Frequency of abdominal wall hernias: is classical teaching out of date?

Spontaneous bowel evisceration through umbilical hernia in an adult non-cirrhotic patient

Few cases of spontaneous bowel evisceration (SBE) through umbilical hernias (UHs) in adult patients have been reported in the literature. Interestingly, the spontaneous rupture of the hernia sac is a rare complication usually seen in adult cirrhotic patients with persistent ascites or in patients with congenital wall defects. A man in his early 50s was admitted to our emergency department with SBE through a long-standing acquired UH. He was not clinically cirrhotic, although being HCV positive. Surgeons performed an urgent laparotomy with ileal resection, latero-lateral ileal anastomosis and direct hernioplasty without mesh. Given the rarity of this presentation, we reported it and reviewed the available literature on this subject. Elective hernioplasty is currently suggested to lower the risk of complications. Mesh placement should be preferred, but only if comorbidities and infectious risks do not contraindicate its use. In emergency situations, a direct hernia repair is preferred.

The significance of initial lactate levels in emergency department presentations of abdominal wall hernia

INTRODUCTION

Abdominal wall hernias are a frequent cause of abdominal pain-related emergency department visits. Our study aimed to establish the connection between lactate levels and patient outcomes in those with abdominal pain due to abdominal wall hernias.

MATERIALS AND METHODS

Our research followed a retrospective, observational, and descriptive approach and two center. We included patients who visited the emergency department for abdominal pain and were confirmed to have abdominal wall hernias through ultrasound.

RESULTS

We enrolled 493 patients meeting the criteria. Median age was 65 years, with 54% (n = 266) being male. Regarding outcomes, 40.5% (n = 200) were hospitalized, 27.7% (n = 137) underwent surgery, and 7.9% (n = 39) underwent bowel resection. Mortality rate during hernia-related hospital admission was 0.6% (n = 3). For hospitalized patients, there were significant differences in white blood cell count, neutrophil count and percentage, platelet count, lymphocyte count, and percentage (p < 0.05). Patients undergoing resection showed significant differences in neutrophil count, neutrophil percentage, lymphocyte count, and lymphocyte percentage (p < 0.05). Lactate levels were statistically significant in all patient groups requiring hospitalization, surgery, and resection (p < 0.05). Sensitivity and specificity of lactate test results indicated in patients undergoing bowel resection, lactate values ≥1.96 mmol/L had a specificity of 64%, sensitivity of 71%, and a negative predictive value of 96% (p < 0.05).

CONCLUSION

Low lactate levels in patients presenting to the emergency department with abdominal pain caused by abdominal wall hernias have a high negative predictive value for excluding strangulation and the need for bowel resection. Therefore, we recommend the use of lactate as an additional diagnostic tool in emergency department presentations related to abdominal wall hernias.

Eye morphometry, body size, and flexibility parameters in myopic adolescents

The aim of this study was to investigate the anatomical and physiological ocular parameters in adolescents with myopia and to examine the relations between refractive error (SER), ocular biometry, body size and flexibility parameters in myopic adolescents. A cross-sectional study of 184 myopic adolescents, aged 15 to 19 years was conducted. Refractive error and corneal curvature measures of the eye were evaluated using an autorefractometer under cycloplegia. Central corneal thickness was determined by contact pachymetry. The ocular axial length, anterior and vitreous chamber depth, and lens thickness were measured using A-scan biometry ultrasonography. Height and body weight were measured according to a standardized protocol. Body mass index (BMI) was subsequently calculated. Beighton scale was used to measure joint flexibility. Body stature was positively correlated with ocular axial length (r = 0.39, p < 0.001) and vitreous chamber depth (r = 0.37, p < 0.001). There was a negative correlation between height and SER (r = - 0.46; p < 0.001). Beighton score and body weight had weak positive correlations with axial length and vitreous chamber depth, and a weak negative correlation with SER. A significantly more negative SER was observed in the increased joint mobility group (p < 0.05; U = 5065.5) as compared to normal joint mobility group: mean - 4.37 ± 1.85 D (median - 4.25; IQR - 6.25 to - 3.25 D) and mean - 3.72 ± 1.66 D (median - 3.50; IQR - 4.75 to - 2.25 D) respectively. There was a strong association between height and axial length, as well as SER. Higher degree of myopia significantly correlated with greater Beighton score (increased joint mobility).

T-line Hernia Mesh Repairs of Large Umbilical Hernias: Technique and Short-term Outcomes

Background

The T-line hernia mesh is a synthetic, polypropylene mesh specifically designed to prevent anchor point failure by evenly distributing tension through mesh suture extensions. This case series illustrates the first clinical application of the T-line mesh for umbilical hernia repair (UHR).

Methods

This study is a retrospective, consecutive cases series of all adult patients presenting to a single surgeon with symptomatic umbilical hernia requiring surgical repair using the T-line hernia mesh. Patient demographics, surgical details, and 30-day postoperative complications were collected. Descriptive statistics were computed in Microsoft Excel (Redmond, Va.).

Results

Three patients presented for UHR. All three patients were obese with mean body mass index of 37.5 ± 6.6. Two patients were former smokers, and two had presented after hernia recurrence. The average defect size was 80.1 cm2 ± 94.0 cm2. Two patients had UHR with onlay mesh placement, whereas one had a transversus abdominus release followed by retrorectus mesh placement. The average mesh size was 192.3 cm2 ± 82.5 cm2. All three cases were classified as clean. There were no intraoperative complications. No patients experienced 30-day postoperative complications or recurrence.

Conclusions

We present a case series of three patients presenting with large, symptomatic umbilical hernias who underwent UHR with T-line hernia mesh reinforcement without short term complications or hernia recurrence at last follow-up.

Incidence, types, and associated factors of external abdominal hernias among adult patients visiting the surgical outpatient department, eastern Ethiopia: a multicentre cross-sectional study

Background

Abdominal hernia is the most common surgical alignment that affects all age groups and sexes. It is characterized by the protrusion of abdominal contents through the abdominal wall's muscles and fascia. In this study, the incidence, types, and associated factors of external abdominal hernias at Hiwotfana Comprehensive Specialized Hospital and Jugal Regional Hospital, eastern Ethiopia, were ascertained.

Objective

To identify the incidence, types, and associated factors of external abdominal hernia among adult patients who visited the surgical outpatient department of Hiwotfana comprehensive specialized hospital and Jugal regional hospital from 20 October to 5 December 2022.

Methods

A cross-sectional study was conducted from 20 October to 5 December 2022, on adult patients who visited the surgical outpatient department at the Hiwotfana Comprehensive Specialized Hospital and Jugal Regional Hospital in eastern Ethiopia. All adult patients who visited the surgical outpatient department of each hospital were enroled in the study using a stratified random sampling technique. Both descriptive and inferential statistics were conducted, and the results were presented in text, graphs, and tables. Odd ratios for the strength and directions of association were used with a 95% CI, and a P value of less than 0.05 was considered to declare statistical significance.

Result

A total of 403 participants were included in this study from two different governmental hospitals in Harar town, with a 100% response rate. The incidence of the external abdominal wall hernia was 41 (10.2%). The epigastric hernia had the highest prevalence (41.5%, n=17). Constipation [adjusted odds ratio (AOR)=2.91, CI=1.119-7.579), prolonged cough (AOR=3.993, CI=1.358-11.741), history of abdominal surgery (AOR=5.764, CI=1.837-18.083) and heavy lifting (AOR=5.476, CI=2.505-11.969) had statistically significant association (P≤0.05).

Conclusion

The incidence of external abdominal wall hernia in our area is similar to the other existing literature reported from different areas. Epigastric hernia is the most prevalent type of external abdominal hernia and is commonly encountered in female patients. Constipation, a prolonged cough, previous abdominal surgery, and heavy lifting are significantly associated with an external abdominal wall hernia.

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

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

A Complicated Case of Strangulated Inguinal Hernia of the Sigmoid Colon With Secondary Ischemic-Compromise of Scrotal Tissue: A Multi-Disciplinary Surgical Approach

Inguinal hernia is amongst the most common acute abdominal disease that presents in the Emergency Department (ED). Pathologically, it involves the displacement and herniation of abdominal, pelvic, or groin tissue through weaknesses in the abdominal wall. Many inguinal hernias are simple and asymptomatic, managed conservatively without the need for surgical intervention. However, under rare circumstances, hernias are susceptible to significant complications requiring emergent surgery. This report follows the case of a 61-year-old Hispanic-American male presenting to the ED with signs of a complex strangulated inguinal hernia and consequent infarction of the testis with Fournier's Gangrene. Clinical evaluation elucidated a one-week worsening abdominal pain, non-reducible painful inguinal hernia, nausea, vomiting, constipation, groin discoloration, dysuria, and a history of failed primary hernia repair during childhood. The patient underwent emergent surgery to excise ischemic-necrotic portions of the sigmoid colon, creation of end-colostomy, non-mesh repair of inguinal hernia, and right-sided complete orchiectomy with the removal of adjacent scrotal-Dartos tissues and spermatic cord due to Fournier's Gangrene. This report provides both a report for a potentially preventable consequence in one of the most common surgical presentations and a review of the multi-disciplinary expertise that is required in the surgical management of complex inguinal hernias.

Awareness of Hernias and Their Risk Factors Among Adults in the Western Region of Saudi Arabia

Objective To assess the awareness of hernia and its risk factors among adults in the western region of Saudi Arabia. Our hypothesis was that the studied population was in need of education regarding this matter.  Methods This cross-sectional study was conducted in the western region of Saudi Arabia from November to December 2022, using a Google form. The generated questionnaire consisting of two parts was distributed electronically through social media platforms. The targeted population included adults from the western region of Saudi Arabia. The data were obtained using Microsoft Excel and analyzed using Statistical Package for Social Sciences (SPSS) v. 26 software (IBM Corp., Armonk, NY). Results A total of 1570 adults from the western region of Saudi Arabia were included in our study. We found that 13% of the participants had good overall knowledge about hernia, 31% had poor knowledge, and 56% had moderate knowledge. Alarmingly, 55% of the participants had a poor attitude, and 27% were evaluated as having poor practice. In addition, we found a significant association between people's level of knowledge and multiple factors, including age (p-value < 0.001), marital status (p-value< 0.001), and occupation (p-value< 0.001).  Conclusion Based on our research, more than half of our population had a moderate level of knowledge regarding hernias including their risk factors and complications, with alarming levels of poor attitudes toward the disease. Healthcare workers were our participants' leading source of medical information, which directs us towards fully equipping them with the knowledge to educate the public effectively.

Twelve-year outcomes of watchful waiting versus surgery of mildly symptomatic or asymptomatic inguinal hernia in men aged 50 years and older: a randomised controlled trial

Background

Inguinal hernia belongs to the most common surgical pathology worldwide. Approximately, one third is asymptomatic. The value of watchful waiting (WW) in patients with asymptomatic or mildly symptomatic inguinal hernia has been established in a few randomised controlled trials (RCTs). The aim of this study was to assess long-term outcomes of a RCT comparing WW and elective surgery.

Methods

In the original study, men aged ≥50 years with an asymptomatic or mildly symptomatic inguinal hernia were randomly assigned to WW or elective repair. In the present study, the primary outcome was the 12-year crossover rate to surgery, secondary outcomes were time-to-crossover, patient regret, pain, quality of life and incarceration. Dutch Trial Registry: NTR629.

Findings

Out of 496 originally analysed patients, 488 (98.4%) were evaluable for chart review (WW: n = 258, surgery: n = 230), and 200 (41.0%) for telephone contact (WW: n = 106, surgery: n = 94) between November 2021 and March 2022 with a median 12 years follow-up (IQR 9-14). After 12 years, the estimated cumulative crossover rate to surgery was 64.2%, which was higher in mildly symptomatic than in asymptomatic patients (71.7% versus 60.4%, HR 1.451, 95% CI: 1.064-1.979). Time-to-crossover was longer in asymptomatic patients (50% after 6.0 years versus 2.0 years, p = 0.019). Patient regret was higher in the WW group (37.7 versus 18.0%, p = 0.002), as well as pain/discomfort (p = 0.031). Quality of life did not differ (p = 0.737). In the WW group, incarceration occurred in 10/255 patients (3.9%).

Interpretation

During 12-year follow-up, most WW patients crossed over to surgery, significantly earlier with mildly symptomatic hernia. Considering the relatively low incarceration rate, WW might still be an option in asymptomatic patients with a clear preference and being well-informed about pros and cons.

Funding

The initial trial was funded by the Netherlands Organisation for Health Research and Development (ZonMW). This long-term study did not receive funding.

An obstetrician-gynecologist's review of hernias: risk factors, diagnosis, prevention, and repair

Management of obstetrical and gynecologic patients with hernias poses challenges to providers. Risks for hernia development include well-described factors that impair surgical wound healing and increase abdominal pressure. Among the diverse populations cared for by obstetricians and gynecologists, pregnant patients and those with gynecologic malignancies are at the highest risk for hernia formation. This article provides an overview of the existing literature, with a focus on patients cared for by obstetrician-gynecologists and commonly encountered preoperative and intraoperative scenarios. We highlight scenarios when a hernia repair is not commonly performed, including those of patients undergoing nonelective surgeries with known or suspected gynecologic cancers. Finally, we offer multidisciplinary recommendations on the timing of elective hernia repair with obstetrical and gynecologic procedures, with attention to the primary surgical procedure, the type of preexisting hernia, and patient characteristics.

Non-destructive processing of silver containing glass ceramic antibacterial coating on polymeric surgical mesh surfaces

Surgical meshes composed of bioinert polymers such as polypropylene are widely used in millions of hernia repair procedures to prevent the recurrence of organ protrusion from the damaged abdominal wall. However, post-operative mesh infection remains a significant complication, elevating hernia recurrence risks from 3.6% to 10%, depending on the procedure type. While attempts have been made to mitigate these infection-related complications by using antibiotic coatings, the rise in antibiotic-resistant bacterial strains threatens their effectiveness. Bioactive glass-ceramics featuring noble metals, notably silver nanoparticles (AgNPs), have recently gained traction for their wide antibacterial properties and biocompatibility. Yet, conventional methods of synthesizing and coating of such materials often require high temperatures, thus making them impractical to be implemented on temperature-sensitive polymeric substrates. To circumvent this challenge, a unique approach has been explored to deposit these functional compounds onto temperature-sensitive polypropylene mesh (PP-M) surfaces. This approach is based on the recent advancements in cold atmospheric plasma (CAP) assisted deposition of SiO2 thin films and laser surface treatment (LST), enabling the selective heating and formation of functional glass-ceramic compounds under atmospheric conditions. A systematic study was conducted to identify optimal LST conditions that resulted in the effective formation of a bioactive glass-ceramic structure without significantly altering the chemical and mechanical properties of the underlying PP-M (less than 1% change compared to the original properties). The developed coating with optimized processing conditions demonstrated high biocompatibility and persistent antibacterial properties (>7 days) against both Gram-positive and Gram-negative bacteria. The developed process is expected to provide a new stepping stone towards depositing a wide range of functional bioceramic coatings onto different implant surfaces, thereby decreasing their risk of infection and associated complications.

A Paper-Based Simulation Model for Teaching Inguinal Hernia Anatomy

BACKGROUND

Inguinal hernias remain a challenging area of learning for medical students due to its relatively complex anatomy. Modern curriculum delivery methods are conventionally limited to didactic lectures and demonstration of anatomy intraoperatively. These strategies have limitations; lectures are inherently descriptive and based on 2-dimensional models, while intraoperative teaching is often unstructured and opportunistic.

METHODS

A paper-based model was developed comprising three overlapping paper panels simulating the anatomical layers of the inguinal canal which can be modified readily to further simulate various hernia pathologies and their surgical repair. These models were incorporated into a timetabled structured learning session for 3^rd- and 4^th-year medical students. Learners responded to fully anonymised surveys before and after the learning session.

FINDINGS

A total of 45 students participated in these sessions over a period of 6 months. Pre-learning session mean ratings for the learners' confidence in their understanding of the layers of the inguinal canal, identifying indirect and direct inguinal hernias and in naming the contents of the inguinal canal were 2.5, 3.3 and 2.9, while post-learning session mean ratings were 8.0, 9.4 and 8.2, respectively. Paired samples Student's t-tests for all three questions were statistically significant (p < 0.001). The mean rating for usefulness of the session was 9.6/10. Free comments from students emphasised the models' usefulness as a visual learning aid.

DISCUSSION AND CONCLUSION

Our novel, low-cost paper model was associated with an improvement in learners' perceived knowledge and understanding of inguinal canal anatomy and pathology.

Study of Demographics, Clinical Profile and Risk Factors of Inguinal Hernia: A Public Health Problem in Elderly Males

BACKGROUND

Inguinal hernia repair is the most commonly performed elective surgery in India draining significant healthcare resources. This observational study was conducted at a tertiary-level institute in northern India to look into the demographics, clinical profile and risk factors of inguinal hernia.

METHOD

 This study was conducted as an observational study at the tertiary care centre of northern India, including 110 patients who had come to the surgical outpatient department for inguinal hernia repair. After obtaining informed consent from all the participants, demographic details, history and clinical examination were recorded. This was a prospective, single-centre, non-randomized, observational study.

RESULTS AND DISCUSSION

 In our study, 43 patients (39%) were >50 years of age. One hundred and seven patients (97.27%) were males, and three (2.72%) were females. Male: Female ratio was 32:1. The preponderance of males was due to their involvement in more strenuous exercises and lifting weights and the anatomical differences between them. The main risk factor in the present study was lifting heavy weights 55%, followed by altered bowel habits 36.36% and respiratory disease (chronic obstructive airway disease). Smoking and diabetes were also associated as risk factors for the hernia. In this study, the most common side of hernia was on the right side, 63%, on the left, 33% and bilateral in 4% of patients. The indirect hernia was the most common type.

CONCLUSION

Inguinal hernia is a surgical problem found commonly in the male elderly. Right-sided inguinal hernia is common, with the indirect type being more frequent. Heavy weight lifting and strenuous exercises were commonly found risk factors.

Evaluation of inguinal hernia repair using post-operative pain and quality of life metrics

BACKGROUND AND PURPOSE

Elective inguinal hernia repair is a ubiquitous procedure that carries risks; chronic pain and impacts on quality of life (QoL) must be considered when advising patients around repair. The length of time from surgery date and impacts on quality of life are often limited to only a few years of follow-up and despite hernia repair being quite common, long-term outcomes are not often reported.

METHODS

A cohort of patients who had received Lichtenstein inguinal hernia repair over the previous 10 years were contacted and surveyed using the Brief Pain Inventory Short Form (BPI) to assess chronic pain and its effects on their QoL. Patient and operative factors were correlated with pain through linear regression and t-test analysis provided statistical significance for mean comparisons (P < 0.05).

RESULTS

The rate of chronic pain was 17.2% with recurrence of 3.1% at an average post-operative interval of 5.84 years. Of the various metrics compared between groups, age was one of the only significant predictors of chronic pain with younger patients reporting higher pain. Further time from surgery also translated to significantly less pain with a difference of 1.3 years. BPI respondents identified pain that interfered to varying degrees in different aspects of life but had relatively low average magnitudes (range: 1.82/10-2.91/10).

CONCLUSIONS

These long-term considerations of post-surgical impact should be considered alongside potential benefits when advising patients about surgery and may help moderate post-operative expectations to optimize the outcome of common inguinal hernia repairs.

Alarmins and Related Molecules in Elective Surgery

Surgery is associated with alterations of alarmins' and related molecules' levels. The aim of this study was to investigate which biomarkers are most involved in surgery. The studied group consisted of 58 patients with inguinal or umbilical hernia or cholecystolithiasis and 21 healthy controls for compa-rison. We also added seven acute patients with appendicitis, cholecystitis and incarcerated hernia. Serum concentrations of soluble receptor of advanced glycation end-products (sRAGE), extracellular newly identified receptor for advanced glycation end-products binding protein (EN-RAGE), calprotectin, high mobility group box 1 (HMGB1) and interleukin 6 (IL-6) were analysed by ELISA before and after surgery. Preoperative concentrations of calprotectin were significantly decreased while concentrations of sRAGE were significantly increased in patients compared to controls; the concentrations of EN-RAGE and HMGB1 did not differ significantly. IL-6 levels were undetectable in elective patients preoperatively and in controls. Postoperatively, there was a significant increase of EN-RAGE, calprotectin, HMGB1, and IL-6 and a significant decrease of sRAGE compared to preoperative levels. In acute patients, all tested molecules except for sRAGE were significantly increased preoperatively, and sRAGE was significantly decreased. In contrast, after surgery, we could observe a further increase in IL-6; the other biomarkers did not differ significantly. We can conclude that the concentrations of all tested biomarkers are significantly influenced by elective surgery. The postoperative levels of all tested molecules increase except for sRAGE, whose level is significantly decreased after surgery. In acute states, these molecules are already increased, and the influence of surgery is, apart from IL-6, insignificant.

Laparoscopic versus robotic inguinal hernia repair: a single-center case-matched study

INTRODUCTION

Robotic inguinal hernia repair (RIHR) is becoming increasingly common and is the minimally invasive alternative to laparoscopic inguinal hernia repair (LIHR). Thus far, there is little data directly comparing LIHR and RIHR. The purpose of this study will be to compare outcomes for LIHR and RIHR at a single center.

METHODS

A prospective institutional hernia database was queried for patients who underwent transabdominal LIHR or RIHR from 2012 to 2020. The patients were then matched based on the surgeon performing the operation (single, expert hernia surgeon) and laterality of repair. Standard descriptive statistics were used.

RESULTS

There were 282 patients who met criteria for the study, 141 LIHR and 141 RIHR; 32.6% of patients in each group had a bilateral repair (p = 1.00). LIHR patients were slightly younger (54.4 ± 15.6 vs 58.6 ± 13.8; p = 0.03) but similar in terms of BMI (27.1 ± 5.1 vs 29.1 ± 2.1; p = 0.70) and number of comorbidities (2.9 ± 2.5 vs 2.6 ± 2.2; p = 0.59). Operative time was found to be longer in the RIHR group, but when evaluating RIHR at the beginning of the study versus the end of the study, there was a 50-min decrease in operative time (p < 0.01). Recurrence rates were low for both groups (0.7% vs 1.4%; p = 0.38) with mean follow-up time 13.0 ± 13.3 months. There was only one wound infection, which was in the robotic group. No patients required return to the operating room for complications relating to their surgery. There were no 30-day readmissions in the LIHR group and three 30-day readmissions in the RIHR group (p = 0.28).

CONCLUSION

LIHR and RIHR are both performed with low morbidity and have comparable overall outcomes. The total charges were increased in the RIHR group. Either LIHR or RIHR may be considered when performing inguinal hernia repair and should depend on surgeon and patient preference; continued evaluation of the outcomes is warranted.

Hernia recurrence after primary repair of small umbilical hernia defects

BACKGROUND

An evidence-based approach to the repair of umbilical hernias (UH)<1 cm has yet to be defined.

METHODS

A prospectively maintained, institutional hernia database was queried for patients undergoing primary suture repair of UH ≤ 1 cm. The primary outcome was recurrence and secondary outcomes were wound complications.

RESULTS

Of 332 patients included (226-primary, 106-incisional), recurrence was identified in 4 (1.8%) primary versus 8 (7.5%) incisional-UH (p = 0.022), with follow-up of 4.7 ± 4.4 years. There were 10 (3.0%) wound complications: 4 (1.2%) superficial wound infections, 1 (0.3%) superficial wound dehiscence, and 5 (1.5%) seromas. On multivariable analysis of recurrence, incisional-UH had an odds ratio of 4.2 compared to primary. Suture choice, diabetes, BMI, tobacco-use history, and wound complications were not significant.

CONCLUSIONS

With long term follow-up, recurrence after primary suture repair of UH ≤ 1 cm occurred in 1.8% of primary and 7.5% of incisional UH. On multivariable analysis, incisional-UH increased recurrence odds by 4.2 times compared to primary.

İnguinal Hernilerde Balonsuz ve Mesh Sabitleyicisiz Laparoskopik Total Ekstraperitoneal Onarımın Cerrahi Deneyim ile Korelasyonu

Giriş: Günümüzde laparoskopik herni onarımları altın standart olma yolunda ilerlemektedir. Fakat laparoskopik total ektraperitoneal (TEP) inguinal herni onarımlarında disseksiyon balonun ve mesh sabitleyicinin getirdiği maliyet bu ameliyatların yapılmasında engel teşkil etmektedir. Bu çalışmanın amacı cerrahi deneyimle birlikte maliyetli malzemeler kullanmadan standart laparaskopik aletlerle bu ameliyatların yapılabilirliğini irdelemektir. Yöntemler: Mart 2019-Nisan 2021 tarihleri arasında disseksiyon balonu ve mesh sabitleyici kullanılmadan laparoskopik TEP inguinal herni onarımı yapılan hastalar retrospektif olarak incelendi. Yaş,cinsiyet, intraoperatif ve postoperatif görülen komplikasyonlar, ameliyat süresi, hospitalizasyon süresi, günlük aktiviteye dönüş süresi, nüks parametreleri değerlendirildi. Bulgular: Çalışma 86’sı sağ,76’sı sol, 44’ü çift taraflı olmak üzere 220 fıtık hastasına uygulanan TEP onarımı sonuçları üzerinden yapılmıştır. Ortalama yaş 52.55±18.02 yıldır. 186’sı erkek, 34’ü kadındır. Günlük aktiviteye dönüş sürelerinin ortalaması 3.98±1.68 gün, ameliyat süresinin ortalaması 39.55±11.32 dakikadır. Hastanede kalış süresinin ortalaması 0.78±0.16 gündür. Olguların 23 ünde intraoperatif komplikasyon, %5’inde seroma görülmüştür. 6. ay kontrolünde 3 hastada nüks görülmüştür. Tartışma: Disseksiyon balonu ve mesh sabitleyici kullanılmadan yapılan laparoskopik TEP inguinal herni onarımı; literatürdeki diğer laporoskopik onarımlar ile kıyaslandığında komplikasyon oranlarının hastanede yatış ve günlük aktiviteye dönüş sürelerin benzer olması ve daha az maliyetli bir yöntem olmasından dolayı yaygın bir şekilde kullanılması önerilir.

Acute appendicitis in the context of De Garengeot hernia: a case report

De Garengeot hernia is a rare type of hernia so called when the vermiform appendix is found within the hernia sac of a femoral hernia. For the appendix to be inflamed is yet more uncommon. We present the case of a 61-year-old man who presented with a painful right groin lump. Computed tomography imaging reported an inguinal hernia containing a non-inflamed appendix however, intraoperative findings confirmed a femoral hernia containing an appendix with a necrotic tip. As such, these cases prove a diagnostic challenge as not only are the clinical findings illusive, but the radiological findings are often misleading. Diagnosis is often intraoperative and case reports such as this are useful in highlighting this challenging pathology.

The influence of preoperative CT imaging on surgical delay in patients with acutely symptomatic abdominal wall hernias

PURPOSE

Abdominal wall hernias are common in the UK and many present in an emergent fashion. The widespread introduction of computed tomography (CT) imaging has transformed surgical practice but out of hours access can be limited by hospital resources and introduce delays. We investigated the influence of preoperative CT imaging in acutely symptomatic hernia and the association with surgical delay and risks of bowel ischemia.

METHODS

A retrospective analysis of patients undergoing emergency hernia surgery between 2013 and 2021 in a busy UK district general hospital. We evaluated the role of preoperative CT and its influence on timing of surgery, postoperative complications, critical care admission and hospital length of stay.

RESULTS

Five hundred and five patients were studied. Of these, 191 had a preoperative CT scan. Sites of hernia included inguinal in 164 patients (33%); umbilical in 164 (33%); femoral in 69 (14%); incisional in 69 (14%); epigastric in 30 (6%) and Spigelian hernia 9 (2%). Preoperative CT imaging was associated with surgical delay (22.0 h vs 13.0 h, p < 0.001) and an increased need for bowel resection (12% vs 6%, p = 0.027). Delay in surgery was not associated with increased postoperative complications (5% vs 4%, p = 0.474) but was associated with increased critical care admission (11.0% vs 4.8%, p = 0.014).

CONCLUSIONS

Preoperative CT scan for emergent hernias can delay often inevitable surgery and is associated with an increasing need for more complex, resectional surgery .

Are Surgeons of the Abdominal Core Health Quality Collaborative Following Guidelines in Umbilical and Epigastric Hernia Repair?

BACKGROUND

Umbilical and epigastric hernias are among the top three most common hernia surgeries performed in the USA with varied techniques. The European and Americas Hernia Societies (EAHS) recently published guidelines for repair of umbilical and epigastric hernias. We evaluated how closely the general surgeons of the Abdominal Core Health Quality Collaborative (ACHQC) follow these guidelines and to identify areas for possible improvement.

METHOD

Data from patients undergoing elective and emergent umbilical or epigastric hernia repair from 2013 to 2021 were extracted from the ACHQC database. The procedures performed on eligible subjects were compared to those proposed by the EAHS guidelines. Data was reported as a percentage and a cutoff of 70% was selected to determine compliance.

RESULTS

Based on these criteria, 11,088 patients were included and most of the recommendations, including appropriate preoperative antibiotic dosing (96.1% umbilical; 97.2% epigastric), permanent mesh selection (umbilical 97.8%; 96.1 epigastric), mesh fixation with suture (83.6% umbilical; 75.5% epigastric), use of mesh for open repair of hernias greater than 1 cm (83.6 umbilical; 85.7 epigastric), and primary defect closure during open (98.6% umbilical; 97.5% epigastric) and laparoscopic (99.6% umbilical; 100% epigastric) repair, were met.

DISCUSSION

Surgeons of the ACHQC adhere to most of the published guidelines on umbilical and epigastric hernia repair. Further research is needed to reinforce or modify the existing recommendations. Standardization of surgical approach will facilitate additional research needed to improve procedural efficiency, while reducing negative outcomes and cost.

Persistent low rates of same-day umbilical hernia repair in Australia over the past 20 years: is there a need to change?

BACKGROUND

Several recent reports have identified significant variations in discharge practices following umbilical hernia repair (UHR). The primary aim of this paper is to determine Australian UHR same day discharge (SDD) rates over the past two decades. Secondary aims are to analyse factors which may contribute to variation in discharge practices, compare Australian UHR SDD rates internationally and determine LOS trends.

METHODS

A retrospective, population-based cohort study was conducted using de-identified data from the Australian Institute of Health and Welfare (1 July 1998 to 30 June 2019). SDD rates and LOS were calculated for age, gender and complexity. Negative binomial models were used to investigate associations between characteristics.

RESULTS

The overall mean UHR SDD rate was 41.2% with a modest improvement over the study period (36.5% to 44.4%, P < 0.0001). The mean LOS was 3.4 days, and this decreased over the study period (P = 0.01). Males had a higher rate of SDD (42.1% vs. 39.4%, P < 0.0001) and shorter LOS (3.0 vs. 3.7 days, P < 0.0001) compared with females. Increased age was associated with decreased SDD (P < 0.0001) and increased LOS (P < 0.0001). Australia's SDD rate was lower than in both New Zealand and the United Kingdom.

CONCLUSION

While SDD and LOS following UHR improved across the study period, SDD rates remain below the RACS recommendation and compare unfavourably internationally. Advancing age and female gender were associated with decreased SDD and increased LOS demonstrating potential areas for improvement. Multiple strategies are discussed to address the persistently low rates of SDD after UHR.

Abdominal wall hernia is a frequent complication of polycystic liver disease and associated with hepatomegaly

BACKGROUND AND AIM

Polycystic liver disease (PLD) is related to hepatomegaly which causes an increased mechanical pressure on the abdominal wall. This may lead to abdominal wall herniation (AWH). We set out to establish the prevalence of AWH in PLD and explore risk factors.

METHODS

In this cross-sectional cohort study, we assessed the presence of AWHs from PLD patients with at least 1 abdominal computed tomography or magnetic resonance imaging scan. AWH presence on imaging was independently evaluated by two researchers. Data on potential risk factors were extracted from clinical files.

RESULTS

We included 484 patients of which 40.1% (n = 194) had an AWH. We found a clear predominance of umbilical hernias (25.8%, n = 125) while multiple hernias were present in 6.2% (n = 30). Using multivariate analysis, male sex (odds ratio [OR] 2.727 p < .001), abdominal surgery (OR 2.575, p < .001) and disease severity according to the Gigot classification (Type 3 OR 2.853, p < .001) were identified as risk factors. Height-adjusted total liver volume was an independent PLD-specific risk factor in the subgroup of patients with known total liver volume (OR 1.363, p = .001). Patients with multiple hernias were older (62.1 vs. 55.1, p = .001) and more frequently male (22.0% vs. 50.0%, p = .001).

CONCLUSION

AWHs occur frequently in PLD with a predominance of umbilical hernias. Hepatomegaly is a clear disease-specific risk factor.

The effects of age and sex on the elastic mechanical properties of human abdominal fascia

BACKGROUND

The abdominal hernias become more prevalent with age, that can adversely affect life quality. The mechanical properties of abdominal wall layers are supposed to play a significant role in developing of an abdominal hernia.The objective of this study was to determine the mechanical properties of the human abdominal layer - fascia and the effects of age and sex on it for choosing the proper brand of hernia mesh.

METHODS

78 samples harvested from 19 fresh cadavers were subjected to uniaxial tension tests and divided into four groups according to age. Group A corresponds to age up to 60 years, Group B to age 61-70 years, Group C to age 71-80 years and Group D to 81-90 years. Median stress-stretch ratio curves with respect to age, sex and direction of loading were obtained. Median values of the maximum tensile stress, stretch at maximum stress and elastic modulus calculated at 5% strain were determined.

FINDINGS

The abdominal fascia showed large variations between specimens depending on age and sex. The stiffness of the fascia increased with age. There is statistically significant differences between the median curves of male samples (P = 0.008) and female samples (P = 0.019) according to age in the L direction. Statistically significant differences between the values of maximum stress (P = 0.01) and elastic modulus (P = 0.003) from Group C in the L direction and maximum stress (P = 0.03) from Group D in the T direction was established.

INTERPRETATION

The female samples are stiffer than male samples especially after 80 years.

The Value of Contrast-Enhanced Ultrasound (CEUS) in the Detection of Perfusion Disturbances in Abdominal Wall Hernias Compared with Surgical and Histological Assessment

Purpose: This study aimed to evaluate the value of contrast-enhanced ultrasound (CEUS) in the evaluation of perfusion disturbance in irreducible abdominal wall hernias (AWHs). Methods: From 2006 to 2018, 50 patients with an irreducible AWH were examined using B-mode ultrasound (B-US) and CEUS. The ultrasound findings were correlated with subsequent surgical and histological results. The presence of non-enhanced areas (NEAs) in hernia contents on CEUS and the presence of non-perfused areas (NPAs) on surgical and histological evaluation were analyzed retrospectively. Results: On CEUS, 13/50 hernia contents (26.0%) revealed NEAs during complete CEUS examination and 37/50 (74.0%) revealed no NEAs during CEUS examination. On surgical and histological evaluation, NPAs in hernia contents were identified in 11/13 cases (93.3%) with NEAs on CEUS. CEUS was found to have a sensitivity of 100.0%, a specificity of 94.9%, a positive predictive value of 84.6%, and a negative predictive value of 100.0% for the identification of perfusion disturbance in AWHs. Conclusions: The findings of this study demonstrate that using CEUS as an imaging method may be helpful for evaluating the perfusion of hernia contents in incarcerated AWHs. On CEUS, the presence of NEAs may suggest perfusion disturbance in hernia contents.

Quality of Life After Umbilical Hernia Repair

Background: Mesh is beneficial in the repair of umbilical hernias. But it may cause chronic pain due to inflammatory reactions, which may impair the patient's quality of life.

Objectives: To assess and compare the quality of life of patients following umbilical hernia repair with and without mesh.

Methods: During the study period, 45 patients underwent umbilical hernia repair. The study was conducted at King Abdul-Aziz University Hospital (KAUH), KSA. Data were collected using medical records, and each patient was contacted by telephone, to fill the “Carolina Comfort Scale (CCS)” survey. The survey assesses the grade of pain, sensation of mesh, and movement limitation in different situations.

Results: A non-significant difference was found between mean quality of life (QOL) scores of mesh and non-mesh groups. The relationship between CCS and gender was not significant in both groups. However, males had significantly higher CCS scores in mesh-treated cases. There was no statistically significant relationship between CCS and comorbidity, nationality, or symptoms. The overall CCS score did not differ statistically between mesh-treated and non-mesh-treated cases. 

Conclusion: The CCS score did not differ between mesh-treated and non-mesh-treated cases. It is suggested that future multicentric studies with a larger sample size be conducted.

A National Evaluation of Surgeon Experiences in Telemedicine for the Care of Hernia and Abdominal Core Health Patients

Background

Surgeons are increasingly utilizing telemedicine to provide perioperative services to patients. Safety, satisfaction, and feasibility of these programs in general populations have been established, but it is unclear how telemedicine can be integrated into subspecialty care. We report results of a national survey related to telehealth practices among members of the Abdominal Core Health Quality Collaborative (ACHQC).

Methods

Survey responses were analyzed to determine current strategies in telemedicine utilization. Surgeon preferences, perceptions of validity, and identified barriers to implementation of telemedicine were assessed.

Results

Forty surgeons within the ACHQC responded, with 90% of respondents reporting use of telemedicine to deliver perioperative care to patients with hernias and abdominal core health concerns. Surgeons appeared to be more comfortable managing preoperative patients with image-confirmed diagnoses of hernias. Surgeons were universally more comfortable delivering postoperative care via telemedicine. Connectivity, patient engagement, and reimbursement were identified as potential barriers to expansion of telemedicine. Seventy-eight percent of respondents reported that they would increase telemedicine utilization if current regulations were maintained in the future.

Conclusions

This study found that hernia specialists are utilizing telemedicine at a higher rate than before the COVID-19 pandemic, with surgeons reporting interest in continued use of this modality beyond the pandemic. These findings suggest that future work in telemedicine optimization may improve the quality of care that can be delivered to patients with abdominal core health concerns.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-021-06332-9.

The effect of surgery on the levels of matrix metalloproteinases in patients with inguinal hernia

Matrix metalloproteinases (MMPs) are associated with the alteration of extracellular matrix. The purpose of this study was to investigate how the levels of matrix metalloproteinases and their inhibitors - TIMPs are influenced by the presence of inguinal hernia as well as by its surgical treatment. The studied group consisted of 25 patients with inguinal hernia and 21 healthy controls for comparison. Two blood samples - before and after the treatment were collected from patients. Serum concentrations of MMPs and TIMPs were analysed by multiplex immunoassays. There was a difference in circulating levels of MMPs in patients before the surgery compared to healthy controls - the concentrations of MMP-2 and MMP-9 were significantly lower (p=0.026, p=0.018, respectively). After the surgery, the levels of MMPs, especially MMP-2 (p<0.0001), were significantly decreased in patients compared to the preoperative values, apart from MMP-9. On the contrary, MMP-9 showed significant increase after the surgery (p<0.0001). Circulation levels of TIMP-2 in patients were significantly decreased in comparison with controls (p=0.004), whereas levels of TIMP-1 were similar to controls. Both tested metalloproteinase inhibitors showed a significant decrease in detected levels (TIMP-1 p=0.0004; TIMP-2 p<0.0001) after the procedure compared to the preoperative values. The levels of MMPs, especially MMP-2 and MMP-9, and their inhibitors TIMP-1 and TIMP-2 are involved by the presence of inguinal hernia as well as are influenced by the surgery.

Small Bowel Obstruction Due to Incarcerated Obturator Hernia: Successfull Surgical Management with Modified Mesh-Plug Hernioplasty

BACKGROUND Obturator hernia is an uncommon (0.07-1% incidence rate) subtype of hernia of the abdominal wall, with its incarceration being a rare cause of bowel obstruction. Obturator hernia has a higher incidence in elderly women and in malnourished people. This type of hernia has the highest morbidity and mortality rates of all abdominal wall hernias. This article reports a case of an emaciated 93-year-old woman who presented with small bowel obstruction due to incarcerated obturator hernia, successfully managed surgically with a modified mesh-plug hernioplasty. CASE REPORT An emaciated 93-year-old woman presented with diffuse abdominal pain, more intense on the right iliac fossa, radiating to the right thigh, with 8-h evolution and associated with dark-colored vomiting but normal bowel transit. This patient had a surgical history of right Richter´s femoral hernia, strangulated, with previous intestinal resection and a right femoral hernioplasty. A computed tomography (CT) scan revealed an incarcerated obturator hernia on the right side containing a short segment of small intestine. The patient underwent an exploratory laparotomy and a mesh-plug hernioplasty. During follow-up, there was no evidence of recurrence or complications. CONCLUSIONS Obturator hernia diagnosis is challenging due to its rarity and its signs and symptoms being often unspecific. CT scan has the highest sensitivity and is the best diagnostic tool. Surgical management is the only possible treatment for obturator hernia. Awareness of this condition is essential to allow an earlier approach and attempt to mitigate the associated high morbidity and mortality rates.

Laparoscopic Treatment of Incisional and Ventral Hernia

Background and Objectives

Although several large studies regarding patients undergoing minimally invasive repair of incisional hernia are currently available, the results are not particularly reliable as they are based on heterogeneous groups, different surgical techniques, different mesh types, or with a too short follow period.

Methods

We conducted a retrospective observational trial, collecting data from patients who underwent laparoscopic repair of a primary abdominal wall or an incisional hernia using the laparoscopic Intraperitoneal Onlay Mesh technique and a single mesh type, i.e., a composite polyester mesh with a hydrophilic film (Parietex Composite^TM mesh - Medtronic, Minneapolis, MN - USA). All patients signed an informed consent.

Results

One thousand seven hundred seventy-seven patients were enrolled. The median surgery time was 50 minutes and the median length of hospital stay was 2 days. Intraoperative complications occurred in 12 patients (0.7%), while early postoperative surgical complications occurred in 115 (6.5%); during follow-up, bulging mesh was diagnosed in 4.5% of cases and hernia recurred in 4.3% of patients. An overlap equal or greater than 4 cm resulted as a significant protective factor, while the use of absorbable fixing devices was a risk factor for recurrence (odds ration: 9.06, p < 0.001, 95% confidence interval: 4.19 - 19.57).

Conclusions

Minimally invasive treatment of primary and postincisional abdominal wall hernias is a safe, effective, and reproducible procedure. An overlap equal or greater than 4 cm, the use of nonabsorbable fixing devices and a postoperative care and follow-up regime are crucial in order to obtain good results and low recurrence rates.

Robotic Direct Inguinal Hernia Repair: To Plicate or Not to Plicate?

BACKGROUND

Closure of the direct inguinal defect with plication in minimally invasive direct inguinal hernia repair may have potential benefits in terms of reducing postoperative surgical site events (SSEs) and recurrences. However, these advantages remain unclear, particularly in the robotic literature. This is the first comparative study to investigate the outcomes after robotic direct inguinal hernia repair (RDIHR) with defect plication.

MATERIALS AND METHODS

Among patients who underwent RIHR between 2013 and 2020, those who underwent RDIHR were selected. Patients were then stratified into 2 groups based on defect plication status, and univariate analyses were used to compare variables across preoperative, intraoperative, and postoperative timeframes.

RESULTS

A total of 225 RDIHRs were performed in 176 patients, where 74 were assigned to the Plication (+) group and 102 patients were assigned to the Plication (-) group. There was a significantly higher proportion of females in the Plication (-) group (10.8% vs. 1.4%, P=0.015), which accounts for the higher incidence of accompanying femoral hernias in this group. While most M1 hernia defects were left patent, most M2 and M3 hernias were plicated. Larger mesh sizes were used in the Plication (+) group (P<0.001). Three SSEs were observed in the Plication (-) group versus 2 SSEs in the Plication (+) group. No significant differences in postoperative outcomes were found between the 2 groups.

CONCLUSIONS

Postoperative seroma incidence, pain scores, and recurrence rates were similar between the 2 study groups. Multicenter studies with larger populations and higher complication counts are needed to establish the role of defect plication in RDIHR.

Techniques of Concomitant Abdominoplasty and Umbilical Hernia Repair: A Review

BACKGROUND

Different methods of performing full abdominoplasty and umbilical hernia (UH) repair simultaneously have been proposed.

OBJECTIVES

The aim of this study was to review and compare UH repair outcomes and umbilical stalk survival.

METHODS

A literature research was performed through 28 December 2019. Other hernia repairs and mini-abdominoplasty (without umbilical transposition) were excluded. The primary outcomes analyzed were rates of UH recurrence, mesh infection, and umbilical necrosis.

RESULTS

Six studies were included (5 retrospectives series, 1 case report). Hernia was repaired by an open approach (3 studies, 28 patients) or a laparoscopic approach (3 studies, 67 patients). UH repair consisted of mesh placement in the intraperitoneal or retromuscular/preperitoneal plane, or suture technique in the intraperitoneal plane. No hernia recurrence, mesh infection, or umbilical necrosis was described.

CONCLUSIONS

Both open and laparoscopic approaches to simultaneous abdominoplasty and UH repair seem to be safe based on the rates of umbilical stalk vascularization, hernia recurrence, and mesh infection. However, more well-designed studies are needed to prove this hypothesis.

LEVEL OF EVIDENCE: 4

Mesh fixation techniques in primary ventral or incisional hernia repair

BACKGROUND

The use of a mesh in primary ventral or incisional hernia repair lowers the recurrence rate  and is the accepted standard of care for larger defects. In laparoscopic primary ventral or incisional hernia repair the insertion of a mesh is indispensable. Different mesh fixation techniques have been used and refined over the years. The type of fixation technique is claimed to have a major impact on recurrence rates, chronic pain, health-related quality of life (HRQOL) and complication rates.

OBJECTIVES

To determine the impact of different mesh fixation techniques for primary and incisional ventral hernia repair on hernia recurrence, chronic pain, HRQOL and complications.

SEARCH METHODS

On 2 October 2020 we searched CENTRAL, MEDLINE (Ovid MEDLINE(R)) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R)), Ovid Embase, and two trials registries. We also performed handsearches, and contacted experts from the European Hernia Society (EHS).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) including adults with primary ventral or incisional hernia that compared different types of mesh fixation techniques (absorbable/nonabsorbable sutures, absorbable/nonabsorbable tacks, fibrin glue, and combinations of these techniques).

DATA COLLECTION AND ANALYSIS

We extracted data in standardised piloted tables, or if necessary, directly into Review Manager 5. We assessed risks of bias with the Cochrane 'Risk of bias' tool. Two review authors independently selected the publications, and extracted data on results. We calculated risk ratios (RRs) for binary outcomes and mean differences (MDs) for continuous outcomes. For pooling we used an inverse-variance random-effects meta-analysis or the Peto method in the case of rare events. We prepared GRADE 'Summary of findings' tables. For laparoscopic repair we considered absorbable tacks compared to nonabsorbable tacks, and nonabsorbable tacks compared to nonabsorbable sutures as key comparisons.

MAIN RESULTS

We included 10 trials with a total of 787 participants. The number of randomised participants ranged from 40 to 199 per comparison. Eight studies included participants with both primary and incisional ventral hernia. One study included only participants with umbilical hernia, and another only participants with incisional hernia. Hernia size varied between studies. We judged the risk of bias as moderate to high. Absorbable tacks compared to nonabsorbable tacks Recurrence rates in the groups were similar (RR 0.74, 95% confidence interval (CI) 0.17 to 3.22; 2 studies, 101 participants). It is uncertain whether there is a difference between absorbable tacks and nonabsorbable tacks in recurrence because the certainty of evidence was very low. Evidence suggests that the difference between groups in early postoperative, late follow-up, chronic pain and HRQOL is negligible. Nonabsorbable tacks compared to nonabsorbable sutures At six months there was one recurrence in each group (RR 1.00, 95% CI 0.07 to 14.79; 1 study, 36 participants). It is uncertain whether there is a difference between nonabsorbable tacks and nonabsorbable sutures in recurrence because the certainty of evidence was very low. Evidence suggests that the difference between groups in early postoperative, late follow-up and chronic pain is negligible. We found no study that assessed HRQOL. Absorbable tacks compared to absorbable sutures No recurrence was observed at one year (very low certainty of evidence). Early postoperative pain was higher in the tacks group (VAS 0 - 10: MD -2.70, 95% CI -6.67 to 1.27; 1 study, 48 participants). It is uncertain whether there is a difference between absorbable tacks compared to absorbable sutures in early postoperative pain because the certainty of evidence was very low. The MD for late follow-up pain was -0.30 (95% CI -0.74 to 0.14; 1 study, 48 participants). We found no study that assessed HRQOL. Combination of different fixation types (tacks and sutures) or materials (absorbable and nonabsorbable) There were mostly negligible or only small differences between combinations (e.g. tacks plus sutures) compared to a single technique (e.g. sutures only), as well as combinations compared to other combinations (e.g. absorbable sutures combined with nonabsorbable sutures compared to absorbable tacks combined with nonabsorbable tacks) in all outcomes. It is uncertain whether there is an advantage for combining different fixation types or materials for recurrence, chronic pain, HRQOL and complications, because the evidence certainty was very low or low, or we found no study on important outcomes. Nonabsorbable tacks compared to fibrin sealant The two studies showed different directions of effects: one showed higher rates for nonabsorbable tacks, and the other showed higher rates for fibrin sealant. Low-certainty evidence suggests that the difference between groups in early postoperative, late follow-up, chronic pain and HRQOL is negligible. Absorbable tacks compared to fibrin sealant One recurrence in the tacks group and none in the fibrin sealant group were noted after one year (low certainty of evidence). Early postoperative pain might be slightly lower using tacks (VAS 0 - 100; MD -12.40, 95% CI -27.60 to, 2.80;1 study, 50 participants; low-certainty evidence). The pattern of pain and HRQOL course over time (up to 1 year) was similar in the groups (low certainty of evidence).

AUTHORS' CONCLUSIONS

Currently none of the techniques can be considered superior to any other, because the certainty of evidence was low or very low for all outcomes.

Local Anesthesia is Associated with Fewer Complications in Umbilical Hernia Repair in Frail Veterans

BACKGROUND

The optimal anesthesia modality for umbilical hernia repair is unclear. We hypothesized that using local rather than general anesthesia would be associated with improved outcomes, especially for frail patients.

METHODS

We utilized the 1998-2018 Veterans Affairs Surgical Quality Improvement Program to identify patients who underwent elective, open umbilical hernia repair under general or local anesthesia. We used the Risk Analysis Index to measure frailty. Outcomes included complications and operative time.

RESULTS

There were 4958 Veterans (13%) whose hernias were repaired under local anesthesia. Compared to general anesthesia, local was associated with a 12%-24% faster operative time for all patients, and an 86% lower (OR 0.14, 95%CI 0.03-0.72) complication rate for frail patients.

CONCLUSIONS

Local anesthesia may reduce the operative time for all patients and complications for frail patients having umbilical hernia repair.

Chronic pain after open inguinal hernia repair: expertise-based randomized clinical trial of heavyweight or lightweight mesh

BACKGROUND

There is a shortage of high-quality studies regarding choice of mesh in open anterior inguinal hernia repair in relation to long-term chronic pain. The authors hypothesized that heavyweight compared with lightweight mesh causes increased postoperative pain.

METHODS

An RCT was undertaken between 2007 and 2009 at two sites in Sweden. Men aged 25 years or older with an inguinal hernia evaluated in the outpatient clinic were randomized in an unblinded fashion to heavyweight or lightweight mesh for open anterior inguinal hernia repair. Data on pain affecting daily activities, as measured by the Short-Form Inguinal Pain Questionnaire 9-12 years after surgery, were collected as the primary outcome. Differences between groups were evaluated by generalized odds and numbers needed to treat.

RESULTS

A total of 412 patients were randomized; 363 were analysed with 320 questionnaires sent out. A total of 271 questionnaires (84.7 per cent) were returned; of these, 121 and 150 patients were in the heavyweight and lightweight mesh groups respectively. Pain affecting daily activities was more pronounced in patients randomized to heavyweight versus lightweight mesh (generalized odds 1.33, 95 per cent c.i. 1.10 to 1.61). This translated into a number needed to treat of 7.06 (95 per cent c.i. 4.28 to 21.44). Two reoperations for recurrence were noted in the heavyweight mesh group, and one in the lightweight mesh group.

CONCLUSION

A large-pore lightweight mesh causes significantly less pain affecting daily activities a decade after open anterior inguinal hernia repair. Registration number: NCT00451893 (http://www.clinicaltrials.gov).

Evaluation of Scientific Quality of YouTube Video Content Related to Umbilical Hernia

OBJECTIVE

Patients with umbilical hernias frequently refer to the YouTube videos to learn and perhaps apply traditional treatment methods. It is very difficult for these users to distinguish these videos as useful or harmful. In this study, we aimed to evaluate the scientific quality of YouTube video content on umbilical hernia.

METHODS

A total of 50 videos on YouTube pertaining to umbilical hernia were included in the study. All videos were evaluated by two experienced general surgeons. The uploader, video content, length, upload date, time since upload, number of views, numbers of comments, likes, and dislikes and Video Power Index (VPI) rates videos were recorded and evaluated. The videos were scored using the Quality Criteria for Consumer Health Information (DISCERN) and Global Quality Scale (GQS).

RESULTS

A total of 9,836 comments were made to the videos, 118,478 likes were made, and 15,009 dislikes were made. The mean DISCERN score given to the videos by the researchers was 2.57 ± 1.82 (min-max: 1-5) and the average GQS score was 2.62 ± 1.86. A statistically significant difference was found in terms of both DISCERN and GQS scores of videos uploaded by doctors compared to videos uploaded by nondoctors (p < 0.001). A statistically significant level of good agreement was found among investigators in terms of both DISCERN (p < 0.001, r = 0.778) and GQS (p < 0.001, r = 0.807) scores.  Conclusion: Videos with health content should definitely be uploaded by experts. Studies investigating the scientific quality of health videos uploaded on YouTube and similar platforms should be carried out continuously.

Abdominal Wall Hernias: An Epidemiological Profile and Surgical Experience from a Rural Medical College in Central India

Background  Abdominal wall hernia is a common surgical entity worldwide with groin hernias having the most common presentation among them. They are a cause of morbidity and mortality if not addressed in time. A variety of surgical methods are available for the repair of hernias. The tension-free repair using synthetic mesh has the least recurrence and is the most accepted.

Aim  To describe the surgical burden and clinical profile of abdominal wall hernias as well as experiences in their management in a rural setup.

Methods  This was a retrospective observational study of all the cases of abdominal wall hernias presenting to various surgical divisions of Mahatma Gandhi Institute of Medical Sciences, Sevagram, during a two-year period from December 2011 to November 2013. Relevant details were collected from the hospital information statistics and patient file records and analysis of obtained data was done.

Result  A total of 910 out of 90,056 surgical outpatients (10.10%) seen during this period had abdominal wall hernias; 816 (89.67%) got operated. A total of 163 (20%) of 816 were operated in an emergency. Groin hernias were the most common 653 (80%), followed by incisional 82 (10%), umbilical and paraumbilical 41 (5%), epigastric 33 (4%), and rarer hernias in 8 (1%). Of 816 operations, 24 (2.9%) had recurrent hernias and 83 (10.17%) were pediatric patients. Male to female ratio was 9:1 in adults and 4:1 in children. The median age among adults was 49 years (range: 14–95 years), and among the pediatric age group, it was 7 years (range: 3 months–14 years). The majority of the adult patients were from a low-income group and presented more than 2 years after symptoms appeared. Comorbid conditions encountered were hypertension in 212 (26%), diabetes in 155 (19%), chronic airway disorders in 449 (55%), cardiac problems in 163 (20%), obesity in 10 (1.2%), and chronic renal failure and liver disorder in 82 (1%). Predisposing factors in the majority of the patients were chronic cough 449 (55%), prostatic problems in 187 (23%), chronic constipation in 163 (20%), previous surgeries in 82 (10%), obesity in 10 (1.2%), and ascites in 9 (0.1%). Hernia surgery was performed laparoscopically in 51 (6.25%) patients. Simultaneous other surgeries were performed in 130 (16%) patients. Mortality occurred in 2 (0.24%) patients operated in emergency, and chief morbidity was due to wound infection in 25 (3%) and chronic pain in 30 (3.9%) patients.

Conclusion  Abdominal wall hernias are common clinical entities. Although the pattern of presentation and management is similar, the challenges faced in a rural setup are due to ignorance, social inhibitions, and financial restraints, leading to delayed presentations which increase their morbidity and mortality. Health programs and surveys to increase awareness in rural areas as well as cutting down on expenses could help these patients.

Exercise-Induced Inguinal Hydrocele: An Unconventional Presentation of a Common Problem

Inguinal hernias are very common. Well-established diagnostic criteria including examination and imaging are available. Ultrasound, herniography, CT, and MR imaging can provide additional diagnostic information when examination alone is not deemed sufficient. However, decision making should not be overly dependent on imaging but must factor in all relevant information. Described here is a case that would have been a missed diagnosis and an example of unconventional documentation that facilitated the patient getting their care.

Treating incarcerated inguinal hernias with TEP is a viable option for experienced surgeons

Despite inguinal hernias being a common problem in public health, there is still scarce information about the epidemiology of the complications, especially incarceration, and their influence on the laparoscopic surgical methods considering the role of the learning process of the surgeon. Compare laparoscopic totally extraperitoneal (TEP) approach in the repair of incarcerated and non-incarcerated inguinal hernias from the perspective of technical difficulty for trained surgeons. We obtained data about sex, age, location and type of hernia, surgery duration, ASA score, postoperative complications, previous surgeries and BMI. Groups were descriptively analyzed and statistically compared to verify how similar the samples were. 265 (90.1%) patients had non-incarcerated hernias and 29 (9.9%) incarcerated. We observed that there was no significant difference in the pattern of location (right, left or bilateral), sex, ASA, previous or complications between the two groups. Unilateral incarcerated hernias had longer operative times compared to non-incarcerated. No difference was found between bilateral hernias. We didn´t find significant epidemiological differences between incarcerated and non-incarcerated hernias. In our experience, with the limitation of a single-surgeon series, laparoscopic hernia repair achieved satisfactory results in terms of feasibility (especially for bilateral hernias) and safety.

Chinese expert consensus on adult ventral abdominal wall defect repair and reconstruction

BACKGROUND

Surgical management of patients with ventral abdominal wall defects, especially complex abdominal wall defects, remains a challenging problem for abdominal wall reconstructive surgeons. Effective surgical treatment requires appropriate preoperative assessment, surgical planning, and correct operative procedure in order to improve postoperative clinical outcomes and minimize complications. Although substantial advances have been made in surgical techniques and prosthetic technologies, there is still insufficient high-level evidence favoring a specific technique. Broad variability in existing practice patterns, including clinical pre-operative evaluation, surgical techniques and surgical procedure selection, are still common.

DATA SOURCES

With the purpose of providing a best practice algorithm, a comprehensive search was conducted in Medline and PubMed. Sixty-four surgeons considered as experts on abdominal wall defect repair and reconstruction in China were solicited to develop a Chinese consensus and give recommendations to help surgeons standardize their techniques and improve clinical results.

CONCLUSIONS

This consensus serves as a starting point to provide recommendations for adult ventral abdominal wall repair and reconstruction in China and may help build opportunities for international cooperation to refine AWR practice.

Symptomatic inguinal bladder hernia causes post-renal acute kidney injury: A rare case report

Introduction

Inguinal bladder hernia (IBH) is a rare condition representing less than 5% of all inguinal hernias. Most cases occur in elderly overweight men. Patients may present with variable symptoms such as urinary symptoms, inguinal swelling, or pain; however, most of them are asymptomatic and only less than 7% are diagnosed pre-operatively. Different radiological studies can be used if IBH suspected preoperatively including ultrasound, computed tomography scan; however, cystography is the most sensitive test for diagnosis of IBH. Open reduction and hernia repair are the standard treatment of IBH.

Case presentation

We report a rare case of an-83-year-old male who presented with left inguinal pain associated with lower urinary tract symptoms including dysuria, nocturia, post-voidal dribbling, and urinary frequency. Laboratory studies showed acute kidney injury (AKI), and computed tomography (CT) of abdomen and pelvis without contrast CT revealed a herniation of 80% of the bladder through the left inguinal canal into the left scrotal sac, with moderate bilateral hydronephrosis and hydroureter, though no obstructing calculi are seen. Pre-operative diagnosis of incarcerated inguinal bladder hernia (IBH) was made, and a timely surgical intervention preceded by bladder catheterization led to a significant improvement of AKI and an excellent outcome without post-operative complications.

Discussion and conclusion

IBH is uncommon condition that can present with non-specific urinary symptoms; therefore, high index of suspicion is mandated for diagnosis especially in patients with risk factors. Pre-operative radiological evaluation to avoid iatrogenic bladder injury with subsequent surgical repair is the standard management for IBH as we accomplished in our case.

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Consider inguinal bladder hernia in patients with urinary symptoms and large inguinal hernia.

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Proper evaluation and pre-operative diagnosis of inguinal bladder hernia is important to prevent any iatrogenic bladder injury.

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Pre-operative urinary catheterization and surgical repair is the treatment of choice in inguinal bladder hernia.

Most cited 100 articles from Turkey on abdominal wall hernias: a bibliometric study

Objectives

The aim of the present study was to search the most-cited articles from Turkey on abdominal wall hernias and analyze their characteristics with several parameters.

Material and Methods

In March 2019, a search was conducted through all databases in the Web of Science (WoS) to determine the most-cited articles on abdominal wall hernias. Each article was evaluated in regard to host journal, year of publication, the complete list of authors, the type of article, main subject of the study, institution of the study group. Citation counts in Google Scholar (GSch) were also obtained.

Results

Mean number of citations of the top 100 articles in herniology was 30.50. Articles were published in 38 journals; Hernia is the leading host. No correlation was observed between the journal impact factors and the number of the citations. Two thirds of the articles were clinical studies. Article types had no significant effect on the citation counts. Inguinal hernia was the most frequent topic by taking place in 58 papers. Articles related to incisional hernias had a higher mean number of citations in comparison with other topics. Ankara University School of Medicine had most cited articles, the highest number of total citations, and the highest citation per articles. Ankara Numune Training and Research Hospital and Istanbul University School of Medicine had the highest number of the articles in the list.

Conclusion

Citation counts of hernia related articles from Turkey are relatively low. Hernia is the leading journal for Turkish studies. Inguinal hernia is the most frequent topic whereas papers about incisional hernias receive more citations than others.

Prospective observational study of abdominal wall reconstruction with THT technique in primary midline defects with diastasis recti: clinical and functional outcomes in 110 consecutive patients

INTRODUCTION

Surgical treatment of diastasis recti is still a matter of debate. Open approaches such as abdominoplasty, which offer the possibility to combine reparation of the diastasis with abdominal cosmetic surgery, are challenged by the emerging less-invasive laparoscopic or robotic techniques that offer shorter recovery for patients. However, evidence in favour of one of the two approaches concerning both short- and long-term complications and functional results is still lacking. In this paper, we analysed clinical and functional results of a new endo-laparoscopic technique for midline reconstruction (THT technique) in patients with primary abdominal wall defects associated with diastasis recti.

METHODS

Prospective observational study on 110 consecutive patients was submitted to endo-laparoscopic reconstruction of the abdominal wall with linear staplers. Morbidity and relapse rates with clinical and radiological follow-up were recorded at 1, 6, 12, and 24 months after the operation. Data regarding the impact of surgery on patients' quality of life (EuraHSQol) on chronic low back pain (Oswestry Disability Index, ODI) and urinary stress incontinence (Incontinence Severity Index, ISI) were gathered.

RESULTS

After a mean follow-up of 14 months, the morbidity rate was 9.1% and no recurrences were recorded. 6-month follow-up ultrasound showed a rectus muscles mean distance of 6.7 mm; EuraHSQol, ODI, and ISI scores significantly improved in 93%, 77%, and 63% of the cases, respectively.

CONCLUSIONS

The THT technique proved to be a feasible, safe, and effective alternative for corrective surgery of primary midline hernias associated with diastasis recti. Short- and mid-term results are encouraging but need to be confirmed by further studies with longer follow-up. The achieved midline reconstruction offers a significant improvement of patients' perceived quality of life through reduction of abdominal wall pain, bulging, low back pain, and urinary stress incontinence.

Changing the innate consensus about mesh fixation in trans-abdominal preperitoneal laparoscopic inguinal hernioplasty in adults: Short and long term outcome. Randomized controlled clinical trial

INTRODUCTION

Inguinal hernioplasty is the standard treatment for inguinal hernia in adults. Mesh fixation was used to keep mesh in place for which various mesh fixation techniques have been used in laparoscopic inguinal hernia repair in adults, but their effectiveness has remained inconclusive.

AIM OF THE WORK

to evaluate non fixation method of mesh laparoscopic inguinal hernioplasty as safe and effective as regard short and long term outcomes.

PATIENTS AND METHODS

Over the period from July 2013 to July 2018, 798 patients with oblique inguinal hernias undergoing Trans abdominal preperitoneal technique (TAPP) were randomized into 3 groups: Group A; mesh non fixation 266 patients. Group B; tacker mesh fixation 266 patients Group C: Cyanoacrylic tissue glues (Histoacryl) mesh fixation 266 patients. Clinical effects were assessed by the following variables: intraoperative data, postoperative outcome as regard recurrence rate, postoperative pain [on visual analogue score (VAS)], analgesic consumption, operation time, hospital stay, and patient costs. Follow up was 18 months.

RESULTS

There was no statistical difference between groups (A) and Group (C) regarding operative time, postoperative complications, and length of hospital stay and risk of chronic groin pain, postoperative pain score. In Group (B): the postoperative pain and complications were higher. There were 5 cases of hernia recurrence in all groups, but no significant differences among the three groups.

CONCLUSION

Tacker Mesh fixation increased the risk of chronic groin pain. Pain score was higher with tacker mesh fixation. Laparoscopic TAPP inguinal hernia repair without tacker mesh fixation was safe and feasible with no significant increase in recurrence rates. Furthermore, mesh fixation with tacker procedure increased the risk of postoperative complications and patient costs. All ethical approval was given by our Faculty of Medicine medical ethical committee.