Endoscopic Mini- or Less-Open Sublay operation with transversus abdominis muscle release using a single-port platform for incisional hernia: A video vignette

TECHNIQUE

The Endoscopic Mini- or Less-open Sublay operation (EMILOS) is a transhernial repair that allows endoscopic dissection and mesh placement in the retrorectus/retromuscular space, and simultaneous transversus abdominis release (TAR) for larger hernias. The operative summary is as follows. 1 A 7-cm longitudinal skin incision was made immediately above the hernial orifice. 2 The hernial sac was circumferentially dissected to the border of the defect, and the abdomen was opened. 3 The posterior rectus sheath (PRS) was incised approximately 5 mm lateral to the medial border of the rectus sheath to enter the retrorectus space. 4 Exploratory laparoscopy was performed, and the peritoneum was closed. 5 A single port platform was attached to the wound, and the abdominal wall was insufflated. The retrorectal space was dissected laterally to the outer edge of the rectus abdominis muscle. The linea alba was incised at least 5 cm cranially and caudally from the border of the hernia defect to obtain sufficient mesh overlap. 6 The TAR was added to the left side to facilitate medial advancement of the PRS. (7) The PRS was approximated with continuous suture. A self-gripping mesh was trimmed and implanted in the retrorectus space. The mesh was secured with 3-0 absorbable sutures (8) A closed-suction drain was placed on the mesh, and the wound was trimmed and closed.

RESULTS

The postoperative course was uneventful. No recurrence was observed at 6-month follow-up.

CONCLUSIONS

This technique may be advantageous because it allows minimal skin incision with physiological reconstruction of abdominal wall.

Fibroblast matrix implants-a better alternative for incisional hernia repair?

The standard surgical procedure for abdominal hernia repair with conventional prosthetic mesh still results in a high recurrence rate. In the present study, we propose a fibroblast matrix implant (FMI), which is a three-dimensional (3D) poly-L-lactic acid scaffold coated with collagen (matrix) and seeded with fibroblasts, as an alternative mesh for hernia repair. The matrix was seeded with fibroblasts (cellularized) and treated with a conditioned medium (CM) of human Umbilical Cord Mesenchymal Stem Cells (hUC-MSC). Fibroblast proliferation and function were assessed and compared between treated with CM hUC-MSC and untreated group, 24 h after seeding onto the matrix (n= 3). To study the matricesin vivo,the hernia was surgically created on male Sprague Dawley rats and repaired with four different grafts (n= 3), including a commercial mesh (mesh group), a matrix without cells (cell-free group), a matrix seeded with fibroblasts (FMI group), and a matrix seeded with fibroblasts and cultured in medium treated with 1% CM hUC-MSC (FMI-CM group).In vitroexamination showed that the fibroblasts' proliferation on the matrices (treated group) did not differ significantly compared to the untreated group. CM hUC-MSC was able to promote the collagen synthesis of the fibroblasts, resulting in a higher collagen concentration compared to the untreated group. Furthermore, thein vivostudy showed that the matrices allowed fibroblast growth and supported cell functionality for at least 1 month after implantation. The highest number of fibroblasts was observed in the FMI group at the 14 d endpoint, but at the 28 d endpoint, the FMI-CM group had the highest. Collagen deposition area and neovascularization at the implantation site were observed in all groups without any significant difference between the groups. FMI combined with CM hUC-MSC may serve as a better option for hernia repair, providing additional reinforcement which in turn should reduce hernia recurrence.

Devices in Hernia Surgery

Despite the heavy reliance of surgeons on mesh with which to repair hernias, less attention is paid to the technical specifications of mesh and/or regulatory processes for bringing medical devices to market during surgical training. This article summarizes some of the key controversies and points regarding mesh materials and regulatory processes related to mesh devices.

Slowly absorbable mesh versus standard care in the management of contaminated midline incisional hernia (COMpACT-BIO): a multicentre randomised controlled phase III trial including a health economic evaluation

INTRODUCTION

Incisional hernia (IH) is the most frequent mid-term and long-term complication after midline laparotomy. The current standard treatment includes repair using a mesh. In a contaminated field, the use of a non-absorbable mesh increases the risk of surgical site infection and the costs. Slowly absorbable meshes are safe in contaminated fields, but no data have been reported regarding their long-term recurrence rate. COMpACT-BIO is a multicentre prospective randomised controlled phase III trial designed to compare the 3-year recurrence rate in patients undergoing contaminated IH repair with either a slowly absorbable mesh or standard care.

METHODS

In patients undergoing midline IH repair in a contaminated surgical field (grade III of the modified Ventral Hernia Working Group classification), the COMpACT-BIO study compares the use of a slowly absorbable mesh with that of conventional care according to standardised surgical procedures (primary closure, non-absorbable synthetic mesh or biologic mesh, at the discretion of the surgeon). Randomisation is done during surgery before closure the fascia with an allocation ratio of 1:1. The choice of the slowly absorbable mesh is left to the criteria of each centre. The primary endpoint is the proportion of patients with scan-confirmed IH recurrence within 3 years after repair.

ETHICS/DISSEMINATION

This trial is conducted in compliance with international standards for research practice and reporting. Written informed consent will be obtained from patients prior to inclusion. All data were identified and anonymised prior to analysis. The protocol has been approved by an Institutional Review Board (2020-A0823-36/SI:20.07.03.66831), and will be conducted in compliance with the CONSORT (Consolidated Standards of Reporting Trials) statement. Results will be submitted for publication in peer-reviewed medical journals and presented to patients and healthcare professionals.

PROTOCOL VERSION

Version 2-13 October 2020.

TRIAL REGISTRATION NUMBER

NCT04597840.

Laparoscopic Paraesophageal Hernia Repair: To Mesh or not to Mesh. Systematic Review and Meta-analysis

OBJECTIVE

This study aimed to compare outcomes after laparoscopic paraesophageal hernia repair (LPEHR) with mesh or primary repair alone.

SUMMARY OF BACKGROUND DATA

High recurrence rates after LPEHR have been reported. Whether the use of mesh improves outcomes remains elusive.

METHODS

A systematic literature search was performed to identify randomized controlled trials (RCTs) comparing LPEHR with mesh repair versus suture repair alone. Early (≤6 months) and late (>6 months) recurrence rates were used as primary endpoints to assess efficacy. Intraoperative complications, overall morbidity, and reoperation rates were used as secondary endpoints to assess safety. A meta-analysis was conducted using relative risks (RR) with 95% confidence intervals (CI) for the analyzed outcomes.

RESULTS

Seven RCTs comparing mesh (n = 383) versus suture only (n = 352) repair were included for analysis. Patients undergoing LPEHR with mesh reinforcement had similar early (RR = 0.74, 95% CI = 0.26-2.07, P = 0.46) and late (RR = 0.75, 95% CI = 0.27-2.08, P = 0.48) recurrence rates as those with primary repair. Similar recurrence rates were also found when stratifying the analysis by the type of mesh utilized (absorbable and nonabsorbable). Intraoperative complications (RR = 1.03, 95% CI = 0.33-3.28, P = 0.92) and reoperation rates (RR = 0.75, 95% CI = 0.29-1.92, P = 0.45) were also similar in both groups. Overall morbidity, however, was higher after mesh repair with nonabsorbable mesh (RR = 1.45, 95% CI = 1.24-1.71, P < 0.01).

CONCLUSIONS

Patients undergoing LPEHR have similar early and late recurrence rates with either mesh reinforcement or suture only repair, regardless of the type of mesh utilized. Overall morbidity, however, seems to be higher in patients repaired with nonabsorbable mesh.

Impact of Trainee Participation on Inguinal Hernia Repair Outcome: A Study Based on the Swedish Hernia Register

OBJECTIVE

The aim of this study was to investigate whether differences in postoperative outcome exist between open inguinal hernia repairs performed by surgical trainees and those performed by specialist surgeons.

SUMMARY OF BACKGROUND DATA

Inguinal hernia repair is the prototype educational surgical procedure. The impact of trainee participation on postoperative outcome is still controversial and despite earlier studies no reliable hernia-specific data exist.

METHODS

The study cohort was based on the Swedish Hernia Register and consisted of 61,161 cases of male patients aged 18 years and older with open anterior mesh repair of a primary inguinal hernia between January 1, 2002, and December 31, 2014. The study cohort was selected to represent the typical trainee procedure in Sweden. Primary outcome measures were reoperation due to hernia recurrence and postoperative 30-day complications.

RESULTS

Procedures with longer operating times were at a higher risk for reoperation when performed by supervised trainees [57 to 72 minutes: hazard ratio (HR) 1.55, 99% confidence interval (99% CI) 1.05-2.27] or unsupervised trainees (57 to 72 minutes: HR 1.60, 99% CI 1.18-2.17; >72 minutes: HR 1.72, 99% CI 1.25-2.37). The same was true for specialist and trainee-assisted specialists with operating times <43 minutes (HR 1.63, 99% CI 1.25-2.13; HR 1.58, 99% CI 1.09-2.28). Postoperative 30-day complications were generally associated with longer operating times and occurred at all levels of experience.

CONCLUSION

Trainee participation in open inguinal repair in combination with longer operating time is a risk factor associated with higher reoperation rates. This calls for a more structured supervision of trainees in an assumedly basic procedure.

Total endoscopic sublay mesh repair for umbilical hernias

Umbilical hernias constitute some of the most common surgical diseases addressed by surgeons. Endoscopic techniques have become standard of care together with the conventional open techniques for the treatment of umbilical hernias. Several different approaches were described to achieve laparoscopic sublay repair.We prospectively collected and reviewed the medical records of 10 patients with umbilical hernias underwent total endoscopic sublay repair (TES) at our institution from November 2017 to November 2019. All operations were performed by a same surgical team. The demographics, intraoperative details, and postoperative complications were evaluated.All TES procedures were successfully performed without conversion to an open operation. No intraoperative morbidity was encountered. The average operative time was 109.5 minutes (range, 80-140 minutes). All the patients resumed an oral diet within 6 hours after the intervention. The mean time to ambulation was 7.5 hours (range, 4-14 hours), and mean postoperative hospital stay was 2.2 day (range, 1-4 days). One patient developed postoperative seroma. No wound complications, chronic pain, or recurrence were registered during the follow-up.Initial experiences with this technique show that the TES is a safe, and effective procedure for the treatment of umbilical hernias.

Engineering multifunctional bactericidal nanofibers for abdominal hernia repair

The engineering of multifunctional surgical bactericidal nanofibers with inherent suitable mechanical and biological properties, through facile and cheap fabrication technology, is a great challenge. Moreover, hernia, which is when organ is pushed through an opening in the muscle or adjacent tissue due to damage of tissue structure or function, is a dire clinical challenge that currently needs surgery for recovery. Nevertheless, post-surgical hernia complications, like infection, fibrosis, tissue adhesions, scaffold rejection, inflammation, and recurrence still remain important clinical problems. Herein, through an integrated electrospinning, plasma treatment and direct surface modification strategy, multifunctional bactericidal nanofibers were engineered showing optimal properties for hernia repair. The nanofibers displayed good bactericidal activity, low inflammatory response, good biodegradation, as well as optimal collagen-, stress fiber- and blood vessel formation and associated tissue ingrowth in vivo. The disclosed engineering strategy serves as a prominent platform for the design of other multifunctional materials for various biomedical challenges.

Four-year follow-up in 33 patients after inguinal hernioplasty using the NeT Plug & Patch device

AIM

To prove that the Net Plug & Patch is a valid device for the surgical treatment of inguinal hernia.

MATERIAL OF STUDY

The authors of a previous study decided to continue the follow-up for a further three years on 33 patients who had had hernia repair surgery using the three-dimensional NeT Plug & Patch device at their Hernia Center.

RESULTS

All of the patients involved took part and the follow-up appointments were scheduled as follows: clinical examination at two years; telephone contact at three years and telephone contact and questionnaire at four years. No symptoms were observed at the second, third and fourth year follow-up time-points. There were no cases of recurrence.

DISCUSSION

The Lichtenstein technique is currently considered the gold standard. However, many surgeons now prefer to use the MPR (Mesh Plug Repair) technique, despite the potential complications of using a plug. The technique had a short learning curve with no complications associated directly with the plug used such as migration or possible erosion of the adjacent hollow abdominal organs or blood vessels.

CONCLUSIONS

the NeT Plug & Patch device thus proved to be comfortable, safe and efficacious in inguinal repair surgery using the MPR technique.

KEY WORDS

Mesh Plug Repair (MPR), Plug migration, Trabucco repair.

Tension-free mesh versus suture-alone cruroplasty in antireflux surgery: a randomized, double-blind clinical trial

BACKGROUND

Antireflux surgery is effective for the treatment of gastro-oesophageal reflux disease (GORD) but recurrence of hiatal hernia remains a challenge. In other types of hernia repair, use of mesh is associated with reduced recurrence rates. The aim of this study was to compare the use of mesh versus sutures alone for the repair of hiatal hernia in laparoscopic antireflux surgery.

METHODS

Patients undergoing laparoscopic Nissen fundoplication for GORD between January 2006 and December 2010 were allocated randomly to closure of the diaphragmatic hiatus with crural sutures or non-absorbable polytetrafluoroethylene mesh (CruraSoft®). The primary outcome was recurrence of hiatal hernia, as determined by barium swallow study 12 months after surgery. Secondary outcomes were: intraoperative and postoperative complications, use of antireflux medication, postoperative oesophageal acid exposure, quality of life, dysphagia and duration of hospital stay.

RESULTS

Some 77 patients were randomized to the suture technique and 82 patients underwent mesh repair. At 1 year, the hiatal hernia had recurred in six of 64 patients (9 per cent) in the mesh group and two of 64 (3 per cent) in the suture group (P = 0·144). Reflux symptoms, use of proton pump inhibitors and oesophageal acid exposure did not differ between the groups. At 3 years, recurrence rates were 13 and 10 per cent in the mesh and suture groups respectively (P = 0·692). Dysphagia scores decreased in both groups, but more patients had dysphagia for solid food after mesh closure (P = 0·013). Quality-of-life scores were comparable between the groups.

CONCLUSION

Tension-free crural repair with non-absorbable mesh does not reduce the incidence of recurrent hiatal hernia compared with use of sutures alone in patients undergoing laparoscopic fundoplication. NCT03730233 ( http://www.clinicaltrials.gov).

Three-dimensional visualization and measurement of myopectineal orifice in non-inguinal hernia patients

PURPOSE

The myopectineal orifice (MPO) is a weak area at lower part of the anterior abdominal wall that directly determines the mesh size required in inguinal hernia repair. However, MPO data have mainly been acquired from measurements of cadavers or anesthetized patients. Furthermore, there are very few reports on the measurement of the MPO in Chinese patients. The present study aimed to use three-dimensional visualization technology to measure the MPO in live non-anesthetized Chinese patients, and to use this information to indicate the appropriate mesh size required for inguinal hernia repair.

METHODS

In this study, we used the parameters of the MPO and the pelvis that were measured in 40 patients with peripheral arterial disease of the lower limb arteries (80 inguinal regions) using Medraw software (Image Medraw Technology Co., Ltd., China).

RESULTS

The result showed that the average width and height of the MPO were 5.71 ± 0.99 cm and 4.96 ± 0.69 cm, respectively (5.22 ± 0.77 cm and 5.13 ± 0.63 cm in males, and 6.20 ± 0.95 cm and 4.80 ± 0.71 cm in females). The average projected area of the MPO was 16.06 ± 4.37 cm² on the left, and 15.61 ± 4.10 cm² on the right (P > 0.05).

CONCLUSION

Three-dimensional visualization was used to measure the area, width, and height of the MPO in living non-anesthetized Chinese patients. MPO area was correlated with age, but not with pelvic parameters.

The current state of robotic retromuscular repairs-a qualitative review of the literature

BACKGROUND

The management of ventral incisional hernias (VIH) has undergone many iterations over the last 5 years due to evolution in surgical techniques and advancement in robotic surgery. Four general principles have emerged: mesh usage, retromuscular mesh placement, primary fascial closure, and usage of minimally invasive techniques when possible. The application of robotic retromuscular repairs in VIH allow these principles to be applied simultaneously. This qualitative review attempts to answer what robotic retromuscular repairs are described, which patients are selected for these techniques, and what are current outcomes.

METHODS

Using the key words: "robotic retromuscular repair", "robotic Rives Stoppa", and "robotic transversus abdominis release", a PubMed search of articles written up to December 2019 was critically reviewed.

RESULTS

44 articles were encountered, 9 high-quality articles were analyzed for this manuscript. Level of evidence ranged from 2B to 2C. Robotic TAR patients had BMI of 33 kg/m², defect sizes ranging from 7-14 cm wide to 12-19 cm long, longer OR times, no difference in surgical site events, and shorter length of stay (LOS). The techniques to perform robotic Rives Stoppa (RS) were heterogeneous; however, extended totally extraperitoneal (ETEP) approach is most described. Defect width for RS repairs ranged 4-7 cm and LOS was less than 1 day. Complication rates were low, there is no long-term data on hernia recurrence, and information on cost is limited.

CONCLUSION

In short-term follow-up, robotic retromuscular repairs show promise that VIH can be repaired with intramuscular mesh, few complications, and shorter LOS. Data on hernia recurrence, long-term complications, and rigorous cost analysis are needed to demonstrate generalizability.

Trans-umbilical single-incision laparoscopic trans-abdominal pre-peritoneal hernioplasty of inguinal hernia by self-made glove port

Laparoscopic inguinal herniorrhaphy has been well established for the management of primary and recurrent inguinal hernias. Single-incision laparoscopic surgery (SILS) has now been accepted as a less invasive alternative to conventional laparoscopic surgery. However, commercially available access devices for SILS had disadvantages such as rigidness and crowding. This series aimed to analyze the feasibility and safety of single-incision laparoscopic trans-abdominal pre-peritoneal hernioplasty (SILS-TAPP) by applying our self-made device for managing inguinal hernia.We collected and reviewed the medical records of patients who received SILS-TAPP using a self-made glove-port device between January 2014 and January 2016. All operations were performed by the same surgical team. The demographics and intra- and perioperative outcomes were evaluated.SILS-TAPP was successfully performed in 105 patients (131 inguinal hernia repairs). No major intra- and postoperative morbidities were encountered, and no conversion to a conventional 3-port approach or open surgery was required. The mean operative time was 73.5 min and the mean postoperative hospital stay was 2.1 days. Three minor short-term complications were noted, which were resolved without surgical intervention. One recurrence was diagnosed during follow-up and treated using a second TAPP procedure.SILS-TAPP was shown to be a feasible, safe procedure in patients with an inguinal hernia. A simple self-made glove-port device was proven as a practical method of SILS-TAPP.

Poly-4-hydroxybutyrate (Phasix™) mesh onlay in complex abdominal wall repair

BACKGROUND

Poly-4-hydroxybutyric acid (P4HB, Phasix™) is a biosynthetic polymer that degrades by hydrolysis that can be woven into a mesh for use in soft tissue reinforcement. Herein, we describe our initial experience performing complex abdominal wall repair (CAWR) utilizing component separation and P4HB mesh as onlay reinforcement.

METHODS

All patients undergoing CAWR between June 2014 and May 2017 were followed prospectively for postoperative outcomes. Only those patients who underwent components separation with primary repair of the fascial edges followed by onlay of P4HB mesh were included in this study.

RESULTS

105 patients (52 male, 53 female; mean age 59.2 years, range 22-84) met inclusion criteria. Mean BMI was 29.1 (range 16-48); 52% patients had prior attempted hernia repair, most with multiple medical comorbidities (71% of patients with ASA 3 or greater). 30% of cases were not clean at the time of repair (CDC class 2 or greater). Median follow-up was 36 months (range 9-63). Eighteen patients (17%) developed a hernia recurrence ranging from 2 to 36 months postoperatively. Five (5%) patients developed a localized superficial infection treated with antibiotics, three (2.8%) required re-operation for non-healing wounds, and six (6%) patients developed seroma.

CONCLUSIONS

These data demonstrate a relatively low rate of hernia recurrence, seroma, and other common complications of CAWR in a highly morbid patient population. Importantly, the rate of mesh infection was low and no patients required complete mesh removal, even when placed into a contaminated or infected surgical field.

Mini-mesh and Lichtenstein repair compared with a modified Kugel technique for femoral hernia: a randomised controlled trial

INTRODUCTION

A modified Kugel patch is more expensive than ordinary mesh and demands a wide dissection of the preperitoneal space in femoral hernia repair. We therefore adopted a novel method using mini-mesh and a Lichtenstein repair. This study compared mini-mesh and Lichtenstein repair with a modified Kugel technique in patients with a primary unilateral femoral hernia.

METHODS

Patients with unilateral femoral hernia were assigned randomly to undergo mini-mesh and Lichtenstein repair (M group) or modified Kugel repair (K group), followed-up at one week, three months, one year and two years. Demographics, hernia characteristics and operative outcomes of two groups were analysed.

RESULTS

A total of 48 patients in the K group and 49 participants in the M group completed follow-up. The operation time for the M group (68.6 ± 13.4 minutes) was significantly shorter than that of the K group (80.6 ± 10.1 minutes; p=0.030). There was no significant difference between the two groups for chronic pain, foreign body feeling and quality of life, and no recurrence occurred.

CONCLUSIONS

Mini-mesh and Lichtenstein repairs have reasonable results in the patients with femoral hernia in this study, with a reduced operation time compared with a modified Kugel repair. The trial was registered with the Chinese Clinical Trials Registry: ChiCTR1900022264.

Hernia Repair Strength Enhanced With Antioxidants

BACKGROUND

Incisional hernia is one of the most common complications of abdominal surgery, and repairs are associated with significant recurrence rates. Mesh repairs are associated with the best outcomes, but failures are not uncommon. Doxycycline has been demonstrated to enhance mesh hernia repair outcomes with associated increases in collagen deposition and improved tensiometric strength. This study compares the outcomes of incisional hernia repair with doxycycline administration and the antioxidant tempol.

MATERIALS AND METHODS

Twenty-eight male Sprague Dawley rats underwent a midline hernia creation and an intraabdominal polypropylene mesh repair. The animals were administered saline, doxycycline, tempol, or both, daily for 8 wk. The abdominal wall was harvested at 8 wk and tensiometric strength and biochemical analysis was performed.

RESULTS

The tensiometric strength of the repair was increased in all experimental groups. Collagen type 1 deposition was increased, and collagen type 3 deposition was decreased in each of the experimental groups relative to control. There was no difference in MMP-2 and MMP-9 levels between control and experimental groups.

CONCLUSIONS

The hernia repair strength is equally enhanced with the administration of doxycycline or tempol. Dual therapy provided no benefit over treatment with either single agent. All treatment groups had an increase in collagen type 1:3 ratios, but the mechanism is not well understood. The benefits of antioxidant treatment following hernia repair are similar to treatment with doxycycline. Given the high frequency of incisional hernia repair failures, this study has implications for improving outcomes following ventral hernia repair through the use of either doxycycline or antioxidant therapy.

Retromuscular mesh and hernial sac technique in the reconstruction of 139 cases of large median incisional hernias: one institution's experience

PURPOSE

Incisional hernia is the most common complication of laparotomy. Postoperative parietal defects tend to relapse, even after the most optimal surgical methods. The aim of this study was to present the effectiveness of an adapted retromuscular technique with prolene mesh and a hernial sac, in patients with large incisional median hernias. The reported results were obtained by our team after more than 15 years of experience.

METHODS

This retrospective study included 139 consecutive cases of large median incisional hernias operated on using a retromuscular mesh and hernial sac technique. The cross-sectional diameter of incisional hernias was larger than 10 cm, being classified in the W₃ group, according to the European Hernia Society classification.

RESULTS

The study included 83 females (59.71%) and 56 males (40.29%) with a median age of 62.4 ± 16.6 years and an average body mass index of 32.4 ± 7.6 kg. The hernia was supraumbilically located in 54 cases, subumbilically in 61 cases, and supra- and subumbilically in 24 cases. Postoperative complications were recorded in eight cases (5.75%): one case with a hematoma in the right abdominal muscle sheath; five cases with supra-aponeurotic seromas; two cases with skin necrosis and one with a mesh infection. Recurrence occurred in seven cases (5.03%): four cases in the first 2 years postoperatively and three cases in the third year after surgery.

CONCLUSIONS

The retromuscular technique with prolene mesh and a hernial sac is an effective method of restoring the integrity of the abdominal wall in large median incisional hernias with low rates of morbidity and recurrence.

Ovarian inguinal hernia

INTRODUCTION

Gynaecological structures such as the ovaries, fallopian tubes, ligaments and uterus are rarely encountered inside a hernial sac. The prevalence of groin hernias containing parts of female genitalia remains unknown. The aim of this review was to summarise the existing evidence on inguinal hernias containing ovaries with or without the other female adnexa.

METHODS

A systematic search was conducted for literature published up to February 2018 using the MEDLINE®, Scopus® and Google Scholar™ databases along with the references of the full-text articles retrieved. Papers on observational studies and case reports concerning women who were diagnosed with an ovarian inguinal hernia (pre or intraoperatively) were considered eligible for inclusion in the review.

RESULTS

Fifteen papers (13 case reports, 2 case series) comprising seventeen patients (mean age 47.9 years) were evaluated. A left-sided hernia was noted in 13 cases (77%) whereas 4 patients had a right-sided hernia. Eight patients underwent preoperative imaging with computed tomography, ultrasonography or both. This was diagnostic in five cases. In 11 patients, hernia contents were repositioned, 2 had a salpingo-oophorectomy and 2 an oophorectomy. Eight patients underwent hernia repair with mesh placement while three had a herniorrhaphy.

CONCLUSIONS

Ovarian inguinal hernias should be considered among the differential diagnoses of a groin mass or swelling. In women of reproductive age, repair of the hernia with the intent to preserve fertility is of critical importance.

Randomized Trial Comparing Self-Gripping Mesh with Polypropylene Mesh in Female Lichtenstein Hernioplasty

Several randomized trials comparing self-gripping mesh with polypropylene (PL) mesh in Lichtenstein hernioplasty revealed that the self-gripping mesh significantly reduced the operation time. In these studies, some enrolled only male patients, and in others, the proportion of women was extremely low. The aim of this research was to compare outcomes after self-gripping mesh repair with PL mesh secured with sutures in female Lichtenstein hernioplasty. Female patients with primary unilateral inguinal hernia were assigned randomly to undergo Lichtenstein hernioplasty with a self-gripping ProGrip (PG) mesh or a sutured PL mesh, followed-up at one week, one month, three months, one year, and two years. Demographics, hernia characteristics, and operative outcomes data were analyzed. Pain was assessed with a visual analog scale (0-10), and quality of life (QOL) was estimated by a 36-item short-form general survey (0-26). Forty eight patients in the PG group and 51 participants in the PL group completed the follow-up. The operation time of the PG (54.1 ± 12 minutes) group was significantly shorter than that of the PL (60.9 ± 11.3 minutes) group (P = 0.045). At the one-month follow-up, the incidence of foreign body feeling in the PG group was significantly higher than that in the PL group (P = 0.031), whereas no significant difference was observed in visual analog scale ≥3 and QOL. In a follow-up of three months, one year, and two years, there was no significant difference in foreign body feeling, chronic pain, QOL, and recurrence between two groups. The surgical outcomes of self-gripping mesh are comparable to those of the ordinary PL mesh with a reduced operation time in female Lichtenstein hernioplasty. Registration number: ChiCTR1800017360 (<ext-link ext-link-type="uri" xlink:href="http://www.chictr.org.cn">http://www.chictr.org.cn</ext-link>).

A rare case report of bilateral recurrent inguinal hernia due to persistent Müllerian duct syndrome treated by transabdominal preperitoneal repair

INTRODUCTION

Persistent Müllerian duct syndrome (PMDS) is a rare disease occurring in men with an otherwise completely normal phenotype, in which female internal sex organs are present, including a uterus, fallopian tubes, cervix, and vagina. We report a case of bilateral recurrent inguinal hernia due to PMDS treated by transabdominal preperitoneal repair (TAPP).

PATIENT CONCERNS

A 72-year-old male presented with a complaint of swelling on both sides of the groin. The patient had undergone bilateral inguinal hernia suture repair 50 years ago.

DIAGNOSIS

Bilateral recurrent inguinal hernia INTERVENTIONS:: TAPP was performed. There was a fibrous structure linking the left and right hernia orifice and a muscular structure in the hernia sac on the left. We noticed that the muscular structure was a vagina and fibrous structure was the salpinx, and we diagnosed the patient with PMDS. Supravaginal hysterectomy and right salpingectomy were performed. After that a preperitoneal mesh repair was performed for bilateral inguinal hernia.

OUTCOMES

Histologically, the diagnosis was confirmed as PMDS. The patient had an uneventful recovery.

CONCLUSION

This case is the first case of bilateral recurrent inguinal hernia due to PMDS managed by TAPP.

Chronic pain and risk for reoperation for recurrence after inguinal hernia repair using self-gripping mesh

BACKGROUND

Improved recurrence rates after groin hernia surgery have led to chronic pain becoming the most troublesome postoperative complication. Self-gripping mesh was developed to decrease the risk for development of chronic pain. The aim of this nationwide cohort study was to compare recurrence rate and chronic pain 1 year after an open, anterior mesh repair of inguinal hernias with either a self-gripping mesh or other lightweight mesh.

METHOD

All operations registered as open anterior mesh repair (Lichtenstein) in the Swedish Hernia Registry between September 2012 and October 2016 were selected. At 1 year after repair, patients were sent a pain questionnaire assessing chronic pain. We compared the prevalence of chronic pain and reoperation for recurrence using lightweight, sutured mesh or self-gripping mesh.

RESULTS

We analyzed the 1,803 repairs using self-gripping mesh and 16,567 repairs using lightweight mesh. We found no difference in the prevalence of chronic pain 1 year after the hernia repair between self-gripping mesh and sutured lightweight mesh (OR 0.92, CI 95% 0.80-1.06, P = .257). There was no increase in reoperation for recurrence when using self-gripping mesh (HR 0.71, CI 95% 0.45-1.14, P = .156). Mean operation time was considerably less when using self-gripping mesh (43 vs 70 minutes; P > .001).

CONCLUSION

The use of self-gripping mesh does not decrease the incidence of chronic pain and reoperation for recurrence compared with lightweight, sutured mesh for open anterior mesh repair of inguinal hernias. Furthermore, the use of self-gripping mesh is associated with a clinically important, lesser operation time.

Mesh fixation technique for inguinal hernia repair: protocol for an umbrella review with integrated and updated network meta-analysis

INTRODUCTION

Inguinal hernia mesh repair is the standard care for symptomatic inguinal hernia. Mesh fixation is used to keep mesh in place for which various mesh fixation techniques have been used in open and laparoscopic inguinal hernia repair, but their effectiveness has remained inconclusive. Therefore, we developed a protocol for an umbrella review in order to summarise the evidences with integrate and update data of different mesh fixation techniques in both open and laparoscopic inguinal hernia repair.

METHODS AND ANALYSIS

Previous systematic reviews and meta-analyses will be identified from Medline, Scopus, Cochrane Databases, EMBASE, Database of Abstracts of Reviews of Effects, PROSPERO Register, CINAHL, JBISRIS, EPPI-Centre, Wiley Online Library and Science Direct database. Two reviewers will independently determine studies for eligibility. Disagreement will be solved by consensus and arbitrated by the third reviewer. Data extraction will also be performed by two independent reviewers. For umbrella review, a descriptive analysis will be applied to describe evidence of mesh fixation effectiveness. Overlapping studies and excess significance test will be performed to assess whether previous evidences are bias. In addition, individual studies from meta-analysis and additional published studies will be pooled using network meta-analyses. We will use I² statistic and Cochran's Q test to assess heterogeneity. Risk of bias and publication bias, if appropriate, will be evaluated, as well as overall strength of the evidence.

ETHICS AND DISSEMINATION

This protocol has been registered with PROSPERO and approved with Institutional Review Board, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand (COA 167/2018). The results will be published in peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42018111773.

Minimising recurrence after primary femoral hernia repair; is mesh mandatory?

PURPOSE

The recent international hernia guidelines advocate laparoscopic pre-peritoneal mesh repair for primary femoral hernias. However, no randomised trial has demonstrated a lower recurrence rate compared to suture repair. This study aimed to determine the 5-year recurrence rate following femoral hernia repair, in elective and emergency settings, according to surgical approach (open or laparoscopic) and method (suture, suture + mesh, or mesh alone).

METHODS

Consecutive patients undergoing primary femoral hernia repairs within a single health board, between 2007 and 2013, were identified from a prospective audit. Patients who had died or were uncontactable during the period of follow-up were excluded. Recurrence was defined as the clinical suspicion of an ipsilateral groin hernia at outpatient review or patient reported ipsilateral groin swelling.

RESULTS

A total of 297 patients underwent primary femoral hernia repairs in the time period. Of the 138 cases with complete follow-up, 25 patients experienced recurrence at 5 years (18%), with 60% of recurrences evident within the first post-operative year. The median follow-up of the remaining 113 patients was 93 months (range 63-127). No difference could be detected in recurrence rates (P = 0.372, P = 0.353), or time to recurrence (P = 0.421, P = 0.295), according to repair type (suture only, suture and mesh, or mesh only) or surgical approach (high open, low open and laparoscopic pre-peritoneal), respectively.

CONCLUSIONS

Use of different surgical approaches and types of repair for primary presentations of femoral hernia did not affect the recurrence rate or time to recurrence. Use of a pre-peritoneal mesh did not alter the recurrence rate or recurrence free survival, in either elective or emergency settings, compared to simple suture repair. Recurrence following primary femoral hernia repair tends to occur within the first post-operative year, suggesting that technical factors may be as important as suture or mesh failure.

Non-Cross-Linked Collagen Mesh Performs Best in a Physiologic, Noncontaminated Rat Model

BACKGROUND

In laparoscopic incisional hernia repair, direct contact between the prosthesis and abdominal viscera is inevitable and may lead to adhesions. Despite the large variety of mesh prosthesis, little is known about their in vivo behavior. Biological meshes are considered to have many advantages, but due to their price they are rarely used. A rat model was used to assess biological and conventional synthetic meshes on their in vivo characteristics.

DESIGN

One-hundred twenty male Wistar rats were randomized into five groups of 24 rats. A mesh was implanted intraperitoneally and fixated with nonresorbable sutures. The following five meshes were implanted: Parietene (polypropylene), Permacol (cross-linked porcine acellular dermal matrix), Strattice (non-cross-linked porcine acellular dermal matrix), XCM Biologic (non-cross-linked porcine acellular dermal matrix), and Omyra Mesh (condensed polytetrafluoroethylene). The rats were sacrificed after 30, 90, or 180 days. Incorporation, shrinkage, adhesions, abscess formation, and histology were assessed for all meshes.

RESULTS

All animals thrived postoperatively. After 180 days, Permacol, Parietene, and Omyra Mesh had a significantly better incorporation than Strattice ( P = .001, P = .019, and P = .037 respectively). After 180 days, Strattice had significantly fewer adhesions on the surface of the mesh than Parietene ( P < .001), Omyra Mesh ( P = .011), and Permacol ( P = .027). After 30 days, Permacol had significantly stronger adhesions than Strattice ( P = .030). However, this difference was not significant anymore after 180 days. After 180 days, there was significantly less shrinkage in Permacol than in Strattice ( P = .001) and Omyra Mesh ( P = .050).

CONCLUSION

Based on incorporation, adhesions, mesh shrinkage, and histologic parameters, Strattice performed best in this experimental rat model.

Long-term Outcome of Incisional Hernia Repairs Using the Erlangen Inlay Onlay Mesh (EIOM) Technique

BACKGROUND

The objective of this study was to investigate the long-term outcome of incisional hernias treated with the Erlangen Inlay Onlay Mesh (EIOM) repair technique, taking into account recurrence, complications, and patient satisfaction.

METHODS

A total of 163 patients treated in the surgical department of Erlangen university hospital with the EIOM repair between the years 1996 and 2009 were evaluated retrospectively.

RESULTS

The collected data revealed a mean follow-up period of 70 (18-190) months. Incisional hernia recurrence after EIOM repair was observed in 6 (3.7%) patients after a mean observation period of 70 mo (18-190) postoperatively. The recurrence rate increased significantly when the body mass index (BMI) was higher than 32 kg/m². Here, a recurrence rate of 10.5% for BMI> 32 versus 1.7% with BMI ≤32 was reported. There were no significant differences in hernia recurrence if haven been operated by an assistant under supervision or by a consultant. In regard to patient satisfaction, 91% of patients included in this study were satisfied with the surgical outcome.

CONCLUSIONS

The EIOM procedure is a safe surgical technique that can be used for the treatment of all, also for giant incisional abdominal wall hernias regardless of the size, BMI, or position of the incisional hernia.

Robotic Inguinal Hernia Repair (TAPP) First Experience with the New Senhance Robotic System

INTRODUCTION

This retrospective study was performed to evaluate the safety and feasibility of the new Senhance Robotic System (TransEnterix Inc., Morrisville, North Carolina) for inguinal hernia repairs using the transabdominal preperitoneal approach.

MATERIALS AND METHODS

From March to September 2017, 76 inguinal hernia repairs in 64 patients were performed using the Senhance Robotic System. Patients were between 18 and 90 years of age, eligible for a laparoscopic procedure with general anesthesia, had no life-threatening disease with a life expectancy of less than 12 months, and a body mass index (BMI) < 35. A retrospective chart review was performed for a variety of pre-, peri-, and postoperative data including, but not limited to, patient demographics, hernia characteristics, and intraoperative and postoperative complications.

RESULTS

Fifty-four male and 10 female patients were included in the study. Median age was 56.5 years (range 22-86 years), and median BMI was 25.9 kg/m2 (range 19.5-31.8 kg/m2). Median docking time was seven minutes (range 2-21 minutes), and median operative time was 48 minutes (range 18-142 minutes). Two cases were converted to standard laparoscopic surgery due to robot malfunction and abdominal wall bleeding, respectively. Median length of stay was one day.

CONCLUSION

We report the first series of laparoscopic inguinal hernia repairs using the new Senhance Robotic System. Compared to conventional laparoscopic transabdominal preperitoneal (TAPP) hernia repairs, there was no significant difference in operative time or perioperative complications. Additionally, there was no significant learning curve detected due to its intuitive applicability. Therefore, the Senhance Robotic System promises broad applicability across a range of laparoscopic general surgical operations.

Laparoscopic Inguinal Hernia Repair Using ProGrip Self-Fixating Mesh: Technical Learning Curve and Mid-Term Outcomes

PURPOSE

Self-fixating mesh has been introduced to further improve the quality results already seen with laparoscopic inguinal hernia repair. An observational study was undertaken to evaluate the technical learning curve and mid-term outcomes associated with the use of ProGrip (Medtronic, Minneapolis, MN, USA) laparoscopic self-fixating mesh in transabdominal preperitoneal (TAPP) inguinal herniorrhaphy.

METHODS

Patients who underwent elective laparoscopic TAPP inguinal herniorrhaphy by a single surgeon using ProGrip laparoscopic self-fixating mesh within a one-year period were studied. The primary outcome measures included the time from mesh introduction to the final position (MI-FP), surgical complications, and pain scores. Demographic and other perioperative outcome data were collected and analyzed.

RESULTS

Forty hernias were repaired in 29 patients with a laparoscopic TAPP approach. The average MI-FP was 249.4 seconds for the first 20 repairs, and 118.6 seconds (p < 0.001) for the final 20. Minor post-operative surgical complications were reported by 13.8% of patients; there were no major surgical complications. The average pain score on a scale of 0 to 5 was 0.9 (SD = 0.67, range 0-3).

CONCLUSIONS

Surgeons with reasonable laparoscopic experience can expect to become fully proficient in the manipulation of self-fixating mesh after 15 to 20 repairs. Use of this product yielded low intraoperative and mid-term postoperative complication rates as well as low postoperative pain.

Lumbar Incisional Hernia Repair: Complete Reconstruction of the Deficient Myofascial Component Using Christmas Tree Bone Anchors

Lumbar incisional hernias are difficult to repair because one of the hernia margins is bone, namely, the iliac crest. Previous studies have described the use of orthopedic bone anchors that fix a mesh onto the iliac crest. We present a novel technique for open repair of large lumbar incisional hernias using a double-mesh technique in combination with suture-loaded bone anchors to reattach the abdominal wall musculature onto the iliac crest. The surgical technique involves creating a preperitoneal plane behind the transversus abdominus and above the iliac crest and iliacus, below the iliac crest, with application of a Prolene mesh in this layer. This is followed by the drilling of suture-loaded Christmas Tree bone anchors™ along the rim of the iliac crest. The preloaded sutures are used to attach the myofascial component on the iliac crest, followed by the placement of a second Prolene mesh in an on-lay fashion. Drains are left in the preperitoneal and subcutaneous spaces. Unlike other reported techniques in the literature which only fix mesh onto the iliac crest, our technique with the use of Christmas Tree bone anchors™ allows for complete reconstruction of the lumbar abdominal wall defect and its myofascial components.

Is Onlay Polypropylene Mesh Repair an Available Option for Incisional Hernia Repair? A Retrospective Cohort Study

Lately, incisional hernia repair (IHR) with onlay polypropylene mesh has been replaced by other surgical procedures. The aim of this study was to compare the complication and recurrence rate after onlay mesh repair and other surgical procedures for IHR. A retrospective cohort study of patients who underwent IHR in a single center was conducted. The data were obtained from electronic medical records. Patients who had been lost during follow-up were contacted for a visit in the clinic. Univariate and multivariate analysis was performed with Stata 13.0 to analyze the factors associated with postoperative complications and hernia recurrence. Between June 2004 and December 2015, 1078 patients underwent IHR in a single center. Onlay mesh repair was performed in 125 patients (11.6%). Other surgical procedures included Rives procedure (29.3%), sublay mesh repair (38.6%), intrabdominal mesh repair (17.1%), and primary closure (3.4%). After a mean follow-up of 2.8 years, 73 (7%) patients developed a recurrence. A higher percentage of complications were seen after onlay mesh repair than after other surgical procedures (22.4% vs 13.1%, P = 0.005). Nevertheless, recurrence was less frequent after onlay mesh repair (4.2% vs 7.1%, P = 0.241). Logistic regression discarded an association between onlay mesh repair and hernia recurrence or postoperative complications. Incisional hernia repair with onlay polypropylene mesh repair was not associated with a higher incidence of postoperative complications or recurrence rate. So, this procedure should not be discarded in selected patients presenting with incisional hernia.

Repair of small abdominal wall hernias. The comparison of open in-lay and on-lay techniques

BACKGROUND

Our aim was to report the results of open in-lay placement of a composite mesh for repair of small abdominal wall hernias compared to a control group of on-lay polypropylene mesh placement.

MATERIALS AND METHODS

The patients were divided into two groups in which group-1 (n=27) included patients who underwent a repair with composite mesh, Ventralex Patch, which was fixed in-lay to the abdominal wall and group-2 (n=34) included patients with a repair with simple polypropylene mesh fixed on-lay to the abdominal wall. Due to the limited dimensions of the Ventralex Patch, in order to match the defects in both groups no randomization was done prior to the operation and patients were divided into groups consequently. All the patients were explored under general or spinal anesthesia. No further subcutaneous dissection was performed in order not to increase the seroma during onlay mesh placement.

RESULTS

The demographic data between study groups were similar. The postoperative complication rate was significantly low in group 1 (0%), compared to group 2 (23.5%) which included seroma (n=3) and wound infection (n=5), however, the mean operative time was significantly high in group l (61 minutes) compared to group 2 (39 minutes). There were no recurrences occurred in both group.

CONCLUSION

Although, the patch itself has tendency to make a dome formation when placed intra-abdominally, a composite polypropylene and ePTFE hernia patch has better outcomes if placed precisely with minimal extra-peritoneal and extensive intra-peritoneal dissection. We assume that inadequate liberation of omental attachments around the defect enhances the prior reported failures of the product.

KEY WORDS

Composite mesh, Hernia, Ventralex patch.

Lower Incidence of Postoperative Pain after Open Inguinal Hernia Surgery with the Usage of Synthetic Glue-Coated Mesh (Adhesix®)

Chronic groin pain after inguinal hernia mesh repair is a common problem. Mesh fixation without sutures has been suggested to have several advantages over the traditional suture fixation. The aim of this study was to compare two self-adhering meshes, the glued Adhesix® (AH) and the gripping Parietene ProGrip® (PP), and evaluate their impact on postoperative chronic pain and overall recovery. Two consultant surgeons performed altogether 393 open inguinal hernia operations at the Helsinki University Hospital during 2014 to 2015. The two groups, AH (n = 169) and PP (n = 224) were similar and comparable in terms of demographic data. The data were collected and analyzed from the patients' medical records in the hospital's register. The patients were followed up for a period of 19 months (5-31 months). The number of patient contacts due to postoperative pain was significantly less common in the AH group than in the PP group, 4/169 (2.4%) versus 19/224 (8.5%) patients, respectively (P = 0.011). The duration of pain was under three months for most patients, only two patients in the PP group had pain for over one year. The pain was treated most patients with anti-inflammatory painkillers, whereas injections of a local anesthetic and corticosteroid, and chronic pain medication was needed in some cases. It seems that the use of glue-coated mesh (Adhesix®) was associated with less postoperative visits due to pain compared with the self-fixating mesh with absorbable anchoring system (ProGrip®). Further studies with long-term follow-up are needed to confirm these results.

Laparoscopic transabdominal preperitoneal technique versus open surgery with the ULTRAPRO Hernia System for the repair of female primary femoral hernias-an observational retrospective study

Femoral hernias (FHs), predominantly seen in females, require surgery for cure. To date, surgical repair of primary FHs in female patients with either open surgery or laparoscopic operation has been poorly documented. We retrospectively investigated the treatment of female primary FHs with open surgery using the ULTRAPRO Hernia System (UHS procedure) or the laparoscopic procedure, namely, the transabdominal preperitoneal (TAPP) technique. A total of 41 female patients with primary FHs who had undergone UHS or TAPP were included in this study. The procedural parameters, post-surgical complications, treatment expense, and follow-up results were analyzed. The vast majority of patients (39/41) underwent elective operations: 15 received UHS (including 2 emergency cases) and 26 had TAPP (P = .08). The UHS group had a greater average age, due to the fact that FHs occur often in people with advanced age who tend to have systemic disease, limiting the use of general anesthesia required for TAPP. Compared with UHS, TAPP took a significantly shorter time to complete and patients undergoing TAPP had a dramatically shorter hospital stay. While no recurrence was observed in both groups, post-procedure pain and foreign body sensation were reported by significantly more patients in UHS group. The cost was greater with TAPP. Taken together, we concluded that both UHS and TAPP are effective in the management of female FHs. In view of the advantages and disadvantages between the open and the laparoscopic operation, surgeons can select a procedure according to their skills and patients' situation.

Pierre Franco (1505-1578): An Innovative Surgeon of the 16th Century in the Treatment of Hernia and Lithotomy

Pierre Franco (1505-1578) was a brilliant surgeon of the Renaissance, a contemporary of Ambroise Paré. He made an impact on the history of surgery with his innovative approaches in the treatment of hernia, lithotomy, and the use of the suprapubic incision. The purpose of this study is to present a detailed account of his work, innovations, and achievements as well as the impact he made on the surgery of the Renaissance.

Modified 2-port laparoscopic herniorrhaphy with Kirschner wire in children: A retrospective review

BACKGROUND

Pediatric inguinal hernia is one of the most common diseases in children, and laparoscopy is the main surgical method. This study aims to evaluate the efficacy of a new modified 2-port laparoscopic herniorrhaphy with Kirschner wire (TLHK) for inguinal hernia in children.

METHODS

A total of 5304 children with inguinal hernia hospitalized at the Jiangmen Center Hospital from June 2003 to May 2016 were enrolled in this retrospective study. Four thousand one hundred thirty-five children underwent TLHK that comprised the observation group, while 1169 received single incision laparoscopy (SIL) as the control group (CG). A propensity score matched cohort study was conducted between these groups. We included all patients who were diagnosed as inguinal hernia and matched comparators with a proportion of 1:1. The propensity score was calculated using logistic regression with forward stepwise selection in 4 variables. The patients' operative details, intra- and postoperative complications, and postoperative hospital stay were analyzed. The follow-up lasted from 1 month to 2 years.

RESULTS

Among 5304 potential patients, the propensity score identified 270 (135 TLHK cases and 135 comparators) patients. The age, sex, body mass index, and the hernia type and location did not differ between CG and TLHK. TLHK group had a shorter operative time (unilateral: 17.4 ± 3.35 minutes vs 20.7 ± 3.71 minutes; bilateral: 20.4 ± 5.17 minutes vs 25.2 ± 5.43 minutes), less complications (2.10% vs 2.65%), lower recurrence rate (0% vs 4.44%), and similar hospital stay (2.3 ± 1.1 vs 2.1 ± 1.3) as compared with CG. No iliac vessel injury, spermatic cord vessels injury, vas deferens injury, or iatrogenic cryptorchidism occurred in either of the groups.

CONCLUSION

TLHK is a safe and feasible treatment for inguinal hernia in children due to less invasion and less recurrence rate than SIL.

A Coupled Magnetoelastic Strain Sensor Array for Guiding and Monitoring Hernia Repairs

OBJECTIVE

Ventral hernia repairs using mesh prosthetics suffer from high recurrence rates, with 10%-20% of repairs failing within three years. Uneven distribution of stress within the implanted mesh prosthetic is thought to contribute to the high recurrence rate. We propose a method for providing quantitative guidance and monitoring of hernia repairs using an array of magnetoelastic strain sensors.

METHODS

The magnetoelastic strain sensors presented here are based on a coupled design to achieve measurements with higher signal-to-noise ratio (SNR). A first magnetoelastic element (the transducer) is bonded to the mesh prosthetic and is characterized by a strain-dependent magnetic field. The resonance frequency of a second magnetoelastic element (the resonator) encased in a rigid casing is biased by the transducer element's magneticity and can be measured noninvasively using an external interrogation coil. The coupled magnetoelastic strain sensors are assembled using a combination of photochemical machining, patterning, and heat sealing.

RESULTS

The dynamic range of the coupled sensors can be tuned by altering the transducer geometry. Additional spring elements are integrated onto the transducer element to achieve high dynamic range measurements saturating at 74 millistrains.

CONCLUSION

A coupled magnetoelastic strain sensor combines a transducer with an encased resonator element to measure strain with high SNR on an implantable flexible hernia mesh substrate.

SIGNIFICANCE

This study provides surgeons and researchers with a clinically relevant tool to quantify the strain distributions within implanted mesh prosthetics, with the ultimate goal of reducing the recurrence rate of ventral hernia repairs.

Updates in Mesh and Biomaterials

Prior publications of the Surgical Clinics of North America have highlighted the technical challenges of abdominal wall reconstruction. This article provides an update on synthetic, biologic, and biosynthetic mesh research since the 2013 Surgical Clinics of North America hernia publication and highlights the future of mesh research. This update features research that has been conducted since the prior publication to guide surgeons to choose the best and most appropriate mesh for their patients.

COMPARATIVE EVALUATION OF TAPP HERNIOPLASTY WITH USE OF VARIOUS METHODS OF FIXING THE RETICULAR ENDOPROSTHESIS AND TEP IN THE TREATMENT OF INGUINAL HERNIAS

The study was conducted with the aim to improve the results of treatment of patients with inguinal hernia by the mode of glue fixation of mesh implant in laparoscopic hernioplasty. Laparoscopic hernioplasty was performed on 96 patients at the N.D. Monastyrsky Department of Surgery of North-Western State Medical University named after I.I. Mechnikov, on the base of L.G. Sokolov Clinical Hospital № 122, in the period from 2014 to 2016. The patients were divided into three groups: I group - 36 patients, who underwent laparoscopic transabdominal preperitoneal inguinal hernia repair (TAPP) without supplying of mesh implant under spermatic cord and its fixation with cyanoacrylate glue "B-Braun" with elimination of peritoneum defect above the implant with a thread V-loc; II group consisted of 34 patients, treated with laparoscopic TAPP without cutting of mesh implant and its fixation along the periphery with titanium staples with the subsequent closing of peritoneum defect with titanium staples. Group III included 26 patients who underwent total extraperitonеal laparoscopic hernioplasty without fixation of mesh implant. All patients were males. Complex analysis of the duration of surgical procedure, patients' quality of life, number of complications and level of abdominal pain in incipient post-operative period was carried out. Laparoscopic transabdominal preperitoneal inguinal hernia repair in combination with use of glue composition for fixation of mesh implant improves the quality of life of a patient during post-operative period, contributes to early discharge from the hospital and quicker recovery for resuming job activities.

Biomechanical Comparison of Fibrin Sealants for Mesh Fixation

Adhesive use for fixation in hernia repair allows for complete and immediate mesh surface area adherence. Little is known about the fixation strengths of the products and application methods available. The purpose of this study was to compare the immediate and early strength of fixation of Tisseel™ and Evicel™ using hand and spray application techniques. Sixteen Mongrel swine underwent implantation of large-pore, mid-weight polypropylene mesh fixated with either Tisseel™ or Evicel™, applied by hand or with a spray apparatus. Time points studied were zero and four days. All samples underwent lap shear testing to quantify the strength of the mesh-tissue interface as an indicator of mesh fixation strength. Thirty Day 4 and 16 Day 0 samples were tested. Manually applied Tisseel™ mean fixation strength was 2.05 N/cm at Day 0 and 6.02 N/cm at Day 4. Sprayed Tisseel™ had mean fixation strength of 1.22 N/cm at Day 0 and 7.21 N/cm at Day 4. Manually applied Evicel™ showed mean fixation strength of 0.92 N/cm at Day 0 and 6.73 N/cm at Day 4. Mean fixation strength of sprayed Evicel™ was 0.72 N/cm at Day 0 and 6.70 N/cm at Day 4. Analysis of variance showed no difference between groups at Day 0 or Day 4. Immediate strength of mesh fixation could have significant implications for early recurrence and mesh contraction. This study demonstrates that no difference exists in immediate or early fixation strength between these two brands of sealants or their method of application.

A meta-analysis of randomized control trials assessing mesh fixation with glue versus suture in Lichtenstein inguinal hernia repair

BACKGROUND

The use of glue to fix mesh instead of sutures in Lichtenstein inguinal hernia repair has been accepted worldwide, with the increasing worries about postoperative chronic groin pain and recurrence. The aim of this meta-analysis was to clarify which mesh fixation method was more suitable in Lichtenstein inguinal hernia repair.

METHODS

Articles published up to July 2017 were searched using MEDLINE, the Cochrane Library, Embase, and the Web of Science. Randomized controlled trials (RCTs) comparing glue versus suture mesh fixation in Lichtenstein inguinal hernia repair were included in the review. The quality assessment and data extraction of included studies were applied by 2 independent authors. Statistical analysis was performed using RevMan 5.2 software.

RESULTS

Thirteen RCTs with 2375 patients were eligible for inclusion. Eight trials compared synthetic glue with suture fixation and 5 compared biological glue with suture fixation. The results showed that there was a lower incidence of early chronic pain (subgroup analysis, biological glue versus sutures, odds ratio (OR) = 0.41; 95% confidence interval (CI), 0.19-0.90; P = .03), and hematoma (subgroup analysis, synthetic glue versus sutures, OR = 0.56; 95% CI, 0.34-0.95; P = .03) in the glue fixation group. Suture mesh fixation method cost more time in operation than glue (mean difference = -4.60, 95% CI -7.60 to -1.60; P = .003). There was no evidence of an increase in chronic pain or recurrence rates with glue fixation method in the long-term follow-up.

CONCLUSIONS

Mesh fixation with glue compared with sutures in Lichtenstein repair inguinal hernia is faster and less painful, without an increasing in terms of recurrence rates in the long term.

A New Approach to an Old Technique-The S.U.T.R. First Technique

Ventral and incisional hernias of the abdominal wall are common problems treated by surgeons around the globe. Incisional hernias are common postoperative complications of abdominal laparotomies with a reported incidence of up to 20 per cent. The increasing use of prosthetic mesh in open ventral hernia repairs necessitated the development of different operative techniques used in the repairs. It also required that surgeons become facile with placement of the mesh in different anatomical positions on the abdominal wall. One of the most common locations is placement of the mesh in the underlay position. Many surgeons who use the underlay technique have expressed significant concerns. Among these are fear of an inadvertent bowel injury while placing the mesh, poor visualization during mesh placement, and the inability to use the underlay technique for difficult hernias. We present a very useful, if not, novel technique of open hernia repair using mesh in the underlay position that helps to 1) prevent complications, 2) facilitate easier mesh fixation, 3) simplify open repair of atypical ventral hernias, and 4) reduce total operative time while still adhering to the important fundamental principles of a tension-free hernia repair. This technique as we describe it has been compared with the old parachute technique, but we think this is a significant improvement of that seldom used technique. We believe the use of this technique for the underlay position makes open ventral hernia repair safer, faster, and easier; however, our goal for this article is to describe the procedure in detail. In addition, we recently have started using this technique to fix the mesh when doing the retrorectus approach as well.

Different types of mesh fixation for laparoscopic repair of inguinal hernia: A protocol for systematic review and network meta-analysis with randomized controlled trials

BACKGROUND

Laparoscopic inguinal hernia repair has become a valid option for repair of an inguinal hernia. Due to there are several types of mesh fixation for laparoscopic repair of inguinal hernia. The study aims to assess and compare the efficacy of different types of mesh fixation for laparoscopic repair of inguinal hernia using network meta-analysis.

METHODS

We will systematically search PubMed, EMBASE the Cochrane library, and Chinese Biomedical Literature Database from their inception to March 2018. Randomized controlled trials (RCTs) that compared the effect of different types of mesh fixation for laparoscopic inguinal hernia repair will be included. The primary outcomes are chronic groin pain, incidence risk of hernia recurrence, and complications. Risk of bias assessment of the included RCTs will be conducted using to Cochrane risk of bias tool. A network meta-analysis will be performed using WinBUGS 1.4.3 software and the result figures will be generated using R x64 3.1.2 software and STATA V.12.0 software. Grading of Recommendations Assessment, Development and Evaluation (GRADE) will be used to assess the quality of evidence.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSION

Our study will generate evidence of laparoscopic repair of mesh fixation for adult patients with inguinal hernia and provide suggestions for clinical practice or guideline.

Biomechanical and Histologic Evaluation of LifeMesh™: A Novel Self-Fixating Mesh Adhesive

Mesh fixation with the use of adhesives results in an immediate and total surface area adhesion of the mesh, removing the need for penetrating fixation points. The purpose of this study was to evaluate LifeMesh™, a prototype mesh adhesive technology which coats polypropylene mesh. The strength of the interface between mesh and tissue, inflammatory responses, and histology were measured at varying time points in a swine model, and these results were compared with sutures. Twenty Mongrel swine underwent implantation of LifeMesh™ and one piece of bare polypropylene mesh secured with suture (control). One additional piece of either LifeMesh™ or control was used for histopathologic evaluation. The implants were retrieved at 3, 7, and 14 days. Only 3- and 7-day specimens underwent lap shear testing. On Day 3, LifeMesh™ samples showed considerably less contraction than sutured samples. The interfacial strength of Day 3 LifeMesh™ samples was similar to that of sutured samples. At seven days, LifeMesh™ samples continued to show significantly less contraction than sutured samples. The strength of fixation at seven days was greater in the control samples. The histologic findings were similar in LifeMesh™ and control samples. LifeMesh™ showed significantly less contraction than sutured samples at all measured time points. Although fixation strength was similar at three days, the interfacial strength of LifeMesh™ remained unchanged, whereas sutured controls increased by day 7. With histologic equivalence, considerably less contraction, and similar early fixation strength, LifeMesh™ is a viable mesh fixation technology.

What is the evidence for the use of biologic or biosynthetic meshes in abdominal wall reconstruction?

INTRODUCTION

Although many surgeons have adopted the use of biologic and biosynthetic meshes in complex abdominal wall hernia repair, others have questioned the use of these products. Criticism is addressed in several review articles on the poor standard of studies reporting on the use of biologic meshes for different abdominal wall repairs. The aim of this consensus review is to conduct an evidence-based analysis of the efficacy of biologic and biosynthetic meshes in predefined clinical situations.

METHODS

A European working group, "BioMesh Study Group", composed of invited surgeons with a special interest in surgical meshes, formulated key questions, and forwarded them for processing in subgroups. In January 2016, a workshop was held in Berlin where the findings were presented, discussed, and voted on for consensus. Findings were set out in writing by the subgroups followed by consensus being reached. For the review, 114 studies and background analyses were used.

RESULTS

The cumulative data regarding biologic mesh under contaminated conditions do not support the claim that it is better than synthetic mesh. Biologic mesh use should be avoided when bridging is needed. In inguinal hernia repair biologic and biosynthetic meshes do not have a clear advantage over the synthetic meshes. For prevention of incisional or parastomal hernias, there is no evidence to support the use of biologic/biosynthetic meshes. In complex abdominal wall hernia repairs (incarcerated hernia, parastomal hernia, infected mesh, open abdomen, enterocutaneous fistula, and component separation technique), biologic and biosynthetic meshes do not provide a superior alternative to synthetic meshes.

CONCLUSION

The routine use of biologic and biosynthetic meshes cannot be recommended.

Determination of Proper Timing for the Placement of Intra-Abdominal Mesh after Incidental Enterotomy in a Rodent Model (Rattus norvegicus)

Controversy exists regarding the appropriate timing for placement of permanent intra-abdominal mesh after inadvertent enterotomy during elective hernia repair. The aim of this study was to examine mesh placement at variable postoperative periods and the subsequent risk of infection. Fifty rodents were divided into five groups. Groups one to four underwent laparotomy, enterotomy, and repair. Physiomesh® was placed at the index operation one, three, or seven days postoperatively in Groups 1, 2, 3, and 4. Group 5 underwent mesh placement only. Necropsy with mesh harvest was performed seven days after placement. Cultures of mesh were obtained and Fisher's exact test was used to compare groups. Bacterial growth postsonication was identified in 30, 30, 50, and 90 per cent versus 20 per cent in controls. Compared with controls, there was significantly increased risk of mesh infection when it was placed seven days after enterotomy (P = 0.006). There was no significant difference in bacterial growth when mesh was placed at the time of enterotomy, one or three days later. The risk of bacterial contamination of permanent mesh placed immediately after inadvertent enterotomy during elective hernia repair is as safe as placing mesh at one or three days. Placing mesh at seven days significantly increased the risk of mesh contamination.

[Evidence-based TEP technique]

The guidelines of all international hernia societies recommend as procedures of choice the laparoendoscopic techniques total extraperitoneal patch plasty (TEP) and transabdominal preperitoneal patch plasty (TAPP) as well as the open Lichtenstein operation for elective inguinal hernia repair. The learning curve associated with the laparoendoscopic techniques, in particular TEP, is longer than that for the open Lichtenstein technique due to the complexity of the procedures. Accordingly, for laparoendoscopic techniques it is particularly important that the operations are conducted in a standardized manner in compliance with the evidence-based recommendations given for the technical details. When procedures are carried out in strict compliance with the guidelines of the international hernia societies, low rates of perioperative complications, complication-related reoperations, recurrences and chronic pain can be expected for TEP. Compliance with the guidelines can also positively impact mastery of the learning curve for TEP. The technical guidelines on TEP are based on study results and on the experiences of numerous experts; therefore, it is imperative that they are implemented in routine surgical practice.

Prosthetic Mesh Repair in the Emergency Management of Acutely Strangulated Groin Hernias with Grade I Bowel Necrosis: A Rational Choice

The aim of this study was to determine the feasibility of prosthetic mesh repair according to the degree of bowel necrosis in the emergency management of acutely strangulated groin hernias. Emergency prosthetic mesh repair versus primary suture repair was randomly performed in 208 consecutive strangulated groin hernia patients with bowel necrosis between January 2005 and August 2016. The degree of bowel necrosis of each patient was determined according to a modified three-grade classification system. Patient characteristics sorted by repair method were analyzed by using Pearson's chi-squared tests. Correlations between mortality and wound-related morbidity with bowel necrosis grade and repair method were analyzed. There was no difference in gender, age, body mass index, comorbid diseases, hernia type (left or right, primary or recurrent), necrosis grade, and mortality between the mesh repair and suture repair groups (all P > 0.05). However, with regard to wound-related morbidity, there was significant difference between the two groups (P < 0.05). Mortality and wound-related morbidity showed significant relationship with necrosis grade, especially with regard to postoperative wound infection (P < 0.001). The wound infection rate with mesh repair was significantly higher than that with primary suture in Grade II and III necrosis patients (P < 0.05), but there was no difference in Grade I patients (P > 0.05). The use of prosthetic mesh in the emergency repair of acutely strangulated groin hernias seems to be as safe as suture-only repair in patients with noninfected strangulated bowel (Grade I necrosis). The use of prosthetic mesh repair is a rational choice made based on the degree of bowel necrosis in the emergency management of acutely strangulated hernias.

Prospective Analysis of Epigastric, Umbilical, and Small Incisional Hernia Repair Using the Modified Kugel Oval Patch

The study was performed to determine the complication and recurrence rate using the modified Kugel oval patch for small ventral hernia repair. Another aim of the study was to find risk factors for recurrence in patients with this repair. Seventy-three patients underwent ventral hernia repair with the modified Kugel oval patch between April 2013 and February 2015. Prospective follow-up data (18 months postoperative) were collected and evaluated. A total of 58 primary (18 epigastric/40 umbilical) and 15 incisional ventral hernias were repaired with the modified Kugel oval patch (7.6/10.2 cm/8 × 12 cm). We found three patients suffered superficial wound infection and two participants got hernia recurrence. Placement of mesh was found to be a significant risk factor for hernia recurrence. Small ventral hernia repair using the modified Kugel oval patch is a novel and useful approach and we recommend placing the patch preperitoneally.