Assessment of systemic inflammatory response after total extraperitoneal repair and Lichtenstein repair for inguinal hernia

Effect of Laparoscopic Inguinal Hernia Repairs on Inflammatory Factors, Oxidative Stress Levels and Postoperative Recovery

Objective

To unravel the effects of different laparoscopic inguinal hernia repairs (IHRs) on inflammatory factors, oxidative stress, and postoperative recovery of inguinal hernia (IH) patients.

Methods

A total of 88 patients for laparoscopic treatment of IH were studied in a retrospective cohort, and were randomized into the transabdominal preperitoneal (TAPP) repair group (n = 44) and the total extraperitoneal (TEP) repair group (n = 44) according to the method of treatment. Patients in the TAPP group underwent laparoscopic TAPP IHR, while patients in the TEP group underwent laparoscopic TEP IHR. Visual analogue scores (VAS) were measured at 1, 3, and 7 d after repair. Gastrin (GAS), motilin (MTL), matrix metalloproteinase (MMP)-2, MMP-9, and tissue inhibitor of metalloproteinases-1 (TIMP-1) were assessed by enzyme-linked immunosorbent assay. Superoxide dismutase (SOD) was tested by spectrophotometry and malondialdehyde (MDA) and β-endorphin (β-EP) were examined by radioimmunoprecipitation. Total antioxidant capacity (T-AOC) was evaluated by chemical colorimetry, quality of life was evaluated by SF-36, and fibrinogen (FIB), C-reactive protein (CRP), antitrypsin (al-AT), and interleukin-6 (IL-6) levels were determined by immunoturbidimetry. Complications and postoperative recurrence were recorded.

Results

VAS scores in the TEP group were lower than those in the TAPP group. Operative time, hospital stay, time for postoperative activity out of bed, and time taken to exhaust were shorter in the TEP group than in the TAPP group. Intraoperative blood loss was less in the TEP group than in the TAPP group. GAS, MTL, SOD, and T-AOC were higher, and MDA, β-EP, CRP, FIB, alAT, IL-6, MMP-2, MMP-9, and TIMP-1 were lower in the TEP group than the TAPP group. Quality of life was improved in the TEP group compared with the TAPP group. There was no significant difference in the rate of postoperative complications and recurrence rates between both groups of patients.

Conclusion

For IHs, laparoscopic TEP repair can effectively relieve pain, reduce inflammatory factors and oxidative stress indices, and facilitate postoperative recovery.

Inflammation in Hernia and the epigenetic control

Inflammation is much more intrinsic to hernia then is what is generally appreciated. The occurrence of hernias is associated with swelling, stress and inflammation. Surgery remains an important intervention to treat hernias and for many years, post-surgical levels of inflammatory cytokines have been evaluated to compare the different strategies for their comparative advantages. All surgical procedures elicit some sort of inflammatory response and moreover the meshes used for hernia repair are also associated with elevated inflammatory response, although some favor predominantly a pro-inflammatory response while the other meshes favor anti-inflammatory response. An estimated more than 90% of hernia repairs involve some meshes with polypropylene considered as the gold standard. Efforts are underway to modulate polypropylene meshes associated inflammation through use of alternative materials as well as modifications to polypropylene meshes themselves. In the last one decade, miRNAs have entered hernia research and the data on a role of miRNAs in different hernias is slowly emerging, providing the first evidence of epigenetics in hernia. Some reports are connecting miRNAs with inflammation in hernia. All these aspects, such as, surgery-related to mesh-related inflammation as well as miRNA-related inflammation, are discussed in this article to present an up-to-date information on the topic.

Surgical outcomes of laparoscopic total extraperitoneal (TEP) inguinal hernia repair compared with Lichtenstein tension-free open mesh inguinal hernia repair: A prospective randomized study

Inguinal hernia repair is one of the most frequently performed surgery. The ideal procedure for inguinal hernia repair remains controversial. Open Lichtenstein tension-free mesh repair (LMR) is one of the most preferred open techniques with satisfactory outcomes. Laparoscopic approach in inguinal hernia surgery remains controversial, especially in comparison with open procedures. In this study, we have reported a comparison of laparoscopic total extraperitoneal (TEP) inguinal hernia repair with LMR. Postoperative pain, operative time, complications like seroma, wound infection, chronic groin pain, and recurrence rate were parameters to evaluate the outcome. One hundred seventy-four patients were included in the study by consecutive randomized prospective sampling. The patients were divided into 2 groups: group A, laparoscopic TEP inguinal hernia repair, and group B, LMR. The procedures were performed by experienced surgeons. The primary outcomes were evaluated based on postoperative pain and recurrence rate. Secondary outcomes considered for evaluation were operative time, complications like seroma, infection, and chronic groin pain. Severe pain was reported in group A (7.9%) compared to group B (15.1%), which was statistically significant (P < .001). Moderate pain was reported more in group B (70.9%) compared to group A (29.5%) (P < .001). The mean operative time in group A was 84.6 ± 32.2, which was significantly higher than that in group B, 59.2 ± 14.8. There was no major complication in both groups. The chronic pain postoperatively was significantly in higher number of patients in group B vs group A (22.09% vs 3.4%). The postoperative hospital stay period was significantly lesser for group A vs for group B (2.68 ± 1.52 vs 3.86 ± 6.16). Time duration taken to resume normal activities was significantly lower in group A (13.6 ± 6.8) vs (19.8 ± 4.6) in group B (P < .001). Although there is definite evidence of longer operative time and learning curve, laparoscopic TEP has added advantages like less postoperative pain, early resumption of normal activities, less chronic groin pain, and comparable recurrence rate compared to open Lichtenstein repair. Laparoscopic TEP can be performed with acceptable outcomes and less postoperative complications if performed by experienced hands.

The effect of dexmedetomidine premedication on postoperative systemic inflammatory response in children undergoing hernia repair surgery: A randomized controlled trial

BACKGROUND

Surgery results in systemic inflammation, which can affect the central nervous system, leading to changes in mood, emotion, and behavior. Our previous study has shown that compared to midazolam, dexmedetomidine premedication effectively decreased children's postoperative anxiety.

AIM

To investigate whether dexmedetomidine infusion before hernia repair alleviates postoperative systemic inflammation in children and whether postoperative anxiety may be associated with postoperative inflammation.

METHODS

This prospective double-blind randomized controlled trial was conducted in 120 children scheduled to undergo elective hernia repair. Before anesthesia induction, all children received an intravenous infusion consisted of dexmedetomidine (n = 40; 0.5 µg/g, group D), midazolam (n = 40; 0.08 mg/kg, group M), or normal saline (n = 40; group C). One-way ANOVA with least significant difference multiple comparison test was used for multigroup comparisons of postoperative plasma levels of inflammatory cytokines and m-YPAS scores. Spearman rank correlation tests were used for analyzing m-YPAS scores with postoperative plasma levels of inflammatory cytokines.

RESULTS

Plasma levels of tumor necrosis factor-alpha (7.0 ± 1.6 vs. 8.1 ± 1.6, mean difference [95% CI]: 1.19 [0.26-2.11], p = .008) (pg/ml) and of interleukin-6 (1.8 ± 1.2 vs. 3.3 ± 1.6, mean difference [95% CI]: 1.49 [0.74-2.25], p < .001) (pg/ml) and neutrophils-to-lymphocyte ratio (1.0 ± 0.5 vs. 1.5 ± 0.7, mean difference [95% CI]: 0.48 [0.17-0.78], p < .001) were significantly lower in group D than in group C. Furthermore, compared to group M, group D showed significantly lower plasma tumor necrosis factor-alpha levels (7.0 ± 1.6 vs. 7.9 ± 1.9, mean difference [95% CI]: 0.96 [0.04-1.88], p = .04) (pg/ml) and interleukin-6 levels (1.8 ± 1.2 vs. 2.9 ± 1.5, mean difference [95% CI]: 1.06 [0.31-1.81], p = .004) (pg/ml), and neutrophil-to-lymphocyte ratio (1.0 ± 0.5 vs. 1.5 ± 0.6, mean difference [95% CI]: 0.42 [0.11-0.72], p = .004). Anxiety scores at postoperative 2 and 4 h in the three groups positively correlated with plasma levels of proinflammatory cytokines.

CONCLUSION

A single preoperative intravenous dexmedetomidine dose in children undergoing same-day surgery reduces postoperative systemic inflammation.

Multinutrient Supplementation Increases Collagen Synthesis during Early Wound Repair in a Randomized Controlled Trial in Patients with Inguinal Hernia

BACKGROUND

Inguinal hernia disease is associated with an imbalanced collagen metabolism. Surgical stress has a negative impact on nutrients important for collagen synthesis.

OBJECTIVE

We hypothesized that supplementation with a combination of nutrients would enhance collagen biosynthesis in inguinal hernia disease patients when undergoing hernia repair.

METHODS

In this exploratory randomized controlled trial, 21 men (age: 55.2 ± 2.8 y; BMI: 25.0 ± 0.7 kg/m2) scheduled for Lichtenstein inguinal hernia repair were assigned to multinutrient supplementation (n = 10; multinutrient group) or no multinutrient supplementation (n = 11; control group). The multinutrient group received 14 g l-arginine, 14 g l-glutamine, 1250 mg vitamin C, and 55 mg zinc daily starting 14 d before surgery and ending 14 d after surgery. The multinutrient and control groups received high-quality protein to ensure a daily intake of 1.5 g protein/kg. Collagen biosynthesis was measured by the biomarkers type I procollagen propeptide (CICP), type III procollagen propeptide (PRO-C3), and type V procollagen propeptide (PRO-C5) in the sera on days -14, 0, and 1, and in the wound fluids on postoperative days 1 and 2. Compliance was recorded after the 28-d intervention period.

RESULTS

Serum PRO-C5 concentrations decreased (P < 0.05) postoperatively in the control but not the multinutrient group. Neither CICP nor PRO-C3 serum concentrations differed significantly between the 2 groups. In wound fluid, the CICP concentrations increased (P < 0.05) from days 1 to 2 in the multinutrient group and were 49% higher (P = 0.10) than those in the control group on day 2. Wound fluid concentrations PRO-C3 and PRO-C5 showed no significant time or group differences. The 28-d compliance was similar (P = 0.27) in the 2 groups.

CONCLUSION

Oral supplementation with arginine, glutamine, vitamin C, and zinc augment collagen synthesis during the first 2 d after inguinal hernia repair. This trial was registered at clinicaltrials.gov as NCT03221686.

Influence of IL-6, TNF-α and Hs-CRP on Insulin Sensitivity in Patients after Laparoscopic Cholecystectomy or Open Hernia Repair

BACKGROUND

The aim of this study was to investigate the influence of IL-6, TNF-α and hs-CRP on insulin sensitivity during postoperative follow-up in patients with laparoscopic cholecystectomy (LC) or open hernia repair (OHR).

METHODS

65 patients were studied: after laparoscopic cholecystectomy (LC; n=40) or open hernia repair (OHR; n=25). Glucose, insulin, hs-CRP, IL-6 and TNF-a were determined at day 0 (before the operation) and at days 1, 3 and 7 (after the operation).

RESULTS

There were no difference between LC and OHR groups concerning age, BMI, glucose, insulin, hs-CRP, IL-6 and TNF-α at day 0. hs-CRP increased at day 1, 3 and 7 vs. day 0 (p<0.0005), without difference between groups (p=0.561). IL-6 increased at day 1 and day 3 vs. day 0 (p<0.005). IL-6 was higher at day 1 in OHR group in comparison with LC group (p=0.044). There were no differences in TNF-a levels between LC and OHR groups (p=0.056). There was increase of HOMA-IR at day 1, 3 and 7 vs. day 0 (p<0.0005) in both groups. Significantly higher increase of HOMA-IR was in OHR group compared with LC group at day 1 (p=0.045). There was a positive correlation between hs-CRP and HOMA-IR (r=0.46; p=0.025) and between IL-6 and HOMA-IR at day 1 in OHR group (r=0.44; p=0.030).

CONCLUSIONS

Significantly higher HOMA-IR was found in OHR group compared with LC. Positive correlation between hs-CRP and IL-6 with HOMA-IR in OHR group at day 1, indicate possible influence of this mediators on impairment of insulin sensitivity.