Current Concepts of Inguinal Hernia Repair

Inguinal hernia repair: a global perspective

BACKGROUND

Inguinal hernia repair is one of the most common operations performed worldwide with most of the burden of these occurring in low- or middle-income countries (LMICs). There has been much research investigating the most effective method of hernia repair in resource-rich countries, however very little has been done to determine the most cost-beneficial method of hernia repair in LMICs.

METHODS

A systematic review of the English literature through PubMed and Scopus was conducted according to the PRISMA statement.

RESULTS

Twenty-eight studies met the inclusion criteria of which 17 were randomised controlled trials and 11 were systematic reviews. Three areas of investigation were established from the literature search, namely operative method and type of mesh used (where applicable). Open-mesh procedures were shown to be less costly and have shorter operative times than laparoscopic methods. People who underwent laparoscopic hernia repair regularly returned to normal activities earlier than those who had open-mesh procedures. However, there was no other difference in complication rates between these two methods. Recent investigations have revealed that sterilised synthetic mosquito net was similar to hernia-specific meshes whilst significantly reducing cost.

CONCLUSION

We postulate that the most cost-beneficial method of hernia repair for implementation in LMICs is using open-mesh procedures with sterilised mosquito net under local anaesthetic. Further cost-benefit research is required in this area.

The use of polypropylene mesh in inguinal hernia surgery: A retrospective study

Previously, inguinal hernia surgery was based exclusively on repairing the abdominal wall defects using the patient's own tissues, which were put in contact with and tensioned to recalibrate the natural orifices. At present, inguinal hernia surgery is based almost solely on mounting an allograft, which has the role of strengthening the weakened groin region that allowed the herniation. This modern method of operation on inguinal hernia can be performed in a classic or laparoscopic manner. The mesh is made of polypropylene, which is a polymer of cyclic hydrocarbons. The aim of the present study was to evaluate the effectiveness, biocompatibility, as well as the immediate and long-term complications in textile allografts used in open surgery of inguinal hernia repair. Another aim was to demonstrate once again the superiority of low-weight meshes with large pores by decreasing the number of complications caused by the synthetic material used, but also by a decrease in the tension on the tissues to which it was fixed. The present study included 255 cases submitted to inguinal hernia surgery. Only 1.5% required immediate reintervention before discharge to evacuate hematoma. The short duration of hospitalization, the quality-price ratio, the good postoperative results, as well as the rapid socio-professional reintegration, render the use of polypropylene mesh in inguinal hernia surgery very attractive for patients.

Surgical treatment for chronic pain after inguinal hernia repair: a systematic literature review

PURPOSE

Chronic postoperative inguinal pain (CPIP) is a frequent complication after inguinal surgery with a significant decrease in quality of life. There is still no clear algorithm regarding surgical treatment. The aim of this systematic review was to provide an overview on the principles and outcome of surgical interventions for CPIP based on the available literature.

MATERIALS AND METHODS

A literature search was performed using the databases PubMed and SCOPUS following the PRISMA statement. Used Mesh terms and keywords were "postoperative pain," "chronic pain," "inguinal hernia," and "surgical treatment." All articles were reviewed regarding surgical technique and outcome. MINORS criteria for the assessment of the methodological quality of non-randomized surgical studies were applied.

RESULTS

Eighteen articles, of which 17 cohort studies and one randomized controlled trial (RCT), described the surgical management of CPIP. Selective as well as triple neurectomy, often in combination with mesh removal and removal of suture material, was performed. Success rate, defined as significant or complete relief of pain, ranged from 33 until 100%, with most articles reaching success rates above 70%, showing a clear advantage of surgical therapy for chronic pain.

CONCLUSIONS

The use of surgical triple neurectomy seems effective and helpful in a high percentage of patients with CPIP. Surgical treatment should only be considered after adequate preoperative diagnostic evaluation of which the dermatome sensory mapping seems a useful tool for detailed neurophysiological assessment of patients with persistent post-herniorrhaphy pain undergoing remedial neurectomy.

Case Report: How an Iliac Vein Lesion During Totally Endoscopic Preperitoneal Repair of an Inguinal Hernia Can Be Safely Managed

Inguinal hernia repair is a common surgical procedure with an acceptably low complication rate. However, complications with potentially life-threating consequences may occur in rare cases. These complications might be very challenging to manage, even more in laparo-endoscopic interventions compared to open repair. One of these challenges can be the treatment of an intraoperative injury to the iliac vein. To the best of our knowledge, a lesion of the iliac vein during TEP (totally endoscopic preperitoneal) for inguinal hernia repair, and a safe technique for its management have not been reported yet. We report the case of a 75-year-old male patient with previous abdominal surgery scheduled for TEP repair of an inguinal hernia. During surgery, the iliac vein was damaged. If we had performed a laparotomy in this situation, the potentially life-threatening condition of the patient could have deteriorated further. Instead, to avoid a potential CO₂ associated embolism, the preperitoneal pressure was gradually reduced, and the positive end expiratory pressure (PEEP) was increased in the manner that a balance between excessive bleeding and potential development of a CO₂ embolism was achieved. The injured vein was sutured endoscopically, and in addition a hemostatic patch was applied. We then continued with the planned surgical procedure. Thrombosis of the sutured vein was prevented by prophylactic administration of low molecular weight heparin until the 14th postoperative day. We conclude that in case of major vein injury during TEP, which might happen irrespective of prior abdominal surgery, the preperitoneal pressure and PEEP adjustment can be used to handle the complication.

Laparoscopic totally extraperitoneal hernia repair performed by surgical trainees: Overcoming the learning curve

BACKGROUND

Surgical trainees struggle to obtain experience in laparoscopic inguinal hernia repair (LIHR) due to a perceived steep learning curve. The purpose of this study was to compare outcomes in totally extraperitoneal (TEP) repair performed by surgical consultants and trainees under supervision as part of a standardised training regimen to assess the safety of residency training in this technique.

METHODS

A retrospective review of patients managed by TEP repair by either a consultant or a supervised trainee was performed. Demographic, perioperative and postoperative data were collected and compared. All trainees underwent a standardised approach to teaching TEP repair.

RESULTS

Trainees performed 133 procedures and consultants performed 121 procedures. Estimated blood loss was minimal in both cohorts. A significant difference was noted in mean operating time between consultants and trainees (33 vs. 50 min). However, it was also observed that the trainee mean operating time reduced significantly with experience (from 61 to 42 min). No statistically significant difference was demonstrated in postoperative complications, recurrence rate or length of stay. All trainees achieved the ability to complete a laparoscopic TEP repair under unscrubbed consultant supervision during a 1-year placement.

CONCLUSION

With senior supervision and in the presence of a structured training regimen, trainees can safely and effectively perform LIHR, progressing to performing the procedure under unscrubbed consultant supervision. This is valuable information that can serve to inform the structure and direction of surgical training programmes as the ability to offer LIHR is increasingly becoming an expectation of consultant surgeons.

Peritoneal defect herniation causing small bowel obstruction: a rare complication of transabdominal preperitoneal repair

Laparoscopic approaches to inguinal hernia repair are becoming increasingly more popular as they offer many advantages to open techniques including faster recovery and lower rates of wound infection. However, it is important to recognize complications associated with newer techniques which only become apparent with increased volume and experience. In this report, we describe a rare case of small bowel obstruction (SBO) secondary to peritoneal defect herniation post-transabdominal preperitoneal repair (TAPP). This is an uncommon complication that is sparsely reported in the literature but may have devastating consequences for the patient if unrecognized or mistakenly attributed to adhesional SBO. A high index of suspicion for internal herniation and a low index for reoperation are important with SBO in the early postoperative phase post-TAPP.

Bowel obstruction secondary to gallstone ileus within an inguinoscrotal hernia: a rare diagnosis in an elderly patient

Gallstone ileus and obstructed inguinal hernias are respectively, rare and common causes of small bowel obstruction. There are no published cases of these pathologies occurring simultaneously. Here, we describe a unique case of an elderly male patient presenting with a small bowel obstruction caused by these combined pathologies. Following an acute presentation with obstructive symptoms, a CT scan demonstrated small bowel obstruction due to a large gallstone lodged in the neck of an inguinoscrotal hernia with associated pneumobilia. The case may have been managed conservatively if it was not for the presence of the gallstone. Previous imaging had incidentally demonstrated gallstones in the gallbladder and a large uncomplicated right inguinoscrotal hernia. It is presumed that a cholecystoduodenal fistula formed and a gallstone then migrated downstream to lodge within the neck of the inguinoscrotal hernia. This case underscores the concept that even in the presence of an “obvious” cause of small bowel obstruction, such as an irreducible, large inguinoscrotal hernia, we must always maintain a healthy clinical skepticism and an open mind to other unexpected aetiologies, which may account for the clinical presentation that might impact subsequent management.

Trends and outcomes of open, laparoscopic, and robotic inguinal hernia repair in the veterans affairs system

PURPOSE

Robotic inguinal hernia repair (RHR) is an evolving technique but is comparatively expensive and has yet to show superior outcomes versus open (OHR) or laparoscopic (LHR) approaches. The utilization and clinical outcomes of RHR have not been reported within the veterans affairs (VA) system. This study analyzes trends in utilization and 30-day post-operative outcomes between OHR, LHR, and RHR in veterans.

METHODS

This is a retrospective review of patients that underwent inguinal herniorrhaphy using the Veterans Affairs Quality Improvement Program database. Multivariable analysis of outcomes was performed adjusting for pre-operative confounding covariates between OHR, LHR, and RHR. Trends in utilization, complication rates, and operative times were also reported.

RESULTS

From 2008-2019, 124,978 cases of inguinal herniorrhaphy were identified: 100,880 (80.7%) OHR, 18,035 (14.4%) LHR, and 6063 (4.9%) RHR. Compared to LHR, RHR was associated with 4.94 times higher odds of complications, 100 min longer mean operative time, and 1.5 days longer median length of stay (LOS). Compared to OHR, RHR was associated with 5.92 times higher odds of complications, 57 min longer mean operative time, and 1.1 days longer median LOS. Utilization of RHR and LHR significantly increased over time. RHR complication rates decreased over time (2008: 20.8% to 2019: 3.2%) along with mean operative times (2008: 4.9 h to 2019: 2.8 h; p < 0.05).

CONCLUSION

While this study demonstrated inferior outcomes after RHR, the temporal trends are encouraging. This may be due to increased surgeon experience with robotics. Further prospective data will elucidate the role of RHR as this technique increases.

Quality and reliability evaluation of current Internet information regarding mesh use in inguinal hernia surgery using HONcode and the DISCERN instrument

INTRODUCTION

Mesh-related complications following pelvic prolapse surgery has potentiated societal fear and led to increased investigation into mesh use in inguinal hernia repair (IHR) surgery online. However concern exists regarding the quality of Internet health informatics. The DISCERN Instrument and HONcode  tool can be used to assess the quality and reliability of online health information. The aim of this study is to investigate the reliability and quality of online information pertaining to mesh use in IHR surgery using the DISCERN instrument and HONcode tool.

METHODS

An Internet search using the keywords: 'mesh', 'inguinal hernia' and 'surgery' was carried out via Google, Yahoo, Bing, Facebook and Twitter. The HONcode and DISCERN scores were generated for each of the first ten search engine result pages (SERPs).

RESULTS

Google provided the most reliable [Median HONcode score 77% (IQR 25.5%)] and highest quality information [Median DISCERN score; 61.5 (IQR 18.25)]. Social media yielded both the most unreliable and lowest quality information. Facebook was the most unreliable [Median HONcode score 21% (IQR 14.25%)], while Twitter imparted the lowest quality information [Median DISCERN score of 18.5 (IQR 25.25)].

DISCUSSION

A 2018 Cochrane review concluded the use of mesh in IHR to be safe and associated with superior outcomes. However, numerous SERPs present results contradicting this, based solely upon Level 5 evidence. Commercialisation of the Internet has resulted in search engine optimisation, which can permit lesser quality sites to obtain higher SERP ranking. Alarmingly  if only a limited search is carried out by patients [4], lower quality, sensationalist evidence may be the only information they are exposed to. As such this may negatively influence the patient decision-making process detrimentally. However utilisation of social media by healthcare professionals may offer a solution to bridge the gap between the public and high quality medical information.

CONCLUSIONS

Online information regarding mesh repair of inguinal herniae is of variable quality and reliability. Enhanced quality assurance of online health information is necessary. However, increased presence by hernia societies on social media may help to disseminate high quality information to patients, thus enabling pre-hospital education to set the scene prior to formal hospital consultation.

Inguinal hernia repair in Spain. A population-based study of 263,283 patients: factors associated with the choice of laparoscopic approach

PURPOSE

The objective of this study is to evaluate the laparoscopic inguinal hernia repair (IHR) rate in Spain and identify the factors associated with the choice of this surgical approach.

METHODS

A retrospective cohort study of 263,283 patients who underwent IHR from January 2016 to December 2018 was conducted. Data were extracted from the Spanish Minimum Basic Data Set (MBDS) of the Health Ministry database. The primary outcome was laparoscopic (LAP) rate utilization. Univariate analysis and multivariable logistic regression analysis were performed to identify factors associated with LAP-IHR.

RESULTS

Only 5.7% (15,059) patients underwent LAP-IHR, whereas the remnant 94.3% (248,224 patients) underwent open repair. High variability in the LAP-IHR rate across the country was observed; ranged between provinces from 0 to 19.7%, for a unilateral hernia, and between 0 to 57.4% in the case of bilateral hernias. On multivariate logistic regression analysis, the patient place of residence was the most remarkable factor associated with the likelihood of receiving LAP-IHR (OR 4.96; p < 0.001). There were also significant differences favoring LAP-IHR for bilateral operation (OR 4.596; p < 0.001), insurance coverage (OR 4.439, p < 0.001) and self-pay patients (OR 2.317; p < 0.001), as well as a recurrent hernia (OR 1.780; p < 0.001), age younger than 65 years (OR 1.555; p < 0.001) and male sex (OR 1.162, p < 0.001).

CONCLUSION

LAP-IHR remains a not frequent choice among surgeons in Spain, even when dealing with recurrent and bilateral hernias. The results suggest that the choice of LAP-IHR could depend on the surgeon's preference rather than on the indication appropriateness.

Trends in Emergent Groin Hernia Repair-An Analysis From the Herniamed Registry

Introduction: While the proportion of emergency groin hernia repairs in developed countries is 2.5–7.7%, the percentage in developing countries can be as high as 76.9%. The mortality rate for emergency groin hernia repair in developed countries is 1.7–7.0% and can rise to 6–25% if bowel resection is needed. In this present analysis of data from the Herniamed Registry, patients with emergency admission and operation within 24 h are analyzed.

Methods: Between 2010 and 2019 a total of 13,028 patients with emergency admission and groin hernia repairs within 24 h were enrolled in the Herniamed Registry. The outcome results were assigned to the year of repair and summarized as curves. The total patient collective is broken down into the subgroups with pre-operative manual reduction (taxis) of the hernia content, operative reduction of the hernia content without bowel resection and with bowel resection. The explorative Fisher's exact test was used for statistical assessment of significant differences with Bonferroni adjustment for multiple testing.

Results: The proportion of emergency admissions with groin hernia repair within 24 h was 2.7%. The percentage of women across the years was consistently 33%. The part of femoral hernias was 16%. The proportion of patients with pre-operative reduction (taxis) remained unchanged at around 21% and the share needing bowel resection was around 10%. The proportion of TAPP repairs rose from 21.9% in 2013 to 38.0% in 2019 (p < 0.001). Between the three groups with pre-operative taxis, without bowel resection and with bowel resection, highly significant differences were identified between the patients with regard to the rates of post-operative complications (4% vs. 6.5% vs. 22.7%; p < 0.0001), complication-related reoperations (1.9% vs. 3.8% vs. 17.7%; p < 0.0001), and mortality rate (0.3% vs. 0.9% vs. 7.5%; p < 0.001). In addition to emergency groin hernia repair subgroups female gender and age ≥66 years are unfavorable influencing factors for perioperative outcomes.

Conclusion: For patients with emergency groin hernia repair the need for surgical reduction or bowel resection, female gender and age ≥66 years have a highly significantly unfavorable influence on the perioperative outcomes.

Meta-analysis of mesh-plug repair and Lichtenstein repair in the treatment of primary inguinal hernia

The present study systematically evaluated the clinical effects of mesh-plug and Lichtenstein herniorrhaphy in the treatment of primary inguinal hernia. PubMed, Embase, and the Cochrane Library (cut-off: May 25, 2020) databases were searched to select randomized controlled trials (RCTs) on mesh-plug and Lichtenstein herniorrhaphy for the treatment of primary inguinal hernia. Articles that met the inclusion criteria were screened and evaluated for quality. RevMan 5.3 software was used to perform a meta-analysis of operation time, discomfort in the inguinal region, haematoma, seroma, infection, time to return to normal activities, incidence of postoperative chronic pain, and recurrence rate. Eleven RCTs with 1457 patients in the mesh-plug group and 1472 in the Lichtenstein group were included. Meta-analysis showed that the mesh-plug herniorrhaphy group had a shorter operation time than the Lichtenstein herniorrhaphy group [P < 0.0001] but a longer time to return to normal activities after surgery [MD = 1.48, 95% CI (0.58, 2.38), P = 0.001]. There were no significant differences in postoperative discomfort in the inguinal region [P = 0.90], seroma [P = 0.10], haematoma [P = 0.27], infection [P = 0.40], incidence of postoperative chronic pain [P = 0.90], or recurrence rate [P = 0.77] between groups. Mesh-plug herniorrhaphy requires a shorter operation time than Lichtenstein herniorrhaphy, and there is no significant difference in postoperative complications or recurrence rate between the two methods. Clinical trial registration: INPLASY202070088. Meta-analysis of mesh -plug repair and Lichtenstein repair in the treatment of primary inguinal hernia.

Inguinal hernia repair among men: development and validation of a preoperative risk score for persistent postoperative pain

PURPOSE

Persistent postoperative pain (PPP) is a prevalent complication after inguinal hernia repair. The aim of this study was to develop and validate a preoperative risk score for PPP.

METHODS

We developed the risk score based on a cohort of 2,508 Danish men, who answered a questionnaire six months after inguinal hernia repair performed 2015-2016. PPP was defined as a numerical rating scale score ≥ 2 during activity six months postoperatively. Logistic regression analyses were undertaken to determine statistically significant predictors of PPP. Univariable analysis selected potential predictors with a p value ≤ 0.20, and a subsequent multivariable model was built using backward elimination with a criterion of p value < 0.10. We created a risk score based on the β coefficients of the multivariable model. The risk score was validated internally using Hosmer-Lemeshow goodness of fit test, calibration belt test, and receiver operating characteristic curve analyses with 95% confidence intervals based on the bootstrap analysis. External validation was performed in a cohort of 293 men recruited preoperatively.

RESULTS

Predictors of PPP were age 18-49 and 50-59 (versus ≥ 60) years (p < 0.001), total load lifted > 1,000 kg/day (p = 0.001), working in a bent-over position > 1 h/day (p < 0.001), leisure-time physical activity < 2 h/week (p = 0.009), increasing body mass index (per unit) (p < 0.003), and repair of recurrent hernia (p = 0.001).The preoperative risk score predicted risks of 6-61% in the development population. The model showed good internal and external validity.

CONCLUSION

The results suggest that the risk of PPP after inguinal hernia repair can be predicted using a preoperative risk score.

Previous unilateral inguinal hernia repair increase risk of new developed inguinal hernia: a nationwide Longitudinal Cohort Study in Asian male adult patients

INTRODUCTION

Our study aims to identify that patients who received hernia repair previously did have higher risk of occurrence of newly developed inguinal hernia, named as a contralateral inguinal hernia (CIH), than patients who never received inguinal hernia surgery before.

MATERIALS AND METHODS

We collected data from the National Health Insurance Research Database (NHIRD) of Taiwan retrospectively. In the study cohort, 64,089 Asian male adults who underwent primary unilateral inguinal hernia repair during 2003-2008 were included using ICD-9 diagnostic and surgical codes. Another 64,089 male adults without hernia repair history were included as control group via propensity score match.

RESULTS

The median follow-up period is 93.53 months. After multivariate analysis, the risk of newly developed inguinal hernia in unilateral inguinal hernia (UIH) repair cohort was significantly higher (adjusted HR 6.364, 95% CI 6.012-6.737, P < 0.001) than the control group. In subgroup analysis, patients without mesh repair (adjusted HR 6.706, P < 0.001) and patients with mesh repair (adjusted HR 5.559, P < 0.001) both showed higher risk of developing newly developed inguinal hernia which needs repair.

CONCLUSIONS

Asian men with UIH repair history had a higher risk of developing new inguinal hernia at the contralateral site, namely CIH, than the general population. The surgeon should inform the possibility of CIH after initial herniorrhaphy, therefore, monitoring the occurrence of CIH is necessary.

[Staged bilateral total extraperitoneal allohernioplasty by e-TEP in a patient with recurrent oblique inguinal hernia on the left and combined strangulated femoral hernia on the right]

A case of two-stage minimally invasive surgical treatment of an elderly patient with bilateral inguinal hernia is presented: a recurrent oblique on the left, combined (femoral, obturator, oblique and direct inguinal) on the right with incarceration and necrosis of the small intestine in the femoral canal. Previously, the patient underwent closure of perforated ulcer of duodenum from upper-midline laparotomy, epicystostomy, transvesical adenomectomy from the lower-midline laparotomy. The first stage we performed diagnostic laparoscopy, minilaparotomy, reduction and resection of necrotic small intestine loop. The second stage was carried endovideoscopic total extraperitoneal allohernioplasty by the method of Extended-View Totally Extraperitoneal (e-TEP) on two sides. The positive results of the treatment indicate a high efficiency of video endoscopic alloplasty of occult hernias in a complex case. To diagnose and perform adequate surgical intervention with a combined femoral hernia, when the obturator and inguinal hernias are formed, but clinically do not manifest themselves, it is possible only with endoscopic examination of potential sites of hernia formation in the inguinal region, which is not possible with open plastic hernia of the inguinal region.

Comparison of types 2 and 3 quadratus lumborum muscle blocks : Open inguinal hernia surgery in patients with spinal anesthesia

OBJECTIVE

The efficacy of quadratus lumborum muscle block (QLB) in abdominal surgery is known; however, the efficacy of different QLB types is unclear. The objective of this study was to investigate the effects of ultrasound-guided QLB type 2 and type 3 on postoperative opioid consumption and pain scores in patients undergoing inguinal hernia surgery.

MATERIAL AND METHODS

In this study 60 patients undergoing open inguinal hernia surgery were randomly assigned to 3 groups. Group QLB2 received ultrasound-guided QLB type 2 and group QLB3 received ultrasound-guided QLB type 3 with 0.25% 20 mL bupivacaine. In the control group (group C) no intervention was performed. Postoperative analgesia was performed intravenously with 1000 mg paracetamol every 6 h and patient-controlled analgesia with fentanyl. Postoperative visual analog scale scores (VAS), opioid consumption, and first analgesic requirement time were evaluated.

RESULTS

Fentanyl consumption was significantly higher in group C compared to the other groups at all time intervals (p < 0.05). Fentanyl consumption was significantly higher in group QLB2 compared to QLB3 at the 4-8 h, 8-24 h, and total 24 h. Passive VAS 4h and 8 h, active VAS 4h, 8h, and 12 h were significantly lower in group QLB3 compared to QLB2 (p < 0.05). The first analgesic time was significantly later in group QLB2 compared to group C (280.52 ± 89.20 min and 183.75 ± 42.79 min, respectively) and even later in group QLB3 compared to the other two groups (463.42 ± 142.43 min, p < 0.05).

CONCLUSION

The use of QLB2 and QLB3 decreased postoperative opioid consumption and pain scores in patients undergoing inguinal hernia surgery. Furthermore, QLB3 provided more effective and longer lasting postoperative analgesia and lower opioid consumption compared to QLB2.

Chronic inguinal pain after laparoscopic transabdominal preperitonal hernioplasty in inguinal hernia

The ubiquitous application of inguinal hernioplasty performed by various methods does not exclude the occurrence of certain late postoperative complications, the cause of which is sometimes extremely difficult to establish. The article describes a clinical case of observing a patient with chronic postoperative pain 6 months after inguinal hernioplasty using the TAPP technique. When studying the possible causes, the presence of a fixing material (tacker) in the triangle of pain was found, the removal of the latter led to a complete leveling of the clinical picture. Thus, despite the simplicity of performing inguinal hernioplasty, the surgeons desire for excessive fixation and a violation of the principles of this operation can lead to undesirable complications and temporary disability of the patient.

The reality of general surgery training and increased complexity of abdominal wall hernia surgery

INTRODUCTION

The Accreditation and Certification of Hernia Centers and Surgeons (ACCESS) Group of the European Hernia Society (EHS) recognizes that there is a growing need to train specialist abdominal wall surgeons. The most important and relevant argument for this proposal and statement is the growing acceptance of the increasing complexity of abdominal wall surgery due to newer techniques, more challenging cases and the required 'tailored' approach to such surgery. There is now also an increasing public awareness with social media, whereby optimal treatment results are demanded by patients. However, to date the complexity of abdominal wall surgery has not been properly or adequately defined in the current literature.

METHODS

A systematic search of the available literature was performed in May 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, with 75 publications identified as relevant. In addition, an analysis of data from the Herniamed Hernia Registry was performed. The percentage of patients with hernia- or patient-related characteristics which unfavorably impacted the outcome of inguinal and incisional hernia repair was also calculated.

RESULTS

All present guidelines for abdominal wall surgery recommend the utilization of a 'tailored' approach. This relies on the prerequisite that any surgical technique used has already been mastered, as well as the recognized learning curves for each of the several techniques that can be used for both inguinal hernia (Lichtenstein, TEP, TAPP, Shouldice) and incisional hernia repairs (laparoscopic IPOM, open sublay, open IPOM, open onlay, open or endoscopic component separation technique). Other hernia- and patient-related characteristics that have recognized complexity include emergency surgery, obesity, recurrent hernias, bilateral inguinal hernias, groin hernia in women, scrotal hernias, large defects, high ASA scores, > 80 years of age, increased medical risk factors and previous lower abdominal surgery. The proportion of patients with at least one of these characteristics in the Herniamed Hernia Registry in the case of both inguinal and incisional hernia is noted to be relatively high at around 70%. In general surgery training approximately 50-100 hernia repairs on average are performed by each trainee, with around only 25 laparo-endoscopic procedures.

CONCLUSION

A tailored approach is now employed and seen more so in hernia surgery and this fact is referred to and highlighted in the contemporaneous hernia guidelines published to date. In addition, with the increasing complexity of abdominal wall surgery, the number of procedures actually performed by trainees is no longer considered adequate to overcome any recognized learning curve. Therefore, to supplement general surgery training young surgeons should be offered a clinical fellowship to obtain an additional qualification as an abdominal wall surgeon and thus improve their clinical and operative experience under supervision in this field. Practicing general surgeons with a special interest in hernia surgery can undertake intensive further training in this area by participating in clinical work shadowing in hernia centers, workshops and congresses.

Implementation of a new constitutive model for abdominal muscles

BACKGROUND AND OBJECTIVE

Abdominal hernia repair is one of the most often performed surgical procedures worldwide. Numerical simulations of the abdominal wall mechanics can be a valuable tool to devise actions aimed at preventing hernia formation. A first step towards this goal is the development of consistent constitutive models for the tissues that form the human abdominal wall. In this study we propose, for each of the tissues involved, a new formulation of the so-called transversely isotropic hyperelastic model (TIHM).

METHODS

We propose a new TIHM for the human abdominal wall tissues and we present a systemic view of the methodology that we have implemented in the present study. First we consider the mathematical background of the TIHM. The novelty of our formulation is that both the isotropic and the fiber contributions to the strain energy function are characterized exclusively by polynomial convex functions of certain invariant quantities. Then, we provide a detailed description on how the constitutive model is implemented into an open source finite element (FE) software. In our approach we use the specific interface provided by the MFront software to incorporate our TIHM formulation into the Code Aster FE solver. For each of the tissues considered, the values of the TIHM constants are adjusted by means of a numerical simulation of previous experimental data from tensile tests.

RESULTS

We studied the following abdominal wall tissues: linea alba, rectus sheath, external oblique muscle, internal oblique muscle, transversus abdominis muscle and rectus abdominis muscle. Our formulation closely reproduces tensile test data for each tissue in the corresponding FE numerical simulation.

CONCLUSIONS

The new TIHM formulation is suitable for a future numerical investigation of the abdominal wall, which will in turn help us to assess the best zone to practice a colostomy. The methodology implemented in the present study can be easily extended in the future to develop and implement a TIHM for active muscles and/or a different type of constitutive model which might be suitable to characterize other tissues of biomedical interest.

Laparoscopic inguinal hernia repair in women: Trends, disparities, and postoperative outcomes

INTRODUCTION

This study analyzed trends in laparoscopic inguinal hernia repair over time, rates of laparoscopic repair in women, and subsequent postoperative outcomes.

METHODS

Data for 237,503 patients undergoing repair of an initial, reducible inguinal hernia were analyzed using the National Surgical Quality Improvement Program (NSQIP) database for years 2006-2017. Data were analyzed by univariate and multivariate analysis.

RESULTS

Since 2006, there was an increased proportion of laparoscopic inguinal hernia surgeries, from 20.49% in 2006 to 36.36% in 2017 (p < .001). The percentage of women with bilateral inguinal hernias that underwent laparoscopic repair was less than the percentage of men (31.58% vs. 41.43%, p < .001). Based on multivariate analysis, women were less likely to have laparoscopic hernia repair (OR 0.74, CI 0.71-0.76). Postoperative complications were overall low.

CONCLUSION

A greater proportion of inguinal hernia repairs are performed laparoscopically. Women with bilateral inguinal hernias are more likely than men to undergo open rather than laparoscopic inguinal hernia repair.

Absorbable Mg surgical tack: Proof of concept &in situ fixation strength

A prototype magnesium (Mg) surgical tack is tested comparatively against commercially available tacks made of titanium (ProTack^tm, Medtronic) and PLGA (AbsorbaTack^tm, Medtronic). The pull-out force is measured in situ in a lap-shear pull-out test, using porcine abdominal muscle tissue as a model. The Mg tack had a pull-out force comparable to those of the commercially available tacks. The majority of the Mg tacks also had a more ductile failure mode (i.e. the tacks deformed prior to failure), compared to the commercial tacks which pulled directly from the tissue with no deformation. The Mg tacks deformed as they were removed from the tissue, causing less damage to the tissue in the process. This is the first reported use of a Mg alloy in this application, and the proof of concept indicates that this is an area that deserves further interest and study.

TEP for elective primary unilateral inguinal hernia repair in men: what do we know?

INTRODUCTION

Based on the new international guidelines for groin hernia management, there is no one surgical technique that is suited to all patient characteristics and diagnostic findings. Therefore, a tailored approach should be used. Here, a distinction must be made between primary unilateral inguinal hernia in men and in women, bilateral inguinal hernia, scrotal inguinal hernia, inguinal hernia following pelvic and lower abdominal procedures, patients with severe cardiopulmonary complications, recurrent inguinal hernias and incarcerated inguinal and femoral hernias. This paper now explores the relevant studies on TEP for elective primary unilateral inguinal hernia in men, which constitutes the most common indication for repair.

MATERIAL

A systematic search of the available literature was performed in February 2019 using Medline, PubMed, Scopus, Embase, Springer Link and the Cochrane Library. Only meta-analyses, systematic reviews, RCTs and comparative registry studies were considered. 117 publications were identified as relevant.

RESULTS

RCTs and comparative registry analyses demonstrated the advantages of TEP with regard to postoperative complications, complication-related reoperations, and postoperative and chronic pain compared with Lichtenstein repair for elective primary unilateral inguinal hernia repair in men. No relevant differences were found compared with TAPP. Mesh fixation is not needed in TEP, but heavyweight meshes result in a lower recurrence rate. Extraperitoneal bupivacaine analgesia vs placebo does not demonstrate any advantages, but drainage is advantageous for seroma prophylaxis. The risk of chronic pain is negatively influenced by small defects, younger patient age, preoperative pain, higher BMI, postoperative complications, higher ASA score and risk factors.

CONCLUSION

For the subgroup of elective primary unilateral inguinal hernia in men, accounting for a proportion of less than 50% of the total collective, advantages were identified for TEP compared with open Lichtenstein repair but not versus TAPP.

The Use of Prosthetic Mesh in the Emergency Management of Acute Incarcerated Inguinal Hernias

INTRODUCTION

Tension-free hernia repair has been regarded as a gold standard treatment for selected inguinal hernias, but the use of prosthetic mesh in acute incarcerated inguinal hernias is controversial. Our study focused on evaluating the safety and efficacy of the prosthetic mesh repair for emergency cases.

METHODS

Patients with acute incarcerated inguinal hernias who underwent emergency prosthetic mesh repair during 2009 to 2014 at our department were included. Patient characteristics, operative approaches and results, and complications were retrospectively analyzed.

RESULTS

A total of 167 patients were included in our study. One hundred and twenty-two patients underwent open surgery while the remaining 45 patients underwent transabdominal preperitoneal laparoscopic approach. The hernia was indirect inguinal in 133 patients (79.6%), direct inguinal in 15 patients (9.0%), and femoral in 19 patients (11.4%). The overall wound infection rate of these patients was 3%. Nonviable intestinal resection was performed in 25 patients (8.4%), only 2 of whom underwent wound infection. Another 3 patients who developed wound infection had viable hernia content. There was no mesh-related infection. There was no statistically significant difference in wound infection rates between patients with viable hernia contents and those with nonviable contents ( P < .05).

CONCLUSION

The use of the prosthetic mesh in the treatment of acute incarcerated inguinal hernia is safe and effective. Nonviable intestinal resection cannot be regarded as a contradiction of the mesh repair.

Feasibility of totally extraperitoneal (TEP) laparoscopic hernia repair in elderly patients

INTRODUCTION

Laparoscopic total extraperitoneal peritoneal (TEP) repair has become increasingly popular since its introduction. The purpose of this study is to establish the safety and feasibility of TEP in elderly patients compared to that in younger patients.

METHODS

The clinical records of patients who received TEP hernia repair from August 2007 to September 2016 were reviewed. The patients were categorized into two groups: younger than 70 and 70 years or older. The patient demographics, operative time, estimated blood loss, rate of open conversion, complications, length of hospital stay, rate of readmission, rate of recurrence were compared.

RESULTS

A total of 425 cases were documented. 317 (74.6%) patients were younger than 70 years and 108 (25.4%) were 70 years or older. The mean ages were 51.6 years in the younger group and 75.3 years in the older group. Co-morbidities (34.0% vs 72.2%, p = 0.000) and ASA score III and IV (4.1% vs. 6.5%, p value = 0.000) were more common in the elderly group. There were no significant differences between the two groups in the percentage of history of previous surgery in the lower abdominal region (23.9% vs 29.6%, p = 0.292), overall complications (7.2% vs 12.7%, p value = 0.177), and anesthesia-related complications (0% vs 1%, p value = 0.617). The operative time was similar between the two groups (54.3 vs 57.1 p = 0.220). The length of hospital stay (2.7 vs 3.0, p = 0.022) was longer in the elderly group.

CONCLUSIONS

Laparoscopic TEP hernia repair can be performed safely in elderly patients without differences in perioperative complications and recurrence rate compared to that in a younger population despite a longer hospital stay.

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.

Comparison of Lichtenstein Repair and Mesh Plug Repair Methods in The Treatment of Indirect Inguinal Hernia

Objective: The lifetime risk to develop an inguinal hernia is 27%-43% for men and 3%-6% for women. Methods of hernia repair currently involve prosthetic mesh applications. The aim of this study is to compare the Lichtenstein repair and Mesh-plug repair methods in the surgical treatment of indirect inguinal hernias and to identify which of these two techniques is superior regarding its conferred advantages.

Materials and Methods: In this study, a total of 102 patients who were diagnosed with indirect inguinal hernia between the years 2014 and 2015 without a previous operation were analyzed. Patients undergoing Lichtenstein repair and Mesh-plug repair were compared, especially during operation time, hospital stay, postoperative pain and other aspects.

Results: The mean age of patients was 28.7 years (19-73). The mean duration of operations and hospitalizations was significantly shorter in patients who had undergone mesh-plug repair. Inguinal pain in the operation area on postoperative day one, two weeks and six months was significantly less in patients who had undergone mesh-plug repair. Patients were followed-up for two years.

Conclusion: We concluded that mesh-plug repair was superior to Lichtenstein repair regarding postoperative pain, quality of life of the patient, shorter duration of operation, and duration of hospital stay although the two methods were similar regarding both recurrence and complication rates. Considering this information, we suggest that mesh-plug repair can be used safely for the treatment of indirect inguinal hernias.