Effect of Body Mass Index on Groin Hernia Surgery

Risk factors for incarceration in groin hernia: a prospective observational study

PURPOSE

Groin hernia is one of the most common benign pathologies requiring surgical intervention. Incarcerated groin hernia is a cause of serious morbidity and mortality. In our study, we aimed to identify the risk factors for incarceration in patients with groin hernia and to better understand the factors associated with incarceration, we studied patients who applied to our clinic for groin hernia and underwent surgery.

METHODS

A prospective observational study was performed, including all patients who applied to the general surgery out patient clinic or emergency department at Bakirköy Dr Sadi Konuk Training & Research Hospital and were diagnosed with groin or incarcerated groin hernia and underwent hernia repair surgery. Patients were divided into two groups; elective surgery and emergency surgery (incarcerated hernia). Multivariate logistic regression was performed to identify risk factors for incarceration.

RESULTS

The study was performed with a total of 654 cases between January 2021 and February 2023. Of these, 79.4% (n = 519) had elective surgery and 20.6% (n = 135) had emergency surgery. Increase in defect width, which was determined according to the EHS classification, was significantly associated with an incarcerated hernia (ODDS ratio 4.463 and 17.636, respectively). Additionally, female gender, femoral hernia type, chronic cough, and chronic constipation were found to be independent risk factors for incarceration.

CONCLUSION

Female gender, chronic cough, chronic constipation, femoral hernia type, and increased defect diameter are independent risk factors for urgent surgery and therefore incarceration in groin.

TRIAL REGISTRATION NUMBER

The ClinicalTrials.gov ID number of the study is NCT04785430.

Critical values for body mass index related to morbidity in high-volume low-complexity general surgery: a systematic review and meta-analysis

INTRODUCTION

The aim of this study was to investigate the effect of body mass index (BMI, kg/m2) on outcomes of high-volume low-complexity (HVLC) general surgery procedures and to determine critical values for BMI when selecting patients into HVLC programmes.

METHODS

A systematic review was conducted of studies looking at patients in different BMI categories undergoing HVLC general surgery procedures (laparoscopic cholecystectomy, inguinal hernia repair and umbilical or paraumbilical hernia repair), in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. A comparison meta-analysis model was constructed to compare the outcomes using random-effects modelling. The QUIPS (Quality In Prognosis Studies) tool and GRADE (Grading of Recommendations Assessment, Development and Evaluation) system were used to assess bias.

RESULTS

A total of 26 studies including 486,392 patients were examined. In laparoscopic cholecystectomy, BMI ≥40 was associated with higher conversion to open surgery (odds ratio [OR]: 1.33, p=0.040) but did not affect complications (OR: 0.69, p=0.400) or length of hospital stay (mean difference [MD]: -0.01 days, p=0.900). In inguinal hernia repair, BMI ≥35 was associated with longer operative time (MD: 18.00 minutes, p<0.00001), and higher risk of wound complications (OR: 3.01, p<0.00001) and hospital readmission (OR: 1.46, p=0.0008). In umbilical or paraumbilical hernia repair, BMI ≥30 was associated with higher risk of wound complications (OR: 6.45, p<0.0001) and hospital readmission (OR: 5.56, p<0.00001), and longer operative time (MD: 4.01 minutes, p=0.030).

CONCLUSIONS

Obesity was associated with longer operative time (up to 23 minutes) and higher risk of postoperative morbidity (up to 4-fold) in HVLC procedures. BMI <40 (moderate GRADE certainty - laparoscopic cholecystectomy) and BMI <35 (moderate GRADE certainty - inguinal hernia) appear to represent optimal critical values for perioperative safety metrics.

Association between different obesity metrics and risk of inguinal hernia

PURPOSE

Obesity is closely associated with a lower risk of inguinal hernia, but the association between different obesity metrics and the risk of inguinal hernia is still unclear.

METHODS

In our study, we categorized obesity measurement indicators into three groups based on the difficulty of measurement: (1) indicators easily available, such as body mass index (BMI), waist circumference (WC), hip circumference (HC), and waist-to-hip ratio (WHR); (2) indicators accessible with moderate difficulty, such as body fat percentage and body fat mass; (3) indicators difficultly accessible, such as the volume of visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT). Mendelian randomization (MR) analysis was used to investigate the causal relationship between various adiposity measures and the risk of inguinal hernia in both European ancestry and East Asians.

RESULTS

We identified a total of 17,096 patients with inguinal hernia in the FinnGen cohort and 1664 cases in the Japan Biobank cohort. For European ancestry, MR analysis reported a significant causal association between one standard deviation increase of BMI, WC, HC, body fat percentage, and body fat mass and the lower risk of inguinal hernia, rather than WHR, VAT, and SAT. After the adjustment of BMI, increased WC is still causally associated with a lower risk of inguinal hernia (OR: 0.52; 95% CI: 0.33-0.80; P < 0.01). Among East Asians, only body fat mass is causally associated with a reduced risk of inguinal hernia, rather than BMI, WC, and HC.

CONCLUSION

Obesity is causally associated with a relatively lower risk of inguinal hernia. The association between different obesity measures and the risk of inguinal hernia has ethnic specificity. These findings help us deepen our understanding of the intrinsic causal relationship between fat distribution and the risk of inguinal hernias at the genetic level.

Is the recurrence rate higher in obese patients undergoing inguinal hernia surgery?

PURPOSE

This study aimed to evaluate whether obese patients undergoing inguinal hernia repair surgery have a higher recurrence rate and compare the clinical outcomes of obese and non-obese patients.

MATERIALS AND METHODS

The databases of PubMed, EMBASE, and Cochrane Library were used to search for eligible studies from inception to November 1, 2024. Mean difference (MD), Odds ratios (OR) and 95% confidence intervals (Cl) were pooled up to analyze. The Newcastle-Ottawa Scale (NOS) scores were used to evaluate the quality of the included studies. This study was performed with Stata (V.16.0) software.

RESULTS

A total of nine studies involving 56,833 patients were included in this study. By comparing the baseline information, we found that the obese group had Fewer older (MD=-0.08, I²=62.41%, 95%CI=-0.16 to -0.00, P = 0.04), higher BMI (MD = 2.45, I²=93.67%, 95%CI = 2.08 to 2.81, P < 0.01), more hypertension patients (OR = 1.32, I²=32.96%, 95%CI = 1.02 to 1.67, P = 0.04), more BPH (OR = 0.68, I²=0.00%, 95%CI = 0.49 to 0.94, P = 0.02) and more local anesthesia (OR = 0.82, I²=14.73%, 95%CI = 0.79 to 0.86, P < 0.01) than the none-obese group. In terms of postoperative outcomes, We found that the obese group had higher recurrence rate (OR = 1.27, I²=21.89%, 95%CI = 1.10 to 1.47, P < 0.01), more wound infection (OR = 1.43, I²=0.00%, 95%CI = 1.20 to 1.69, P < 0.01), and more overall complications (OR = 1.12, I²=28.20%, 95%CI = 1.05 to 1.20, P < 0.01).

CONCLUSION

Compared with the non-obese group, the obese group has a higher recurrence rate, more wound infections, and overall more complications.

Higher rates of recurrence and worse quality of life in obese patients undergoing inguinal hernia repair

PURPOSE

Prior investigations regarding the effect of obesity on inguinal hernia repair have been mixed. The aim of our study was to retrospectively compare perioperative outcomes, recurrence rate, and quality of life between obese and non-obese patients undergoing inguinal hernia repair.

METHODS

Patients who underwent inguinal hernia repair by any approach at a single institution were identified from a prospectively maintained quality database. Patients with a body mass index (BMI) greater than or equal to 30 kg/m2 were considered obese. Quality of life was measured with the Surgical Outcomes Measurement System (SOMS) and Carolinas Comfort Scale (CSS) surveys. Differences between obese and non-obese patients were assessed using independent samples t-tests, Wilcoxon rank-sum, and chi-square tests.

RESULTS

Between 2010 and 2021, a total of 5575 patients underwent inguinal hernia repair. Fifteen percent of patients were identified as obese (835 patients, mean BMI 33.2 ± 3.3 kg/m2). A significantly higher percentage of obese patients were diabetic, and operative time and estimated blood loss were higher in the obese group (all p < 0.001). Rates of hernia recurrence in obese patients was significantly more likely than in non-obese patients (4.2% vs 2.0%, p < 0.001). Up to 2 years postoperatively, a greater percentage of obese patients reported worse quality of life on the SOMS and more bothersome symptoms on the CCS.

CONCLUSIONS

Inguinal hernia repair in obese patients is a more technically challenging operation. Long-term follow-up revealed a greater risk of hernia recurrence and worse quality of life up to 2 years postoperatively in this patient population.

Patient's Perception of the Role of Gym Activity in Abdominal Wall Herniation in Adults: A Prospective Study

BACKGROUND

Despite significant changes in healthcare, work practices, and leisure activity, the proposed precipitating factors for abdominal wall hernias have remained largely unchanged for almost two centuries. We aimed to investigate if there have been shifts in these factors over time by examining patients' perception of precipitating factors for abdominal wall hernia development. This study was conducted in the Royal College of Surgeons In Ireland Department of Surgery, Connolly Hospital, Blanchardstown, Dublin, where patients with abdominal wall hernias completed a questionnaire  .

RESULTS

A total of 277 patients (mean age 55.7; 85.6% male) with abdominal wall hernia completed the questionnaire (66.1% inguinal; 10.8% umbilical; 6.9% paraumbilical; 10.5% epigastric; 3.2% incisional; 1.4% femoral, and 1.1% port-site). One hundred and twenty patients (43.3%) believed their hernia was due to lifting, 71 (25.6%) cited gym activity and 17 (6.1%) cited other sporting activities as the precipitating factor. Traditional factors - chronic cough and constipation - were cumulatively cited only by 11 patients (4.0%), while prostatic obstruction was not cited by any.

CONCLUSION

This study suggests that fitness pursuits may be an increasing contributor to the development of abdominal wall hernia. Greater attention should be paid to the proper use of gym equipment to minimise the risk of hernia development.

Incidence of groin hernia repairs in women and parity: a population-based cohort study among women born in Sweden between 1956 and 1983

INTRODUCTION

The aim of this study was to evaluate the association between parity and the incidence rate of groin hernia repair in women.

METHOD

This study was based on two Swedish national registers, the Medical Birth Register (MBR), and the Swedish Hernia Register (SHR). The cohort constituted of women born between 1956 and 1983. Data on vaginal and cesarean deliveries were retrieved from the MBR. The birth and hernia registers were cross matched to identify hernia repairs carried out after deliveries.

RESULTS

A total of 1,535,379 women were born between 1956 and 1983. Among these, 1,417,237 (92.3%) were registered for at least one birth. The incidence rate for Inguinal Hernia Repair (IHR) and Femoral Hernia Repair (FHR) was 10.7 per 100,000 person-year and 2.6 per 100,000 person-year, respectively. Compared with women registered for one delivery, the incidence rate ratio for IHR was 1.31 (95% Confidence Interval: 1.23-1.40) among women registered for two deliveries, 1.70 (1.58-1.82) among women registered for ≥ 3 deliveries. Additionally, the incidence rate ratios were higher 1.30 (1.14-1.49) and 1.70 (1.49-1.95) for FHR among women with two and  ≥ 3 registered deliveries, respectively.

CONCLUSION

In the present cohort, higher parity was associated with a higher incidence of inguinal as well as FHRs.

Obesity and abdominal hernia in ambulatory patients, 2018-2023

PURPOSE

To determine the relationship between abdominal hernia and obesity. Although obesity is frequently cited as a risk factor for abdominal hernia, few studies have confirmed this association (Menzo et al. Surg Obes Relat Dis 14:1221-1232. 10.1016/j.soard.2018.07.005, 2018).

METHODS

A cross-sectional study of primary care ambulatory patients aged older than 16 years treated at UCLA Health from 01/01/2018 to 06/06/2023. Abdominal hernia was identified by clinic encounter ICD-10 codes (K40-K46).

RESULTS

There were 41,703 hernias identified among 1,362,440 patients (306.1 per10,000) with a mean age of 62.5 ± 16.1 years, and 57.6% were men. Nearly half (44.7%) of all abdominal hernias were diaphragmatic. There was an approximately equal distribution of the ventral (28.7%) and inguinal (24.3%) hernia. Each hernia type had a different relationship with obesity: The odds of having a ventral hernia increased with BMI in both sexes: BMI 25-29.9 kg/m2 odds ratio (OR) = 1.65, (CI 1.56-1.74); BMI 30-39.9 kg/m2 OR = 2.42 (CI 2.29-2.56), BMI 40-49.9 kg/m2 OR = 2.28 (CI 2.05-2.54) and BMI >  = 50 kg/m2 OR = 2.54 (CI 2.03-3.17) all relative to normal BMI. In contrast, the odds of having an inguinal hernia decreased with obesity relative to normal weight [obesity (BMI 30-39.9 kg/m2): OR = 0.60 (CI 0.56-0.65)], morbid obesity (BMI 40-49.9 kg/m2): OR = 0.29 (CI 0.23-0.37). The OR for diaphragmatic hernia peaks with obesity in women and overweight status in men but was found to decrease with morbid obesity [OR = 1.18 (CI 1.07-1.30)]. There was no significant difference between men and women in the prevalence of femoral hernia (men: 0.7/per10,000, women: 0.9/per10,000, p = 0.19).

CONCLUSIONS

The relationship between hernia and obesity is complex with some hernias decreasing in prevalence as obesity increases. Further research is needed to better understand this paradoxical relationship.

Risk factors for reoperation following inguinal hernia repair: results from a cohort of patients from an integrated healthcare system

PURPOSE

Inguinal hernia repair is one of the most common operations performed globally. Identification of risk factors that contribute to hernia recurrence following an index inguinal hernia repair, especially those that are modifiable, is of paramount importance. Therefore, we sought to investigate risk factors for reoperation following index inguinal hernia repair.

METHODS

125,133 patients aged ≥ 18 years who underwent their first inguinal hernia repair with mesh within a large US integrated healthcare system were identified for a cohort study (2010-2020). Laparoscopic, robotic, and open procedures were included. The system's integrated electronic health record was used to obtain data on demographics, patient characteristics, surgical characteristics, and reoperations. The association of these characteristics with ipsilateral reoperation during follow-up was modeled using Cox proportional-hazards regression. Risk factors were selected into the final model by stepwise regression with Akaike Information Criteria, which quantifies the amount of information lost if a factor is left out of the model. Factors associated with reoperation with p < 0.05 were considered statistically significant.

RESULTS

The cumulative incidence of reoperation at 5-year follow-up was 2.4% (95% CI 2.3-2.5). Increasing age, female gender, increasing body mass index, White race, chronic pulmonary disease, diabetes, drug abuse, peripheral vascular disease, and bilateral procedures all associated with a higher risk for reoperation during follow-up.

CONCLUSION

This study identifies several risk factors associated with reoperation following inguinal hernia repair. These risk factors may serve as targets for optimization protocols prior to elective inguinal hernia repair, with the goal of reducing reoperation risk.

Laparoscopic Inguinal Hernia Repair in the Obese Patient Population: A Single-Center Five-Year Experience

Purpose The objective of the present study is to evaluate the distribution of the transabdominal preperitoneal (TAPP) and the totally extraperitoneal repair (TEP) procedures among the obese and non-obese patient populations, to show how obesity impacts daily practice by reviewing the experience of a single center, and finally, to assess the outcomes of the operations. Methods All patients who underwent elective, minimally invasive inguinal hernia repair in our hospital from January 2017 to January 2022 were included in the present study. The data that were analyzed were patient demographics, each individual patient's American Society of Anesthesiology (ASA) score, the minimally invasive technique (TAPP or TEP) utilized, the body mass index (BMI), and other comorbidities such as underlying diabetes, hypertension, and smoking status. Results A total of 109 patients were included in the present analysis, of which 81 (74.3%) underwent elective TEP repairs while 28 (25.7%) underwent elective TAPP repairs. Overall, 39 (35.7%) patients were included in the obesity subgroup with an average BMI of 35.4 ± 4.9, with a range from 30.1 to 52.7, and 70 (64.3%) were included in the non-obese subgroup, with an average BMI of 23.2 ± 3.3 and a range from 16.2 to 29.7. Conclusions The laparoscopic approach to the inguinal hernia repair in obese patients has similar outcomes as an open approach regarding the 30-day events, in the hands of experienced surgeons with the advantages of the laparoscopic approach vs. the open one.

Association of body mass index with 30-day outcomes following groin hernia repair

PURPOSE

Although groin hernia repairs are relatively safe, efforts to identify factors associated with greater morbidity and resource utilization following these operations are warranted. An emphasis on obesity has limited studies from a comprehensive evaluation of the association between body mass index (BMI) and outcomes following groin hernia repair. Thus, we aimed to ascertain the association between BMI class with 30-day outcomes following these operations.

METHODS

The 2014-2020 National Surgical Quality Improvement Program database was queried to identify adults undergoing non-recurrent groin hernia repair. Patient BMI was used to stratify patients into six groups: underweight, normal, overweight, and obesity classes I-III. Association of BMI with major adverse events (MAE), wound complication, and prolonged length of stay (pLOS) as well as 30-day readmission and reoperation were evaluated using multivariable regressions.

RESULTS

Of the 163,373 adults who underwent groin hernia repair, the majority of patients were considered overweight (44.4%). Underweight patients more commonly underwent emergent operations and femoral hernia repair compared to others. After adjustment of intergoup differences, obesity class III was associated with greater odds of an MAE (AOR 1.50), wound complication (AOR 4.30), pLOS (AOR 1.40), and 30-day readmission (AOR 1.50) and reoperation (AOR 1.75, all p < 0.05). Underweight BMI portended greater odds of pLOS and unplanned readmission.

CONCLUSION

Consideration of BMI in patients requiring groin hernia repair could help inform perioperative expectations. Preoperative optimization and deployment of a minimally invasive approach when feasible may further reduce morbidity in patients at the extremes of the BMI spectrum.

Female Groin Hernia Repairs in the Swedish Hernia Register 1992-2022: A Review With Updates

Introduction: Groin hernias in women is much less common than in men; it constitutes only 9% of all groin hernia operations. Historically, studies have been performed on men and the results applied to both genders. However, prospectively registered operations within national registers have contributed to new knowledge regarding groin hernias in women. The aim of this paper was to investigate and present a body of literature based upon the Swedish Hernia Register together with recent data from the register's annual report. Patients and Methods: PubMed and Embase were searched for studies based on the Swedish Hernia Register between 1992 and 2023. Based on the initial reading of abstracts, studies that presented results separately for women were selected and read. Recent data were acquired from the 2022 annual report of the Swedish Hernia Register. Results: A total of 73 studies of interest were identified. Of these, 52 included women, but only 19 presented separate results for women. Four themes emerged and were analysed further: emergency surgery and mortality, femoral hernias, the risk of reoperation for recurrence, and chronic pain following female groin hernia repairs. Discussion: Studies from the Swedish Hernia Register clearly describe that both the presentation of hernias and outcomes after repair differ significantly between the two genders. The differences that have been identified over the years have been incorporated into the national guidelines. Register data indicates that the guidelines have been implemented and are fairly well adhered to. As a result, significant improvements in outcomes regarding recurrences have been made for women with groin hernias in Sweden.

Current opinions in inguinal hernia emergencies: A comprehensive review of related evidences

INTRODUCTION:

Groins hernia emergencies are evaluated under two definitions: incarceration that is defined as a hernia in which its content becomes irreducible at the passage in the abdominal wall and strangulation that compromises the blood supply to the omentum and/or intestines within the hernia sac. The purpose of this paper was to determine the latest knowledge about groin hernia emergencies.

MATERIALS AND METHODS:

PubMed and Google Scholar searches were done by using combinations of “inguinal hernia” and “emergency”, and “groin hernia” and “emergency” keywords at first. More detailed searches were performed to enrich the “Surgical treatment” part of the paper by using “emergency hernia” and “mesh”, “emergency hernia,” and “laparoscopic versus open” keywords afterward.

RESULTS:

Approximately 5%–10% of all inguinal repairs are performed in emergency settings. Both lateral and medial inguinal hernias can get incarcerated or strangulated, whereas the risk for femoral hernias is higher. Manual reduction of incarcerated inguinal hernias is successful in approximately 60% of the cases. The prediction of bowel ischemia due to strangulation may be possible with some blood tests and imaging studies like ultrasound and computed tomography. It has been shown that the longer the duration of incarceration the higher the risk of bowel ischemia. Bowel resection which is more frequently necessary in patients with advanced age, female gender, and femoral hernia, is associated with an increased risk of perioperative mortality. Some surgeons still use tissue-suture repairs in an emergency setting; however, mesh repairs have been shown to be safe unless there is an overt contamination.

CONCLUSION:

Early treatment of complicated groin hernias is the key to favorable outcomes. The need for bowel resection and advanced age are the most prominent factors for morbidity and mortality. Mesh repairs are safe in most cases. Minimally invasive approaches promise good results in experienced centers.

The global, regional, and national burden and its trends of inguinal, femoral, and abdominal hernia from 1990 to 2019: findings from the 2019 Global Burden of Disease Study - a cross-sectional study

BACKGROUND

Inguinal, femoral, and abdominal hernia repairs are the most common surgical procedure worldwide. However, studies on hernia disease burden are notably limited, in both developed and low-income and middle-income countries (LMICs). We investigated temporal trends in the incidence and prevalence of inguinal, femoral, and abdominal hernias at global, regional, and national levels in 204 countries and territories from 1990 to 2019 using data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019).

MATERIALS AND METHODS

Annual incident cases, prevalent cases, age-standardized incidence rates (ASIRs), and age-standardized prevalence rates (ASPRs) of inguinal, femoral, and abdominal hernias between 1990 and 2019 were extracted from the GBD 2019 study and stratified by sex, age, and location. Percentage changes in incident cases and prevalent cases, and the estimated annual percentage changes of ASIRs and ASPRs were calculated to quantify the trends in the incidence and prevalence of inguinal, femoral, and abdominal hernias. Data analysis for the present study was conducted from 15 June 2022 to 15 July 2022.

RESULTS

Globally, there were 32.53 million [95% uncertainty interval (UI): 27.71-37.79] prevalent cases and 13.02 million (10.68-15.49) incident cases of inguinal, femoral, and abdominal hernias in 2019, which increased by 36.00% and 63.67%, respectively, compared with 1990. Eighty-six percent of the incident cases were males, the male-to-female ratio was 6 : 1, and most patients were aged 50-69 years. India (2.45 million), China (1.95 million), and Brazil (0.71 million) accounted for more than one-third (39%) of the incident cases worldwide. From 1990 to 2019, the ASIR and ASPR showed a decreasing trend worldwide, except in Central Sub-Saharan Africa, which had an increasing trend in ASIR and ASPR.

CONCLUSION

The global incident cases and prevalent cases of inguinal, femoral, and abdominal hernias increased substantially from 1990 to 2019, with a heavier burden observed in males, older adults, and in LMICs such as India and China. In addition, the ASIR and ASPR increased substantially in Central Sub-Saharan Africa. More efforts are warranted for hernia management to reduce the burden of inguinal, femoral, and abdominal hernias, such as by providing safe hernia surgical treatment for males, older adults, and LMICs.

Short-term outcomes of robotic inguinal hernia repair during robotic prostatectomy - An analysis of the Abdominal Core Health Quality Collaborative

BACKGROUND

Concomitant robotic-assisted laparoscopic prostatectomy (RALP) and robotic inguinal hernia repair (RIHR) has been reported. Nevertheless, data on its safety is lacking and some surgeons avoid performing both operations concurrently due to the potential risk of mesh related complications in the setting of a fresh vesicourethral anastomosis. We aimed to investigate differences in 30-day outcomes between patients undergoing RALP+RIHR and those undergoing RIHR alone.

METHODS

Patients who have undergone concomitant RALP and RIHR with 30-day follow-up available were identified within the Abdominal Core Health Quality Collaborative. Using a propensity score algorithm, they were matched with a cohort of patients undergoing RIHR alone based on confounders such as body mass index, age, ASA class, smoking, hernia size and recurrent status and prior pelvic operation. The groups were compared for 30-day rates of surgical site infection (SSI), surgical site occurrences (SSO), surgical site occurrences requiring operative intervention (SSOPI) and hernia recurrence.

RESULTS

24 patients underwent RALP + RIHR and were matched to 72 patients who underwent RIHR alone (3:1). Median age was 64 years, 33% were obese and 17% smokers. No significant differences were found on 30-day rates of overall complications (21% RALP + RIHR vs. 15% RIHR, p = 0.53) and surgical site occurrences (12% RALP + RIHR vs.11% RIHR, p = 0.85). No patient in the RALP + RIHR group had a 30-day SSI, SSOPI or early recurrence.

CONCLUSION

RALP+RIHR appears not to result in increased rates of wound complications, overall complications or early recurrence when compared to patient undergoing RIHR alone. Prospective, controlled studies with larger number of patients are needed to confirm our findings.

Intestinal erosion caused by meshoma displacement: A case report

BACKGROUND

A meshoma formation and erosion to the small intestine is rare. Herein, we report one case of a meshoma that was not treated early; causing it to displace and erode the small intestine, with infection, complete control of symptoms was achieved after removal of the infected patch mass, no recurrence of hernia after 2 years of follow-up.

CASE SUMMARY

A 62-year-old male patient presented with recurrent abdominal pain repeatedly for 1 wk, which has worsened 2 d before admition, accompanied by fever. Five years before presentation he underwent right inguinal hernia Plug and patch repair approach. Two years ago, a computed tomography scan revealed a right lower abdominal mass with soft tissue density, measuring approximately 30 mm × 17 mm, which was diagnosed as meshoma that was not treated. The patient had poorly controlled diabetes in the past year.

CONCLUSION

The formation of meshoma is rare, and that if not treated in time it might erode and require resection of the involved organ.

Mesh versus non-mesh repair of groin hernias: a rapid review

BACKGROUND

Mesh is frequently utilized intraoperatively for the repair of groin hernias. However, patients may request non-mesh hernia repairs owing to adverse events reported in other mesh procedures. To inform surgical safety, this study aimed to compare postoperative complications between mesh and non-mesh groin hernia repairs and identify other operative and patient-related risk factors associated with poor postoperative outcomes.

METHODS

Ovid MEDLINE and grey literature were searched to 9 June 2021 for studies comparing mesh to non-mesh techniques for primary groin hernia repair. Outcomes of interest were postoperative complications, recurrence of hernia, pain and risk factors associated with poorer surgical outcomes. Methodological quality was appraised using the AMSTAR 2 tool.

RESULTS

The systematic search returned 4268 results, which included seven systematic reviews and five registry analyses. Mesh repair techniques resulted in lower hernia recurrence rates, with no difference in chronic pain, seroma, haematoma or wound infection, compared to non-mesh techniques. Risk factors associated with increased risk of hernia recurrence were increased body mass index (BMI), positive smoking status and direct hernia. These were independent of surgical technique. Patients under 40 years of age were at increased risk of postoperative pain.

CONCLUSIONS

Surgical repair of primary groin hernias using mesh achieves lower recurrence rates, with no difference in safety outcomes, compared with non-mesh repairs. Additional risk factors associated with increased recurrence include increased BMI, history of smoking and hernia subtype.

The relationship between glycine levels in collagen in the anterior rectus sheath tissue and the onset of indirect inguinal hernia: A cross-sectional study

Introduction

An inguinal hernia is a protrusion of abdominal-cavity contents through the inguinal canal. Protection against an inguinal hernia depends on the integrity of fascial tissue, which is maintained by collagen. Collagen is a structural protein consisting of amino acids, the most common of which is glycine. This study aimed to determine the relationship between glycine and the appearance of lateral inguinal hernias. To this end, the researchers examined the profile of collagen and glycine levels in the tissue of the sheath of the rectus femoris in patients with lateral inguinal hernia (indirect inguinal hernia).

Methods

The study used a cross-sectional design to determine glycine levels in rectus anterior sheath tissue in patients with indirect inguinal hernia. Examination of collagen glycine levels was conducted using the ELISA (Enzyme-Linked immunosorbent assay) method. Data were analyzed using the Statistical Package for the Social Science (SPSS) program. An ANOVA test, Pearson's correlation test, and Spearman's correlation test were also performed. A p-value <0.05 was said to be significant.

Results

Across 72 samples, the mean body mass index (BMI) was 22.5 kg/m2 and, the mean clinical onset was 28.02 months. Correlation tests showed a correlation between glycine levels and clinical onset (p = 0.026). The ANOVA test showed a difference between glycine levels with age group (p = 0.025) and BMI (p = 0.015). The correlation between glycine levels and clinical-grade (p = 0.416) was not statistically significant.

Conclusion

There is a significant relationship between glycine levels and age, BMI, and clinical onset of indirect inguinal hernia.

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The stability of the abdominal wall depends on the integrity of muscle and fascial tissue.

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Collagen is a structural protein that helps tissues maintain their mechanical characteristics, structure, and shape.

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The collagen structure contains amino acids such as glycine, proline, hydroxyproline, alanine, and hydroxylysine.

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The high glycine content of collagen is vital to promoting collagen turnover, as its deficiency reduces collagen turnover.

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There is a relationship between glycine levels and age, body mass index, and clinical onset of indirect inguinal hernia.

Urinary Bladder Hernia: A Rare Cause of Urinary Frequency

Hernia repair is one of the most commonly performed surgical operations worldwide. Inguinal hernia is a common condition and has a high prevalence rate. Advanced age and male sex are the most important risk factors. Inguinal hernia usually presents with groin swelling with abdominal discomfort. We report the case of a 39-year-old man who presented to our urologic clinic with a complaint of urinary frequency for the last two months. This was associated with nocturia, feeling of incomplete emptying, and groin swelling. There was no history of hesitancy, intermittency, or weak stream. The patient was otherwise healthy with no significant previous medical or surgical history. Abdominal examination showed a right groin swelling with associated visible and palpable cough impulse in keeping with inguinal hernia. There was no abdominal guarding or rigidity, and the abdomen was non-tender. Examination of the genitalia was unremarkable. No abnormal findings were noted in the examination of other systems. Routine laboratory markers did not show any abnormalities. Urinalysis findings showed no leukocytes and had negative results for leukocyte esterase and nitrites. A computed tomography (CT) scan confirmed the presence of a right-sided inguinal hernia, with part of the urinary bladder seen herniating into the right inguinal canal. The patient underwent a laparoscopic surgery in which the herniated bladder was reduced and the defect was closed with a synthetic mesh. The patient recovered with no complications. Postoperatively, the patient reported significant improvement in his symptoms. Herniation of the bladder through the inguinal canal is an uncommon surgical condition. The case highlighted the importance of considering this diagnosis when they encounter a patient with unexplained lower urinary symptoms. Laparoscopic repair is a feasible and safe option if the surgical team was experienced with this approach.

Asymptomatic contralateral inguinal and ventral hernias among people with a workers' compensation claim for hernia

STUDY AIM

There is a gap in evidence that demonstrates an increased risk of hernia formation in laborers. A notable incidence of a second asymptomatic hernia among people making a workers' compensation claim for a hernia would suggest that the pathology is not acute and probably not related to work, or the performance of a single strenuous event.

PATIENTS AND METHODS

We performed a retrospective database study of a consecutive sample of 106 adults who claimed a work-related abdominal hernia between September 2016 and December 2018 and had a Computed Tomography (CT) scan as part of a diagnostic workup. Hernias were classified as incidental if patients had a contralateral inguinal hernia with unilateral groin symptoms, or if patients had a ventral hernia with only groin symptoms or vice versa.

RESULTS

Thirty-three percent of patients had an incidental hernia. No patient factors were associated with having an incidental hernia. Higher BMI and having a concurrent incidental hernia were associated with lower odds of surgical treatment under the injury claim.

CONCLUSION

Abdominal symptoms after a work event might lead to a diagnosis of hernia, and there is a notable likelihood that the hernia is incidental and unrelated to work. New symptoms at or near the site of an abdominal hernia may or may not be from the hernia, and very often are more consistent with an abdominal muscle strain. The clinical or imaging finding of an abdominal wall defect or the presence of a hernia may be incidental, unrelated to the physical activity.

Waist Circumference is not Superior to Body Mass Index in Predicting Groin Hernia Repair in Either Men or Women

Background and aims

A high body mass index (BMI) is considered a risk factor for ventral abdominal wall hernias but protective for the development of groin hernias. The reason for this is unclear. The surrounding abdominal fat in obesity might “protect” and limit the passage through the inguinal canal. The aim was to compare two different methods used for obesity registration in groin hernia patients and to investigate the hypothesis of high BMI/low groin hernia risk phenomenon.

Methods

This was a population-based observational study comparing BMI to waist circumference (WC) as well as their correlations to the quantity of groin hernia repair performed in either sex. Two national registers were crosslinked to a large regional register including information on WC.

Results

A larger WC and a higher BMI were associated with a lower risk of having groin hernia repair in both sexes. There was no difference using either WC or BMI as a risk factor for groin hernia repair in either sex. There was no advantage to using body composition based on WC rather than BMI for surgery indication.

Conclusions

Overweight patients, both men and women, have a lower risk of undergoing groin hernia repair regardless of fat distribution. BMI is a well-established method for obesity registration and is recommended in the evaluation of hernia patients.

Perioperative outcome in groin hernia repair: what are the most important influencing factors?

INTRODUCTION

Using registry analyses, a large number of influencing factors on the perioperative outcome of groin hernia repair has been identified. The interactions between several influencing factors and differences in the influencing value have to date been inadequately investigated.

METHODS

This retrospective analysis of prospectively collected data from the Herniamed Registry included all fully documented cases with minimum age of 16 years and groin hernia repair. Patients were assigned to the risk groups unilateral, bilateral, recurrent and emergency groin hernia repair. Multivariable analysis was performed to investigate the influence of confirmatory defined patient- and procedure-related characteristics on the outcome parameters intraoperative, postoperative general and postoperative surgical complications, complication-related reoperation and total perioperative complications.

RESULTS

A highly significantly unfavorable association with the total perioperative complication rate was identified for emergency groin hernia repair, scrotal hernia, anticoagulant medication and coagulopathy. A significantly unfavorable relation with the total perioperative complication rate was found for recurrence procedure, bilateral repair, high age, ASA score III/IV, femoral hernia, antithrombotic medication, smoking, COPD and corticosteroid medication. A significantly favorable correlation with the total perioperative complication rate was observed for the laparo-endoscopic techniques, smaller defects, female gender, normal weight and medial hernia.

CONCLUSION

Both the number of potential influencing factors and their influencing value on the perioperative outcome should be considered when estimating the individual risk of a patient with groin hernia repair.

Impact of ultrasound on inguinal hernia repair rates in Australia: a population-based analysis

BACKGROUND

Inguinal hernias are a common pathology that often requires surgical management. The use of groin ultrasound (GU) to investigate inguinal hernias is a growing area of concern as an inefficient use of healthcare resources. Our aim was to assess changes in the rates of GU and the impact on surgical practice.

METHODS

Medicare Item Reports and the Australian Institute of Health and Welfare Database were used to estimate annual GU and inguinal hernia repair (IHR) rates per 100 000 population for the period 2000/2001-2017/2018. Pearson's correlation coefficients and linear regression analyses were performed to assess associations between these variables.

RESULTS

Over the 18-year period, GU rates increased 13-fold from 88 to 1174 per 100 000 population. Overall, total IHR rates decreased from 217 to 192 per 100 000. Overall, unilateral IHR rates have decreased (182-146 per 100 000), bilateral IHRs have increased (35-46 per 100 000), laparoscopic IHR has increased (30-86 per 100 000) and open surgery has declined (187-106 per 100 000). The increase in GU rates were strongly associated with the decrease in unilateral (r = -0.936, P = <0.001) and increase in bilateral IHR rates (r = 0.924, P = <0.001).

CONCLUSION

The use of GU has increased substantially, potentially representing an unnecessary cost to the healthcare system. Rising GU rates are not associated with an increase in IHR, however, may contribute to the increasing rates of bilateral IHRs. This study supports the opinion that more extensive clinical and health policy initiatives are needed in Australia to address this health issue.

Outcomes of obese compared to non-obese veterans undergoing open inguinal hernia repair: a case-control study

BACKGROUND

The optimal approach for inguinal hernia repair in the obese remains elusive. Minimally invasive techniques show equivocal results compared to the open method. None of the current analyses include a non-obese control group because the differences in factors leading to complications vary widely between these two cohorts.

MATERIALS AND METHODS

In the present study, we matched (1:1) obese to non-obese patients undergoing an open inguinal hernia repair. Matching was performed by age, hernia type (bilateral, inguinal, femoral, recurrent, primary, direct, pantaloon, and scrotal component), type of repair (tissue repair vs. mesh), concurrent umbilical hernia repair, current smoking, ASA Class, a history of DM and COPD.

RESULTS

Demographics in the unmatched cohorts demonstrated significantly (p < 0.05) wide differences between obese (n = 319) and non-obese (n = 1137) veterans: age (58.0- vs. 63.4-year-old), indirect hernia (37.7% vs. 45.5%), scrotal component (14.4% vs. 9.9%), current smoking (23.5% vs. 34.4%), DM (20.8% vs. 13.1%), OSA (13.2% vs. 3.6%), COPD (12.2% vs. 18.5%), and BPH (16.9% vs. 23.3). After matching, there were 300 obese and 300 non-obese patients available for analysis. There was no difference in 30-day morbidity between obese and non-obese patients in the unmatched (11.0% vs. 7.9%; p = 0.09) and matched (10.7% vs. 8.1%, p = 0.27) cohorts. Similarly, no differences in inguinodynia and recurrence were observed in either matched or unmatched cohorts.

CONCLUSION

Obese patients pose no further risk in outcomes compared to non-obese veterans undergoing open inguinal hernia repair. The best technique for an inguinal hernia repair in obese patients should rest on the comfort and the experience of the surgeon.

Trends in Australian inguinal hernia repair rates: a 15-year population study

BACKGROUND

An inguinal hernia is one of the most common surgical pathologies, and therefore the repair of an inguinal hernia is one of the most common general surgical procedures. The aim of this study was to assess the trend in inguinal hernia repair (IHR) rates in Australia between 2000/2001 and 2014/2015 using population data from public and private hospitals.

METHODS

ICD-10 data cubes from the Australian Institute of Health and Welfare were analysed to determine the number of inguinal hernia repairs performed, open or laparoscopically, between 2000/2001 and 2014/2015 financial years. These data were combined with the Australian Bureau of Statistics population data estimates for the corresponding years, to give a procedure per 100 000 estimates.

RESULTS

Incidence of IHRs within Australia decreased from 217 to 194 per 100 000 population over the 15-year study period. There was a clear shift towards increased uptake of laparoscopic surgery with a subsequent fall in rates of open IHRs. Males accounted for the majority of IHR procedures. Unilateral repair was more common; however, the incidence of unilateral repair rates decreased while bilateral IHR rates increased over the study period.

CONCLUSION

Laparoscopic techniques are increasingly being used within public and private institutions across the country for inguinal hernia repair. There has also been a decrease in the incidence of IHR procedures performed per year over the 15-year period studied, consistent with published literature from Europe and the USA.

Nutritional status and constipation scoring of inguinal hernia patients: a case-control study

PURPOSE

There are many risk factors for inguinal hernia that have been determined in the literature, but the relationship between nutritional status and inguinal hernia has not yet been examined. In this study, we evaluated the constipation scale and food consumption of patients with inguinal hernia.

METHODS

This prospective case-control study was performed between March 2018 and March 2019. The patients who were admitted for inguinal hernia operation were the case group, and those patients who had been admitted to the same hospital without inguinal hernia were the control group. The age, body mass index, alcohol and smoking habits, daily activity, and the Wexner constipation scoring were examined using a questionnaire and 3-day food consumption records were noted.

RESULTS

A total of 203 volunteers were included in the study. Of these, 88 patients were in the control group, and 115 patients were in the case group. The age and gender distribution of the groups was similar. Cigarette and alcohol usages are statistically high in the case group. The Wexner constipation scale of the groups was statistically high in the case group. In the univariate analysis, smoking, alcohol consumption, total constipation score, red meat consumption, chicken consumption, bread consumption, low fiber consumption, low egg consumption, low carbohydrate, and low energy intake were effective in hernia formation, and in the multivariate analysis, total constipation score, red meat consumption, chicken consumption, excess bread consumption, low energy intake, and low fiber consumption were significant as independent variables.

CONCLUSION

Our study is the first to evaluate whether there is a relationship between inguinal hernia and nutrition, according to the literature. Lifestyle modifications and a healthy diet with the consumption of less meat and more vegetables may have an impact on the reduction of hernia occurrence.

Clinical impact of psoas muscle volume on the development of inguinal hernia after robot-assisted radical prostatectomy

BACKGROUND

Sarcopenia, a syndrome characterized by the loss of skeletal muscle mass, has attracted attention in the field of oncology, as it reflects poor nutritional status. The present study aimed to determine the risk factors for postoperative inguinal hernia (PIH) development after robot-assisted laparoscopic radical prostatectomy (RARP) for prostate cancer, and discuss whether sarcopenia could be used as a sensitive predictor of PIH.

METHODS

We reviewed the medical records of 147 patients who underwent RARP at our institution. The psoas muscle volume (PMV), as an indicator of sarcopenia, was quantified from computed tomography images using a 3-dimensional image analysis system. Multivariate cox regression analyses were performed to identify independent predictors of PIH, including pre- and peri-operative factors.

RESULTS

The mean PMV was 393 cm³, and the correlation coefficient between PMV and body mass index was 0.37 (p < 0.01). The PIH-free rate at 2 years postoperatively was 78.2% among all patients. The multivariate analysis revealed that a PMV < 350 cm³ was a significant risk factor for PIH (p = 0.03; hazard ratio 2.19). Body mass index, age, prostate volume, lymph node dissection, nerve sparing, rectus muscle thickness, and console time were not related to PIH development. The PIH-free rate at 2 years postoperatively was 83.4% and 68.9% in patients with a PMV ≥ 350 cm³ and < 350 cm³, respectively (p < 0.05).

CONCLUSIONS

PIH occurred significantly more frequently in patients with a PMV < 350 cm³ than in patients with a PMV ≥ 350 cm³, and a low PMV was an independent risk factor for PIH. Thus, urologists should pay attention to the cumulative incidence of IH after RARP, especially in patients with a PMV < 350 cm³.

Risk of hernia formation after radical prostatectomy: a comparison between open and robot-assisted laparoscopic radical prostatectomy within the prospectively controlled LAPPRO trial

Purpose

In addition to incisional hernia, inguinal hernia is a recognized complication to radical retropubic prostatectomy. To compare the risk of developing inguinal and incisional hernias after open radical prostatectomy compared to robot-assisted laparoscopic prostatectomy.

Method

Patients planned for prostatectomy were enrolled in the prospective, controlled LAPPRO trial between September 2008 and November 2011 at 14 hospitals in Sweden. Information regarding patient characteristics, operative techniques and occurrence of postoperative inguinal and incisional hernia were retrieved using six clinical record forms and four validated questionnaires.

Results

3447 patients operated with radical prostatectomy were analyzed. Within 24 months, 262 patients developed an inguinal hernia, 189 (7.3%) after robot-assisted laparoscopic prostatectomy and 73 (8.4%) after open radical prostatectomy. The relative risk of having an inguinal hernia after robot-assisted laparoscopic prostatectomy was 18% lower compared to open radical retropubic prostatectomy, a non-significant difference. Risk factors for developing an inguinal hernia after prostatectomy were increased age, low BMI and previous hernia repair. The incidence of incisional hernia was low regardless of surgical technique. Limitations are the non-randomised setting.

Conclusions

We found no difference in incidence of inguinal hernia after open retropubic and robot-assisted laparoscopic radical prostatectomy. The low incidence of incisional hernia after both procedures did not allow for statistical analysis. Risk factors for developing an inguinal hernia after prostatectomy were increased age and BMI.

Electronic supplementary material

The online version of this article (10.1007/s10029-020-02178-7) contains supplementary material, which is available to authorized users.

Consensus on international guidelines for management of groin hernias

BACKGROUND

Groin hernia management has a significant worldwide diversity with multiple surgical techniques and variable outcomes. The International guidelines for groin hernia management serve to help in groin hernia management, but the acceptance among general surgeons remains unknown. The aim of our study was to gauge the degree of agreement with the guidelines among health care professionals worldwide.

METHODS

Forty-six key statements and recommendations of the International guidelines for groin hernia management were selected and presented at plenary consensus conferences at four international congresses in Europe, the America's and Asia. Participants could cast their votes through live voting. Additionally, a web survey was sent out to all society members allowing online voting after each congress. Consensus was defined as > 70% agreement among all participants.

RESULTS

In total 822 surgeons cast their vote on the key statements and recommendations during the four plenary consensus meetings or via the web survey. Consensus was reached on 34 out of 39 (87%) recommendations, and on six out of seven (86%) statements. No consensus was reached on the use of light versus heavy-weight meshes (69%), superior cost-effectiveness of day-case laparo-endoscopic repair (69%), omitting prophylactic antibiotics in hernia repair, general or local versus regional anesthesia in elderly patients (55%) and re-operation in case of immediate postoperative pain (59%).

CONCLUSION

Globally, there is 87% consensus regarding the diagnosis and management of groin hernias. This provides a solid basis for standardizing the care path of patients with groin hernias.

Association of Body Mass Index and Serum Markers of Tissue Damage with Postoperative Pain. The Role of Lactate Dehydrogenase for Postoperative Pain Prediction

Objectives

i) To analyze the association of body mass index (BMI) and some serum tissue damage markers with postoperative pain. ii) To establish a biochemical marker cutoff point able to predict moderate to severe postoperative pain.

Design

Cross-sectional study.

Subjects

Ninety-six adult male patients from Southern Spain (55 ± 13 years old) who underwent an inguinal hernioplasty.

Methods

Postoperative pain (eight hours after surgery) was assessed through a visual analog scale (VAS). Moderate to severe pain was defined as a VAS &gt; 50 mm. BMI was calculated and medication, alcohol consumption, and smoking habit registered. Eight hours after surgery, some serum markers such as fibrinogen, lactate dehydrogenase (LDH), C-reactive protein, cortisol, creatine kinase, glutamic-pyruvic, glutamic oxaloacetic, and gamma-glutamyltransferase transaminases were determined by standard procedures.

Results

After adjusting for potential confounders, BMI was not associated with postoperative pain (P &gt; 0.05). Serum fibrinogen was associated with greater postoperative pain (β = 0.333, P &lt; 0.05). Serum LDH concentration was strongly associated with greater postoperative pain (β = 0.606, P &lt; 0.001). Alcohol consumption was associated with higher postoperative pain (β = 0.212, P &lt; 0.05). No associations were observed regarding age, tobacco consumption, and the rest of serum markers studied. Serum LDH concentration was able to discriminate between presence/absence of moderate to severe postoperative pain (receiver operating characteristic area under the curve = 0.655, P ≤ 0.01). An LDH concentration &gt;204 IU/L was associated with a three-times increased odds ratio of moderate to severe postoperative pain.

Conclusions

Contrary to expectations, greater BMI was not associated with higher postoperative pain. Notwithstanding, the assessment of serum LDH might provide useful information to predict moderate to severe postoperative pain.

Study of mesh infection management following inguinal hernioplasty with an analysis of risk factors: a 10-year experience

PURPOSE

We present a review of our 10-year experience in managing patients with mesh infection following hernioplasty and analyze the occurrence of known predisposing factors.

METHODS

We analyzed 392 cases of mesh infection treated at our center between 2007 and 2018 after a preoperative work-up. (Thirty-one patients underwent the primary hernia repair procedure at our hospital, whereas the others underwent the primary surgery at other local centers and were referred to our center.) The method of infected mesh removal (open or laparoscopic) was selected depending on the primary surgical approach. Open repair involved the excision of the mesh, infected tissue, and sinus (if present). The laparoscopic approach was used to identify the abscess, excise the mesh, and allow drainage into the preperitoneal space.

RESULTS

The operative course in all patients was uneventful. A second surgery to extract the residual mesh around the pubic bone was performed in 7 patients. Hernia recurred in 29 patients after mesh removal. The discharge culture results were positive in 193 patients. Of these, Staphylococcus spp. was identified as the causative organism in 126 patients. Risk factors for mesh infection, including obesity, smoking, and diabetes, were identified in 182 (46.5%), 154 (39.3%), and 35 (8.9%) patients, respectively.

CONCLUSIONS

It is recommended the approach of mesh removal is tailored as per the primary hernioplasty method. We analyzed the occurrence of risk factors for mesh infection in this study, but further studies are needed to develop a predictive model that is both internally and externally validated to evaluate the probability of mesh infection.

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.

Groin Hernias in Women-A Review of the Literature

Background: To date, there are few studies and no systematic reviews focusing specifically on groin hernia in women. Most of the existing knowledge comes from registry data. Objective: This present review now reports on such findings as are available on groin hernia in women. Materials and Methods: A systematic search of the available literature was performed in September 2018 using Medline, PubMed, Google Scholar, and the Cochrane Library. For the present analysis 80 publications were identified. Results: The lifetime risk of developing a groin hernia in women is 3-5.8%. The proportion of women in the overall collective of operated groin hernias is 8.0-11.5%. In women, the proportion of femoral hernias is 16.7-37%. Risk factors for development of a groin hernia in women of high age and with a positive family history. A groin hernia during pregnancy should not be operated on. The rate of emergency procedures in women, at 14.5-17.0%, is 3 to 4-fold higher than in men and at 40.6% is even higher for femoral hernia. Therefore, watchful waiting is not indicated in women. During surgical repair of groin hernia in females the presence of a femoral hernia should always be excluded and if detected should be repaired using a laparo-endoscopic or open preperitoneal mesh technique. A higher rate of chronic postoperative inguinal pain must be expected in females. Conclusion: Special characteristics must be taken into account for repair of groin hernia in women.

Mesh versus non-mesh for inguinal and femoral hernia repair

BACKGROUND

This is an update of a Cochrane Review first published in 2001.Hernias are protrusions of all or part of an organ through the body wall that normally contains it. Groin hernias include inguinal (96%) and femoral (4%) hernias, and are often symptomatic with discomfort. They are extremely common, with an estimated lifetime risk in men of 27%. Occasionally they may present as emergencies with complications such as bowel incarceration, obstruction and strangulation. The definitive treatment of all hernias is surgical repair, inguinal hernia repair being one of the most common surgical procedures performed. Mesh (hernioplasty) and the traditional non-mesh repairs (herniorrhaphy) are commonly used, with an increasing preference towards mesh repairs in high-income countries.

OBJECTIVES

To evaluate the benefits and harms of different inguinal and femoral hernia repair techniques in adults, specifically comparing closure with mesh versus without mesh. Outcomes include hernia recurrence, complications (including neurovascular or visceral injury, haematoma, seroma, testicular injury, infection, postoperative pain), mortality, duration of operation, postoperative hospital stay and time to return to activities of daily living.

SEARCH METHODS

We searched the following databases on 9 May 2018: Cochrane Colorectal Cancer Group Specialized Register, Cochrane Central Register of Controlled Trials (Issue 1), Ovid MEDLINE (from 1950), Ovid Embase (from 1974) and Web of Science (from 1900). Furthermore, we checked the WHO International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov for trials. We applied no language or publication restrictions. We also searched the reference lists of included trials and review articles.

SELECTION CRITERIA

We included randomised controlled trials of mesh compared to non-mesh inguinal or femoral hernia repairs in adults over the age of 18 years.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Where available, we collected information on adverse effects. We presented dichotomous data as risk ratios, and where possible we calculated the number needed to treat for an additional beneficial outcome (NNTB). We presented continuous data as mean difference. Analysis of missing data was based on intention-to-treat principles, and we assessed heterogeneity using an evaluation of clinical and methodological diversity, Chi² test and I² statistic. We used GRADE to assess the quality of evidence for each outcome.

MAIN RESULTS

We included 25 studies (6293 participants) in this review. All included studies specified inguinal hernias, and two studies reported that femoral hernias were included.Mesh repair probably reduces the risk of hernia recurrence compared to non-mesh repair (21 studies, 5575 participants; RR 0.46, 95% CI 0.26 to 0.80, I² = 44%, moderate-quality evidence). In absolute numbers, one hernia recurrence was prevented for every 46 mesh repairs compared with non-mesh repairs. Twenty-four studies (6293 participants) assessed a wide range of complications with varying follow-up times. Neurovascular and visceral injuries were more common in non-mesh repair groups (RR 0.61, 95% CI 0.49 to 0.76, I² = 0%, NNTB = 22, high-quality evidence). Wound infection was found slightly more commonly in the mesh group (20 studies, 4540 participants; RR 1.29, 95% CI 0.89 to 1.86, I² = 0%, NNTB = 200, low-quality evidence). Mesh repair reduced the risk of haematoma compared to non-mesh repair (15 studies, 3773 participants; RR 0.88, 95% CI 0.68 to 1.13, I² = 0%, NNTB = 143, low-quality evidence). Seromas probably occur more frequently with mesh repair than with non-mesh repair (14 studies, 2640 participants; RR 1.63, 95% CI 1.03 to 2.59, I² = 0%, NNTB = 72, moderate-quality evidence), as does wound swelling (two studies, 388 participants; RR 4.56, 95% CI 1.02 to 20.48, I² = 33%, NNTB = 72, moderate-quality evidence). The comparative effect on wound dehiscence is uncertain due to wide confidence intervals (two studies, 329 participants; RR 0.55, 95% CI 0.12 to 2.48, I² = 37% NNTB = 77, low-quality evidence). Testicular complications showed nearly equivocal results; they probably occurred slightly more often in the mesh group however the confidence interval around the effect was wide (14 studies, 3741 participants; RR 1.06, 95% CI 0.63 to 1.76, I² = 0%, NNTB = 2000, low-quality evidence). Mesh reduced the risk of postoperative urinary retention compared to non-mesh (eight studies, 1539 participants; RR 0.53, 95% CI 0.38 to 0.73, I² = 56%, NNTB = 16, moderate-quality evidence).Postoperative and chronic pain could not be compared due to variations in measurement methods and follow-up time (low-quality evidence).No deaths occurred during the follow-up periods reported in the seven studies (2546 participants) reporting this outcome (high-quality evidence).The average operating time was longer for non-mesh repairs by a mean of 4 minutes 22 seconds, despite wide variation across the studies regarding size and direction of effect, thus this result is uncertain (20 studies, 4148 participants; 95% CI -6.85 to -1.60, I²= 97%, very low-quality evidence). Hospital stay may be shorter with mesh repair, by 0.6 days (12 studies, 2966 participants; 95% CI -0.86 to -0.34, I² = 98%, low-quality evidence), and participants undergoing mesh repairs may return to normal activities of daily living a mean of 2.87 days sooner than those with non-mesh repair (10 studies, 3183 participants; 95% CI -4.42 to -1.32, I² = 96%, low-quality evidence), although the results of both these outcomes are also limited by wide variation in the size and direction of effect across the studies.

AUTHORS' CONCLUSIONS

Mesh and non-mesh repairs are effective surgical approaches in treating hernias, each demonstrating benefits in different areas. Compared to non-mesh repairs, mesh repairs probably reduce the rate of hernia recurrence, and reduce visceral or neurovascular injuries, making mesh repair a common repair approach. Mesh repairs may result in a reduced length of hospital stay and time to return to activities of daily living, but these results are uncertain due to variation in the results of the studies. Non-mesh repair is less likely to cause seroma formation and has been favoured in low-income countries due to low cost and reduced availability of mesh materials. Risk of bias in the included studies was low to moderate and generally handled well by study authors, with attention to details of allocation, blinding, attrition and reporting.

IMPACT OF OBESITY AND SURGICAL SKILLS IN LAPAROSCOPIC TOTALLY EXTRAPERITONEAL HERNIOPLASTY

Background:

Laparoscopic totally extraperitoneal (TEP) hernia repair is a technically demanding procedure. Recent studies have identified BMI as an independent factor for technical difficulty in the learning period.

Aim:

To analyze the effect of overweight and obesity on the technical difficulties of TEP.

Method:

Prospective study on patients who underwent a symptomatic inguinal hernia by means of the TEP technique. Were analyzed gender, BMI, previous surgery, hernia type, operative time and complications. Technical difficulty was defined by operative time, major complications and recurrence. Patients were classified into four groups: 1) underweight, if less than 18,5 kg/m²; 2) normal range if BMI between 18,5 and 24,9 kg/m²; 3) overweight if BMI between 25-29,9 kg/m²; and 4) obese if BMI≥30 kg/m².

Results:

The cohort had a total of 190 patients, 185 men and 5 women. BMI values ranged from 16-36 kg/m² (average 26 kg/m²). Average operating time was 55.4 min in bilateral hernia (15-150) and 37.8 min in unilateral (13-150). Time of surgery was statistically correlated with increased BMI in the first 93 patients (p=0.049).

Conclusion:

High BMI and prolonged operative time are undoubtedly correlated. However, this relationship may be statistically significant only in the learning period. Although several clinical features can influence surgical time, upon reaching an experienced level, surgeons appear to easily handle the challenges.

Proportion of femoral hernia repairs performed for recurrence in the United States

PURPOSE

Recurrence rates after femoral hernia repair (FHR) have not been reliably established in the USA. We sought to determine this trend over time.

METHODS

The proportion of primary and recurrent FHRs was determined for patients age ≥ 18 from: ACS-NSQIP (1/2005-12/2014), Premier (1/2010-09/2015), and institutional (1/2005-12/2014) data. Trends were analyzed using a one-tailed Cochran-Armitage test.

RESULTS

In the NSQIP database, 6649 patients underwent a FHR. In females, the proportion of FHRs performed for recurrence decreased from 14.0% in 2005 to 6.2% in 2014, p = 0.02. In males, there was no change: 16.7-16.1% 2005-2014 (p = 0.18). The Premier database included 4495 FHRs and our institution 315 FHRs. There was no difference for either gender over time in either data source, all p > 0.05.

CONCLUSIONS

The proportion of femoral hernia repairs performed for recurrence in the USA remained relatively constant in males in two large national databases between 2005 and 2015. In females, a decrease was seen in one of the large national databases.

International guidelines for groin hernia management

INTRODUCTION

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

METHODS

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

Early outcomes of robotic-assisted inguinal hernia repair in obese patients: a multi-institutional, retrospective study

BACKGROUND

Minimally invasive inguinal hernia repair (IHR) in general and particularly in obese patients has not been widely adopted, potentially due to the perceived technical challenges and the well-documented learning curve associated with laparoscopic repair. Outcomes in robotic-assisted IHR in obese (BMI ≥ 30 kg/m²) patients have not been described and warrant study.

METHODS

Seven surgeons conducted a multicenter retrospective chart review of their early robotic-assisted IHR (RHR) cases and compared them with their open IHR (OHR) cases. Demographics, operative characteristics, and perioperative morbidity were compared for unadjusted and propensity-matched populations.

RESULTS

651 robotic-assisted cases and 593 open cases were collected. The outcomes of 148 RHRs to 113 OHRs in obese patients were compared. For obese populations-whether unadjusted (robotic-assisted, n = 148; open, n = 113) or matched (1:1) (robotic-assisted, n = 95; open, n = 93)-the robotic-assisted and open cohorts were comparable in terms of demographics and baseline characteristics. Significantly higher percentages of OHR patients experienced postoperative complications post-discharge (unadjusted: 11.5% vs. 2.7%, p = 0.005; and matched: 10.8% vs. 3.2%, p = 0.047). More concomitant procedures and bilateral repairs were conducted in obese RHR patients than in obese OHR patients (unadjusted 29.7% vs. 16.8%, p = 0.019; and unadjusted 35.1% vs. 11.5%, p < 0.0001-respectively). Prior laparoscopic IHR experience did not affect 30-day outcomes.

CONCLUSIONS

Obese patients who undergo RHR have a lower rate of postoperative complications compared to obese patients who undergo OHR. Previous laparoscopic IHR experience, more bilateral repairs, and more concomitant procedures were not associated with increased complications in RHR patients. These outcomes may facilitate increased adoption of minimally invasive IHR approaches in the obese population.

Data and outcome of inguinal hernia repair in hernia registers - a review of the literature

Register-based observational studies in inguinal hernia repair deliver real-world data from very large patient populations and give answers to important clinical questions never evaluated in randomized controlled trials. Data from hernia registers can provide evidence of effectiveness of therapies in the general population. Hernia registers with high case load have existed in Sweden since 1992, in Denmark since 1998, and in Germany/Austria/Switzerland since 2009. In this review, the most important findings of register-based observational studies in inguinal hernia repair are presented. After an intensive literature search, 85 articles are relevant for this review. Numerous findings from these register-based studies have been incorporated into the various guidelines on inguinal hernia repair. These highlight the particular importance of hernia registers in answering key scientific and clinical questions in hernia surgery. The myriad of surgical techniques described – spanning more than 100 and with ongoing new additions – as well as the large number of associated medical devices call for, more than in other surgical disciplines, meticulous documentation of the methods used for the treatment of inguinal hernias.

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.