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Cao Z, Zhang Z, Wang Y, Zhu Y, Li Z, Li X, Shen Y, Chen J, Liu Z. Exploring serum N-glycome patterns as candidate non-invasive biomarkers in inguinal hernia. Heliyon 2024; 10:e35908. [PMID: 39211922 PMCID: PMC11357755 DOI: 10.1016/j.heliyon.2024.e35908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 07/05/2024] [Accepted: 08/06/2024] [Indexed: 09/04/2024] Open
Abstract
Introduction Although inguinal hernia (IH) is prevalent in elderly males, research on its specific diagnostic biomarkers is limited. Protein N-glycosylation is one of the most important and ubiquitous post-translational modifications and often results in a remarkable heterogeneity of protein glycoforms. Protein N-glycosylation often changes in a disease and holds great potential for discovering non-invasive biomarkers. This study aimed to gain insights into total serum protein N-glycosylation of IH to identify candidate non-invasive biomarkers for diagnosis and subtype classification of IH. Methods Linkage-specific sialylation derivatization combined with matrix-assisted laser desorption/ionization time-of-flight mass spectrometry detection was used to analyze serum protein N-glycosylation patterns in IH patients and healthy controls. Results IH patients had abnormal glycan fucosylation and sialylation compared to healthy controls (HC), of which two glycan traits representing linkage-specific sialylation within monoantennary glycans showed high potential as diagnostic biomarkers for IH with an area under the curve (AUC) of 0.75. Additionally, serum N-glycans were different between indirect IH and direct IH in glycosylation features, namely complexity, fucosylation, galactosylation, sialylation, and α2,6-linked sialylation. Four distinctive glycans between the two subtypes showed good performance with AUC >0.8, suggesting that these glycan traits have potential as biomarkers for subtype classification. Conclusions We first reported the serum N-glycomic features of IH patients. Furthermore, we identified several potential biomarkers for the diagnosis and subtype classification of IH. These findings can deepen the understanding of IH.
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Affiliation(s)
- Zhen Cao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zejian Zhang
- Institute of Clinical Medicine, State Key Laboratory of Complex Severe and Rare Diseases, National Infrastructure for Translational Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuanyang Wang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yilin Zhu
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zepeng Li
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaobin Li
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yingmo Shen
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jie Chen
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Ziwen Liu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Physiologic Cyclical Load on Inguinal Hernia Scaffold ProFlor Turns Biological Response into Tissue Regeneration. BIOLOGY 2023; 12:biology12030434. [PMID: 36979126 PMCID: PMC10045722 DOI: 10.3390/biology12030434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 03/01/2023] [Accepted: 03/10/2023] [Indexed: 03/16/2023]
Abstract
Surgical repair of groin protrusions is one of the most frequently performed procedures. Currently, open or laparoscopic repair of inguinal hernias with flat meshes deployed over the hernial defect is considered the gold standard. However, fixation of the implant, poor quality biologic response to meshes and defective management of the defect represent sources of continuous debates. To overcome these issues, a different treatment concept has recently been proposed. It is based on a 3D scaffold named ProFlor, a flower shaped multilamellar device compressible on all planes. This 3D device is introduced into the hernial opening and, thanks to its inherent centrifugal expansion, permanently obliterates the defect in fixation-free fashion. While being made of the same polypropylene material as conventional hernia implants, the 3D design of ProFlor confers a proprietary dynamic responsivity, which unlike the foreign body reaction of flat/static meshes, promotes a true regenerative response. A long series of scientific evidence confirms that, moving in compliance with the physiologic cyclical load of the groin, ProFlor attracts tissue growth factors inducing the development of newly formed muscular, vascular and nervous structures, thus re-establishing the inguinal barrier formerly wasted by hernia disease. The development up to complete maturation of these highly specialized tissue elements was followed thanks to biopsies excised from ProFlor from the short-term up to years post implantation. Immunohistochemistry made it possible to document the concurrence of specific growth factors in the regenerative phenomena. The results achieved with ProFlor likely demonstrate that modifying the two-dimensional design of hernia meshes into a 3D outline and arranging the device to respond to kinetic stresses turns a conventional regressive foreign body response into advanced probiotic tissue regeneration.
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Amato G, Romano G, Rodolico V, Puleio R, Calò PG, Di Buono G, Cicero L, Romano G, Goetze TO, Agrusa A. Dynamic Responsive Inguinal Scaffold Activates Myogenic Growth Factors Finalizing the Regeneration of the Herniated Groin. J Funct Biomater 2022; 13:jfb13040253. [PMID: 36412894 PMCID: PMC9680268 DOI: 10.3390/jfb13040253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/12/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Postoperative chronic pain caused by fixation and/or fibrotic incorporation of hernia meshes are the main concerns in inguinal herniorrhaphy. As inguinal hernia is a degenerative disease, logically the treatment should aim at stopping degeneration and activating regeneration. Unfortunately, in conventional prosthetic herniorrhaphy no relationship exists between pathogenesis and treatment. To overcome these incongruences, a 3D dynamic responsive multilamellar scaffold has been developed for fixation-free inguinal hernia repair. Made of polypropylene like conventional flat meshes, the dynamic behavior of the scaffold allows for the regeneration of all typical inguinal components: connective tissue, vessels, nerves, and myocytes. This investigation aims to demonstrate that, moving in tune with the groin, the 3D scaffold attracts myogenic growth factors activating the development of mature myocytes and, thus, re-establishing the herniated inguinal barrier. METHODS Biopsy samples excised from the 3D scaffold at different postoperative stages were stained with H&E and Azan-Mallory; immunohistochemistry for NGF and NGFR p75 was performed to verify the degree of involvement of muscular growth factors in the neomyogenesis. RESULTS Histological evidence of progressive muscle development and immunohistochemical proof of NFG and NFGRp75 contribution in neomyogenesis within the 3D scaffold was documented and statistically validated. CONCLUSION The investigation appears to confirm that a 3D polypropylene scaffold designed to confer dynamic responsivity, unlike the fibrotic scar plate of static meshes, attracts myogenic growth factors turning the biological response into tissue regeneration. Newly developed muscles allow the scaffold to restore the integrity of the inguinal barrier.
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Affiliation(s)
- Giuseppe Amato
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy
- Correspondence: (G.A.); (L.C.)
| | - Giorgio Romano
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy
| | - Vito Rodolico
- Department PROMISE, Section Pathological Anatomy, University of Palermo, 90127 Palermo, Italy
| | - Roberto Puleio
- Department of Pathologic Anatomy and Histology, IZSS, 90129 Palermo, Italy
| | - Pietro Giorgio Calò
- Department of Surgical Sciences, University of Cagliari, 09042 Cagliari, Italy
| | - Giuseppe Di Buono
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy
| | - Luca Cicero
- CEMERIT—IZSS, Via Gino Marinuzzi, 3, 90129 Palermo, Italy
- Correspondence: (G.A.); (L.C.)
| | - Giorgio Romano
- Postgraduate School of General Surgery, University of Palermo, 90127 Palermo, Italy
| | - Thorsten Oliver Goetze
- Institut für Klinisch-Onkologische Forschung Krankenhaus Nordwest, 60488 Frankfurt/Main, Germany
| | - Antonino Agrusa
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy
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Amato G, Agrusa A, Calò PG, Di Buono G, Buscemi S, Cordova A, Zanghì G, Romano G. Fixation free laparoscopic obliteration of inguinal hernia defects with the 3D dynamic responsive scaffold ProFlor. Sci Rep 2022; 12:18971. [PMID: 36347998 PMCID: PMC9643531 DOI: 10.1038/s41598-022-23128-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/25/2022] [Indexed: 11/09/2022] Open
Abstract
Laparoscopic TAPP/TEP approaches are well-established options for the cure of inguinal hernias. As in the open approach, mesh fixation and poor-quality biologic response represent controversial questions and are a source of concerns. Furthermore, hernia defect patency represents another problem which seems not well acknowledged among surgeons. These problems are considered the cause of frequent intra and postoperative complications. To overcome these concerns, recently a different concept of cure has emerged. Based on a newly developed dynamic responsive 3D scaffold named ProFlor, a permanent hernia defect obliteration has been finalized. Following its inherent centrifugal expansion due to its dynamic responsivity, this hernia device is positioned fixation free within the defect and induces a probiotic biological response allowing for the re-establishment of the degenerated inguinal barrier. A laparoscopic approach with the 3D scaffold has been tested on 71 patients to demonstrate its effectiveness in reducing intra and postoperative complications. The operated patients presented with bilateral and/or recurrent inguinal hernia. Overall, 122 hernia defects were obliterated with 119 dynamic responsive scaffolds. The procedures were carried out from January 2018 to January 2022 with a defined protocol and detailed procedural steps. The laparoscopic technique with the 3D hernia scaffold allowed for fixation free placement, permanent defect obliteration and dynamically induced regenerative effects. The technique proved effective in reducing intra and postoperative complications. In particular, early postoperative pain and discomfort significantly decreased. No chronic pain and no recurrences were reported during follow up. The results achieved with the described laparoscopic technique seem to embody an innovative concept for inguinal hernia repair. Fixation free, dynamic responsive, permanent defect obliteration, histologically proven regenerative effects are the distinctive features of this 3D scaffold. It seems to embody a more physiological and pathogenetically coherent concept of cure, thus improving treatment results of this widespread disease.
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Affiliation(s)
- Giuseppe Amato
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via L. Giuffrè, 5, 90127, Palermo, Italy.
| | - Antonino Agrusa
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via L. Giuffrè, 5, 90127, Palermo, Italy
| | - Pietro Giorgio Calò
- Department of Surgical Sciences, University of Cagliari, Cittadella Universitaria 09042 - Monserrato (CA) - ITALY, Italy
| | - Giuseppe Di Buono
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via L. Giuffrè, 5, 90127, Palermo, Italy
| | - Salvatore Buscemi
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via L. Giuffrè, 5, 90127, Palermo, Italy
| | - Adriana Cordova
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via L. Giuffrè, 5, 90127, Palermo, Italy
| | - Guido Zanghì
- Department of General Surgery, University of Catania, Via Santa Sofia, 76 - 95123 Catania, Italy
| | - Giorgio Romano
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via L. Giuffrè, 5, 90127, Palermo, Italy
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Reply to "A commentary on "A regenerative 3D scaffold for inguinal hernia repair. MR imaging and histological cross evidence. Qualitative study" (Int J Surg 2021;96:106170)". Int J Surg 2022; 99:106245. [PMID: 35123011 DOI: 10.1016/j.ijsu.2022.106245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 11/23/2022]
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Amato G, Agrusa A, Puleio R, Micci G, Cassata G, Cicero L, Di Buono G, Calò PG, Galia M, Romano G. A regenerative 3D scaffold for inguinal hernia repair. MR imaging and histological cross evidence. Qualitative study. Int J Surg 2021; 96:106170. [PMID: 34775110 DOI: 10.1016/j.ijsu.2021.106170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 09/08/2021] [Accepted: 11/03/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Inguinal hernia is a degenerative disease occurring in a high motile surround. Stopping degeneration and promoting tissue regeneration should be the treatment goal. Groin hernias are conventionally managed with static flat meshes, mostly fixated to the delicate inguinal environment. Far from a regenerative effect, the biologic response of conventional hernia meshes is characterized by a foreign body reaction leading to a stiff/shrunken scar plate, which is often the source of unpleasant complications. Recently, a newly engineered 3D device for inguinal hernia repair - ProFlor-has been developed to produce a regenerative biological response. Unlike conventional hernia meshes, this regenerative 3D hernia scaffold seems to demonstrate suitable features for a pathogenetical and physiological coherent treatment of the disease. The aim of this manuscript is to cross evidence these features through magnetic resonance imaging (MRI) and histology. STUDY DESIGN The biological response of ProFlor at three defined post-implantation stages has been evaluated through MRI signal intensity and compared to neighbouring muscles and fat. As additional proof, histology of tissue specimens excised at the same post-implantation periods from porcine models during an experimental attempt were also evaluated. RESULTS MRI of newly ingrown tissue in ProFlor demonstrated similar signal intensity of muscles while fat tissue showed remarkably higher values. These data matched with the histology of ProFlor biopsies excised from pigs. CONCLUSIONS The motile compliance to groin movements of ProFlor appears to induce a probiotic biologic response comparable to a regenerative scaffold, allowing to physiologically resolve the degenerative source of inguinal hernia disease.
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Affiliation(s)
- Giuseppe Amato
- Postgraduate School of General Surgery, University of Cagliari, Italy Department of General Surgery and Emergency, University of Palermo, Italy Experimental Zooprophylactic Institute A. Mirri, Palermo, Italy Department of Biomedicine, Neurosciences and Advanced Diagnostic University of Palermo, Italy Department of Surgical Sciences, University of Cagliari, Italy
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Amato G, Agrusa A, Di Buono G, Calò PG, Cassata G, Cicero L, Romano G. Inguinal Hernia: Defect Obliteration with the 3D Dynamic Regenerative Scaffold Proflor™. Surg Technol Int 2021; 38:199-205. [PMID: 33942884 DOI: 10.52198/21.sti.38.hr1414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Prosthetic inguinal hernia repair presents significant challenges. Some of these, such as mesh fixation and quality of the biologic response, are still debated among surgeons. For example, there is no strong consensus regarding a specific condition that characterizes the surgical procedure during herniorrhaphy. This issue concerns management of the hernia defect, which in conventional hernia repair with flat meshes remains patent. However, a critical analysis of typical postoperative complications after inguinal hernia repair reveals that some of these adverse events are related to patency of the hernial opening. Postoperative discomfort, pain with specific movements and even hernia recurrence can be caused by incomplete or defective management of the hernia defect. For this reason, a deeper understanding of this topic would be useful for improving postoperative outcomes. A recently updated concept for inguinal hernia repair takes this technical aspect into consideration. It is based on the use of a newly developed 3D scaffold-ProFlor™ (Insightra Medical, Inc., Clarksville, TN, USA)-that is intended to be deployed into the defect. This novel hernia repair device has interesting and original features, such as dynamic responsivity in compliance with inguinal movement, fixation-free mode and regenerative behavior that counteracts the degenerative effects of the disease. Another additional proprietary feature of this 3D scaffold is the full and permanent obliteration of the defect, which is a crucial aspect to improve outcomes by avoiding the typical adverse effects of this surgical procedure. Obliteration of the hernia defect with the 3D dynamic regenerative scaffold ProFlor™ appears to be superior to coverage by means of static (passive) flat meshes/plugs used in conventional hernia repair. This report highlights the principles of this procedural approach.
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Affiliation(s)
- Giuseppe Amato
- Department of General Surgery and Urgency, University of Palermo, Palermo, Italy
| | - Antonino Agrusa
- Department of General Surgery and Urgency, University of Palermo, Palermo, Italy
| | - Giuseppe Di Buono
- Department of General Surgery and Urgency, University of Palermo, Palermo, Italy
| | | | - Giovanni Cassata
- Mediterranean Research and Training Center, IZSS, Palermo, Italy
| | - Luca Cicero
- Mediterranean Research and Training Center, IZSS, Palermo, Italy
| | - Giorgio Romano
- Department of General Surgery and Urgency, University of Palermo, Palermo, Italy
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Amato G, Puleio R, Rodolico V, Agrusa A, Calò PG, Di Buono G, Romano G, Goetze T. Enhanced angiogenesis in the 3D dynamic responsive implant for inguinal hernia repair ProFlor. Artif Organs 2021; 45:933-942. [PMID: 33529348 DOI: 10.1111/aor.13926] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 12/19/2022]
Abstract
Biologic response to hernia prostheses represents a continuous source of debate. Conventional hernia meshes, in their typical static, passive configuration have been used for decades to reinforce the herniated abdominal wall. These flat implants, mainly fixated with sutures or tacks, induce poor quality fibrotic ingrowth that shrinks the mesh. In groin hernia repair, flat meshes are applied in the delicate inguinal surrounding where uncontrolled development of a scar plate can impair movement and may incorporate the sensitive nerves crossing this area. Complications deriving from mesh fixation and nerve entrapment are frequent and unpleasant for patients. To remedy these problems, a multilamellar shaped 3D device with a dynamic responsive behavior has recently been developed to repair inguinal hernia. Its inherent dynamic compliance during inguinal movements has shown to induce enhanced biological response with ingrowth of newly formed connective tissue, muscle fibers, and nerves. The function of these highly specialized tissue structures is supported by the contextual development of newly formed arteries and veins. The scope of the study was to assess quantity and quality of vessels, which had ingrown in the 3D hernia device in the short-term, medium-term, and long-term post-implantation, in biopsy specimens gathered from inguinal hernia patients operated with the 3D device. Starting from an early stage, widespread angiogenesis was evident within the 3D structure. Arteries and veins increased in quantity showing progressive development until full maturation of all specific vascular components throughout the mid-term, to long-term, post-implantation. High quality biologic ingrowth in hernia prosthetics needs an adequate vascular support. The broad network of mature arteries and veins evidenced herewith seems to confirm the enhanced biological features of the dynamic responsive 3D device whose features resemble a regenerative scaffold, an ideal feature for the treatment of the degenerative source of inguinal hernia disease.
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Affiliation(s)
- Giuseppe Amato
- Department of General Surgery and Emergency, University of Palermo, Palermo, Italy
| | - Roberto Puleio
- Department of Pathologic Anatomy and Histology, IZSS, Palermo, Italy
| | - Vito Rodolico
- Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Antonino Agrusa
- Department of General Surgery and Emergency, University of Palermo, Palermo, Italy
| | | | - Giuseppe Di Buono
- Department of General Surgery and Emergency, University of Palermo, Palermo, Italy
| | - Giorgio Romano
- Department of General Surgery and Emergency, University of Palermo, Palermo, Italy
| | - Thorsten Goetze
- Institut für Klinisch-Onkologische Forschung Krankenhaus Nordwest, Frankfurt/Main, Germany
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Neo-nervegenesis in 3D dynamic responsive implant for inguinal hernia repair. Qualitative study. Int J Surg 2020; 76:114-119. [DOI: 10.1016/j.ijsu.2020.02.046] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 02/15/2020] [Accepted: 02/26/2020] [Indexed: 11/21/2022]
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Amato G, Romano G, Goetze T, Cicero L, Gulotta E, Calò P, Agrusa A. Fixation free inguinal hernia repair with the 3D dynamic responsive prosthesis ProFlor: Features, procedural steps and long-term results. INTERNATIONAL JOURNAL OF SURGERY OPEN 2019. [DOI: 10.1016/j.ijso.2019.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Amato G, Calò P, Rodolico V, Puleio R, Agrusa A, Gulotta L, Gordini L, Romano G. The Septum Inguinalis: A Clue to Hernia Genesis? J INVEST SURG 2018; 33:231-239. [PMID: 30380341 DOI: 10.1080/08941939.2018.1497734] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Purpose: Double ipsilateral inguinal ("pantaloon") hernias and also the more advanced "combined" inguinal hernia involve disruption of the inguinal floor. In the case of pantaloon hernias, the medial boundary of the internal ring remains intact but in combined hernias this is fully disrupted, producing a single hernial protrusion. Deepening the pathophysiology of these hernias may be helpful in addressing hernia genesis, thus improving strategies for the treatment of this disease. Materials and Methods: A cohort of 22 patients who underwent inguinal hernia repair showed double ipsilateral (pantaloon) hernia, comprising distinct direct and indirect protrusions separated by a tissue septum. In 19 patients, the septal arrangement dividing the 2 hernias showed macroscopically evident structural damages, then excised and histologically studied. Different tissue markers were used for the identification of the structural damages. Results: Macroscopically, the divisor septum represents the boundary between internal ring and Hesselbach's triangle. Anteriorly it is composed by fibers of the internal oblique and transverse muscles, which form a complex with the inferior epigastric vessels on the corresponding posterior side of the inguinal floor. In the patient cohort studied, this anatomical structure showed a progressive sufferance characterized by chronic compressive damage. Conclusion: The anatomical structure which separates the indirect and direct components of a pantaloon hernia, herein referred to as the "septum inguinalis", has been shown progressively alter in both macro- and microscopically until it f undergoes disruption with development of a combined hernia. Understanding of this anatomical concept may help surgeons to perform sound repairs of these complex hernias.
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Affiliation(s)
- Giuseppe Amato
- Postgraduate School of General Surgery, University of Cagliari, Cagliari, Italy
| | - Piergiorgio Calò
- Department of General Surgery, University of Cagliari, Cagliari, Italy
| | - Vito Rodolico
- Department of Pathologic Anatomy and Histology, University of Palermo, Palermo, Italy
| | - Roberto Puleio
- Department of Pathologic Anatomy and Histology, IZSS Palermo, Palermo, Italy
| | - Antonino Agrusa
- Department of General Surgery and Urgency, University of Palermo, Palermo, Italy
| | - Leonardo Gulotta
- Department of General Surgery and Urgency, University of Palermo, Palermo, Italy
| | - Luca Gordini
- Department of General Surgery, University of Cagliari, Cagliari, Italy
| | - Giorgio Romano
- Department of General Surgery and Urgency, University of Palermo, Palermo, Italy
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Shift from androgen to estrogen action causes abdominal muscle fibrosis, atrophy, and inguinal hernia in a transgenic male mouse model. Proc Natl Acad Sci U S A 2018; 115:E10427-E10436. [PMID: 30327348 PMCID: PMC6217386 DOI: 10.1073/pnas.1807765115] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Inguinal hernia is one of the most common disorders that affect elderly men. A major pathology underlying inguinal hernia is the fibrosis and other degenerative changes that affect the lower abdominal muscle strength adjacent to the inguinal canal. Here we describe a critical role of estrogen and its nuclear receptor that enhance fibroblast proliferation and muscle atrophy, leading to inguinal hernia. Further research may reveal a potential role of estrogen ablation to prevent muscle fibrosis or hernia in a subset of elderly men. Inguinal hernia develops primarily in elderly men, and more than one in four men will undergo inguinal hernia repair during their lifetime. However, the underlying mechanisms behind hernia formation remain unknown. It is known that testosterone and estradiol can regulate skeletal muscle mass. We herein demonstrate that the conversion of testosterone to estradiol by the aromatase enzyme in lower abdominal muscle (LAM) tissue causes intense fibrosis, leading to muscle atrophy and inguinal hernia; an aromatase inhibitor entirely prevents this phenotype. LAM tissue is uniquely sensitive to estradiol because it expresses very high levels of estrogen receptor-α. Estradiol acts via estrogen receptor-α in LAM fibroblasts to activate pathways for proliferation and fibrosis that replaces atrophied myocytes, resulting in hernia formation. This is accompanied by decreased serum testosterone and decreased expression of the androgen receptor target genes in LAM tissue. These findings provide a mechanism for LAM tissue fibrosis and atrophy and suggest potential roles of future nonsurgical and preventive approaches in a subset of elderly men with a predisposition for hernia development.
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Amato G, Romano G, Puleio R, Agrusa A, Goetze T, Gulotta E, Gordini L, Erdas E, Calò P. Neomyogenesis in 3D Dynamic Responsive Prosthesis for Inguinal Hernia Repair. Artif Organs 2018; 42:1216-1223. [DOI: 10.1111/aor.13286] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 04/10/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Giuseppe Amato
- Postgraduate School of General Surgery; University of Cagliari; Cagliari Italy
| | - Giorgio Romano
- Department of General Surgery and Emergency; University of Palermo
| | - Roberto Puleio
- Department of Pathologic Anatomy and Histology; IZSS; Palermo
| | - Antonino Agrusa
- Department of General Surgery and Emergency; University of Palermo
| | - Thorsten Goetze
- Institut für Klinisch-Onkologische Forschung Krankenhaus Nordwest Frankfurt/Main; Germany
| | - Eliana Gulotta
- Department of General Surgery and Emergency; University of Palermo
| | - Luca Gordini
- Department of General Surgery; University of Cagliari; Italy
| | - Enrico Erdas
- Department of General Surgery; University of Cagliari; Italy
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Combined inguinal hernia in the elderly. Portraying the progression of hernia disease. Int J Surg 2016; 33 Suppl 1:S20-9. [DOI: 10.1016/j.ijsu.2016.05.055] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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15
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Amato G, Romano G, Agrusa A, Marasa S, Cocorullo G, Gulotta G, Goetze T, Puleio R. Biologic Response of Inguinal Hernia Prosthetics: A Comparative Study of Conventional Static Meshes Versus 3D Dynamic Implants. Artif Organs 2015; 39:E10-23. [DOI: 10.1111/aor.12416] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Giuseppe Amato
- Department of General Surgery and Emergency and Organ Transplantation; University of Palermo; Palermo Italy
| | - Giorgio Romano
- Department of General Surgery and Emergency and Organ Transplantation; University of Palermo; Palermo Italy
| | - Antonino Agrusa
- Department of General Surgery and Emergency and Organ Transplantation; University of Palermo; Palermo Italy
| | - Salvatore Marasa
- Department of Pathologic Anatomy and Histology; University of Palermo; Palermo Italy
| | - Gianfranco Cocorullo
- Department of General Surgery and Emergency and Organ Transplantation; University of Palermo; Palermo Italy
| | - Gaspare Gulotta
- Department of General Surgery and Emergency and Organ Transplantation; University of Palermo; Palermo Italy
| | - Thorsten Goetze
- Department of General and Visceral Surgery; Ketteler Krankenhaus; Offenbach Germany
| | - Roberto Puleio
- Department of Pathologic Anatomy and Histology; Istituto Zooprofilattico Sperimentale della Sicilia; Palermo Italy
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Amato G, Agrusa A, Romano G, Cocorullo G, Di Buono G, Mularo S, Gulotta G. Modified fixation free plug technique using a new 3D multilamellar implant for inguinal hernia repair. Hernia 2013; 18:243-50. [DOI: 10.1007/s10029-013-1102-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2012] [Accepted: 04/26/2013] [Indexed: 10/26/2022]
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Histological findings in direct inguinal hernia. Hernia 2013; 17:757-63. [DOI: 10.1007/s10029-012-1032-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Accepted: 12/11/2012] [Indexed: 11/26/2022]
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Amato G, Agrusa A, Romano G, Salamone G, Gulotta G, Silvestri F, Bussani R. Muscle degeneration in inguinal hernia specimens. Hernia 2011; 16:327-31. [PMID: 22015811 DOI: 10.1007/s10029-011-0890-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Accepted: 10/01/2011] [Indexed: 10/16/2022]
Abstract
BACKGROUND There are few articles in the literature reporting the histological changes of groin structures affected by inguinal hernia. A deeper knowledge of this matter could represent an important step forward in the identification of the causes of hernia protrusion. This study aimed to recognise the pathological modifications of muscular structures in autopsy specimens excised from tissues surrounding the hernia orifice. METHODS Inguinal hernia was identified in 30 autopsied cadavers, which presented different varieties of hernia, including indirect, direct and mixed. Tissue specimens were resected for histological study from structures of the inguinal area surrounding the hernia opening, following a standardised procedure. The histological examination was focussed on the detection of structural changes in the muscle tissues. The results were compared with biopsy specimens resected from corresponding sites of the inguinal region in a control group of 15 fresh cadavers without hernia. RESULTS Significant modification of the muscular arrangement of the inguinal area was recognized. Pathological alterations such as atrophy, hyaline and fibrotic degeneration, as well as fatty dystrophy of the myocytes were detected. These findings were observed consistently in the context of multistructural damage also involving vessels and nerves. In cadavers with hernia these alterations were always present independent of hernia type. No comparable damage was found in control cadavers without hernia. CONCLUSIONS The high degree of degenerative changes in the muscle fibres in the inguinal area involved in hernia protrusion described in this report seems to be consistent with chronic compressive damage. These alterations could embody one important factor among the multifactorial sources of hernia genesis. Conjectures concerning its impact on the physiology and biodynamics of the inguinal region are made. The relationship between the depicted degenerative injuries and the genesis of inguinal hernia is also a focus of discussion in this article.
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Affiliation(s)
- G Amato
- Department of General Surgery, Urgency, and Organ Transplantation, University of Palermo, via del Vespro 129, 90100, Palermo, Italy.
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Amato G, Lo Monte AI, Cassata G, Damiano G, Romano G, Bussani R. A new prosthetic implant for inguinal hernia repair: its features in a porcine experimental model. Artif Organs 2011; 35:E181-90. [PMID: 21752035 DOI: 10.1111/j.1525-1594.2011.01272.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Even after more than 100 years of inguinal hernia repair, the rate of complications and recurrence remains unacceptably high. In the last decades, few effective advances in surgical technique and materials have been made. The authors see them as minor adjustments in the shape and materials of the prosthetic implants. Still, the underlying genesis of inguinal hernia remains undefined. Based upon this, it seems the surgical repair of inguinal protrusions cannot be based upon the pathogenesis because the etiology to date has not been addressed. Most hernia repairs are performed with some degree of point fixation (sutures/tacks) to stop the mesh from migrating and creating high recurrence rates. This should be a priority for our considerations, as fixating mesh puts it in stark contrast to the physiology and dynamics of the myotendineal structures of the groin. Following years of surgical practice, implant fixation, mesh shrinkage, and poor quality of tissue ingrowth still represent an unresolved issue in modern hernia repair. Conventional prosthetics used for inguinal hernia repair are static and passive. They do not move in harmony with the dynamic elements of the groin structure and, as a result, induce the ingrowth of thin scar plates or shrinking regressive tissue that colonizes the implants. The authors strongly believe that these characteristics may be a contributing factor for recurrences and patient discomfort. Other complications are reported in the literature to be a direct result of fixation of the implants, such as bleeding, nerve entrapment, hematoma, pain, discomfort, and testicular complications. To improve results by respecting the physiology and kinetics of the inguinal region, we felt that a new type of prosthesis should be designed that induces a more structured tissue ingrowth similar to the natural biologic components of the abdominal wall. This prosthetic device was specifically designed to be placed with no point fixation. This was achieved by using inherent radial recoil, vertical buffering, friction, and delivering the device in a constrained state. A secondary benefit of this "dynamic" design is that the implant moves in a three-dimensional way in unison with the movements of the myotendineal structures of the groin. The results appear to show that the three-dimensional structure not only acts as a suitable scaffold for a full thickness ingrowth of a tissue barrier but also seems to induce an ordered, supple, elastic tissue, which allows for neorevascularization and neoneural growth. The outcomes indicate a reduced impact of fibrotic shrinkage on the implant/scar tissue when compared with shrinkage of polypropylene meshes reported in the literature. This pilot study shows the features of such an implant in a porcine experimental model.
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Affiliation(s)
- Giuseppe Amato
- Department of General Surgery, Urgency, and Organ Transplantation, University of Palermo, Italy.
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Damage to the vascular structures in inguinal hernia specimens. Hernia 2011; 16:63-7. [PMID: 21739233 DOI: 10.1007/s10029-011-0847-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Accepted: 06/18/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Few scientific reports to date describe the histological modification of structures outlining a hernia opening. This article is focused on the identification of the pathological changes in vascular structures in tissues excised from cadavers with inguinal hernia. A deeper comprehension of this topic could lead to essential improvements in the detection of hernia genesis. MATERIALS AND METHODS Different kinds of hernia, including indirect, direct and mixed, were identified in 30 autopsied subjects. Tissue samples were resected for histological study from abdominal wall structures close to the hernia opening. Histological examination focused on the detection of structural changes in arteries and veins. The results were compared with tissue specimens excised from equivalent sites of the inguinal area in a control group of 15 fresh cadavers without hernia. RESULTS Significant modification of vascular structures were identified in the tissue specimens examined. The veins demonstrated parietal fibrosis, perivascular edema and vascular dilation due to congestion and stasis. The arterial structures detected showed thickening of the media due to medial hyperplasia, ranging from luminal sub-occlusion to a manifest artery occlusion. These findings are present independent of hernia type in cadavers with inguinal hernia. These pathological changes were lacking in the control group of cadavers without hernia. CONCLUSIONS The notable changes in vascular structures described in the report could be the result of a steady compressive effect exerted by the abdominal viscera in the inguinal area. These pathological changes could represent one of the factors involved in the weakening of the inguinal region leading to hernia protrusion.
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Alvarado-Esquivel C, Estrada-Martínez S. Toxoplasma gondii infection and abdominal hernia: evidence of a new association. Parasit Vectors 2011; 4:112. [PMID: 21682896 PMCID: PMC3130683 DOI: 10.1186/1756-3305-4-112] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 06/17/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We performed a retrospective, observational study in 1156 adult subjects from the general population of Durango City, Mexico, Fifty five subjects with a history of abdominal hernia repair and 1101 subjects without hernia were examined with enzyme-linked immunoassays for the presence of anti-Toxoplasma IgG and IgM antibodies. RESULTS The seroprevalence of anti-Toxoplasma IgG antibodies and IgG titers was significantly higher in subjects with abdominal hernia repair than those without hernia. There was a tendency for subjects with hernia repair to have a higher seroprevalence of anti-Toxoplasma IgM antibodies than subjects without hernia. The seroprevalence of anti-Toxoplasma IgG antibodies in subjects with hernia repair was significantly higher in subjects ≥ 50 years old than those < 50 years old. Further analysis in subjects aged ≥ 50 years showed that the seroprevalence of anti-Toxoplasma IgG antibodies was also significantly higher in individuals with hernia repair than those without hernia (OR = 2.72; 95% CI: 1.10-6.57). Matching by age and sex further showed that the seroprevalence of Toxoplasma infection was significantly higher in patients with hernia repair than those without hernia (OR: 4.50; 95% CI: 1.22-17.33). CONCLUSIONS Results indicate that infection with Toxoplasma is associated with abdominal hernia. The contributing role of infection with Toxoplasma in abdominal hernia was observed mainly in subjects aged ≥ 50 years old. Our results might have clinical, prevention and treatment implications and warrant for further investigation.
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Affiliation(s)
- Cosme Alvarado-Esquivel
- Faculty of Medicine and Nutrition, Juárez University of Durango State, Avenida Universidad S/N, 34000 Durango, Durango, Mexico.
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Amato G, Ober E, Romano G, Salamone G, Agrusa A, Gulotta G, Bussani R. Nerve degeneration in inguinal hernia specimens. Hernia 2010; 15:53-8. [PMID: 20953888 DOI: 10.1007/s10029-010-0735-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Accepted: 09/17/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND The histological study of the herniated inguinal area is rare in the literature. This report is focused on the detection of structural changes of the nerves within tissues bordering the inguinal hernia of cadavers. Their physiopathological consequences are hypothesized. MATERIALS AND METHODS Primary inguinal hernia was diagnosed in 30 fresh cadavers. Tissue specimens from the inguinal region close to and around the hernia opening were excised for histological examination. A control of the data was achieved through tissue samples excised from equivalent sites of the inguinal region in 15 cadavers without hernia. RESULTS The detected nerves in the inguinal area demonstrated pathological changes such as fibrotic degeneration, atrophy, and fatty dystrophy of the axons. The thickening of the perineural sheath was constantly seen. These findings were consistently present, independent of the hernia type. CONCLUSIONS The detected nerve alterations lead us to imagine a worsening, or even the cessation, of the nervous impulse to the muscles, leading to atrophy and weakening of the abdominal wall. This could represent one of the multifactorial causes of hernia genesis.
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Affiliation(s)
- G Amato
- Department of General Surgery, Urgency, and Organ Transplantation, University of Palermo, via del Vespro 129, 90100, Palermo, Italy.
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Subhas G, Bakston D, Gupta A, Jacobs MJ, Mittal VK, Silapaswan S. Internal Ring Occlusion and Floor Support: A Novel Technique for Inguinal Hernia Mesh Repair. Am Surg 2010. [DOI: 10.1177/000313481007600923] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Tension-free, open-mesh, inguinal herniorrhaphies have gained wide acceptance. Current mesh techniques reinforcing the internal ring do not provide a comfortable lay to the mesh. To address this, we used the internal ring occlusion and floor support (IROFS) technique. A retrospective review was undertaken of all hernias operated on with the IROFS technique from January 2001 to December 2006. Five hundred twenty-five inguinal hernia repairs were done in 477 male patients. Telephone questionnaires looking into their postoperative course and recurrence were recorded. We contacted 275 (58%) patients. Patients’ ages ranged from 29 to 81 years (mean, 57 years). The hernia was indirect in 50 per cent (n = 146), direct in 35 per cent (n = 102), or both in 15 per cent (n = 44) of patients. The average operative time was 40 minutes. Acute wound pain lasted for less than 1 week in 55 per cent (n = 151) and for 1 to 2 weeks in 24 per cent (n = 66). Postoperative analgesic requirement was less than 1 week in 54 per cent (n = 147) and 1 to 2 weeks in 27 per cent (n = 74). Most patients returned to their daily activities in 2 weeks (75%) and to work in 3 weeks (74%). Chronic pain lasted for 6 to 48 months (mean, 20 months) in only seven patients. No recurrence of hernia was observed during follow-up visits (range, 26-96 months; mean, 53 months). In conclusion, IROFS can be performed with little difficulty, is cost-effective, and is well tolerated by the patient.
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Affiliation(s)
- Gokulakkrishna Subhas
- Department of Surgery, Providence Hospital and Medical Centers, Southfield, Michigan
| | - Daniel Bakston
- Department of Surgery, Providence Hospital and Medical Centers, Southfield, Michigan
| | - Aditya Gupta
- Department of Surgery, Providence Hospital and Medical Centers, Southfield, Michigan
| | - Michael J. Jacobs
- Department of Surgery, Providence Hospital and Medical Centers, Southfield, Michigan
| | - Vijay K. Mittal
- Department of Surgery, Providence Hospital and Medical Centers, Southfield, Michigan
| | - Sumet Silapaswan
- Department of Surgery, Providence Hospital and Medical Centers, Southfield, Michigan
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Reply to the letter: “Histology of the internal inguinal ring: it is really a novelty?” by Barria et al. Hernia (2010) 14:339–340. Hernia 2010; 14:665-7. [DOI: 10.1007/s10029-010-0714-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Accepted: 07/23/2010] [Indexed: 10/19/2022]
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Histology of the internal inguinal ring: it is really a novelty? Hernia 2010; 14:339-40. [PMID: 20437189 DOI: 10.1007/s10029-010-0661-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Accepted: 04/09/2010] [Indexed: 10/19/2022]
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Amato G. Reply to the Letter to Editor by Prof. Desarda: inguinal hernia repair: the hypothesis postulated in the article is not true. Hernia 2009. [DOI: 10.1007/s10029-009-0504-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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