Prosthetic repair, intestinal resection, and potentially contaminated areas: Safe and feasible?

The safety of polypropylene mesh in repairing incarcerated or strangulated hernias with organ resection

BACKGROUND

Organ resection is often required in incarcerated or strangulated hernias, which makes the surgical field more contaminated, and increased contamination makes it possible to elevate the risk of surgical site infections and increase the likelihood of hernia recurrence. The safety of polypropylene mesh for repair in such contaminated conditions is equivocal, leading to controversy concerning its application. This study aims to elucidate this matter by comparing the complications between mesh repair and primary repair specifically in strangulated or incarcerated hernias with organ resection. At the same time, the study contributed to assessing the safety of polypropylene mesh in repairing hernias under conditions where infection is a significant concern.

METHODS

This meta-analysis was reported following PRISMA 2020 guidelines, all studies were searched and retrieved from major databases (PubMed, and Web of Science), and were included if they reported complications between mesh repair and primary repair in incarcerated or strangulated ventral or groin hernias with or without organ resection. Meta-analyses were conducted when possible, and subgroup analyses were made for the severity of complications (major vs minor) and hernia type (ventral vs. groin). According to the study design, the risk of bias was assessed using the Newcastle-Ottawa Scale. All related articles and reference lists in these original studies were also obtained from the above databases.

RESULTS

Nine observational studies containing 1287 patients with incarcerated or strangulated hernias were included. Three findings were found: (1) Overall complications in the mesh repair group were more than those in the primary repair group in incarcerated or strangulated hernias with organ resection (OR = 4.93; 95% CI: 2.54, 9.56; P < 0.00001). (2) There was a slight tendency for more complications to occur in the organ resection group than in the non-resection group with mesh repair, although the difference was subtle (OR = 3.36; 95% CI: 0.86, 13.15; P = 0.08). (3) There was a trend that more complications occurred when mesh was used in emergent ventral hernia repair than in primary repair (OR = 3.33; 95% CI: 0.91, 12.26; P = 0.07), while, this trend was not observed in emergent groin hernia repair.

CONCLUSION

In cases of incarcerated or strangulated hernias requiring organ resection, the use of polypropylene mesh has been correlated with a higher incidence of complications compared to primary repair. Additionally, a trend was observed toward greater complication rates when ventral hernia repair was performed. Therefore, polypropylene mesh should be used cautiously in strangulated hernias with organ resection or in the repair of the ventral hernia.

Simultaneous incisional hernia repair and colorectal surgery: one or two-step procedure?

PURPOSE

Patients requiring colorectal surgery in the context of an incisional hernia are common, but it is not clear whether the repair should be performed as a single or two-step surgery. Our aim was to evaluate complications after concomitant abdominal wall repair and colorectal surgery compared to those after incisional hernia repair alone.

METHODS

Adult patients who underwent elective incisional hernia surgery from 2012-2022 from the EVEREG registry were included. Patients who underwent midline incisional hernia repair as a single procedure and patients who underwent midline incisional hernia repair concomitant with colorectal surgery were included. The primary outcome was surgical site infection (SSI). The secondary outcomes were the Clavien-Dindo classification grade, in-hospital mortality and recurrence.

RESULTS

A total of 7783 patients were included: 256(3.3%) who underwent concomitant surgery and 7527(96.7%) who underwent only midline incisional hernia repair. The first group included more comorbid patients and complex hernias. SSI was found in 55.4% of patients who underwent simultaneous surgery compared to 30.7% of patients who underwent hernia repair alone (P = 0.000). Multivariate analysis revealed that the risk factors for SSI were BMI (OR = 1.07, 95% CI 1.02-1.11; P = 0.004), smoking (OR = 1.89, 95% CI 1.12-3.19; P = 0.017), transverse diameter (OR = 1.06, 95% CI 1.01-1.11; P = 0.017), component separation (OR = 1.996, 95% CI 1.25-3.08; P = 0.037) and clean-contaminated and contaminated surgeries(OR = 3.86, 95% CI 1.36-10.66; P = 0.009). Higher grades of Clavien-Dindo (P = 0.001) and mortality rates (P < 0.001) were found in the colorectal surgery group, although specific risk factors were detected. No differences were observed in terms of recurrence (P = 0.104).

CONCLUSIONS

Concomitant surgery is related to greater risk of complications, especially in patients with comorbidities and complex hernias. In properly selected cases, simultaneous procedures can yield satisfactory results.

The increased angiogenic capacity and decreased inflammatory response when a mesh is used in combination with an omental flap. A prospective experimental study

BACKGROUND

The use of a surgical mesh for abdominal wall reconstruction is well established and has been used for long with minor complications, whereas the omental flap has been used for decades in reconstructive surgery.

AIM

To demonstrate the increased angiogenic capacity and the reduced inflammatory markers of a synthetic mesh when used in combination with an omental flap. Furthermore, we compare two independent meshes when used alone or in combination with the omental flap.

MATERIALS AND METHODS

Twenty-eight rats were included in the study. To determine the effect of using an omental flap under two different meshes, the animals were separated into four groups, i.e., group A (flap + mesh 1), group B (flap + mesh 1 + silicone), group C (flap + mesh 2), and group D (flap + mesh 2 + silicone). A silicone sheet was placed as a barrier between the mesh and the flap. All groups were sacrificed 8 weeks post-operatively.

RESULTS

The use of a silicone sheet barrier between any of the two synthetic meshes and the omental flap in an abdominal wall defect is accompanied by a markedly reduced angiogenesis in terms of a cluster of differentiation (CD)-34 (p < 0.001) and factor VIII (p = 0.0012) and by increased inflammatory response CD-68 (p = 0.0024) and visual scoring (p < 0.001).

CONCLUSIONS

Τhe increased angiogenic capacity and the reduced inflammatory markers of a synthetic surgical mesh when used in combination with an omental flap make it a useful option in the reconstruction of an abdominal wall defect on a large or contaminated wound.

Bowel perforation surgery due to fecal impaction immediately after hernia mesh surgery (TAPP)

Inguinal hernia repair using prosthetic mesh is used as a standard treatment in most countries and considered superior to primary suture repair. Although prosthetic mesh has greatly reduced the risk of recurrence, the risk of mesh infection remains. A 71-year-old man was diagnosed with symptomatic bilateral inguinal hernias. He underwent successful laparoscopic transabdominal preperitoneal (TAPP) repair and was discharged the same day. After 3 days, he was diagnosed with small bowel perforation, and underwent emergency surgery. We found perforation of the distal ileum caused by the fecal impaction and severe intra-abdominal contamination. We performed subtotal colectomy and ileosigmoid anastomosis, but did not remove the prosthetic mesh because the previous TAPP site was intact. The patient recovered well post-operatively. Therefore, contaminated or dirty surgery immediately after the hernia mesh surgery could be a feasible treatment.

Stepwise transversus abdominis muscle release for the treatment of complex bilateral subcostal incisional hernias

BACKGROUND

Management of subcostal incisional hernias is particularly complicated due to their proximity to the costochondral limits in addition to the lack of aponeurosis on the lateral side of the abdomen. We present our results of posterior component separation through the same previous incision as a safe and reproducible technique for these complex cases.

METHODS

We presented a multicenter and prospective cohort of patients diagnosed with bilateral subcostal incisional hernias on either clinical examination or imaging based on computed tomography from 2014 to 2020. The aim of this investigation was to assess the outcomes of abdominal wall reconstruction for subcostal incisional hernias through a new approach. The outcomes reported were short- and long-term complications, including recurrence, pain, and bulging. Quality of life was assessed with the European Registry for Abdominal Wall Hernias Quality of Life score.

RESULTS

A total of 46 patients were identified. All patients underwent posterior component separation. Surgical site occurrences occurred in 10 patients (22%), with only 7 patients (15%) requiring procedural intervention. During a mean follow-up of 18 months (range, 6-62 months), 1 (2%) case of clinical recurrence was registered. Also, there were 8 (17%) patients with asymptomatic but visible bulging. The European Registry for Abdominal Wall Hernias Quality of Life score showed a statistically significant decrease in the 3 domains (pain, restriction, and cosmetic) of the postoperative scores compared with the preoperative score.

CONCLUSION

Posterior component separation technique for the repair of subcostal incisional hernias through the same incision is a safe procedure that avoids injury to the linea alba. It is associated with acceptable morbidity, low recurrence rate, and improvement in patients' reported outcomes.

Prosthetic mesh hernioplasty versus primary repair in incarcerated and strangulated groin and abdominal wall hernias with or without organ resection. Retrospective study

PURPOSE

The use of synthetic materials in emergency surgery for abdominal wall hernia in a potentially infected operating field has long been debated. In the present study, we evaluated the outcome of mesh prostheses in the management of incarcerated and strangulated abdominal wall hernias with or without organ resection.

METHODS

Between March 2012 and January 2020, medical records of 301 patients who underwent emergency surgery for incarcerated and strangulated abdominal wall hernias were retrospectively evaluated. The interventions were exclusively realized by two surgical teams, one of which used polypropylene mesh prostheses (group I), whereas the second team performed primary hernia repair (group II). The outcome of patients was observed for a mean follow-up period of 18.2 months. Categorical data were analyzed with the χ2 test or likelihood ratio. Logistic regression was used for adjustments in multivariate analysis. Statistical analyses were realized with SPSS, version 18. P values < 0.05 were considered statistically significant. For multiple comparisons between types of hernia, the significance level was set to P < 0.0083 according to Bonferroni adjustment.

RESULTS

Of the 301 patients, 190 were men (63.1%), and 111 were women (36.9%). The mean age was 59,98 years (range 17-92). Overall, 226 (75.1%) patients were treated with synthetic mesh replacement. One hundred two organ resections (34%) were performed involving the omentum, small intestine, colon, and appendix. No significant difference was identified in terms of postoperative complications, between the two groups both in patients who underwent organ resection and in patients who did not.

CONCLUSION

Synthetic materials may safely be used in the emergency management of incarcerated and strangulated groin and abdominal wall hernias in patients with or without organ resection, although they cannot formally be recommended due to the limited number of cases of the present study.

Ventral hernia repair with synthetic mesh in a contaminated field: a systematic review and meta-analysis

PURPOSE

The use of mesh in ventral hernia repair becomes especially challenging when associated with a contaminated field. Permanent synthetic mesh use in this setting is currently debated and this discussion is yet to be resolved clinically or in the literature. We aim to systematically assess postoperative outcomes of non-absorbable synthetic mesh (NASM) used in ventral hernia repair in the setting of contamination.

METHODS

A literature search of PubMed, Embase, Scopus, Cinahl, and Cochrane Library identified all articles from 2000-2020 that examined the use of NASM for ventral hernia repair in a contaminated field. Postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Qualitative analysis was completed for all included studies using a modified Newcastle-Ottawa scale.

RESULTS

Of 630 distinct publications and 104 requiring full review, this study included 17 articles published between 2007 and 2020. Meta-analysis demonstrated absorbable mesh was associated with more HR (OR 1.89, 1.15-3.12, p = 0.008), SSO (OR 1.43, 0.96-2.11, p = 0.087), SSI (OR 2.84, 1.85-4.35, p < 0.001), and unplanned reoperation (OR 1.99, 1.19-3.32, p = 0.009) compared to NASM.

CONCLUSION

The use of NASM for ventral hernia repair in a contaminated field may be a safe alternative to absorbable mesh, as evidenced by lower rates of postoperative complications. This review counters the current clinical paradigm, and additional prospective randomized controlled trials are warranted.

Treatment outcomes of Kugel repair for obturator hernias: a retrospective study

Background

We examined the validity and applicability of the Kugel repair approach for obturator hernias, whereby we placed a Kugel patch through the preperitoneal space after placing a short 5-cm skin incision just medial to the anterior iliac spine and 2 cm cranial to the expected origin of the internal inguinal ring.

Methods

We studied patients who underwent surgical Kugel repair for obturator hernias at the Department of General Surgery, Saitama Medical University between 2007 and 2017. We examined the operating time, length of hospital stay, postoperative complications, and mortality rate.

Results

Fifty-eight patients with obturator hernias presented with symptoms of small bowel obstruction. A Kugel approach was used in 53 patients and a midline approach was used in 5 patients with preoperative peritonitis. Of the 53 patients managed using the Kugel approach, 39 did not require intestinal resection; a mesh was used in all these patients. In the remaining 14 patients, intestinal resection was required and performed using the same approach; subsequently, a mesh was used successfully in 6 of these 14 patients. The overall median operating time was 47 min; the corresponding values for procedures with and without intestinal resection were 39 and 68 min, respectively. In terms of postoperative complications, operative mortality was not noted among patients without intestinal perforation; however, superficial surgical site infection developed in 2 patients. Among the 5 patients with preoperative peritonitis who underwent exploratory laparotomy via a midline incision, intestinal perforation was detected during surgery, and all patients required intestinal resection; none of the patients had received a mesh, and 2 patients died after surgery.

Conclusions

The Kugel repair approach was possible even in patients with obturator hernia requiring intestinal resection. However, for patients with perforations, open surgery should be performed after securing the surgical field through a midline incision.

Emergency repair of complicated abdominal wall hernias: WSES guidelines

PURPOSE

In July 2013, the World Society of Emergency Surgery (WSES) held the first Consensus Conference on emergency repair of abdominal wall hernias in adult patients with the intention of producing evidence-based guidelines to assist surgeons in the management of complicated abdominal wall hernias. Guidelines were updated in 2017 in keeping with varying clinical practice: benefits resulting from the increased use of biological prosthesis in the emergency setting were highlighted, as previously published in the World Journal of Emergency Surgery. This executive summary is intended to consolidate knowledge on the emergency management of complicated hernias by providing the broad readership with a practical and concise version of the original guidelines.

METHODS

This executive manuscript summarizes the WSES guidelines reporting on the emergency management of complicated abdominal wall hernias; statements are highlighted focusing the readers' attention on the main concepts presented in the original guidelines.

CONCLUSIONS

Emergency repair of complicated abdominal hernias remains one of the most common and challenging surgical emergencies worldwide. WSES aims to provide an essential version of the evidence-based guidelines focusing on the timing of intervention, laparoscopic approach, surgical repair following the Centers for Disease Control and Prevention (CDC) wound classification, antimicrobial prophylaxis and anesthesia in the emergency setting.

Risk factors of postoperative complications after emergency repair of incarcerated groin hernia for adult patients: a retrospective cohort study

Purpose

This study aimed to explore risk factors of postoperative complications for adult patients with incarcerated groin hernia (IGH).

Methods

From January 2010 to December 2017, consecutive patients undergoing emergency hernia repair for IGH in our center were retrospectively reviewed. Postoperative complications, such as surgical site infection, seroma, hernia recurrence and mortality, were investigated, with risk factors for such complications analyzed using univariate and multivariate regressions.

Results

Sixty-four patients were included, with 51 males and 13 females (mean age 65.1, range 25–98 years). Ten patients (15.6%) underwent resection of necrotic bowel and anastomosis. 43 patients (67.2%) received open tension-free herniorrhaphy with polypropylene mesh, whereas the rest (32.8%) received herniorrhaphy without mesh. The overall postoperative complication rate was 40.6% (26/64), with an incisional complication rate of 31.2% (20/64) and an infection rate of 6.2% (4/64). At a median follow-up of 32 months, hernia recurrence and mortality were recorded in five cases each (7.8%). Mesh repair was associated with decreased recurrence rate compared with non-mesh repair (2.3% vs. 19.0%, p = 0.019). Diabetes mellitus (OR 8.611, 95%CI 1.292–57.405; p = 0.026) was an independent risk factor of postoperative complications, together with chronic obstructive pulmonary disease (COPD; OR 14.365, 95%CI 1.652–127.767, p = 0.016), intestinal necrosis (OR 14.260, 95%CI 1.079–188.460, p = 0.044), and general anesthesia (OR 14.543, 95%CI 1.682–125.711, p = 0.015) as risk for incisional complications after surgery.

Conclusions

Diabetes mellitus was an independent risk factor of postoperative complications for IGH, along with COPD, intestinal necrosis and general anesthesia associated with incisional complications. The use of polypropylene mesh did not increase infection or recurrence rate in this cohort.

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.

2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias

Emergency repair of complicated abdominal wall hernias may be associated with worsen outcome and a significant rate of postoperative complications. There is no consensus on management of complicated abdominal hernias. The main matter of debate is about the use of mesh in case of intestinal resection and the type of mesh to be used. Wound infection is the most common complication encountered and represents an immense burden especially in the presence of a mesh. The recurrence rate is an important topic that influences the final outcome. A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bergamo in July 2013 with the aim to define recommendations for emergency repair of abdominal wall hernias in adults. This document represents the executive summary of the consensus conference approved by a WSES expert panel. In 2016, the guidelines have been revised and updated according to the most recent available literature.

Outcomes following repair of incarcerated and strangulated ventral hernias with or without synthetic mesh

BACKGROUND

The use of synthetic mesh for ventral hernia repair under contaminated conditions is a controversial issue due to the considerable risk of surgical site infection (SSI). This study aimed to review the outcomes of repair of incarcerated and strangulated ventral hernias with or without synthetic mesh in compliance with established clinical guidelines regarding the incidence of SSI and hernia recurrence.

METHODS

The records of patients with complicated ventral hernias who were treated with or without synthetic mesh repair were reviewed. Variables collected included the characteristics of patients and of ventral hernias, type of repair, and incidence of SSI and recurrence.

RESULTS

One hundred twenty-two patients (56 males) of a mean age of 56 years were included. Fifty-two (42.6%) and 70 (57.4%) patients presented with incarcerated and strangulated ventral hernias, respectively. Sixty-six (54%) patients were treated with on-lay mesh repair, and 56 (46%) were managed with suture repair. Twenty-one patients required bowel resection. SSI was detected in eight (6.5%) patients. There was no significant difference between both groups regarding the incidence of SSI (7.5% for mesh group vs 5.3% for suture group). Recurrence occurred in seven patients. Median follow-up period was 24 months. The suture repair group had a significantly higher incidence of recurrence than the mesh group. Diabetes mellitus, previous recurrence, and intestinal resection were significant predictors for SSI.

CONCLUSION

Following established guidelines, synthetic mesh repair of incarcerated and strangulated ventral hernias attained lower recurrence rate, comparable incidence of SSI, and higher rate of seroma formation than suture repair.

TRIAL REGISTRATION

Research Registry, researchregistry1891.

A novel bowel necrosis classification system and examination of patient outcomes in incarcerated groin hernia patients

The objective of this study was to determine a classification system for BN in incarcerated groin hernia patients and to explore the possible relationship between BN staging and patient outcomes. Incarcerated groin hernia patients treated with emergency bowel resection from January 2008 to December 2013 were screened for inclusion in a prospective study. A novel three-stage classification system was proposed for BN (BN stages I–III) and correlations between adverse events (AEs) and mortality with BN stage were determined. A total of 108 patients were included, with 71, 26, and 11 patients in BN stages I, II, and III, respectively. AEs, which included wound and intra-abdominal infections and other systemic complications, increased with higher BN stage (all P < 0.05). Mortality increased with BN stage, with 2.8%, 7.7%, and 27.3% at BN stages I, II, and III, respectively (P < 0.05). The proposed BN staging system can objectively reflect the degree of bowel damage and its corresponding adverse outcomes.

Impact of pericardium bovine patch (Tutomesh(®)) on incisional hernia treatment in contaminated or potentially contaminated fields: retrospective comparative study

PURPOSE

This retrospective comparative study analyzes the outcome of patients affected by incisional hernia in potentially contaminated or contaminated field, treated by three operative techniques.

METHODS

152 patients (62 M:90 F; mean age 65 ± 14 years) underwent incisional hernia repair (January 2002-January 2012) in complicated settings. Criteria of inclusion in the study were represented by the following causes of admission: mesh rejection/infection, obstruction without gangrene but with possible peritoneal bacterial translocation, obstruction with gangrene, enterocutaneous fistula or simultaneous presence of ileo- or colostomy. The patients were divided into three groups: A (n = 76), treated with primary closure technique; B and C (n = 38 each), with reinforcement by synthetic or pericardium bovine mesh (Tutomesh(®)), respectively. The prosthetic groups were divided into Onlay and Sublay subgroups.

RESULTS

Significant decreases in C vs A were observed for wound infection (3 vs 37%) and recurrence (0 vs 14%), and in C vs B for wound infection (3 vs 53%), seroma (0 vs 34%) and recurrence (0 vs 16%). Patients with concomitant bowel resection (BR) (43%) showed (all P < 0.05) an increase of overall morbidity (55 vs 33%) and wound infection rate (42 vs 24%) compared to cases without BR. Morbidity presented no significant differences in C-Onlay or Sublay subgroups. B-Sublay subgroup has (all P < 0.05) lower overall morbidity (20 vs 75%), wound infection (10 vs 68%) and seroma (0 vs 46%) than B-Onlay.

CONCLUSIONS

The pericardium bovine patch seems to be safe and effective to successfully repair ventral hernia in potentially contaminated operative fields, especially in association with bowel resection.

WSES guidelines for emergency repair of complicated abdominal wall hernias

Emergency repair of complicated abdominal hernias is associated with poor prognosis and a high rate of post-operative complications.A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bergamo in July 2013, during the 2nd Congress of the World Society of Emergency Surgery with the goal of defining recommendations for emergency repair of abdominal wall hernias in adults. This document represents the executive summary of the consensus conference approved by a WSES expert panel.

Safety of polypropylene mesh for incarcerated groin and obturator hernias: a retrospective study of 110 patients

PURPOSE

The purpose of this study was to evaluate the mesh repair for an incarcerated groin hernia.

METHODS

A total of 110 patients who underwent emergency surgery for incarcerated hernias were retrospectively analyzed using a multivariate analysis.

RESULTS

The postoperative complications were associated with bowel resection, odds ratio (OR) 2.984, and 95 % confidence interval (CI) 1.273 to 6.994. The risk factors for bowel resection were femoral hernia, (OR 5.621, 95 % CI 2.243 to 14.082), and late hospitalization (24 h<), (OR 2.935, 95 % CI 1.163-7.406). The hernias were repaired with mesh in ten of the 39 (25.6 %) patients with bowel resection and sixty-four of the 71 (90.1 %) patients without bowel resection. The complication rate of the patients with bowel resection was 53.8 % and was 26.8 % in those without. The ratios of wound infection were 23.1 and 0.0 %, respectively. Wound infections were detected in two (20 %) of the ten patients who underwent bowel resection with mesh repair; however, there were no patients in whom the mesh was withdrawn due to infection.

CONCLUSIONS

No wound infections in patients without bowel resection were detected, and mesh repair could be safely performed. Mesh repair for the patients with bowel resection is not contraindicated, as long as the clean-contamination of the wound was maintained during surgery.

Inguinal Hernia Orifice for Specimen Extraction After Laparoscopic Resections

Specimen extraction is an unavoidable step in all laparoscopic resections. To this day there is no standardized retrieval incision for each procedure and the choice is made individually, yet based on the surgeon’s experience and preference. Additionally, worldwide prevalence of inguinal hernia is high and many patients with this condition require surgical intervention for a distinct reason. In these particular cases, the hernia orifice can be seeing as an opportunity, allowing specimen retrieval when an open repair is performed immediately after the laparoscopic resection. In the present article, the authors propose this new option. Three patients who underwent this technique are also presented. Discussion is focused on the advantages and critics of the approach.

Feasibility of mesh repair for strangulated abdominal wall hernias

BACKGROUND

Prosthetic mesh reduces the risk of hernia recurrence. The use of mesh in patients with strangulated hernias requiring bowel resection is controversial.

PATIENTS AND METHODS

Patients with acutely incarcerated hernias (with small intestine contents) who underwent polypropylene mesh hernioplasty were included in this prospective study from June 2005 to Jan. 2011.

RESULTS

163 patients were included; 48 required intestinal resection and anastomosis (Group I) and 115 did not (Group II). Operative times and hospital stay were longer in Group I (P = 0.001). No significant difference was noted between both groups in terms of postoperative morbidities (16.6% vs 13% P = 0.5), wound infection (6% vs 4% P = 0.6), and recurrence rate (2% vs 2.8% P = 0.8), All cases of wound infection were successfully managed with drainage and local wound care and no mesh had to be removed. One patient in Group I and five patients in Group II died of concomitant diseases in the follow-up period (P = 0.5).

CONCLUSION

Mesh hernioplasty is crucial to prevent recurrence, and it is safe to utilize it in repair of acutely incarcerated hernias even if associated with intestinal resection.

Emergency incisional hernia repair: a difficult problem waiting for a solution

Background

Emergency repair of incarcerated incisional hernia with associated bowel obstruction in potentially or contaminated field is technically challenging due to edematous, inflamed and friable tissues with occasional need for concurrent bowel resection and carries high rates of post-operative infectious complications. The aim of this study was to retrospectively assess the wound related morbidity of use of permanent prosthetic mesh in emergency repair of incarcerated incisional hernia with associated bowel obstruction. We also describe a new technique of leaving the mesh exposed to heal by secondary intention with granulation tissue.

Methods

Between 2000 and 2010 a total of 60 patients underwent emergency surgery for incarcerated incisional hernia with associated bowel obstruction with placement of permanent prosthetic mesh. The wound was closed after hernia repair in 55 patients while it was left open to granulate in 5 patients.

Results

In the group of patients with primary wound closure, 11 patients developed superficial surgical site infection, 5 developed deep wound infection and one patient had cellulitis. These patients were treated with wound debridement and antibiotics. Mesh removal was required in one patient. There were no infections in the group of patients who had their surgical wounds left open. One patient in this group died on the fifth postoperative day from septicemia.

Conclusion

Use of permanent prosthetic mesh in emergency repair of incarcerated incisional hernia with associated bowel obstruction. in contaminated field is associated with high risk of wound infection.

Internal supravesical hernia: an unusual cause of small bowel obstruction

Internal hernia of the supravesical fossa is an unusual cause of small bowel obstruction. We report the case of a patient without previous abdominal surgery with an acute abdominal obstruction in which laparoscopic exploration revealed a strangulated internal supravesical hernia. To help clinicians with their pre-operative diagnosis and to better understand the clinical management of this unusual internal hernia, a description of the anatomy of the supravesical fossa is included in this case report.

Searching for the best polypropylene mesh to be used in bowel contamination

PURPOSE

There is still some concern about the use of polypropylene in case of infection or contamination. The biocompatibility of the recently introduced light-weight polypropylene meshes seems to be promising. This experimental study was designed to evaluate three different weights and pore sizes of polypropylene meshes in a contamination model.

METHODS

Thirty rabbits were operated through a pararectal incision. The abdomen, wound and mesh were contaminated with faecal fluid aspirated from the appendix. Groups of ten animals were studied according to three different pore sizes of polypropylene mesh implanted as an inlay technique: very large pore, large pore and medium pore. Five animals of each group were sacrificed on days 21 and 90. Incisional surgical site infection and microbiologic cultures on the 21st and 90th days were the main outcome measures. Tissue integration, shrinkage and biomechanical properties were also tested.

RESULTS

Two rabbits died on day 1. There were six incisional surgical site infections (21.4%). Four animals had positive cultures with no macroscopic infection. None of the surviving rabbits with very large pore mesh had clinical infection or positive microbiologic cultures. Very large pore meshes shrank significantly more on day 21. There were no differences in the tensiometric test results.

CONCLUSIONS

In our experimental model, low-weight, very large pore polypropylene meshes seem to be the best polypropylene mesh in case of intestinal contamination. These results encourage clinical investigation on the use of low-weight, very large pore polypropylene meshes in the treatment and prevention of hernias in the presence of clean-contaminated or contaminated fields.

An incarcerated appendix: report of three cases and a review of the literature

We came across three rare cases of incarcerated hernia, with different presentations. The first case was an elderly female, who presented with an incarcerated incisional hernia on the right lower iliac region diagnosed on contrast enhanced computed tomography (CT); the contents were the small bowel and the perforated tip of the appendix. In the second case of inguinal incarcerated hernia, ultrasonography showed the inflammed appendix in the subcutaneous plane of the hernial sac, which is very rarely diagnosed pre-operatively and was confirmed during surgery. Inflammed appendix with gangrenous tip was found in the inguinal hernial sac. In yet another case of incarcerated inguinal hernia, the contents were a gangrenous part of the ascending colon and transverse colon, with the tip of the inflamed appendix--also only rarely observed. The colon extended to the scrotum in this case. We could find no description within the existing medical literature on either transverse or ascending colon as contents in inguinal hernia although transverse colon alone has been reported in four cases. The surgical options for dealing with the appendix in an Amyand's hernia depend on the mode of presentation. The presence of a normal appendix does not require an appendicectomy to be performed, but its removal is necessary if inflamed.

Comparison of Surgisis, AlloDerm, and Vicryl Woven Mesh grafts for abdominal wall defect repair in an animal model

BACKGROUND

Surgisis and AlloDerm, two biosynthetic materials, have been previously used with success in abdominal wall repairs in the setting of contaminated fields. Historically, Vicryl Woven Mesh, a synthetic material, has also been used in such settings as a temporary bridge for abdominal wall reconstruction. This study compares Surgisis and AlloDerm with Vicryl Woven Mesh with respect to tensile strength, collagen remodeling, and neovascularization using a rat hernia model.

METHODS

A prospective randomized trial of 54 Sprague-Dawley rats were assigned to the Surgisis, AlloDerm, or Vicryl Woven Mesh group with baseline, 30-day, and 60-day end points. A 1.5-cm x 5.0-cm defect was created in the right abdominis rectus muscle and repaired with an underlay bridge graft using the different treatment materials. Tensile strength was measured using an Instron tensiometer. Histologic specimens were evaluated for neovascularization, collagen deposition, and collagen organization at the 30- and 60-day time points.

RESULTS

Surgisis had significantly greater tensile strength compared to Vicryl Woven Mesh at the baseline time point (0.142 vs. 0.091 MPa, p < 0.05). There were no differences between groups tensile strength at 30 or 60 days postoperatively. The Vicryl Woven Mesh and AlloDerm groups showed increases in tensile strength at 30 days postoperatively versus baseline (p < 0.05). Vicryl Woven Mesh, Surgisis, and AlloDerm all showed increases in tensile strength at 60 days postoperatively compared to 30 days postoperatively and at baseline (p < 0.05). Surgisis and AlloDerm had significantly greater (p < 0.05) amounts of collagen deposition and organization at 30 and 60 days compared to Vicryl Woven Mesh. There was no significant difference between AlloDerm and Surgisis with respect to collagen deposition and organization. Surgisis and AlloDerm showed a significantly greater amount (p < 0.05) of neovascularization than Vicryl Woven Mesh at both time points. In addition, Surgisis had a significantly greater amount (p < 0.05) of neovascularization than AlloDerm at both 30 and 60 days.

CONCLUSION

Surgisis has increased baseline tensile strength compared to Vicryl Woven Mesh. Tensile strength in Vicryl Woven Mesh is equal to biosynthetic grafts after tissue incorporation. Biosynthetic grafts showed superior collagen deposition and organization. Surgisis mesh showed increased neovascularization over both AlloDerm and Vicryl Woven Mesh.

Morphological and mechanical characteristics of the reconstructed rat abdominal wall following use of a wet electrospun biodegradable polyurethane elastomer scaffold

Although a variety of materials are currently used for abdominal wall repair, general complications encountered include herniation, infection, and mechanical mismatch with native tissue. An approach wherein a degradable synthetic material is ultimately replaced by tissue mechanically approximating the native state could obviate these complications. We report here on the generation of biodegradable scaffolds for abdominal wall replacement using a wet electrospinning technique in which fibers of a biodegradable elastomer, poly(ester urethane)urea (PEUU), were concurrently deposited with electrosprayed serum-based culture medium. Wet electrospun PEUU (wet ePEUU) was found to exhibit markedly different mechanical behavior and to possess an altered microstructure relative to dry processed ePEUU. In a rat model for abdominal wall replacement, wet ePEUU scaffolds (1x2.5 cm) provided a healing result that developed toward approximating physiologic mechanical behavior at 8 weeks. An extensive cellular infiltrate possessing contractile smooth muscle markers was observed together with extensive extracellular matrix (collagens, elastin) elaboration. Control implants of dry ePEUU and expanded polytetrafluoroethylene did not experience substantial cellular infiltration and did not take on the native mechanical anisotropy of the rat abdominal wall. These results illustrate the markedly different in vivo behavior observed with this newly reported wet electrospinning process, offering a potentially useful refinement of an increasingly common biomaterial processing technique.

The combined laparoscopic approach for the treatment of incarcerated inguinal hernia

BACKGROUND

The traditional open approach to incarcerated inguinal hernia has several drawbacks including difficulty avoiding tension in the swollen and edematous tissues leading to a higher recurrence rate, possible contamination of the mesh if it is implanted in an area of bowel strangulation, and proper evaluation of whether ischemic bowel requires resection or not, which may mandate laparotomy. This study aimed to evaluate an approach that combines intraperitoneal laparoscopic exploration with hernia reduction and total extraperitoneal (TEP) repair of the hernia.

METHODS

An exploratory laparoscopy is performed. The incarcerated content is gently retracted into the abdominal cavity and inspected. If no resection is needed, the gas is deflated, the umbilical trocar is removed, and the preperitoneal space is accessed with a Hasson trocar inserted behind the rectus muscle toward the pelvis. Two additional 5-mm trocars are inserted into the preperitoneal space in the lower midline. A standard TEP repair with mesh is performed.

RESULTS

Between 2005 and 2008, 15 patients underwent laparoscopic exploration for incarcerated inguinal hernia followed by TEP repair. Of the 15 patients, 8 had acute incarceration and 7 had chronic irreducible hernia. Reduction of the incarcerated content was straightforward, and no bowel resection was needed. No major complications or wound or mesh infections occurred.

CONCLUSION

The combined laparoscopic approach offers a solution to incarceration of inguinal hernias while taking advantage of each separate approach. The first part of the procedure enables easy reduction of the incarcerated content and assessment of its viability. The second part enables a simple and standard repair, similar to that for an elective case. If bowel necrosis is suspected preoperatively, an open anterior approach should be taken to avoid possible intraabdominal contamination.

Prophylactic mesh to prevent incisional hernia: a note of caution

BACKGROUND

Ventral hernia is a common complication of open Roux-en-Y gastric bypass (RYGB). The aim of this study was to determine whether prophylactic mesh placement during RYGB would reduce the incidence of postoperative hernias.

METHODS

Obese patients undergoing RYGB by a single surgeon had prosthetic mesh placed in a subfascial location at the conclusion of the procedure. The incidences of recurrent hernia and morbidity associated with the placement of mesh were assessed.

RESULTS

Sixteen patients underwent RYGB with prophylactic mesh placement over 6 months. The average preoperative body mass index was 46.6 kg/m(2). Half of the patients were diabetics. None were smokers. During mean follow-up of 6 months, 4 patients (25%) required mesh excision, 3 for infection and 1 for a persistently symptomatic seroma. One patient was explanted incidentally in the course of reexploration for intractable nausea and vomiting. Another developed an incisional hernia despite prophylactic mesh.

CONCLUSIONS

In the investigators' experience, the use of prophylactic new-generation mesh at the time of open RYGB led to an unacceptable rate of local complications. They caution against this technique in patients undergoing open RYGB.

Prosthetic abdominal wall hernia repair in emergency surgery: from polypropylene to biological meshes

The use of nonabsorbable prosthetic materials such as polypropylene, polyester, and ePTFE, have expanded and are now widely used in reparative surgery for abdominal wall hernias.There are still difficulties to find correct indication for prosthetic implant in emergency hernia surgery: as a matter of fact there is still a great debate if to use non-absorbable prostheses in potentially or truly infected operating fields [e.g. after intestinal resections].All these problems can be avoided with the use of absorbable prosthetic materials such as those composed of lactic acid polymers or lactic and glycolic acid copolymers: however, the use of these absorbable prosthesis exposes the patient to a rapid and inevitable hernia recurrence.It is important to remember that prosthetic repair has been proven to have a significant less risk of recurrence than repair with direct sutures.Recently, new "biologic" prosthetic materials have been developed and proposed for the clinical use in infected fields. These materials can be called "remodeling" for the way by which they are replaced after their placement within the patient. The "remodeling" process is made possible through a process of incorporation, where a reproduction of a site-specific tissue similar to the original host tissue is created.

Abdominal compartment syndrome in patients with strangulated hernia

BACKGROUND

Intestinal obstruction (IO) leads to increased intra-abdominal pressure and abdominal compartment syndrome. The purpose of this study was to investigate the characteristics of abdominal compartment syndrome in patients with IO secondary to strangulated hernia.

METHODS

We studied 81 consecutive unselected patients presenting complicated hernias and IO. We measured intra-abdominal pressure using the intra-vesicular pressure method.

RESULTS

Preoperative (15 min) intra-abdominal pressure was higher in patients with strangulated hernias. Postoperative (15 min) intra-abdominal pressure in both groups decreased to similar values. Intra-abdominal pressure was measured during the preoperative period in patients with strangulated hernias and during the postoperative period at 15 min (13.8 +/- 6.4 mmHg), 24 h (9.8 +/- 3.2 mmHg) and 48 h (7.4 +/- 2.4 mmHg). Abdominal compartment syndrome developed in 47% cases with strangulated hernias with a mortality of five patients.

CONCLUSIONS

Serial measurements of intra-abdominal pressure evidenced the clinical severity of strangulated hernia. Intra-abdominal pressure measurement may be used as a predictor of intestinal strangulation in patients presenting acute abdominal compartment syndrome secondary to complicated hernia.

Prosthetic repair of incarcerated inguinal hernias: is it a reliable method?

BACKGROUND AND AIM

It is generally accepted that most inguinal hernias should be operated on electively using synthetic grafts. However, limited information is available on the usage of these materials in patient with incarcerated and strangulated hernias. The objective of this study is to compare the outcomes of incarcerated inguinal hernia repair with or without graft.

MATERIALS AND METHODS

One hundred-thirteen patients with incarcerated inguinal hernia that underwent surgery were included in this study. Patients who underwent Lichtenstein repair were assigned to group I; those who underwent primary repair were assigned to group II. Demographics and characteristics of patients in each group were compared. Chi-square and Student's t-tests were used.

RESULTS

No statistical difference was found between patients who did and did not receive anastomosis in both groups in terms of surgery duration, length of hospital stay, postoperative morbidity, and mortality. Recurrence was found in 4.0% and 20.8% patients in group I and group II, respectively (P = 0.036).

CONCLUSIONS

Mesh repair can be preferred in incarcerated inguinal hernia patients because recurrence rate was significantly lower in patients who underwent Lichtenstein repair in this study.

Early results from the use of the Lichtenstein repair in the management of strangulated groin hernia

BACKGROUND

Use of prosthetic repairs in the management of strangulated hernias has so far been very limited due to the fear of an associated higher incidence of complications, especially those related to the presence of the mesh. The aim of this study was to prospectively determine whether the use of the Lichtenstein repair in the management of strangulated groin hernias was associated with a higher rate of wound infection and/or mesh-related complications than in the elective setting.

PATIENTS AND METHODS

The results obtained from the use of the Lichtenstein repair in the management of 25 patients with strangulated groin hernias (group I) were compared to those of another 25 age- and sex-matched patients undergoing Lichtenstein repair for elective groin hernia repair (group II).

RESULTS

In group I, one patient (4%) developed a scrotal hematoma. No other postoperative complications were encountered, whether related or unrelated to the presence of the mesh. No complications were encountered in group II patients. Throughout the 20-month duration of the present study, no mesh had to be removed and no recurrences were encountered in either group.

CONCLUSION

The good short-term results of the present study in terms of absence of wound infection, mesh-related complications and recurrence suggest that use of the Lichtenstein repair in the management of strangulated groin hernias is safe and is not associated with a higher rate of complications compared to its use in the elective setting.

Comparison of prosthetic mesh repair and tissue repair in the emergency management of incarcerated para-umbilical hernia: a prospective randomized study

BACKGROUND

Although prosthetic repair has become the gold standard for elective management of para-umbilical hernia (PUH) its use in the setting of acute incarceration is still limited for fear of prosthetic-related complications, mainly infection. The objective of this study was to compare results from prosthetic repair and tissue repair in the management of the acutely incarcerated PUH.

PATIENTS AND METHODS

Forty-two patients were prospectively randomized to either the prosthetic-repair group (group 1 = 21 patients) or the tissue-repair group (group 2 = 21 patients). In group 1, an onlay polypropylene mesh was inserted and the presence of non-viable intestine was not considered a contraindication for mesh repair. Operative time, postoperative hospital stay, and postoperative complications were recorded. Follow-up was performed by physical examination to detect recurrence.

RESULTS

Mean operative time was significantly longer for group 1 (96.9 +/- 14.6 compared with 65.5 +/- 14.6 min for group 2, P < 0.05). Postoperative hospital stay did not differ significantly between the groups (3 +/- 1.6 compared with 3.5 +/- 2.2 days for groups 1 and 2, respectively). Postoperative complications did not differ significantly between the groups (28.6 vs. 23.8% for groups 1 and 2, respectively). No mesh had to be removed. At follow-up (mean 16 +/- 5.5 months) there were four recurrences in group 2 (4/21, 19%) and no recurrences in group 1 (P < 0.05).

CONCLUSION

Use of prosthetic repair for emergency management of incarcerated PUH is safe and leads to superior results, in terms of recurrence, compared with conventional tissue repair. The presence of non-viable intestine cannot, furthermore, be regarded as a contraindication for prosthetic repair.

Use of porcine dermal collagen graft (Permacol) for hernia repair in contaminated fields

BACKGROUND

Complicated hernias often involve contaminating surgical procedures in which the use of polypropylene meshes can be hazardous. Prostheses made of porcine dermal collagen (PDC) have recently been proposed as a means to offset the disadvantages of polypropylene meshes and have since been used in humans for hernia repairs. The aim of our study was to evaluate the safety and efficacy of incisional hernia repair using PDC as a mesh in complicated cases involving contamination.

METHODS

A prospective study of hernia repair of complicated incisional hernias with contamination using PDC grafts was carried out at the Department of General, Emergency and Transplant Surgery of St Orsola-Malpighi University Hospital.

RESULTS

From January 2004 up to the writing of this article, seven patients were treated for complicated incisional hernias with a PDC prosthesis. In six out of seven patients a bowel resection was carried out. There were not surgical complications. Morbidity was 14.2%. No recurrences and wound infections were observed.

CONCLUSIONS

Incisional hernioplasty using PDC grafts is a potentially safe and efficient approach in complicated cases with contamination.

Is the Lichtenstein Operation of Strangulated Groin Hernia a Safe Procedure?

BACKGROUND

In spite of many published articles describing the hernia repairs, there are only a few original reports concerning the polymer mesh application during emergency procedures for strangulated inguinal hernias. The aim of our study was to evaluate the results of the Lichtenstein and Bassini operations for strangulated groin hernias and to show the changing number of the tension-free repairs.

METHODS

From 1997 to 2004, the Bassini procedure was performed in 21 patients, 6 of whom underwent small intestine resection and 2 others required resection of the necrotic omentum. The strangulated intestinal loop or omentum were released in 13 cases. After the repair 1 patient died of shock caused by intestinal necrosis. Of 56 patients who underwent an emergency Lichtenstein procedure, 55 were followed-up. A small intestine resection was performed in 2 cases to correct segmental necrosis. The gangrenous omental appendix of the sigmoid colon was excised in 1 patient, and necrotic omental fragments were resected in 2 cases. The strangulated intestinal loop or omentum was released in 51 patients. All patients were given wide-spectrum antibiotics intravenously.

RESULTS

Between 1997 and 2000 tension-free procedures were performed in half of the patients undergoing emergency operation for strangulated hernia; between 2001 and 2004 such procedures were employed in more than 90% of the cases. In 2 patients we observed a small inflammatory infiltration of the wound that resolved within several days after Lichtenstein repair. A serous fluid collection was present in 2 cases. The treatment consisted of puncture and was successful in both cases.

CONCLUSIONS

The use of monofilament polypropylene mesh for strangulated inguinal hernia repair is safe, and the risk of the local infectious complications is low.

The use of prosthetics in abdominal wall reconstruction

Large ventral or incisional hernias are often difficult to manage. Most commonly patients are referred to reconstructive surgeons after multiple failed attempts of hernia repair. The use of prosthetic and bioprosthetic materials have aided greatly in the management of complex abdominal wall defects. A full understanding of the advantages and disadvantages of specific prosthetic materials available, and the associated complications of use, remains elusive, however. This article provides information concerning the applications of appropriate prosthetic material for temporary or permanent closure of difficult abdominal wall defects.

Adverse effects of porcine small intestine submucosa implants in experimental ventral hernia repair

BACKGROUND

Biomeshes made of porcine small intestine submucosa (SIS) have recently been suggested for repair of ventral hernia. A fully biodegradable combination of implant and fibrin sealant fixation was assessed in a new rat model with sutures serving as control.

METHODS

In 10 Sprague-Dawley rats, two defects per animal were created in the abdominal wall left and right of the linea alba (1 cm in diameter), and the peritoneum was spared. The lesions were left untreated for 10 days to achieve a chronic condition and were then covered with SIS (2 x 2 cm), sealed or sutured (n = 10 per group). Randomization allowed sealant and sutures in one animal. Animals were killed on postoperative day 17, and implant sites were analyzed macroscopically, histologically, and microbiologically.

RESULTS

Abscedation, encapsulation, and putrid seroma were observed in all samples, regardless of fixation technique. Histology revealed lytic necrosis and extensive inflammatory response of the surrounding tissue. Tissue samples obtained from three implant sites were positive for beta-hemolytic Streptococcus. SIS was not detectable after 17 days.

CONCLUSIONS

Adverse effects were observed using SIS in an experimental model of ventral hernia and were not linked to fixation method or study design. Further experimental investigations on SIS are necessary before its clinical use in hernia repair.

Tension-free repair versus modified Bassini technique (Andrews technique) for strangulated inguinal hernia: a comparative study

BACKGROUND

To compare tension-free hernia repair to a modified Bassini technique (Andrew's technique) used to treat complicated inguinal hernia.

METHODS

In the period 1990-2004, 75 patients were submitted to emergency operation because of strangulated inguinal hernia. 33 patients underwent tension-free repair utilizing a polypropylene mesh (group A), whereas the remaining 42 patients underwent a modified Bassini technique (group B).

RESULTS

Mean operative time was significantly longer for group B (91.5+/-9.3 min vs 75.7+/-10.5 min, p<0.05). Postoperative hospital stay was also significantly longer in group B compared to group A (10.3+/-3.4 days vs 4.5+/-2.1 days, p<0.01). Postoperative complication rate did not differ significantly between the two groups (5/33, 15.1% vs 5/42, 11.9%, p=n.s.). No mesh had to be removed. At follow-up (mean 9+/-4.2 years), there was one recurrence in group A (1/33, 3%) and two recurrences in group B (2/42, 4.7%) (p=n.s.).

CONCLUSION

The presence of a strangulated inguinal hernia cannot be considered a contraindication for the use of a prosthetic mesh.