Mesh size in Lichtenstein repair: a systematic review and meta-analysis to determine the importance of mesh size

Lichtenstein technique for inguinal hernia repair: ten recommendations to optimize surgical outcomes

PURPOSE

Approximately 20 million individuals worldwide undergo inguinal hernia surgery annually. The Lichtenstein technique is the most commonly used surgical procedure in this setting. The objective of this study was to revisit this technique and present ten recommendations based on the best practices.

METHODS

PubMed and Scientific Electronic Library Online were used to systematically search for articles about the Lichtenstein technique and its modifications. Literature regarding this technique and surgical strategies to prevent chronic pain were the basis for formulating ten recommendations for best practices during Lichtenstein surgery.

RESULTS

Ten recommendations were proposed based on best practices in the Lichtenstein technique: neuroanatomical assessment, chronic pain prevention, pragmatic neurectomy, spermatic cord structure management, femoral canal assessment, hernia sac management, mesh characteristics, fixation, recurrence prevention, and surgical convalescence.

CONCLUSION

The ten recommendations are practical ways to achieve a safe and successful procedure. We fell that following these recommendations can improve surgical outcomes using the Lichtenstein technique.

The Lichtenstein technique is being used adequately in inguinal hernia repair: national analysis and review of the surgical technique

INTRODUCTION

it is estimated that approximately 20 million people undergo inguinal hernia surgery annually in the world, with the Lichtenstein technique being the most performed surgical procedure. The objective of this study is to analyze the knowledge of the technical principles used in the Lichtenstein technique.

METHOD

Survey-type intersectional study approved by the research ethics committee of São Camilo University Center (CAAE: 70036523.1.0000.0062). During the research period, 11,622 e-mails were sent to members of the main national surgical societies with research on the technical principles of Lichtenstein surgery. The survey was carried out using an electronic form with 10 multiple-choice questions. The form was answered anonymously on the SurveyMonkey and Google Forms platforms.

RESULT

744 responses were received to the electronic form. Based on this number of respondents, our survey has a confidence level of 95% with a margin of error of 3.5%. It was observed that there is no standardization of the technique among the majority of responders (53.4%). Many surgeons still perform digital dissection of the spermatic cord (47%). A small number of interviewees (15.2%) performed sutures with absorbable thread in the region of the internal oblique aponeurosis, while more than half (55.2%) continued to perform sutures with non-absorbable thread. Most surgeons use a small overlap or fix the mesh juxtaposed to the pubic symphysis (51%).

CONCLUSION

Our research identified that a small percentage of respondents adequately know the technical principles of Lichtenstein surgery. The result brings us new insights into the need to review Lichtenstein technique.

Three-dimensional visualization and measurement of myopectineal orifice in non-inguinal hernia patients

PURPOSE

The myopectineal orifice (MPO) is a weak area at lower part of the anterior abdominal wall that directly determines the mesh size required in inguinal hernia repair. However, MPO data have mainly been acquired from measurements of cadavers or anesthetized patients. Furthermore, there are very few reports on the measurement of the MPO in Chinese patients. The present study aimed to use three-dimensional visualization technology to measure the MPO in live non-anesthetized Chinese patients, and to use this information to indicate the appropriate mesh size required for inguinal hernia repair.

METHODS

In this study, we used the parameters of the MPO and the pelvis that were measured in 40 patients with peripheral arterial disease of the lower limb arteries (80 inguinal regions) using Medraw software (Image Medraw Technology Co., Ltd., China).

RESULTS

The result showed that the average width and height of the MPO were 5.71 ± 0.99 cm and 4.96 ± 0.69 cm, respectively (5.22 ± 0.77 cm and 5.13 ± 0.63 cm in males, and 6.20 ± 0.95 cm and 4.80 ± 0.71 cm in females). The average projected area of the MPO was 16.06 ± 4.37 cm² on the left, and 15.61 ± 4.10 cm² on the right (P > 0.05).

CONCLUSION

Three-dimensional visualization was used to measure the area, width, and height of the MPO in living non-anesthetized Chinese patients. MPO area was correlated with age, but not with pelvic parameters.

Individual mesh size for open anterior inguinal hernia repair: an anthropometric study in Turkish male patients

PURPOSE

To conduct a study to determine the measurements of the inguinal region in male patients with inguinal hernias to reveal the proper mesh size for each patient.

METHODS

In this prospective study, the anthropometric measurements were obtained from 100 consecutive adult male patients with unilateral primary inguinal hernias. First, the distance between the pubic tubercle and the medial border of the deep inguinal ring was measured (x). Second, the distance between the inner edge of the inguinal ligament and the uppermost level of the internal oblique aponeurosis at the midpoint of the inguinal ligament corresponding to the Hesselbach triangle was measured (y). Individual mesh sizes were calculated according to the original recommendations for mesh overlap.

RESULTS

The mean x value was 41.6 mm (22-55 mm), the mean y value was 45.2 mm (30-68 mm). The mean dimensions of the mesh were 126.6 mm × 65.2 mm. The largest mesh was 140 mm × 88 mm, and the smallest one was 107 mm × 62 mm. The mean mesh area was 8320 mm². It was larger than the index mesh area recommended by the Lichtenstein Hernia Institute in 45 patients and smaller in 55 patients.

CONCLUSIONS

The intraoperative measurements for ideal mesh size in Lichtenstein repair of inguinal hernias may present somewhat different mesh dimensions in many patients. Individualization of mesh size may be of importance in surgical outcomes.

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

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

Surgical risk factors for recurrence in inguinal hernia repair - a review of the literature

Despite all the progress made in inguinal hernia surgery driven by the development of meshes and laparoendoscopic operative techniques, the proportion of recurrent inguinal hernias is still from 12% to 13%. Recurrences can present very soon after primary inguinal hernia repair generally because of technical failure. However, they can also develop much later after the primary operation probably due to patient-specific factors. Supported by evidence-based data, this review presents the surgical risk factors for recurrent inguinal hernia after the primary operation. The following factors are implicated here: choice of operative technique and mesh, mesh fixation technique, mesh size, management of medial and lateral hernia sac, sliding hernia, lipoma in the inguinal canal, operating time, type of anesthesia, participation in a register database, femoral hernia, postoperative complications, as well as the center and surgeon volume. If these surgical risk factors are taken into account when performing primary inguinal hernia repair, a good outcome can be expected for the patient. Therefore, they should definitely be observed.

Description of robotically assisted single-site transabdominal preperitoneal (RASS-TAPP) inguinal hernia repair and presentation of clinical outcomes

BACKGROUND

The aim of our study is to report our initial clinical experience with robotically assisted single-site transabdominal preperitoneal (RASS-TAPP) hernia repair, to verify the safety and efficacy of the procedure and to describe the surgical procedure.

METHODS

We retrospectively reviewed all patients undergoing RASS-TAPP at our institution from March 2013 through December 2013. Data regarding patient demographics, type and location of hernia, operative time and clinical outcomes were collected and analyzed.

RESULTS

Fourty five hernias were repaired in 34 patients (30M, 4F) by a single surgeon. The mean age was 49.3 years and mean BMI was 26.5. 31 lateral defects, 13 medial defects and 1 femoral defect were repaired. Three patients presented with recurrent hernias and nine had bilateral defects. The mean operative time for all cases was 80.5 min and for all unilateral hernias 69 min. Considering just the unilateral hernias without any additional procedures, operative time was 63 min. The mean follow-up time was 5.5 months. There has been one superficial surgical site infection, but no observed clinical recurrence or neuralgia to date.

CONCLUSION

Robotically assisted single-site transabdominal preperitoneal hernia repair is safe and effective. The absence of clinical evidence of recurrence or neuralgia is encouraging and should promote further study.

Modified transabdominal external needle for mesh size estimation in laparoscopic hernia repair

PURPOSE

The obtaining on the accurate mesh size is the key for the good results and making the procedure easy during laparoscopic hernia repair. This study offers a modified transabdominal external needle technique to achieve this goal.

METHODS

During the period from February 2011 through October 2013, during laparoscopic inguinal hernia repair in 41 patients, the mesh dimensions were determined by novel technique. Where, the mesh size was calculated percutaneous transabdominal by using spinal needle No. 22 with thread inside it. The mean follow up period was 24 months.

RESULTS

The ages of this patients group were ranged from 21 to 65 years (mean, 49 years). The mean time needed to obtain the accurate mesh dimensions was 3 min. No recurrence or mesh bulging or mesh infection were recorded in this patients group during the period of follow up.

CONCLUSION

Our technique for calculation of mesh dimensions during laparoscopic hernia repair is accurate, safe, and easy.