Current treatment concepts for groin hernia. Langenbecks Arch Surg. 2014;399:553-558. [PMID: 24824799 DOI: 10.1007/s00423-014-1212-8]

Tipp versus the Lichtenstein and Shouldice techniques in the repair of inguinal hernias - short-term results

OBJECTIVE

The Lichtenstein mesh technique is recommended as the standard surgical procedure for inguinal hernias. Shouldice is the best non-mesh technique. However, there are reports that the transinguinal preperitoneal technique (TIPP), which uses a preperitoneal mesh, has potential advantages in relation to the Lichtenstein and the Shouldice techniques.

PATIENTS AND METHODS

Three hundred patients with inguinal hernias were randomized into three groups of hundred patients each: Group 1 whose inguinal hernia repair was performed using the Lichtenstein technique; Group 2 using the Shouldice technique; and Group 3 using TIPP. The parameters for monitoring were: length of operation, blood loss, length of hospitalization, length of incision, post-operative pain, and the patient's satisfaction level.

RESULTS

The visual analog scale (VAS) score after 6, 12, 24 and 48 h, and 14 d was lower in TIPP than the Lichtenstein and Shouldice groups (p < .0001). The satisfaction level was higher in TIPP than in the Lichtenstein and Shouldice groups (p < .0001).

CONCLUSIONS

TIPP technique has advantages in comparison with the Lichtenstein and Shouldice techniques. This method takes a shorter time, the skin incision is smaller, the VAS score is lower and the patient satisfaction level is higher. These advantages are in balance with the higher costs of this procedure.

Surgical outcomes of totally extraperitoneal repair for inguinal hernia: A retrospective multicenter propensity score-matched study

BACKGROUND

Laparoscopic surgical approaches, including total extraperitoneal repair (TEP), have been widely accepted for inguinal hernia repair in Japan. However, there are limited data regarding recurrence after TEP in Japan, given the limited versatility of this procedure. This study retrospectively evaluated the rates of hernia recurrence after TEP and open mesh repair at multiple Japanese centers.

METHODS

This retrospective study evaluated 1917 patients who underwent inguinal hernia repair at 32 institutions in the Oita prefecture between January 2014 and December 2015. Eligible patients were grouped according to whether they underwent TEP (1011 patients) or open mesh repair (636 patients). Propensity score matching was performed 1:1 (total: 1076 patients, 538 patients from each group). The outcomes of interest were recurrence, morbidity, and postoperative recovery.

RESULTS

The TEP and open mesh repair groups had similar baseline characteristics. After propensity score matching, there was no significant difference between the two groups in terms of recurrence rate (TEP: 0.5% vs open mesh repair: 1.0%, P = .375). However, the TEP group had significantly longer operating times (median: 70.2 min vs 65.0 min, P < .001), significantly less blood loss (0-5.1 mL vs 0-20.4 mL, P < .001), and significantly shorter postoperative hospital stays (median: 5.0 days vs 6.4 days, P < .001). The overall incidences of morbidity were 6.2% in the TEP group and 7.2% in the open mesh repair group (P = .535).

CONCLUSION

This multicenter retrospective study with propensity score matching revealed that the recurrence rates were similarly low for TEP and open mesh repair of inguinal hernia. Thus, a well-trained surgical team could use TEP as a standard procedure.

Resterilized Polypropylene Mesh for Inguinal Hernia Repair

Purpose:

The use of prosthetic biomaterials for reconstructing and reinforcing the posterior wall of the inguinal canal reduces the incidence of hernia recurrence. Cost, availability of mesh, and perhaps reluctance to adopt a new technique are factors which prevent widespread practice of hernioplasty in low-resource settings. Use of resterilized mesh significantly reduces the cost of hernioplasty and is safe.

Patients and Methods:

Sheets of 30 cm × 30 cm polypropylene mesh were cut into 16 cm × 8 cm to produce mesh strips which were repackaged into SELFSEAL^® (Medical Action Industries Inc., USA) sterilizing pouches measuring 90 mm × 230 mm and autoclaved. At repair, the strips are shaped to fit the anatomy of the posterior wall of the inguinal canal, a slit created at one end and applied in Lichtenstein repair of inguinal hernias. Patients were monitored for seroma collection and wound infection up to 2 weeks postoperative period.

Results:

Sixty inguinal hernia repairs were done in 58 patients using the resterilized mesh; two cases being bilateral. One patient (1.7%) had seroma collection at 2 weeks which was aseptically aspirated. We did not record any case of wound infection.

Conclusion:

The use of sterilized polypropylene mesh for the repair of inguinal hernias is safe and reduced the cost of hernioplasty by reducing the cost of polypropylene mesh. This technique is recommended in low-resource settings.

Do we need changes in the organization of training in the hernia treatment in Poland? A survey on the acknowledgment of the recommendations of international hernia societies by surgeons

In the therapy of an inguinal hernia, there is a huge variety in the way of treating and the choice of surgical technique. Practice shows that the intraoperative improvisation and surgeons' own modifications of the original techniques have become part of routine procedure. No mandatory hernia registration system causes the actual detailed herniology status in our country remains unknown. The aim of the study was to summarize the results of a survey on knowledge of a hernia according to the standards developed by international hernia societies compared with everyday clinical practice. During the International Conference Hernia in Poland, which took place on 10 December 2016 in Zakopane we conducted an interactive session among 106 surgeons dealing with hernias. Surgeons responded to 66 questions about daily surgical practice and decision making in their centers, and 27 questions for the assessment of the world's latest treatment recommendations regarding groin hernias. The most common method of using the implant technique Lichtenstein, used by 91% of doctors. 20% of surgeons in planned operations in adult men routinely uses no mesh technique. Almost 80% of respondents do not apply TEP or TAPP. Only 45.7% of surgeons customize surgical technique to the patient. Only 7 of the 27 analyzed recommendation has been accepted by more than 90% of respondents. 9 of the 27 recommendations were approved by less than half of the surgeons. In the case of 11 recommendations, surgeons simultaneously failed to comply with these recommendations in daily practice. Deficiencies in the system of training and the underfunding of medical procedures cause insufficient TAPP/ TEP availability in Poland in an inguinal hernia. Improvement of the surgeons' knowledge on how to perform surgery.

A systematic review comparing single-incision versus multi-incision laparoscopic surgery for inguinal hernia repair with mesh

OBJECTIVE

The objective of this article is to evaluate whether the surgical outcomes differ between single incision laparoscopic surgery (SILS) versus multi-incision laparoscopic surgery (MILS) for the repair of inguinal hernia.

METHODS

A systematic review of the literature on published studies reporting the surgical outcomes following SILS versus MILS for inguinal hernia repair was undertaken using the principles of meta-analysis.

RESULTS

Fifteen comparative studies on 1651 patients evaluating the surgical outcomes in patients undergoing SILS versus MILS for inguinal hernia repair were systematically analysed. The post-operative recovery time was significantly quicker [odds ratio, -0.35 (CI, -0.57 - 0.14), p = 0.001] following SILS compared to MILS procedure. However, the statistical equivalence was seen in outcomes of length of hospital stay, operative time both for unilateral and bilateral hernias, post-operative pain score, one-week pain score, hernia recurrence [odds ratio, 1.24 (CI, 0.47-3.23), p = 0.66], conversion [odds ratio, 1.07 (CI, 0.37-3.12), p = 0.90], and post-operative complications [odds ratio, 0.95 (CI, 0.66-1.36, p = 0.78] between two approaches. The sub-group analysis of four included randomized, controlled trials showed similarities between outcomes following SILS and MILS except slightly higher postoperative pain score in MILS group.

CONCLUSIONS

Both SILS and MILS approaches of inguinal hernia repair are feasible, safe and can be offered to patients depending upon the availability of expertise and resources.

First Case Report of Acute Renal Failure After Mesh-Plug Inguinal Hernia Repair in a Kidney Transplant Recipient

Acute renal failure due to ureter compression after a mesh-plug inguinal repair in a kidney transplant recipient has not been previously reported to our knowledge. A 62-year-old man, who successfully underwent kidney transplantation from a deceased donor 6 years earlier, was admitted for elective repair of a direct inguinal hernia. The patient underwent an open mesh-plug repair of the inguinal hernia with placement of a plug in the preperitoneal space. We did not observe the transplanted ureter and bladder during dissection of the inguinal canal. Immediately after surgery, the patient became anuric, and a graft sonography demonstrated massive hydronephrosis. The serum creatinine level increased rapidly, and the patient underwent an emergency reoperation 8 hours later. During surgery, we did not identify the ureter but, immediately after plug removal, urine output increased progressively. We completed the hernia repair using the standard technique, without plug interposition, and the postoperative course was uneventful with complete resolution of graft dysfunction 3 days later. Furthermore, we reviewed the clinical features of complications related to inguinal hernia surgery. An increased risk of urological complications was reported recently in patients with a previous prosthetic hernia repair undergoing kidney transplantation, mainly due to the mesh adhesion to surrounding structures, making the extraperitoneal dissection during the transplant surgery very challenging. Moreover, older male kidney transplant recipients undergoing an inguinal hernia repair may be at higher risk of graft dysfunction due to inguinal herniation of a transplanted ureter. Mesh-plug inguinal hernia repair is a safe surgical technique, but this unique case suggests that kidney transplant recipients with inguinal hernia may be at higher risk of serious urological complications. Surgeons must be aware of the graft and ureter position before proceeding with hernia repair. A prompt diagnosis with graft sonography and abdominal computed tomography scan and emergency surgery may avoid the need for nephrostomy and may resolve graft dysfunction more rapidly.

Needlescopic Surgery Versus Single-port Laparoscopy for Inguinal Hernia

Background and Objectives:

In recent years, 2 modifications of laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair—needlescopic (nTAPP) surgery and single-port (sTAPP) surgery—have greatly improved patient outcomes over traditional approaches. For a comparison of these 2 modifications, we sought to investigate and compare the extent of surgical trauma and postoperative consequences for the abdominal wall in these two procedures.

Methods:

In a retrospective study, 50 nTAPP and 35 sTAPP procedures occurring at a community hospital from November 1, 2009, through July 31, 2012 were reviewed. Intraoperative data, including length of the umbilical skin incision and operative time, were recorded. A follow-up evaluation included investigation of hernia recurrence, postoperative pain, abdominal wall mobility, cosmetic satisfaction, and period of sick leave.

Results:

The mean umbilical skin incision was 13 ± 4 mm in nTAPP vs 27 ± 3 mm in sTAPP (P < .001). The nTAPP procedure required less operating time than the sTAPP procedure (54.8 ± 16.9 minutes vs 85.9 ± 19.7 minutes; P < .001). The mean immediate postoperative pain score on the visual analog scale was 2.7 ± 2.1 in the nTAPP group and 4.4 ± 1.9 in the sTAPP group (P = .016). In addition, patients who underwent nTAPP had a shorter period of sick leave (11.2 ± 8.4 days vs 24.1 ± 20.1 days; P = .02). At the follow-up evaluation after approximately 30 months, abdominal wall mobility and cosmetic satisfaction were equally positive, with no hernia recurrence.

Conclusion:

In patients with uncomplicated inguinal hernia, the nTAPP procedure, with less surgical trauma and operating time, has distinct advantages in reduction of immediate postoperative pain and sick leave time.

Laparoscopic surgery: A qualified systematic review

AIM: To review current applications of the laparoscopic surgery while highlighting the standard procedures across different fields.

METHODS: A comprehensive search was undertaken using the PubMed Advanced Search Builder. A total of 321 articles were found in this search. The following criteria had to be met for the publication to be selected: Review article, randomized controlled trials, or meta-analyses discussing the subject of laparoscopic surgery. In addition, publications were hand-searched in the Cochrane database and the high-impact journals. A total of 82 of the findings were included according to matching the inclusion criteria. Overall, 403 full-text articles were reviewed. Of these, 218 were excluded due to not matching the inclusion criteria.

RESULTS: A total of 185 relevant articles were identified matching the search criteria for an overview of the current literature on the laparoscopic surgery. Articles covered the period from the first laparoscopic application through its tremendous advancement over the last several years. Overall, the biggest advantage of the procedure has been minimizing trauma to the abdominal wall compared with open surgery. In the case of cholecystectomy, fundoplication, and adrenalectomy, the procedure has become the gold standard without being proven as a superior technique over the open surgery in randomized controlled trials. Faster recovery, reduced hospital stay, and a quicker return to normal activities are the most evident advantages of the laparoscopic surgery. Positive outcomes, efficiency, a lower rate of wound infections, and reduction in the perioperative morbidity of minimally invasive procedures have been shown in most indications.

CONCLUSION: Improvements in surgical training and developments in instruments, imaging, and surgical techniques have greatly increased safety and feasibility of the laparoscopic surgical procedures.

Emerging Trends in Abdominal Wall Reinforcement: Bringing Bio-Functionality to Meshes

Abdominal wall hernia is a recurrent issue world-wide and requires the implantation of over 1 million meshes per year. Because permanent meshes such as polypropylene and polyester are not free of complications after implantation, many mesh modifications and new functionalities have been investigated over the last decade. Indeed, mesh optimization is the focus of intense development and the biomaterials utilized are now envisioned as being bioactive substrates that trigger various physiological processes in order to prevent complications and to promote tissue integration. In this context, it is of paramount interest to review the most relevant bio-functionalities being brought to new meshes and to open new avenues for the innovative development of the next generation of meshes with enhanced properties for functional abdominal wall hernia repair.

Meta-analysis of randomized trials comparing nonpenetrating vs mechanical mesh fixation in laparoscopic inguinal hernia repair

BACKGROUND

Evidence for open groin hernia repair demonstrates less pain with bioglue mesh fixation compared with invasive methods. This study aimed to assess the short- and long-term effects of laparoscopic groin hernia repair with noninvasive and invasive mesh fixation.

DATA SOURCES

A systematic review of MEDLINE, CENTRAL, and OpenGrey was undertaken. Randomized trials assessing the outcome of laparoscopic groin hernia repair with invasive and noninvasive fixation methods were considered for data synthesis. Nine trials encompassing 1,454 patients subjected to laparoscopic hernia repair with mesh fixation using biologic or biosynthetic glue were identified. Short-term data were inadequate for data synthesis. Chronic pain was less frequently reported by patients subjected to repair with biologic glue fixation than with penetrating methods (odds ratio .46, 95% confidence interval .22 to .93). Duration of surgery, incidence of seroma/hematoma, morbidity, and recurrence were similar.

CONCLUSIONS

Laparoscopic groin hernia repair with bioglue mesh fixation was associated with a reduced incidence of chronic pain compared with mechanical fixation, without increasing morbidity or recurrence. Longer term data on recurrence are necessary.