inguinal hernias, occult and non-occult hernias.

METHODS

We retrospectively reviewed data of patients who underwent TEP for the repair of adult inguinal hernias from January 2012 to November 2018 in our hospital.

RESULTS

Of the data of 259 patients included, 134 (51.7%) and 125 (48.3%) had unilateral and bilateral inguinal hernias, respectively, while 70 patients (27%) were found to have a contralateral occult inguinal hernia, intraoperatively. The mean operative time was 129 ± 48 minutes (range, 43-300 minutes) and 167 ± 55 minutes (range, 85-390 minutes) for the unilateral and bilateral groups, respectively, indicating a significantly longer duration of surgery for the bilateral group (P < .05). Recurrence occurred in 1.5% (5/134) and 0.4% (1/250) of the operated hernias in the unilateral and the bilateral groups, respectively, indicating a significantly lower rate of recurrence in the latter group (P < .05). The two groups showed no statistically significant differences with respect to the remaining perioperative data. The incidence of postoperative complications in occult hernias was not significantly different from that in non-occult hernias.

CONCLUSIONS

Our TEP method, involving a laparoscopic exploration from the intraperitoneal side, can be safely and effectively utilized for the repair of both bilateral and contralateral occult inguinal hernias.

Inguinal Hernia Mesh Repair: The Factors to Consider When Deciding Between Open Versus Laparoscopic Repair

Inguinal hernia repair is one of the most commonly performed surgical procedures worldwide. An inguinal hernia occurs due to a defect in the abdominal wall, which allows the abdominal contents to pass through it. Although the placement of mesh over the defect is the gold standard to close the defect, there are various approaches to achieving it, out of which two of the most widely accepted techniques are laparoscopic inguinal hernia repair (LIHR) and open inguinal hernia repair (OIHR). However, the approach of choice widely fluctuates with regards to various factors such as patient history, type of hernias, and surgeons' preference. It is imperative to understand the variations in outcomes of different approaches and how best they fit an individual patient in deciding the technique to be undertaken. This article has reviewed many studies and compared the two techniques in terms of chronic pain, the time required to return to activity, rate of recurrence, and cost-effectiveness.

Modified Halsted's operation for inguinal hernia repair: A new technique

Background

Inguinal hernia is a frequent problem presented to surgical clinic in Iraq. Surgical treatment options for inguinal hernia are numerous, selecting the appropriate method or technique depends on different factors.

Aim of study

To find a new technique for open inguinal hernia repair with no recurrence even in recurrent cases, without major complications during or after surgery, and can be used even by new surgeons with little experience.

Patients & methods

A retrospective cross sectional study conducted in the Medical City teaching hospital and Private Hospitals in Baghdad, during the period from January 1, 2000, to December 30, 2016 on convenient sample of 408 Iraqi patients with inguinal hernia. The patients were treated by modified Halsted's technique by open surgery applying polypropylene mesh. The patients were followed up through frequent visits and phone calls to assess the recurrence and complications.

Results

No recurrence of inguinal hernia was reported after 5-10 years follow up, while 94.9% of patients reported postoperative complications commonly oedema of spermatic cord. There was a highly significant association between male gender hernia patients and post Modified Halsted operation complications (p < 0.001). A highly significant association was observed between direct hernia and post Modified Halsted operation complications (p < 0.001). The significant risk factors related to complications were anemia and collagen disease.

Conclusions

The modified Halsted's operation for inguinal hernia repair is effective in treatment of inguinal hernia with low recurrence and complications rate.

A multi-center study on recurrent inguinal hernias: assessment of surgeons' compliance to guideline-based repair and evaluation of short-term outcomes

INTRODUCTION

As patients with recurrent inguinal hernia (RIH) are at a higher risk of perioperative complications, international guidelines have been developed to mitigate these risks by recommending the reverse approach for repair. We aim to study the characteristics of RIH, compliance to guidelines-based repair (GR) and determine factors influencing compliance to guidelines.

METHODS

A retrospective study of patients with RIH was carried out at two tertiary institutions in Singapore, over 10 years from January 2010 to 2020.

RESULTS

There were 16 patients with bilateral recurrences and 214 patients with unilateral recurrences. The characteristics of patients with non-guidelines-based repair (NGR) versus GR were similar, p > 0.05. GR was performed for 128 (52.1%) hernias as compared to NGR for 118 (47.9%) hernias. The open approach was more common in NGR than GR, 115/118 (89.8%) versus 58/128 (45.3%), p < 0.001. Forty (n = 40, 16.3%) RIH presented emergently, of which 37 underwent NGR while 3 underwent GR, p < 0.0001. More consultants were present during GR 103/128 (80.5%) as compared to NGR 78/118 (66.1%), p = 0.018. Emergency presentation of hernia recurrence, OR 7.74 (CI 6.11-9.20), p = 0.005, and open repair during the index repair were significantly associated with NGR, OR 6.63 (CI 4.42-8.84), p = 0.01. Median length of stay was shorter in the GR 1 day (IQR 1-2 days) versus 2 days (IQR 2-5 days) in the NGR group, p = 0.02.

CONCLUSION

The compliance rate of GR for RIH is 52%. NGR for RIH had acceptable short-term outcomes. For elective presentation of RIH, GR should be encouraged given a shorter length of hospital stay.

A preventable cause of transplant hydroureteronephrosis: inguinal herniation of the transplant ureter: case report and review of the literature

BACKGROUND

Transplant ureter obstruction is an important cause of graft loss after kidney transplantation. Most cases occur early after transplantation and are related to surgical causes or ischaemic strictures. Underlying mechanisms of late ureteral obstruction are less well understood.

CASE REPORT

We present the case of a 61-year-old man who showed gradual decline in renal allograft function and hydronephrosis nine years after transplantation, due to an inguinal herniation of the transplant ureter. After urinary diversion using a percutaneous nephrostomy, graft function restored and the patient underwent surgery. The ureter was reduced from the inguinal hernia and re-implanted in the bladder, with primary closure of the abdominal wall defect. Postoperative course was uneventful and serum creatinine returned to baseline levels.

DISCUSSION

Search of relevant literature revealed a number of similar cases, which allowed identification of risk factors associated to the development of uretero-inguinal herniation leading to obstructive nephropathy. Diagnosis of this rare cause of transplant dysfunction and operative treatment strategies are discussed.

CONCLUSIONS

Inguinal herniation of the transplant ureter leading to ureteral obstruction is a rare, probably underreported, cause graft of dysfunction. Therefore, we advocate elective repair of inguinal or incisional hernias in renal transplant recipients.

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.

Obstructive Uropathy Due to an Unusual Inguinal Hernia 35 Years After Kidney Transplant

In a kidney transplant recipient, bladder and graft ureter displacement into a groin hernia is a highly unusual cause of obstructive uropathy that may lead to graft dysfunction or graft loss. We report the case of a White man, 56 years old, who had previously, at the age of 19 years, undergone a kidney transplant from a deceased donor, to mitigate chronic glomerulonephritis. The patient presented to us with a reducible left inguinal hernia with worsening kidney function, and we used the Lichtenstein hernioplasty technique to surgically repair the hernia, which was followed by an uneventful postoperative course. Existing literature has identified few cases of kidney graft dysfunction due to inguinal hernias. Groin hernia repair of this type in this specific circumstance remains a subject of debate. However, in our opinion, with attention to appropriate reductions of immunosuppressive therapy, the Lichtenstein technique is safe for transplant recipients and the use of mesh greatly reduces the risk of hernia recurrence.

Postoperative inguinal pain and disability after Lichtenstein versus ONSTEP hernia repair: analysis of responses to the inguinal pain questionnaire in Spanish

PURPOSE

To validate the Inguinal Pain Questionnaire (IPQ) in the Spanish Language and test its use in a randomized controlled trial (RCT) of hernia repair using the Lichtenstein technique vs. the ONSTEP technique. We simplified the IPQ using a principal component analysis (PCA) approach as a secondary objective.

METHODS

The IPQ was translated into Spanish and validated in a cohort of 21 patients. Thereafter, 40 patients were randomized to undergo hernia repair by the Lichtenstein technique or the ONSTEP technique. IPQ and pain visual analogue (VAS) score trends over time were compared using a repeated-measures mixed-effects model.

RESULTS

The Spanish version of the IPQ showed an internal consistency similar to that of the original score. No significant differences were found in the IPQ responses, pain VAS, or the rate of self-reported pain between patients who underwent the Lichtenstein technique and those who underwent the ONSTEP technique. Following PCA analysis, the number of items on the IPQ was reduced from 18 to 10.

CONCLUSIONS

The Spanish version of the IPQ measures postoperative inguinal pain adequately. Based on our findings, the ONSTEP technique was not superior to the Lichtenstein technique. The simplified version of the IPQ is not significantly different from the full version and it is easier to complete.

CLINICAL TRIAL REGISTRATION

NCT04138329, registered on October 24, 2019.

AN IMPROVED TRANSABDOMINAL PREPERITONEAL ALLOPLASTY FOR RECURRENT INGUINAL HERNIAS AFTER LICHTENSTEIN’S SURGERY

The aim. Improve results of the surgical treatment of recurrent inguinal hernias after Lichtenstein's surgery by using an advanced TAPP technique. Materials and methods. An analysis of the surgical treatment of patients with recurrent inguinal hernias after Lichtenstein's surgery using traditional and improved preperitoneal transabdominal alloplasty (TAPP), for the period of 2012–2019, was performed. The traditional TAPP technique was performed for 52 patients who made up the 1st group. An improved TAPP technique was implemented for 53 patients who composed the 2nd group. The features of the improved TAPP technique, which was different from the traditional one, were by additional mobilization of the parietal peritoneum by 3–4 cm along the upper edge of the defect, the mesh implant was used with a larger size in comparison to the classical one – 15×15 cm and fixed, besides the traditional points, additionally on the lower and lateral edges with medical glue Sulfacrylate. Results. The results of surgical treatment in the early postoperative period were not significantly different and were comparable. During the long-term period, 51 patients from the 1st group, and 50 patients from the 2nd group were examined. Thus, in the first group in 4 (7.9 %) cases during 6 months period after the application of the traditional TAРР technique, chronic pain was observed on the site of the implanted mesh; among the 2nd group of patients chronic inguinal pain was not observed. In 5 (9.8 %) patients of the 1st group, the recurrence of inguinal hernia was diagnosed, instead of the 2nd group, where relapse was observed in 1 (2 %) case. Conclusions. Thereby, the results of the traditional and improved TAPP techniques confirm the higher efficiency of the improved technique, due to the absence of the chronic inguinal pain and a lower rate of relapses, which is achieved by wider mobilization of the parietal peritoneum along the upper edge of the defect, and usage of the larger mesh and its additional fixation by gluing it at the lower lateral edge.

Uso de mallas de polipropileno en el reparo de la hernia inguinal con herida sucia o contaminada

Introducción. La hernioplastia con malla de polipropileno es la técnica de elección para el reparo de las hernias inguinales. Actualmente, existe controversia sobre esta técnica en pacientes con heridas sucias o contaminadas; sin embargo, la evidencia en la literatura médica ha demostrado que su uso puede ser seguro. Los autores presentan su experiencia con las mallas de polipropileno en la cirugía contaminada para cierre de hernias inguinales. Método. Se realizó un estudio observacional retrospectivo en el que se incluyeron los pacientes mayores de 18 años atendidos entre enero de 2017 y diciembre de 2018 por presentar hernias inguinales, que requirieron tratamiento quirúrgico de urgencias, y que presentaban heridas sucias o contaminadas. Los criterios evaluados fueron: infección de la herida quirúrgica, morbilidad y mortalidad, necesidad de remoción de la malla y recurrencia de la hernia. Resultados. Diez pacientes fueron sometidos a cirugía de urgencias, requiriendo resección intestinal por necrosis: nueve de ellos, por hernias estranguladas y, uno, por apendicitis perforada. En uno de los diez pacientes, se consideró sucia la herida por presentar necrosis intestinal y perforación. Los nueve restantes presentaban necrosis intestinal sin perforación, por lo cual se consideraron heridas contaminadas. La infección de la herida ocurrió en 1/10 pacientes con infección del sitio operatorio superficial; la eliminación de la malla no fue necesaria en ningún paciente durante todo el período de estudio. No se observaron recidivas y no hubo mortalidad. Conclusión. El uso de malla de polipropileno para la corrección de hernias inguinales, en pacientes con heridas sucias o contaminadas, es efectivo y seguro, con una morbilidad aceptable y buenos resultados a corto plazo.

Use of commercial mesh for hernia repair in a low resource setting: experience after 500 cases

BACKGROUND

The use of mesh has revolutionized the management of hernias in many parts of the world. There is, however, limited experience on its use in sub-Saharan Africa. This study describes a single hospital experience after 500 cases of mesh hernia repairs in a sub-Saharan African country.

METHODS

We reviewed the records of the first 500 cases of abdominal wall hernia operations performed using commercial mesh since year 2007. Socio-demographic characteristics, hernia type, method of repair and outcome data were analyzed and presented as descriptive statistics.

RESULTS

The first 500 cases of mesh hernia repairs were performed between 2007 and 2017 during which a total of 1,175 hernia operations were carried out, mesh repair accounting for 42.5% of the total. There was a progressive rise in the uptake of mesh repairs over time, with mesh repairs overtaking tissue based repairs in the last few years of the review. Inguinal hernia was by far the commonest indication for mesh use (80.4%), followed by incisional hernia (9%). Polypropylene mesh was the most common type of mesh used in about 96.2% of cases. Overall, there were seven recurrences (1.4%) at a mean follow-up period of 15.3 months (1-108 months) CONCLUSION: In spite of resource limitations, the use of mesh for hernia repairs continues to rise and has overtaken tissue-based repairs in a sub-Saharan African setting. Results show good outcomes justifying continued use.

Hernia and Cancer: The Points Where the Roads Intersect

Introduction: This review aimed to present common points, intersections, and potential interactions or mutual effects for hernia and cancer. Besides direct relationships, indirect connections, and possible involvements were searched. Materials and Methods: A literature search of PubMed database was performed in July 2018 as well as a search of relevant journals and reference lists. The total number of screened articles was 1,422. Some articles were found in multiple different searches. A last PubMed search was performed during manuscript writing in December 2018 to update the knowledge. Eventually 427 articles with full text were evaluated, and 264 included, in this review. Results: There is no real evidence for a possible common etiology for abdominal wall hernias and any cancer type. The two different diseases had been found to have some common points in the studies on genes, integrins, and biomarkers, however, to date no meaningful relationship has been identified between these points. There is also some, albeit rather conflicting, evidence for inguinal hernia being a possible risk factor for testicular cancer. Neoadjuvant or adjuvant therapeutic modalities like chemotherapy and radiotherapy may cause postoperative herniation with their adverse effects on tissue repair. Certain specific substances like bevacizumab may cause more serious complications and interfere with hernia repair. There are only two articles in PubMed directly related to the topic of "hernia and cancer." In one of these the authors claimed that there was no association between cancer development and hernia repair with mesh. The other article reported two cases of squamous-cell carcinoma developed secondary to longstanding mesh infections. Conclusion: As expected, the relationship between abdominal wall hernias and cancer is weak. Hernia repair with mesh does not cause cancer, there is only one case report on cancer development following a longstanding prosthetic material infections. However, there are some intersection points between these two disease groups which are worthy of research in the future.

An Analysis of Early Postoperative Returns after Inguinal Hernia Surgery

Although inguinal herniorrhaphy is low risk, patients still return to the urgent care or ED. We performed a retrospective study on 19,296 inguinal hernia operations across 14 Southern California Kaiser Permanente medical centers over five years. Unplanned returns within the first postoperative week were evaluated focusing on four potentially avoidable diagnoses (AD): pain, constipation, urinary retention, and nausea/vomiting. Overall, 1370 (7%) patients returned to the urgent care/emergency department, of which 537 (39%) had an AD. There was no difference in total returns (7.1 vs 7.4%, P = 0.33) or AD returns [2.8 vs 2.6%, ( P = 0.44)] for males vs females. Of the 537 total AD returns, there were 205 (38%) patients with pain, 191 (36%) with urinary retention, 112 (21%) with constipation, and 29 (5%) with nausea/vomiting. Most AD returns (78%) occurred within the first three postoperative days. Pain was greater in open operations [44 vs 26%, ( P < 0.05)], and urinary retention was greater in the laparoscopic group [27 vs 55%, ( P < 0.05)]. The overall rate of return was higher for laparoscopic compared with open unilateral operations [8 vs 6%, ( P < 0.05)], but similar between approaches for bilateral operations [11 vs 10%, ( P = 0.32)].

Surgical risk factors for recurrence in inguinal hernia repair - a review of the literature

Despite all the progress made in inguinal hernia surgery driven by the development of meshes and laparoendoscopic operative techniques, the proportion of recurrent inguinal hernias is still from 12% to 13%. Recurrences can present very soon after primary inguinal hernia repair generally because of technical failure. However, they can also develop much later after the primary operation probably due to patient-specific factors. Supported by evidence-based data, this review presents the surgical risk factors for recurrent inguinal hernia after the primary operation. The following factors are implicated here: choice of operative technique and mesh, mesh fixation technique, mesh size, management of medial and lateral hernia sac, sliding hernia, lipoma in the inguinal canal, operating time, type of anesthesia, participation in a register database, femoral hernia, postoperative complications, as well as the center and surgeon volume. If these surgical risk factors are taken into account when performing primary inguinal hernia repair, a good outcome can be expected for the patient. Therefore, they should definitely be observed.

Linked hospital and primary care database analysis of the impact of short-term complications on recurrence in laparoscopic inguinal hernia repair

OBJECTIVE

To study the effects of short-term complications on recurrence following laparoscopic inguinal hernia repair using routine data.

BACKGROUND

Linked primary and secondary care databases can evaluate the quality of inguinal hernia surgery by quantifying short- and long-term outcome together.

METHODS

Longitudinal analysis of linked primary care (Clinical Practice Research Datalink) and hospital administrative (Hospital Episodes Statistics) databases quantified 30-day complications (wound infection and bleeding) and surgery for recurrence after primary repair performed between 1st April 1997 and 31st March 2012.

RESULTS

Out of 41,545 primary inguinal hernia repairs, 10.3% (4296/41,545) were laparoscopic. Complications were less frequent following laparoscopic (1.8%, 78/4296) compared with open (3.5%, 1288/37,249) inguinal hernia repair (p < 0.05). Recurrence was more frequent following laparoscopic (3.5%, 84/2541) compared with open (1.2%, 366/31,859) repair (p < 0.05). Time to recurrence was shorter for laparoscopic (26.4 months SD 28.5) compared with open (46.7 months SD 37.6) repair (p < 0.05). Overall, complications were associated with recurrence (3.2%, 44/1366 with complications; 1.7%, 700/40,179 without complications; p < 0.05). Complications did not significantly increase the risk of recurrence in open hernia repair (OR = 1.49; 95% CI 0.97-2.30, p = 0.069). Complications following laparoscopic repair was significantly associated with increased risk of recurrence (OR = 7.86; 95% CI 3.46-17.85, p < 0.05).

CONCLUSIONS

Complications recorded in linked routine data predicted recurrence following laparoscopic inguinal hernia repair. Focus must, therefore, be placed on achieving good short-term outcome, which is likely to translate to better longer term results using the laparoscopic approach.

Laparoscopic versus open inguinal hernia repair

The laparoscopic approach to inguinal hernia surgery is safe and reliable. It has a similar recurrence rate as open tension-free mesh repair. Because the laparoscopic approach has less chronic postoperative pain and numbness, fast return to normal activities, and decreased incidence of wound infection and hematoma, it should be considered an appropriate approach for inguinal hernia surgery. These results can be achieved if a surgeon is proficient in the technique, has a clear understanding of the anatomy, and performs it on a regular basis. This article focuses on questions related to laparoscopic inguinal hernia surgery and provides answers based on published literature.