The Septum Inguinalis: A Clue to Hernia Genesis?

A Rare Case of Penoscrotal Webbing and Extensive Hernias: An Anatomical Report With Genetic Insights

During a routine anatomical dissection of an 81-year-old male cadaver received through the Gift Body Program of Saint Louis University School of Medicine (SLU SOM), a massive bulging in the abdominal area was observed that was consistent with numerous hernia repairs noted in the donor's self-reported medical history. Gross anatomical dissection of the cadaveric body revealed extensive herniation of portions of the small intestine and peritoneal sac along the costal margin and extending to the left aspect of the abdomen. Additionally, an uncircumcised phallus was buried within the suprapubic fat pad and demonstrated simple, grade III penoscrotal webbing (PSW), creating an impression of micropenis presence. To gain additional insights into the current case, analysis of the coding regions (exomes) of DNA procured from the body for putative genetic variants was performed using next-generation sequencing (NGS) technology. This analysis revealed 110 rare (minor allele frequency (MAF) ≤ 0.01), pathologic/deleterious genetic mutations. The most relevant variants to this case were the ones associated with male sexual development, BMP1 and BMP4; connective tissue development, COL3A1 and COL5A3; cilia morphogenesis and function, DNAH5 and MAPK15; as well as hormonal homeostasis, ESR1. Direct involvement of BMP1 both in male sexual development and hernia genesis makes it a strong candidate for linking the two pathologies, PSW and multiple hernias, observed in the present case. Yet the presence of a group of mutated genes linked to myopathies (ITGA7, NRAP, POLM, SCN5A, XIRP2) and muscular dystrophy (ITGA7) raises a question about the involvement of these muscular pathologies in hernia genesis and unsuccessful hernia repairs associated with the current case.

Dynamic Responsive Inguinal Scaffold Activates Myogenic Growth Factors Finalizing the Regeneration of the Herniated Groin

BACKGROUND

Postoperative chronic pain caused by fixation and/or fibrotic incorporation of hernia meshes are the main concerns in inguinal herniorrhaphy. As inguinal hernia is a degenerative disease, logically the treatment should aim at stopping degeneration and activating regeneration. Unfortunately, in conventional prosthetic herniorrhaphy no relationship exists between pathogenesis and treatment. To overcome these incongruences, a 3D dynamic responsive multilamellar scaffold has been developed for fixation-free inguinal hernia repair. Made of polypropylene like conventional flat meshes, the dynamic behavior of the scaffold allows for the regeneration of all typical inguinal components: connective tissue, vessels, nerves, and myocytes. This investigation aims to demonstrate that, moving in tune with the groin, the 3D scaffold attracts myogenic growth factors activating the development of mature myocytes and, thus, re-establishing the herniated inguinal barrier.

METHODS

Biopsy samples excised from the 3D scaffold at different postoperative stages were stained with H&E and Azan-Mallory; immunohistochemistry for NGF and NGFR p75 was performed to verify the degree of involvement of muscular growth factors in the neomyogenesis.

RESULTS

Histological evidence of progressive muscle development and immunohistochemical proof of NFG and NFGRp75 contribution in neomyogenesis within the 3D scaffold was documented and statistically validated.

CONCLUSION

The investigation appears to confirm that a 3D polypropylene scaffold designed to confer dynamic responsivity, unlike the fibrotic scar plate of static meshes, attracts myogenic growth factors turning the biological response into tissue regeneration. Newly developed muscles allow the scaffold to restore the integrity of the inguinal barrier.

A regenerative 3D scaffold for inguinal hernia repair. MR imaging and histological cross evidence. Qualitative study

BACKGROUND

Inguinal hernia is a degenerative disease occurring in a high motile surround. Stopping degeneration and promoting tissue regeneration should be the treatment goal. Groin hernias are conventionally managed with static flat meshes, mostly fixated to the delicate inguinal environment. Far from a regenerative effect, the biologic response of conventional hernia meshes is characterized by a foreign body reaction leading to a stiff/shrunken scar plate, which is often the source of unpleasant complications. Recently, a newly engineered 3D device for inguinal hernia repair - ProFlor-has been developed to produce a regenerative biological response. Unlike conventional hernia meshes, this regenerative 3D hernia scaffold seems to demonstrate suitable features for a pathogenetical and physiological coherent treatment of the disease. The aim of this manuscript is to cross evidence these features through magnetic resonance imaging (MRI) and histology.

STUDY DESIGN

The biological response of ProFlor at three defined post-implantation stages has been evaluated through MRI signal intensity and compared to neighbouring muscles and fat. As additional proof, histology of tissue specimens excised at the same post-implantation periods from porcine models during an experimental attempt were also evaluated.

RESULTS

MRI of newly ingrown tissue in ProFlor demonstrated similar signal intensity of muscles while fat tissue showed remarkably higher values. These data matched with the histology of ProFlor biopsies excised from pigs.

CONCLUSIONS

The motile compliance to groin movements of ProFlor appears to induce a probiotic biologic response comparable to a regenerative scaffold, allowing to physiologically resolve the degenerative source of inguinal hernia disease.

First-in-man permanent laparoscopic fixation free obliteration of inguinal hernia defect with the 3D dynamic responsive implant ProFlor-E®. Case report

INTRODUCTION

In the case of inguinal hernia recurrence after primary anterior repair, international guidelines strongly suggest a posterior laparoscopic approach. The 3D dynamic-responsive prosthesis for inguinal hernia repair ProFlor-E® has recently been introduced to the market. The present report describes the results of the first-in-man laparoscopic inguinal hernia repair carried out with ProFlor-E®.

PRESENTATION OF CASE

A 71-year-old male Caucasian presented with recurrent inguinal hernia after primary anterior repair. A fixation free TAPP procedure with ProFlor-E® was planned. Implant delivery and placement to obliterate the defect was quick and safe. Postoperatively, starting from 2nd postop day, pain was practically absent allowing quick return to normal activities. During follow up, US and MRI scans confirmed the permanence of ProFlor-E® in the hernial gap. During 16-month follow-up no complications were reported.

DISCUSSION

Flat meshes used to reinforce the herniated inguinal area is a well-established concept. Notwithstanding, such static and passive implants leave the defect patent and cause specific complications related to mesh fixation and uncontrolled poor quality fibrotic ingrowth. ProFlor-E® respects the inguinal physiology resolving these issues. Its centrifugal expansion and dynamic responsivity allows for fixation-free defect obliteration, thus avoiding complications, above all tissue tear, bleeding, mesh invagination, discomfort and chronic pain. In accord with the degenerative pathogenesis of hernia disease, by acting as a regenerative scaffold, ProFlor-E® restores the inguinal barrier promoting the regeneration of the typical inguinal components.

CONCLUSION

This initial experience seems to prove that ProFlor-E® can also be used with the laparoscopic approach achieving excellent results.