Shrinkage evaluation of heavyweight and lightweight polypropylene meshes in inguinal hernia repair: a randomized controlled trial

Ten steps for proper peripheral nerve handling during inguinal hernia surgery

INTRODUCTION

Post-inguinal pain after a hernia surgery is prevalent and can be quite frustrating for the surgeon and patient alike. There are several sources for possible post-operative inguinal pain after a successful hernia repair; however, in the setting where a recurrent inguinal hernia is not present, it is likely related to the nerves in the inguinal canal or pelvis. Chronic inguinal groin pain after hernia repairs have been reported in a high percentage of patients following inguinal hernia surgery despite being one of the most common procedures performed annually in the USA and worldwide.

MATERIALS AND METHODS

We present ten of the basic concepts utilized by peripheral nerve surgeons to limit nerve injury, which can easily be applied to open inguinal hernia surgery with or without mesh, starting with the firm understanding of the inguinal anatomy to addressing the nerves, meticulous placement of the mesh and the active revision of the surrounding structures and nerve position before closure.

CONCLUSIONS

Understanding the proper handling of the inguinal nerves during hernia surgery can decrease the incidence of post-operative chronic pain by employing microsurgical concepts to day-to-day surgical procedures and prevent complications in an extensive set of patients.

Definition of Mesh Weight and Pore Size in Groin Hernia Repair: A Systematic Scoping Review of Randomised Controlled Trials

Introduction: Groin hernia literature often uses the terms light- and heavyweight and small or large pores to describe meshes. There is no universal definition of these terms, and the aim of this scoping review was to assess how mesh weight and pore sizes are defined in the groin hernia literature. Methods: In this systematic scoping review, we searched PubMed, Embase, and Cochrane CENTRAL. We included randomised controlled trials with adults undergoing groin hernia repair with the Lichtenstein or laparoscopic techniques using a flat permanent polypropylene or polyester mesh. Studies had to use the terms lightweight, mediumweight, or heavyweight to be included, and the outcome was to report how researchers defined these terms as well as pore sizes. Results: We included 48 studies with unique populations. The weight of lightweight meshes ranged from 28 to 60 g/m2 with a median of 39 g/m2, and the pore size ranged from 1.0 to 4.0 mm with a median of 1.6 mm. The weight of heavyweight meshes ranged from 72 to 116 g/m2 with a median of 88 g/m2, and the pore size ranged from 0.08 to 1.8 mm with a median of 1.0 mm. Only one mediumweight mesh was used weighing 55 g/m2 with a pore size of 0.75 mm. Conclusion: There seems to be a consensus that meshes weighing less than 60 g/m2 are defined as lightweight and meshes weighing more than 70 g/m2 are defined as heavyweight. The weight terms were used independently of pore sizes, which slightly overlapped between lightweight and heavyweight meshes.

The Myopectineal Orifice: A Study of Thai Cadavers

Objective

This study aimed to determine the myopectineal orifice size measured in Thai human cadavers.

Materials and Methods

A total of 30 human cadavers, comprising 55 groins, were assessed. Myopectineal orifices (MPOs) were measured in two dimensions: height from the lower border of the conjoined tendon to the upper border of the pectineal ligament and width from the lateral border of pubic tubercle to the medial border of the iliopsoas muscle.

Results

The mean MPO size is 7.13 + 0.14 cm in width and 6.66 + 0.32 m in height. The mean width and height in male cadavers are 7.16 + 0.14 and 6.84 + 0.27 cm, respectively. The mean width and height in female cadavers are 7.09 + 0.12 and 6.45 + 0.24 cm, respectively. The mean MPO area is 37.26 ± 0.027 cm², compared with the area of mesh graft 10 cm × 15 cm, 150 cm². Although the shrinkage of cadaveric tissue and mesh size were adjusted, which were 39.56 ± 0.029 and 81 cm², respectively, they were found to be sufficient for the mean MPO area. It was found that the mesh size was sufficient for the mean MPO area.

Conclusion

A mesh size of 10 cm × 15 cm is found to be the appropriate size to cover the MPO among Thais.

[Titanium mesh implants in herniology]

Literature review is devoted to the main implants used in hernia surgery and their disadvantages. Advisability of titanium mesh implants in surgery of anterior abdominal wall hernias is shown.

Efficacy of robotic versus open transversus abdominis release in a porcine model

PURPOSE

Transversus abdominis muscle release (TAR) combines retromuscular mesh placement with posterior component separation and muscle release. TAR is usually an open technique for abdominal wall reconstruction; however, several centers have performed this operation robotically and claim better clinical outcomes when compared to open surgery. We sought to compare robotic versus open TAR utilizing a porcine model.

METHODS

Animals were randomized to open versus robotic TAR with mesh placement, survived for 4 weeks, then underwent diagnostic laparoscopy to assess adhesive burden and adhesion tenacity. T-peel testing was utilized to assess mesh ingrowth. The primary outcome was adhesive burden; secondary outcomes included mesh incorporation, contraction, and operative time.

RESULTS

Nine robotic and eight open TARs were performed. Mean operative time was significantly shorter for the open cases compared to robotic cases (88.6 ± 12.9 min versus 228.3 ± 46.2, p < 0.01). Operative time in the robotic arm of the study decreased over time, from 300 to 165 min. No difference was seen in the mean adhesion area between the two groups. Adhesion tenacity and mesh flatness were similar. The work required to peel the mesh off surrounding tissue was significantly higher in the open TAR than in the robotic TAR group: 52.6 ± 15.5 and 32.9 ± 10.6 mJ/cm2, respectively (p < 0.01).

CONCLUSIONS

There were no differences in adhesions between the robotic and open approaches, but greater mesh contraction and ingrowth was observed in the open TAR group. Though operative time was longer in the robotic group, time dropped by about 40% from the first case to the last.

Cross-Linked Cholecyst-Derived Extracellular Matrix for Abdominal Wall Repair

Abdominal wall repair frequently utilizes either nondegradable or biodegradable meshes, which are found to stimulate undesirable biological tissue responses or which possess suboptimal degradation rate. In this study, a biologic mesh prototype made from carbodiimide cross-linked cholecyst-derived extracellular matrix (EDCxCEM) was compared with small intestinal submucosa (Surgisis^®), cross-linked bovine pericardium (Peri-Guard^®), and polypropylene (Prolene^®) meshes in an in vivo rabbit model. The macroscopic appearance and stereological parameters of the meshes were evaluated. Tailoring the degradation of the EDCxCEM mesh prevents untimely degradation, while allowing cellular infiltration and mesh remodeling to take place in a slower but predictable manner. The results suggest that the cross-linked biodegradable cholecyst-derived biologic mesh results in no seroma formation, low adhesion, and moderate stretching of the mesh. In contrast to Surgisis, Peri-Guard, and Prolene meshes, the EDCxCEM mesh showed a statistically significant increase in the volume fraction (V_v) of collagen (from 34% to 52.1%) in the central fibrous tissue region at both day 28 and 56. The statistically high length density (L_v), of blood vessels for the EDCxCEM mesh at 28 days was reflected also by the higher cellular activity (high V_v of fibroblast and moderate V_v of nuclei) indicating remodeling of this region in the vicinity of a slowly degrading EDCxCEM mesh. The lack of mesh area stretching/shrinkage in the EDCxCEM mesh showed that the remodeled tissue was adequate to prevent hernia formation. The stereo-histological assays suggest that the EDCxCEM delayed degradation profile supports host wound healing processes including collagen formation, cellular infiltration, and angiogenesis. The use of cross-linked CEM for abdominal wall repair is promising.

International guidelines for groin hernia management

INTRODUCTION

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

METHODS

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

Long-term retromuscular and intraperitoneal mesh size changes within a randomized controlled trial on incisional hernia repair, including a review of the literature

Abstract

Purpose Ingrowth of fibroblasts in a polypropylene mesh may cause contraction and a later recurrence. We assessed mesh contraction in intraabdominal and retromuscular implantation after incisional hernia repair.

Methods

A cohort of patients within an RCT on laparoscopic (LHR) versus open hernia repair (OHR) had their mesh borders marked with metal clips. X-ray was performed on postoperative day 1 and after 1 year. Total length, width, and dislocation were measured. A tacker fixated large-pore polypropylene mesh was used in LHR, and a retromuscular small-pore heavy-weight mesh was sutured to the midline in OHR. Patient’s pain was assessed before surgery and after 1 year.

Results

For analysis 37/47 patients remained: 20 LHR and 17 OHR. Hernia defect area was median 41 cm² in LHR and 25 cm² in OHR (p < 0.140). Implanted mesh size was 300 cm² for LHR and 240 cm² for OHR (p < 0.341). After 1 year the mesh area decreased by 4.4% and 0.5% in LHR and OHR, respectively (p < 0.063). Longitudinal distance decreased by 2.8% in LHR and by 2.6% in OHR (p < 0.269). Transverse distance decreased by 1.6% in LHR but increased by 3.1% in OHR (p < 0.005). Dislocation was seen in four LHR and one OHR. Two recurrent and one port-site hernia were diagnosed after LHR. Measurements between observers were identical in 58% and consensus was made in the remainder. Pain was not correlated to mesh area change.

Conclusions

Mesh contraction after 1 year is not a clinical issue for an intraperitoneal large-pore mesh or a retromuscular small-pore mesh. It is not correlated to postoperative pain.

Totally extraperitoneal laparoscopic inguinal hernia repair using a self-expanding nitinol framed hernia repair device: A prospective case series

BACKGROUND

The use of a self-expanding nitinol framed prosthesis (ReboundHRD^®) for totally extraperitoneal laparoscopic inguinal hernia repair (TEP-IHR) could solve issues of mesh shrinkage and associated pain. We prospectively evaluated the use of the ReboundHRD^® mesh for TEP-IHR.

MATERIALS AND METHODS

All patients who underwent a TEP-IHR using the ReboundHRD^® Large mesh from April 2014 till May 2015, were included. No mesh fixation was performed. Follow-up assessments were performed at the day of surgery, 1, 2, and 7 days, 1, 3, 6, and 12 months. Outcome measures include post-operative pain (visual analogue scale, VAS), operative details, complications, and recurrence rate.

RESULTS

In total, 69 TEP-IHR procedures were performed in 54 patients (15 bilateral hernias). No perioperative and 5 (9%) postoperative complications occurred, all graded Clavien-Dindo I-II. The median length of stay was 1 day (range 0-3), with 78% of the operations performed in an ambulatory setting. Median VAS score decreased from 3 (range 0-4) on the day of surgery to 1 (range 0-2) on day 7. Patients were completely pain-free at a median time of 5 (range 1-60) days. The majority (80.4%, 37/46) of the active patients went back to work within 2 weeks (maximum 6 weeks). At a median follow-up of 19 months (range 16-26 months), no recurrences occurred.

CONCLUSION

TEP-IHR using a self-expanding nitinol framed hernia repair device is a safe technique in longterm follow-up. The technique is associated with a low incidence of postoperative pain, a short hospital stay and quick return to normal activities.

A clinically relevant in vivo model for the assessment of scaffold efficacy in abdominal wall reconstruction

An animal model that allows for assessment of the degree of stretching or contraction of the implant area and the in vivo degradation properties of biological meshes is required to evaluate their performance in vivo. Adult New Zealand rabbits underwent full thickness subtotal unilateral rectus abdominis muscle excision and were reconstructed with the non-biodegradable Peri-Guard^®, Prolene^® or biodegradable Surgisis^® meshes. Following 8 weeks of recovery, the anterior abdominal wall tissue samples were collected for measurement of the implant dimensions. The Peri-Guard and Prolene meshes showed a slight and obvious shrinkage, respectively, whereas the Surgisis mesh showed stretching, resulting in hernia formation. Surgisis meshes showed in vivo biodegradation and increased collagen formation. This surgical rabbit model for abdominal wall defects is advantageous for evaluating the in vivo behaviour of surgical meshes. Implant area stretching and shrinkage were detected corresponding to mesh properties, and histological analysis and stereological methods supported these findings.

Evaluation of the Antimicrobial Efficacy of a Novel Rifampin/Minocycline-Coated, Noncrosslinked Porcine Acellular Dermal Matrix Compared With Uncoated Scaffolds for Soft Tissue Repair

Background Despite meticulous aseptic technique and systemic antibiotics, bacterial colonization of mesh remains a critical issue in hernia repair. A novel minocycline/rifampin tyrosine-coated, noncrosslinked porcine acellular dermal matrix (XenMatrix AB) was developed to protect the device from microbial colonization for up to 7 days. The objective of this study was to evaluate the in vitro and in vivo antimicrobial efficacy of this device against clinically isolated methicillin-resistant Staphylococcus aureus (MRSA) and Escherichia coli. Methods XenMatrix AB was compared with 5 existing uncoated soft tissue repair devices using in vitro methods of zone of inhibition (ZOI) and scanning electron microscopy (SEM) at 24 hours following inoculation with MRSA or E coli These devices were also evaluated at 7 days following dorsal implantation and inoculation with MRSA or E coli (60 male New Zealand white rabbits, n = 10 per group) for viable colony-forming units (CFU), abscess formation and histopathologic response, respectively. Results In vitro studies demonstrated a median ZOI of 36 mm for MRSA and 16 mm for E coli for XenMatrix AB, while all uncoated devices showed no inhibition of bacterial growth (0 mm). SEM also demonstrated no visual evidence of MRSA or E coli colonization on the surface of XenMatrix AB compared with colonization of all other uncoated devices. In vivo XenMatrix AB demonstrated complete inhibition of bacterial colonization, no abscess formation, and a reduced inflammatory response compared with uncoated devices. Conclusion We demonstrated that XenMatrix AB possesses potent in vitro and in vivo antimicrobial efficacy against clinically isolated MRSA and E coli compared with uncoated devices.

What would surgeons like from materials scientists?

Surgery involves the repair, resection, replacement, or improvement of body parts and functions and in numerous ways, surgery should be considered human engineering. There are many areas in which surgical materials could be improved, but surgeons are generally unaware of materials available for use, while materials scientists do not know what surgeons require. This article will review some of the areas where surgeons and materials scientists have interacted in the past and will discuss some of the most pressing problems which remain to be solved. These include better implant materials for hernia repair, breast reconstruction, the treatment of diabetes, vascular stenting and reconstruction, and electrical pacing devices. The combination of tissue engineering and nanomaterials has great potential for application to nearly every aspect of surgery. Tissue engineering will allow cells or artificial organs to be grown for specific uses while nanotechnology will help to ensure maximal biocompatibility. Biosensors will be combined with improved electrodes and pacing devices to control impaired neurological functions.

Variations of Urinary Bladder and the Urogenital Fatty Fascial Compartment with Different Filling of the Bladder are Notable Factors Relevant to Hernia Repair-Related Bladder Injury

The present study investigated bladder and urogenital fatty fascial compartment (UFFC) variations during bladder filling in an attempt to identify other possible causes of hernia repair-related bladder injury besides mesh migration. The study included 30 patients scheduled for abdominal computed tomography (CT) scan for nonhernia diseases. Sixty-four-slice CT scan was performed immediately after urination and no more than 30 minutes later. Three-dimensional images were constructed by two independent experienced readers. The empty bladder was triangular in shape, narrow in the front and broad in the rear. Its vertex deviated from midline of the abdominal wall in 11 cases (36.7%). With normal filling, it appeared as an irregular oval shape. Only two cases (6.7%) of empty bladder extended inside Hesselbach's triangle. However, this area was occupied to some extent in all cases during bladder filling ( P = 0.003). The UFFC formed a molar-like structure in cross-section. In three dimensions, it appeared as an inverted V-shaped structure from the front. In the lateral view it appeared as a spoon that contained the bladder. UFFC volume increased from 61.85 ± 6.23 to 139.23 ± 5.29 cm3with bladder filling ( P < 0.0001). The UFFC can be clearly identified by CT scanning or three-dimensional reconstruction. The considerable spatial variation of the UFFC and movement and deformation of the mesh within this area may be related to bladder injury.

A Meta-analysis Comparing Lightweight Meshes With Heavyweight Meshes in Lichtenstein Inguinal Hernia Repair

Background. To evaluate the influence of lightweight and heavyweight mesh on postoperative recovery in Lichtenstein inguinal hernia repair. Methods. PubMed, EMBASE, and the Cochrane library were used to search for published clinical randomized controlled trials (RCTs), which compared lightweight meshes with heavyweight meshes in Lichtenstein inguinal hernia repair. Two independent reviewers assessed the trials for eligibility and quality, and all the related data matching our standards were abstracted for meta-analysis by RevMan 5.0 software. The evaluation criteria included recurrence, pain, seroma, hematoma, the sensation of a foreign body, wound infection, urine retention, and testicular atrophy. Results. A total of 2231 hernias from 11 RCTs were included. Compared with a heavyweight polypropylene mesh, the lightweight mesh led to less postoperative chronic pain (odds ratio [OR] = 0.64, 95% confidence interval (CI) = 0.51-0.82; P < .05) and less sensation of a foreign body (OR = 0.56; 95% CI = 0.40-0.78; P < .05), regardless of whether the mesh was made of partially absorbable or nonabsorbable material. There was no significant difference in postoperative recurrence, seroma, hematoma, wound infection, urine retention, and testicular atrophy. Conclusion. Current evidence suggests that the use of a lightweight mesh is associated with less postoperative pain and less sensation of a foreign body, without increasing the incidence of recurrence. Further high-quality, long-term follow-up RCTs are needed to provide more reliable evidence.

Repeated in vivo inguinal measurements to estimate a single optimal mesh size for inguinal herniorrhaphy

Background

Inguinal hernia is a common condition and its repair (herniorrhaphy) is one of the most commonly performed procedures in general surgery. The Lichtenstein herniorrhaphy technique is a widely used and effective surgery that uses mesh to reinforce the area of weakness. Although a wide range of mesh sizes are available for use in hernia repair, in low-resource health care settings the provision of multiple products may not be supportable and it may be necessary for the provision and use of a single mesh size. This study aimed to determine whether the recommended 7.0 cm x 15.0 cm size is an appropriate single mesh size.

Methods

In order to determine the optimal mesh size according to recommended surgical practices, in vivo measurements of key dimensions of the inguinal floor were taken in patients undergoing herniorrhaphy.

Results

Measurements were taken in 43 patients: 40 men and 3 women, mean age 43 years (SD 13.6); 39 with indirect hernias, 4 with direct. Allowing for recommended mesh overlaps, the optimal mesh size for provision to be appropriate for the majority of patients was determined to be 8.5 cm x 14.0 cm, 21% wider than the mesh size currently recommended for use in Lichtenstein herniorrhaphy.

Conclusions

An appropriate size for routine provision in low-resource settings, or other settings where the provision of several mesh sizes is not supportable, may be 8.5 cm x 14.0 cm.