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Özdemir K, Akin E, Muhtaroğlu A, Kamburoğlu B, Gönüllü E, Bayhan Z, Altintoprak F. Evaluating surgical techniques for incarcerated incisional hernia: laparoscopic vs. Open repair in a tertiary care setting. Hernia 2025; 29:116. [PMID: 40072615 PMCID: PMC11903634 DOI: 10.1007/s10029-025-03311-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2024] [Accepted: 03/02/2025] [Indexed: 03/14/2025]
Abstract
PURPOSE This study aims to compare the outcomes of laparoscopic versus open repair techniques in patients undergoing emergency surgery for incarcerated incisional hernia in a tertiary care setting. METHODS A prospective evaluation was conducted on 45 patients who underwent emergency laparoscopic and open repair for incarcerated incisional hernia between 2018 and August 2021. Patients were divided into two groups based on the surgical technique used: laparoscopic (n = 15) and open repair (n = 30). Key variables analysed included demographic data, body mass index, American Society of Anesthesiologists scores, operative time, perioperative bleeding, length of hospital stay, postoperative complications, European Hernia Society Quality of Life pain score, and recurrence rates during follow-up. RESULTS Significant differences were found between the laparoscopic and open repair groups regarding pain scores, length of hospital stay, and amount of perioperative bleeding. The laparoscopic repair group demonstrated reduced pain, shorter hospital stays, and less perioperative bleeding compared to the open repair group. CONCLUSION This study shows that laparoscopic repair for incarcerated incisional hernia offers significant advantages over open repair. These findings support the preference for laparoscopic repair in the emergency surgical management of incarcerated incisional hernia in appropriate patients.
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Affiliation(s)
- Kayhan Özdemir
- Department of General Surgery, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Emrah Akin
- Department of General Surgery, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Ali Muhtaroğlu
- Department of General Surgery, Giresun University Faculty of Medicine, Giresun University Training and Research Hospital, Aksu District, Mehmet İzmen Street, Number:145, Giresun, 28100, PC, Turkey.
| | - Burak Kamburoğlu
- Department of General Surgery, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Emre Gönüllü
- Department of General Surgery, Division of Gastroenterological Surgery, Giresun University Faculty of Medicine, Sakarya, Turkey
| | - Zülfü Bayhan
- Department of General Surgery, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Fatih Altintoprak
- Department of General Surgery, Sakarya University Faculty of Medicine, Sakarya, Turkey
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Patel S, Smiley A, Feingold C, Khandehroo B, Kajmolli A, Latifi R. Chances of Mortality Are 3.5-Times Greater in Elderly Patients with Umbilical Hernia Than in Adult Patients: An Analysis of 21,242 Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10402. [PMID: 36012037 PMCID: PMC9408293 DOI: 10.3390/ijerph191610402] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 06/15/2023]
Abstract
The goal of this study was to identify risk factors that are associated with mortality in adult and elderly patients who were hospitalized for umbilical hernia. A total of 14,752 adult patients (ages 18−64 years) and 6490 elderly patients (ages 65+), who were admitted emergently for umbilical hernia, were included in this retrospective cohort study. The data were gathered from the National Inpatient Sample (NIS) 2005−2014 database. Predictors of mortality were identified via a multivariable logistic regression, in patients who underwent surgery and those who did not for adult and elderly age groups. The mean (SD) ages for adult males and females were 48.95 (9.61) and 46.59 (11.35) years, respectively. The mean (SD) ages for elderly males and females were 73.62 (6.83) and 77.31 (7.98) years, respectively. The overall mortality was low (113 or 0.8%) in the adult group and in the elderly group (179 or 2.8%). In adult patients who underwent operation, age (OR = 1.066, 95% CI: 1.040−1.093, p < 0.001) and gangrene (OR = 5.635, 95% CI: 2.288−13.874, p < 0.001) were the main risk factors associated with mortality. Within the same population, female sex was found to be a protective factor (OR = 0.547, 95% CI: 0.351−0.854, p = 0.008). Of the total adult sample, 43% used private insurance, while only 18% of patients in the deceased population used private insurance. Conversely, within the entire adult population, only about 48% of patients used Medicare, Medicaid, or self-pay, while these patients made up 75% of the deceased group. In the elderly surgical group, the main risk factors significantly associated with mortality were frailty (OR = 1.284, 95% CI: 1.105−1.491, p = 0.001), gangrene (OR = 13.914, 95% CI: 5.074−38.154, p < 0.001), and age (OR = 1.034, 95% CI: 1.011−1.057, p = 0.003). In the adult non-operation group, hospital length of stay (HLOS) was a significant risk factor associated with mortality (OR = 1.077, 95% CI: 1.004−1.155, p = 0.038). In the elderly non-operation group, obstruction was the main risk factor (OR = 4.534, 95% CI: 1.387−14.819, p = 0.012). Elderly patients experienced a 3.5-fold higher mortality than adult patients who were emergently admitted with umbilical hernia. Increasing age was a significant risk factor of mortality within all patient populations. In the adult surgical group, gangrene, Medicare, Medicaid, and self-pay were significant risk factors of mortality and female sex was a significant protective factor. In the adult non-surgical group, HLOS was the main risk factor of mortality. In the elderly population, frailty and gangrene were the main risk factors of mortality within the surgical group, and obstruction was the main risk factor for the non-surgical group.
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Affiliation(s)
- Saral Patel
- Westchester Medical Center, School of Medicine, New York Medical College, Valhalla, NY 10595, USA
| | - Abbas Smiley
- Westchester Medical Center, School of Medicine, New York Medical College, Valhalla, NY 10595, USA
| | - Cailan Feingold
- Westchester Medical Center, School of Medicine, New York Medical College, Valhalla, NY 10595, USA
| | - Bardia Khandehroo
- Westchester Medical Center, School of Medicine, New York Medical College, Valhalla, NY 10595, USA
| | - Agon Kajmolli
- Westchester Medical Center, School of Medicine, New York Medical College, Valhalla, NY 10595, USA
| | - Rifat Latifi
- Minister of Health, Republic of Kosova, Adjunct Professor of Surgery, University of Arizona, Tucson, AZ 10000, USA
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Pavithira GJ, Dutta S, Sundaramurthi S, Nelamangala Ramakrishnaiah VP. Outcomes of Emergency Abdominal Wall Hernia Repair: Experience Over a Decade. Cureus 2022; 14:e26324. [PMID: 35911260 PMCID: PMC9311230 DOI: 10.7759/cureus.26324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2022] [Indexed: 11/30/2022] Open
Abstract
Background Abdominal wall hernias are a common surgical entity encountered by the general surgeon. Approximately 10% of abdominal wall hernia patients require emergency surgery. However, these surgeries are associated with a high rate of postoperative morbidity and mortality. This study aimed to analyze the morbidity and mortality in patients undergoing emergency abdominal wall hernia repair and to determine the factors associated with surgical site infection (SSI) and recurrence in these patients attending a tertiary care hospital in south India. Methodology Our study was a single-centered, 10-year retrospective and a one-year prospective study conducted in a tertiary care center in India. All patients who underwent emergency abdominal wall hernia repair between April 2009 and May 2020 were included. Patients' demographic details, comorbidities, intraoperative findings, 30-day surgical outcomes including SSI, and recurrence were studied. Results Out of 383 patients in our study, 63.9% had an inguinal hernia, and 54% of the patients underwent tissue repair. SSI was the most common morbidity (21.9%). Postoperative sepsis was the only independent factor associated with perioperative mortality according to the logistic regression analysis (odds ratio = 22.73, p = 0.022). Conclusions Tissue repair for emergency hernia surgery has better outcomes than mesh repair in clean-contaminated cases.
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Affiliation(s)
- G J Pavithira
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Souradeep Dutta
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
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Bostancı MT, Yılmaz I, Seki A, Saydam M, Kosmaz K, Kaya IO. Haematological inflammatory markers for indicating ischemic bowel in patients with incarcerated abdominal wall hernias. Hernia 2021; 26:349-353. [PMID: 34816325 DOI: 10.1007/s10029-021-02518-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 10/04/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To reveal the clinical significance of preoperative haematological inflammatory markers in the diagnosis of abdominal wall hernias with strangulation. METHODS The data of 200 patients who underwent surgery for incarcerated hernia were retrospectively analysed. The patients were grouped into three groups; Group 1; only surgical reduction and hernia repair, Group 2; small bowel resection and Group 3; omentum resection. Age, gender, hernia type, the presence of radiological bowel obstruction and preoperative complete blood count data were obtained. Neutrophil-leukocyte ratio (NLR), lymphocyte-monocyte ratio (LMR), platelet-lymphocyte ratio (PLR), haematological inflammatory index (HII) and systemic immune-inflammation index (SII) values were calculated. RESULTS The study was consisted of; Group 1: 119 patients (59.5%), Group 2: 46 patients (23%) and Group 3: 35 patients (17.5%). Advanced age (p = 0.001), female gender (p = 0.036), incisional hernias (p = < 0.001) and the presence of bowel obstruction (p = < 0.001) were found to be statistically significant in terms of strangulation. NLR, PLR and SII values were significantly higher in Group 2 compared to Group 1, and PLR values were significantly higher in Group 2 compared with Group 3 (p < 0.05). CONCLUSION The preoperative elevated NLR, PLR and SII values may indicate strangulation and possible intestinal resection, in incarcerated abdominal wall hernias.
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Affiliation(s)
- M T Bostancı
- Department of General Surgery, University of Health Sciences, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara, 06110, Turkey.
| | - I Yılmaz
- Department of General Surgery, University of Health Sciences, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara, 06110, Turkey
| | - A Seki
- Department of General Surgery, University of Health Sciences, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara, 06110, Turkey
| | - M Saydam
- Department of General Surgery, University of Health Sciences, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara, 06110, Turkey
| | - K Kosmaz
- Department of Surgery, University of Health Sciences, Ankara Training and Research Hospital, Ankara, Turkey
| | - I O Kaya
- Department of General Surgery, University of Health Sciences, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara, 06110, Turkey
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Malibary N, Shurrab M, Albariqi MO, Bohairi M, Basabain AS, Alqurashi MY, Madani TA. Quality of Life After Umbilical Hernia Repair. Cureus 2021; 13:e19016. [PMID: 34824932 PMCID: PMC8611248 DOI: 10.7759/cureus.19016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2021] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Nadim Malibary
- Visceral and General Surgery, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
| | | | | | - Mohnad Bohairi
- Surgery Department, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
| | | | | | - Turki A Madani
- Medical Intern, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
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Akhtar M, Donnachie DJ, Siddiqui Z, Ali N, Uppara M. Hierarchical regression of ASA prediction model in predicting mortality prior to performing emergency laparotomy a systematic review. Ann Med Surg (Lond) 2020; 60:743-749. [PMID: 33425345 PMCID: PMC7779956 DOI: 10.1016/j.amsu.2020.11.089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 11/29/2020] [Accepted: 11/29/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND In light of increasing litigations around performing emergency surgery, various predictive tools are used for prediction of mortality prior to surgery. There are many predictive tools reported in literature, with ASA being one of the most widely accepted tools. Therefore, we attempted to perform a systematic review and meta-analysis to conclude ASA's ability in predicting mortality for emergency surgeries. METHODS A wide literature search was conducted across MEDLINE and other databases using PubMed and Ovid with the following keywords; "Emergency laparotomy", "Surgical outcomes", "Mortality" and "Morbidity." A total of 3989 articles were retrieved and only 11 articles met the inclusion criteria for this meta-analysis. Data was pooled and then analysed using the STATA 16.1 software. We conducted hierarchal regression between the following variables; mortality, gender, low ASA (ASA 1-2) and high ASA (ASA 3-5). RESULTS 1. High ASA was associated with a higher rate of mortality in males with 'p' value of 0.0001 at alpha value of 0.025. 2. The female gender itself showed a significantly high mortality rate, irrespective of low ASA or high ASA with 'p' value of 0.04 at alpha value of 0.05. 3. ITU admissions with a high ASA had a greater number of deaths compared to low ASA. 'p' value of 0.0054 at alpha value of 0.01. CONCLUSION Higher ASA showed a direct association with mortality and the male gender. The female gender was associated with a higher risk of mortality regardless of the ASA grades.
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Affiliation(s)
- Muzina Akhtar
- Innovative Statistical Analysis and Publications Ltd., UK
| | - Douglas J. Donnachie
- Clinical Teaching Fellow in Plastic Surgery, Royal Devon and Exeter NHS Foundation Trust, UK
| | | | - Norman Ali
- GPST1, East Kent Hospitals University NHS Foundation Trust, UK
| | - Mallikarjuna Uppara
- Registrar in Upper GI Surgery, ID Medical Agency, England, UK
- CEO of Innovative Statistical Analysis and Publications Ltd., UK
- Surgical Tutor for MSc Students at Queen Mary University of London, UK
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de Almeida Medeiros KA, Carvalho BJ, Pipek LZ, de Mesquita GHA, Nii F, Martines DR, Iuamoto LR, Carneiro-D'Albuquerque LA, Meyer A, Andraus W. Treating incarcerated inguinal hernias with TEP is a viable option for experienced surgeons. Sci Rep 2020; 10:20858. [PMID: 33257763 PMCID: PMC7705708 DOI: 10.1038/s41598-020-77925-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 11/12/2020] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | - Fernanda Nii
- Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, Brazil
| | | | - Leandro Ryuchi Iuamoto
- Department of Orthopaedics and Traumatology, Center of Acupuncture, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Luiz Augusto Carneiro-D'Albuquerque
- Departamento de Gastroenterologia, Faculdade de Medicina, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, Avenida Doutor Arnaldo, 455, São Paulo, Brazil
| | - Alberto Meyer
- Departamento de Gastroenterologia, Faculdade de Medicina, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, Avenida Doutor Arnaldo, 455, São Paulo, Brazil.
| | - Wellington Andraus
- Departamento de Gastroenterologia, Faculdade de Medicina, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, Avenida Doutor Arnaldo, 455, São Paulo, Brazil
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Surek A, Gemici E, Ferahman S, Karli M, Bozkurt MA, Dural AC, Donmez T, Karabulut M, Alis H. Emergency surgery of the abdominal wall hernias: risk factors that increase morbidity and mortality-a single-center experience. Hernia 2020; 25:679-688. [PMID: 32914294 DOI: 10.1007/s10029-020-02293-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/27/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Morbidity and mortality are higher in urgently operated abdominal hernia cases compared to elective surgeries. The present study aims to investigate the factors that cause increased morbidity and mortality in emergency surgical operations. METHODS The files of a total of 426 patients who were operated for non-reducible abdominal hernia between 2015 and 2020 were reviewed retrospectively. Patients' ages, genders, comorbidities, Charlson Comorbidity Index (CCI), ASA score, BMI, hernia types, duration of symptom, laboratory values, intestinal strangulations or necroses, whether intestinal resection was performed, whether mesh was preferred for hernia repair, and rates of morbidity and mortality were recorded. Factors affecting morbidity and mortality rates were analyzed. RESULTS Factors such as gender, BMI (> 30), duration of symptom (> 24 h), presence of bowel necrosis and resection, type of hernia and prolonged operation time were found to cause an increase in morbidity. In the multivariate analysis, however, gender, duration of symptom and BMI (> 30) were statistically significant factors causing increased morbidity (p = 0.009, p < 0.001, p = 0.032, respectively). Advanced age, high ASA scores, CCI and duration of symptom were determined as factors affecting the increase in mortality. In the multivariate analysis, the effect of high ASA scores and advanced age on high mortality rate was statistically significant (p < 0.023, p = 0.039, respectively). CONCLUSIONS The mortality rate is higher, especially in elderly patients with high comorbidity. Therefore, we argue that the cases of abdominal wall hernia should be operated under elective conditions even if they do not give any clinical findings to prevent problems in older ages.
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Affiliation(s)
- A Surek
- Department of General Surgery, Ministry of Health Bakırkoy Dr Sadi Konuk Training and Research Hospital, Building A, Floor 4, Tevfik Saglam Street. Nr: 11, Bakirkoy, 34147, İstanbul, Turkey.
| | - E Gemici
- Department of General Surgery, Ministry of Health Bakırkoy Dr Sadi Konuk Training and Research Hospital, Building A, Floor 4, Tevfik Saglam Street. Nr: 11, Bakirkoy, 34147, İstanbul, Turkey
| | - S Ferahman
- Department of General Surgery, Ministry of Health Bakırkoy Dr Sadi Konuk Training and Research Hospital, Building A, Floor 4, Tevfik Saglam Street. Nr: 11, Bakirkoy, 34147, İstanbul, Turkey
| | - M Karli
- Department of General Surgery, Ministry of Health Bakırkoy Dr Sadi Konuk Training and Research Hospital, Building A, Floor 4, Tevfik Saglam Street. Nr: 11, Bakirkoy, 34147, İstanbul, Turkey
| | - M A Bozkurt
- Department of General Surgery, Ministry of Health Bakırkoy Dr Sadi Konuk Training and Research Hospital, Building A, Floor 4, Tevfik Saglam Street. Nr: 11, Bakirkoy, 34147, İstanbul, Turkey
| | - A C Dural
- Department of General Surgery, Ministry of Health Bakırkoy Dr Sadi Konuk Training and Research Hospital, Building A, Floor 4, Tevfik Saglam Street. Nr: 11, Bakirkoy, 34147, İstanbul, Turkey
| | - T Donmez
- Department of General Surgery, Ministry of Health Bakırkoy Dr Sadi Konuk Training and Research Hospital, Building A, Floor 4, Tevfik Saglam Street. Nr: 11, Bakirkoy, 34147, İstanbul, Turkey
| | - M Karabulut
- Department of General Surgery, Ministry of Health Bakırkoy Dr Sadi Konuk Training and Research Hospital, Building A, Floor 4, Tevfik Saglam Street. Nr: 11, Bakirkoy, 34147, İstanbul, Turkey
| | - H Alis
- Department of General Surgery, Faculty of Medicine, Istanbul Aydin University, Istanbul, Turkey
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Huckaby LV, Dadashzadeh ER, Handzel R, Kacin A, Rosengart MR, van der Windt DJ. Improved Understanding of Acute Incisional Hernia Incarceration: Implications for Addressing the Excess Mortality of Emergent Repair. J Am Coll Surg 2020; 231:536-545.e4. [PMID: 32822886 DOI: 10.1016/j.jamcollsurg.2020.08.735] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Incisional hernia develops in up to 20% of patients undergoing abdominal operations. We sought to identify characteristics associated with poor outcomes after acute incisional hernia incarceration. STUDY DESIGN We performed a retrospective cohort study of adult patients with incisional hernias undergoing elective repair or with acute incarceration between 2010 and 2017. The primary end point was 30-day mortality. Logistic regression was used to determine adjusted odds associated with 30-day mortality. The American College of Surgeons Surgical Risk Calculator was used to estimate outcomes had these patients undergone elective repair. RESULTS A total of 483 patients experienced acute incarceration; 30-day mortality was 9.52%. Increasing age (adjusted odds ratio 1.05; 95% CI, 1.02 to 1.08) and bowel resection (adjusted odds ratio 3.18; 95% CI, 1.45 to 6.95) were associated with mortality. Among those with acute incarceration, 231 patients (47.9%) had no documentation of an earlier surgical evaluation and 252 (52.2%) had been evaluated but had not undergone elective repair. Among patients 80 years and older, 30-day mortality after emergent repair was high (22.9%) compared with estimated 30-day mortality for elective repair (0.73%), based on the American College of Surgeons Surgical Risk Calculator. Estimated mortality was comparable with observed elective repair mortality (0.82%) in an age-matched cohort. Similar mortality trends were noted for patients younger than 60 years and aged 60 to 79 years. CONCLUSIONS Comparison of predicted elective repair and observed emergent repair mortality in patients with acute incarceration suggests that acceptable outcomes could have been achieved with elective repair. Almost one-half of acute incarceration patients had no earlier surgical evaluation, therefore, targeted interventions to address surgical referral can potentially result in fewer incarceration-related deaths.
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Affiliation(s)
| | - Esmaeel Reza Dadashzadeh
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA
| | - Robert Handzel
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA
| | - Alexa Kacin
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Matthew R Rosengart
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Pittsburgh Surgical Outcomes Research Center, University of Pittsburgh, Pittsburgh, PA
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Lorenz R, Oppong C, Frunder A, Lechner M, Sedgwick DM, Tasi A, Wiessner R. Improving surgical education in East Africa with a standardized hernia training program. Hernia 2020; 25:183-192. [PMID: 32157505 DOI: 10.1007/s10029-020-02157-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 02/19/2020] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Inguinal hernias are among the most common surgical diseases in Africa. The current International HerniaSurge Guidelines recommend mesh-based surgical techniques in Low Resource Settings (LRS). This recommendation is currently unachievable in large parts of Africa due to the unaffordability of mesh and lack of appropriate training of the few available surgeons. There is, therefore, a need for formal training in mesh surgery. There is an experience in Hernia Repair for the Underserved in Central and South America, however, inadequate evidence of structured training in Africa. MATERIAL AND METHODS Since 2016, the aid Organizations, Surgeons for Africa and Operation Hernia have developed and employed a structured hernia surgical training program for postgraduate surgical trainees and medical doctors in Rwanda. This course consists of lectures on relevant aspects of hernia surgery and hands-on training in operating theatres. The lectures emphasize anatomy and surgical technique. All parts of the training were evaluated. Formal pre-course evaluation was conducted to assess the personal surgical experience of the trainees. RESULTS Over a 3-year period, a structured hernia training programme was employed to train a total of 36 surgical trainees in both mesh and also non mesh hernia surgery. The key principle in this course is the continuous competence assessment and feedback. Evidence is provided to demonstrate improvement in surgical skills as well as knowledge of surgical anatomy which is essential to acquiring surgical competency. With self-assessment, expressed on a Likert scale, the participants could improve the theoretical knowledge about hernias from median 4.4 (on a scale of 1-10) before training to 8.4 after the training. The specific knowledge about anatomy could be improved in the same assessment from 4.8 before training to 8.1. after the training. After training course 12 of the 36 participants (33.33%) were able to carry out both suture- and mesh-based operations of simple inguinal hernias completely and independently. 20 of the 36 participants (55.55%) required only minimal supervision and only four participants (11.11%) required surgical supervision even after the completion of the course. CONCLUSION We have demonstrated that, medical personnel in Africa can be trained in mesh and non-mesh hernia surgery using a structured training programme.
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Affiliation(s)
- R Lorenz
- 3+CHIRURGEN, Klosterstrasse 34/35, 13581, Berlin, Germany.
| | - C Oppong
- University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth, PL6 8DH, UK
| | - A Frunder
- Lorettoklinik Tübingen, Katharinenstraße 10, 72072, Tübingen, Germany
| | - M Lechner
- Department of Surgery, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | | | - A Tasi
- Asklepios Klinik Barmbek, Rübenkamp 220, 22307, Hamburg, Germany
| | - R Wiessner
- Department of General and Visceral Surgery, Bodden-Kliniken Ribnitz-Damgarten, Sandhufe 2, 18311, Ribnitz-Damgarten, Germany
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Estridge P, Sanders DL, Kingsnorth AN. Worldwide hernia repair: variations in the treatment of primary unilateral inguinal hernias in adults in the United Kingdom and in low- and middle-income countries. Hernia 2019; 23:503-507. [PMID: 31069582 DOI: 10.1007/s10029-019-01960-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 04/21/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION In this invited commentary, we aim to quantify and explain the variation between, and also within, developed healthcare systems (using the UK as an example) and low- to middle-income countries (LMICs). Rather than including complex cases, we have looked only at 'uncomplicated' primary unilateral inguinal hernias, an area where limited variation may be identified. METHODS Data were obtained from Hospital Episode Statistics and structured surveys in the United Kingdom and in low- and middle-income countries. CONCLUSION There is widespread variation in the repair of 'uncomplicated' primary inguinal hernias worldwide and within developed healthcare systems.
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Affiliation(s)
- P Estridge
- Department of Abdominal Wall and Upper GI Surgery, North Devon District Hospital, Barnstaple, UK
| | - D L Sanders
- Department of Abdominal Wall and Upper GI Surgery, North Devon District Hospital, Barnstaple, UK.
| | - A N Kingsnorth
- Former Professor of Surgery, Peninsula College of Medicine and Dentistry, Plymouth, UK
- Hernia International, Plymouth, UK
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Ahmad MH, Pathak S, Clement KD, Aly EH. Meta-analysis of the use of sterilized mosquito net mesh for inguinal hernia repair in less economically developed countries. BJS Open 2019; 3:429-435. [PMID: 31406956 PMCID: PMC6681152 DOI: 10.1002/bjs5.50147] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 01/18/2019] [Indexed: 11/10/2022] Open
Abstract
Background Inguinal hernias are common in less economically developed countries (LEDCs), and associated with significant morbidity and mortality. Tension-free mesh repair is the standard treatment worldwide. Lack of resources combined with the high cost of commercial synthetic mesh (CSM) have limited its use in LEDCs. Sterilized mosquito net mesh (MNM) has emerged as a low-cost, readily available alternative to CSM. The aim of this systematic review and meta-analysis was to evaluate the safety and efficacy of MNM for the use in hernia repair in LEDCs. Methods A systematic review and data meta-analysis of all published articles from inception to August 2018 was performed. Cochrane Central Register of Controlled Trials, MEDLINE and Embase databases were searched. The primary outcome measure was the overall postoperative complication rate of hernia repair when using MNM. Secondary outcome measures were comparisons between MNM and CSM with regard to overall complication rate, wound infection, chronic pain and haematoma formation. Results A total of nine studies were considered relevant (3 RCTs, 1 non-randomized trial and 5 prospective studies), providing a total cohort of 1085 patients using MNM. The overall complication rate for hernia repair using MNM was 9·3 per cent. There was no significant difference between MNM and CSM regarding the overall postoperative complication rate (odds ratio 0·99, 95 per cent c.i. 0·65 to 1·53; P = 0·98), severe or chronic pain (OR 2·52, 0·36 to 17·42; P = 0·35), infection (OR 0·56, 0·19 to 1·61; P = 0·28) or haematoma (OR 1·05, 0·62 to 1·78; P = 0·86). Conclusion MNM has a low overall postoperative complication rate and is unlikely to be inferior to CSM in terms of safety and efficacy. MNM is a suitable low-cost alternative to CSM in the presence of financial constraint.
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Affiliation(s)
- M H Ahmad
- University Hospitals of Leicester Leicester UK
| | - S Pathak
- University Hospitals of Leicester Leicester UK
| | - K D Clement
- Queen Elizabeth University Hospital Glasgow UK
| | - E H Aly
- Department of General Surgery, Aberdeen Royal Infirmary Aberdeen UK.,University of Aberdeen Aberdeen UK
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Abstract
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.
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Patient profiles and outcomes following repair of irreducible and reducible Ventral Wall Hernias. Hernia 2015; 20:239-47. [PMID: 25966808 DOI: 10.1007/s10029-015-1381-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 04/11/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The belief that irreducible hernias are repaired less successfully and with higher morbidity drives patients to seek elective repair. The aims of this study were threefold. First, this study sought to compare characteristics of patients undergoing irreducible and reducible ventral hernia repair. Second, to compare morbidity rates. Third, to determine which factors, including irreducibility, might be associated with recurrence. METHODS This observational study was a retrospective review of 252 consecutive ventral hernia patients divided into two cohorts: 101 patients who underwent repair of an irreducible ventral hernia, and 152 patients underwent repair of a reducible ventral hernia. The mean follow-up time was approximately 4 years in both groups. RESULTS Patients undergoing repair of irreducible hernias had higher median BMI (31 vs. 27 kg/m2, p = 0.005), had their hernias longer (median 34 months compared to 12 months, p = 0.043), had more defects on average (mean 1.8 vs. 1.4, p < 0.001), and were more likely to be symptomatic (83 vs. 55%, p = 0.002). Interestingly, neither hernia size (p = 0.821), nor the location of hernia (p = 0.261) differed significantly between the two groups. Morbidity rates, including rates of surgical site infection, obstruction, and recurrence, did not differ significantly; nor did recurrence-free survival (RFS) distributions. Risk factors for hernia recurrence on multivariate analysis included the repaired hernia being itself recurrent (HR = 2.06, 95% CI = 1.07-3.99, p = 0.031), the occurrence of post-operative surgical site infection (HR = 5.10, 95% CI = 2.18-11.91, p < 0.001), and the occurrence of post-operative intestinal obstruction (HR = 5.18, 95% CI = 1.82-14.75, p = 0.002). Irreducibility was not a significant predictor of recurrence (p = 0.152). CONCLUSION Despite differing profiles, patients with these two types of hernias did not have statistically significant differences in morbidity. Recurrence was not observed to be associated with irreducibility but was found to be associated with other post-operative complications.
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Gonenc M, Bozkurt MA, Kapan S, Aras A, Surek A, Alis H. Acutely incarcerated abdominal wall hernia: what if it is a consequence? Hernia 2013; 18:837-43. [PMID: 24121841 DOI: 10.1007/s10029-013-1166-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 10/01/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The aim of this study was to emphasize the importance of differential diagnosis in patients with acutely incarcerated abdominal wall hernia (AWH). METHODS The medical records of patients who underwent emergency surgery with preoperative diagnosis of acutely incarcerated AWH and in whom acutely incarcerated AWH was the consequence of increased intraabdominal pressure due to other abdominal emergencies were reviewed. The following data were collected: demographics, the duration between the onset of symptoms and admission, clinical findings, biochemical test results that were abnormal, radiological findings, preoperative and intraoperative diagnosis, operative findings, surgical procedure, different diagnosis made in the postoperative period, reoperation, morbidity, mortality, and the length of hospital stay. RESULTS Ten patients were included to the study. The primary pathology was found to be perforated peptic ulcer disease in three, bowel obstruction due to neoplastic mass in three, complicated appendicitis in two, acute mesenteric ischemia in one, and acute diverticulitis in one. The correct diagnosis was made during emergency surgery for hernia repair, whereas the primary pathology was identified postoperatively in two patients. CONCLUSIONS Patients who are diagnosed to have acutely incarcerated AWH preoperatively should undergo further diagnostic workup, if any level of clinical suspicion for differential diagnosis is present. Moreover, the surgeon should consider general abdominal exploration if contradictory findings are encountered during the exploration of the hernia sac, even if preoperative diagnostic studies reveal no gross pathology or non-specific findings.
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Affiliation(s)
- M Gonenc
- Genel Cerrahi Klinigi, Dr. Sadi Konuk Egitim ve Arastirma Hastanesi, Bakirkoy, 34147, Istanbul, Turkey,
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