Hernias- Is it a primary defect or a systemic disorder? Role of collagen III in all hernias- A case control study

A Comprehensive Review of Inguinal Hernia Occurrence in Obese Individuals

Inguinal hernia repair is one of the most commonly performed surgical activities worldwide. Given the circumstances, understanding and identifying the risk and the protective factors is an essential step in order to prevent, diagnose and treat such a common condition. For a long time, obesity was generally considered to be a risk factor in the occurrence of an inguinal hernia. Studies have provided some unexpected data, suggesting that it might actually be a protective factor. This review aims to provide an overview on this topic, taking into account systemic aspects such as collagen distribution and metabolism. In inguinal hernia patients, the ratio between type I collagen and type III collagen is decreased, with type III collagen being responsible for the weakness of the abdominal wall. In obese patients, the extracellular matrix becomes richer in collagen, especially type I collagen, which will generate strength and stiffness. Obesity seems to be a protective factor indeed, but in order to understand the underlying mechanism and to choose the optimal surgical approach, further research is needed.

Incisional Hernia: A Surgical Complication or Medical Disease?

Incisional hernia (IH) is a frequent complication following abdominal surgery. The development of IH could be more sophisticated than a simple anatomical failure of the abdominal wall. Reported IH incidence varies among studies. This review presented an overview of definitions, molecular basis, risk factors, incidence, clinical presentation, surgical techniques, postoperative care, cost, risk prediction tools, and proposed preventative measures. A literature search of PubMed was conducted to include high-quality studies on IH. The incidence of IH depends on the primary surgical pathology, incision site and extent, associated medical comorbidities, and risk factors. The review highlighted inherent and modifiable risk factors. The disorganisation of the extracellular matrix, defective fibroblast functions, and ratio variations of different collagen types are implicated in molecular mechanisms. Elective repair of IH alleviates symptoms, prevents complications, and improves the quality of life (QOL). Recent studies introduced risk prediction tools to implement preventative measures, including suture line reinforcement or prophylactic mesh application in high-risk groups. Elective repair improves QOL and prevents sinister outcomes associated with emergency IH repair. The watchful wait strategy should be reviewed, and options should be discussed thoroughly during patients' counselling. Risk stratification tools for predicting IH would help adopt prophylactic measures.

Shape-Configurable Mesh for Hernia Repair by Synchronizing Anisotropic Body Motion

Continuous progress has been made in elucidating the relationship between material property, device design, and body function to develop surgical meshes. However, an unmet need still exists wherein the surgical mesh can handle the body motion and thereby promote the repair process. Here, the hernia mesh design and the advanced polymer properties are tailored to synchronize with the anisotropic abdominal motion through shape configuration. The thermomechanical property of shape configurable polymer enables molding of mesh shape to fit onto the abdominal structure upon temperature shift, followed by shape fixing with the release of the heat energy. The microstructural design of mesh is produced through finite element modeling to handle the abdominal motion efficiently through the anisotropic longitudinal and transverse directions. The design effects are validated through in vitro, ex vivo, and in vivo mechanical analyses using a self-configurable, body motion responsive (BMR) mesh. The regenerative function of BMR mesh leads to effective repair in a rat hernioplasty model by effectively handling the anisotropic abdomen motion. Subsequently, the device-tissue integration is promoted by promoting healthy collagen synthesis with fibroblast-to-myofibroblast differentiation. This study suggests a potential solution to promote hernia repair by fine-tuning the relationship between material property and mesh design.

Congenital collagenopathies increased the risk of inguinal hernia developing and repair: analysis from a nationwide population-based cohort study

Herein, we aimed to explore whether male patients with congenital collagen diseases had a higher risk of inguinal herniation than patients without these diseases. Data were retrospectively collected from the National Health Insurance Research Database of Taiwan. The study cohort included 1,801 male patients diagnosed with congenital collagen diseases based on the ICD-9 CM diagnostic codes; after propensity score matching, the control group comprised 6,493 men without congenital collagen diseases. The primary endpoint was inguinal hernia repair during the observation period. During a median follow-up period of 133.9 months, the risk of inguinal herniation in the collagen group was significantly higher than that in the control group (HR = 2.237, 95% CI 1.646-3.291, p < 0.001). This phenomenon was observed in patients younger than 18 years (HR: 3.040, 95% CI 1.819-5.083, p < 0.001) and in those aged 18-80 years (HR: 1.909, 95% CI 1.186-3.073, p < 0.001). Asian men with congenital collagen diseases are at a high risk of developing inguinal hernias, regardless of age. Detailed physical examination and patient education should be performed for these patients to prevent inguinal herniation.

Inguinal hernia – epidemiology, risk factors, treatment methods (literature review)

Inguinal hernias (IH) are widespread in the human population and occur in 27–43 % of men and 3–6 % of women. Many risk factors for IH have been overestimated in the last decade: male gender is considered the leading factor (the ratio between men and women is approximately 1:7), less significant factors are heredity (most significant for women), physical activity (more significant for men), age (peak prevalence of IH occurs at 5 years and 70–80 years), congenital or acquired connective tissue dysplasia, history of prostatectomy, low body mass index.Hernioplasty with the use of synthetic mesh prostheses remains the most popular technique for surgical correction of IH. Performing non-prosthetic hernioplasty is only recommended if mesh prostheses are not available, for example in poor countries. In open hernioplasty using mesh prostheses, different methods are used today: Plug & Patch, Prolene Hernia System, Parietene Progrip, sutureless plastic according to Trabucco, Stoppa, preperitoneal techniques TIPP (trans-inguinal pre-peritoneal), TREPP (transrectus pre-peritoneal), TEP (total extraperitoneal), however, none of them showed significant advantages over the gold standard of open hernioplasty – tensionfree repair according to Liechtenstein.Laparoscopic IH correction is represented by the TAPP (transabdominal preperitoneal) technique, performed through the abdominal cavity, and TEP (total extraperitoneal) – extraperitoneal prosthetic hernioplasty. None of them has a significant advantage in the treatment of IH; therefore, when choosing a treatment method, the surgeon should be guided by the cost of the operation and the level of proficiency in one or another hernioplasty technique.

Analysis of tissue inflammatory response, fibroplasia, and foreign body reaction between the polyglactin suture of abdominal aponeurosis in rats and the intraperitoneal implant of polypropylene, polypropylene/polyglecaprone and polyester/porcine collagen meshes

Purpose

To compare tissue inflammatory response, foreign body reaction, fibroplasia, and proportion of type I/III collagen between closure of abdominal wall aponeurosis using polyglactin suture and intraperitoneal implant of polypropylene, polypropylene/polyglecaprone, and polyester/porcine collagen meshes to repair defects in the abdominal wall of rats.

Methods

Forty Wistar rats were placed in four groups, ten animals each, for the intraperitoneal implant of polypropylene, polypropylene/polyglecaprone, and polyester/porcine collagen meshes or suture with polyglactin (sham) after creation of defect in the abdominal wall. Twenty-one days later, histological analysis was performed after staining with hematoxylin-eosin and picrosirius red.

Results

The groups with meshes had a higher inflammation score (p < 0.05) and higher number of gigantocytes (p < 0.05) than the sham group, which had a better fibroplasia with a higher proportion of type I/III collagen than the tissue separating meshes (p < 0.05). There were no statistically significant differences between the three groups with meshes.

Conclusions

The intraperitoneal implant of polypropylene/polyglecaprone and polyester/porcine collagen meshes determined a more intense tissue inflammatory response with exuberant foreign body reaction, immature fibroplasia and low tissue proportion of type I/III collagen compared to suture with polyglactin of abdominal aponeurosis. However, there were no significant differences in relation to the polypropylene mesh group.

Fascinating history of groin hernias: Comprehensive recognition of anatomy, classic considerations for herniorrhaphy, and current controversies in hernioplasty

Groin hernias include indirect inguinal, direct inguinal, femoral, obturator, and supravesical hernias. Here, we summarize historical turning points, anatomical recognition and surgical repairs. Groin hernias have a fascinating history in the fields of anatomy and surgery. The concept of tension-free repair is generally accepted among clinicians. Surgical repair with mesh is categorized as hernioplasty, while classic repair without mesh is considered herniorrhaphy. Although various surgical approaches have been developed, the surgical technique should be carefully chosen for each patient. Regarding as interesting history, crucial anatomy and important surgeries in the field of groin hernia, we here summarized them in detail, respectively. Points of debate are also reviewed; important points are shown using illustrations and schemas. We hope this systematic review is surgical guide for general surgeons including residents. Both a skillful technique and anatomical knowledge are indispensable for successful hernia surgery in the groin.

Profile of collagen prolines level of anterior rectus sheath tissue in indirect inguinal hernia: A cross-sectional study

Introduction

A hernia is a protrusion of an organ or tissue through an abnormal anatomical channel or opening. Epidemiological data indicated an increased prevalence of inguinal hernias in patients with connective tissue diseases. The biomechanical strength of connective tissue is highly dependent on the constituent of the matrix, including collagen. Fibroblasts produce and secrete procollagen containing high concentrations of proline and lysine. Collagen integrity plays an essential role in preventing hernia formation in the abdominal wall. To investigate the relationship between collagen proline levels of the anterior rectus sheath tissue in patients with lateral inguinal hernias (indirect inguinal hernia).

Methods

The study participants consisted of 67 inguinal hernia patients. A sample of anterior rectus tissue was obtained at the time of surgery, then being washed in a PBS buffer (pH 7.4). The measurement of collagen proline levels was subsequently carried out with enzyme linked immunosorbent assay (ELISA).

Results

All study participants were male with mean age of 44 years, mean body mass index of 22.6 kg/m² and mean onset of events of 27 months. Study subjects with reducible, irreducible, and incarcerated hernias were 45.7% (44/67 cases), 14.9% (10/67) and 19.4% (13/67), respectively. The mean proline level of the study subjects was 9.20. Correlation tests showed a correlation of proline levels and age (p = 0.001), body mass index (p = 0.006), and the onset of events (p = 0.023). Meanwhile, correlation of proline levels and occupation (p = 0.235) and clinical degree (p = 0.164) were not statistically significant.

Conclusion

Presence if relationship between proline levels with age, and onset of incidence among indirect inguinal hernia patients.

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Collagen is the main structural protein in the muscle wall layer.

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Defects in collagenases will result in abnormal collagen synthesis leading to pathological collagen degradation.

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Decreases in hydroxyproline and collagen were observed in the fascia and muscle tissue of patients with inguinal hernias.

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There are a relationship between proline levels with age, and onset of incidence among indirect inguinal hernia.

Family History of GERD Does Not Predict Anti-Reflux Surgery Outcomes

Background and Objectives:

Gastroesophageal reflux disease is a common disease and there is little known about the role family history plays in its disease process and incidence. Our study was designed to compare the patients with first degree relatives with and without the disease and see if there was any difference in patients needing antireflux surgery, the outcomes after antireflux surgery, and whether they needed redo surgery.

Methods:

An institutional review board approved registry for patients undergoing antireflux surgery at a single institution was used. Patients were asked specific questions about their family history of gastroesophageal reflux disease at their pre-operative visit. Patients with a family history and those without were compared.

Results:

There was no statistical difference between the patients with family history of gastroesophageal reflux disease for likelihood to undergo surgery, outcomes from surgery, or the need for redo surgery. There were more females than males in the study and there were more patients with a positive family history in the study than those without.

Conclusion:

Since there is no impact of family history of gastroesophageal reflux disease on antireflux surgery, patients can be counseled that their decision to undergo antireflux surgery is independent from the response of their first degree relatives.

The Role of Mesh Implants in Surgical Treatment of Parastomal Hernia

A parastomal hernia is a common complication following stoma surgery. Due to the large number of hernial relapses and other complications, such as infections, adhesion to the intestines, or the formation of adhesions, the treatment of hernias is still a surgical challenge. The current standard for the preventive and causal treatment of parastomal hernias is to perform a procedure with the use of a mesh implant. Researchers are currently focusing on the analysis of many relevant options, including the type of mesh (synthetic, composite, or biological), the available surgical techniques (Sugarbaker’s, “keyhole”, or “sandwich”), the surgical approach used (open or laparoscopic), and the implant position (onlay, sublay, or intraperitoneal onlay mesh). Current surface modification methods and combinations of different materials are actively explored areas for the creation of biocompatible mesh implants with different properties on the visceral and parietal peritoneal side. It has been shown that placing the implant in the sublay and intraperitoneal onlay mesh positions and the use of a specially developed implant with a 3D structure are associated with a lower frequency of recurrences. It has been shown that the prophylactic use of a mesh during stoma formation significantly reduces the incidence of parastomal hernias and is becoming a standard method in medical practice.

Comparison of Single-Port Laparoscopic Totally Extraperitoneal Hernioplasty Versus Conventional Laparoscopic Totally Extraperitoneal Hernioplasty : A Single-Center Study

BACKGROUND

To evaluate the safety and outcomes of single-port laparoscopic totally extraperitoneal (SPLTEP) and conventional laparoscopic totally extraperitoneal (CLTEP) hernioplasty.

METHODS

Retrospectively, we collected patients who underwent a laparoscopic totally extraperitoneal approach. The inclusion criteria were as follows: (1) male patients aged >20 years, (2) untreated hernia, and (3) American Society of Anesthesiologists (ASA) score ≤3. The exclusion criteria included: (1) additional procedures received during surgery, (2) inguinoscrotal hernia, (3) ASA score >3, (4) previous lower abdominal surgery, (5) bleeding disorders, and (6) incarcerated, obstructed, strangulated, or recurrent inguinal hernias. Patients were classified into SPLTEP and CLTEP groups. The demographics, body mass index (BMI), ASA score, comorbidities, blood loss, operation time, postoperative length of stay (LOS)/complications, hernia recurrence, visual analog scale (VAS), and postoperative analgesic requirements were collected for analysis.

RESULTS

A total of 246 patients were enrolled. There were 103 patients in the SPLTEP group and 143 patients in the CLTEP group. The mean age was 56.1 ± 16.2 years versus 57.9 ± 15.1 years. There were no significances in demographics, BMI, ASA score, comorbidities, blood loss, operation time, postoperative LOS/complications, and hernia recurrence. The SPLTEP group had a shorter postoperative LOS, lower VAS at 18 hours postoperation, and a reduced amount of 24-hour postoperative analgesics.

CONCLUSION

SPLTEP hernioplasty is as safe as the CLTEP procedure. In addition, the SPLTEP group had a shorter LOS and a lower VAS score and required less postoperative analgesics. Further studies may focus on long-term complications, hernia recurrence, and chronic pain in these 2 groups.

Comparative study of collagen and elastin content of abdominal wall fascia in inguinal hernia and non-hernia patients in an African population

PURPOSE

Altered composition of collagen and elastin in abdominal fascia has been linked with the pathogenesis of hernias. This has not been studied amongst Africans who have hernia presentations which vary significantly from Caucasian cohorts. The aim of this study was to determine, and compare, the collagen and elastin contents of the transversalis fascia and rectus sheath of inguinal hernia patients with non-hernia controls.

METHODS

Twenty-five patients with solitary, primary, uncomplicated inguinal hernia and twenty-five non-hernia controls were evaluated. Biopsies of the transversalis fascia and anterior rectus sheath were stained with Masson Trichrome and Verhöeff van-Gieson to isolate collagen and elastin respectively, which were quantified using the ImageJ/Fiji® image analysis software.

RESULTS

Inguinal hernia patients were aged 19-85 years with a mean age of 45.2 years, mean body mass index (BMI) of 23.3 kg/m² and mean duration of hernia of 42.5 months. Lateral hernias with no hernia defect or posterior wall defect [PL0] were the predominant clinical type. There were significantly lower collagen and higher elastin content in the transversalis fascia and rectus sheath of inguinal hernia patients [P < 0.001]. Regression analysis identified smoking and long duration of hernias as independent predictors of low collagen levels in this study CONCLUSION: Inguinal hernia patients in the study population demonstrated depleted collagen in the connective tissue of the inguinal canal. This might justify the routine use of prosthetic mesh for the reinforcement of the posterior wall during hernia repair.

Molecular Mechanisms and Potential Therapeutic Targets in Incisional Hernia

The pathophysiology underlying the formation, progression, and surgical healing of incisional hernia (IH) that develops as a major complication associated with abdominal laparotomy is poorly understood. The proposed mechanisms include the switch of collagen phenotype and the proliferation of abnormal fibroblasts after surgery. The focus of this article was to critically review the cellular, biochemical, and potential molecular events associated with the development of IH. The disturbance in collagen homeostasis with alterations in the expression of collagen subtypes, including type 1, type 3, type 4, and type 5, and impairment in the transdifferentiation of fibroblasts to myofibroblasts are discussed. The phenotype switch of wound-repair fibroblasts results in mechanically compromised extracellular matrix that triggers the proliferation of abnormal fibroblasts. High-mobility group box 1 could be involved in wound progression, whereas signaling events mediated by tumor necrosis factor β1, connective tissue growth factor, lysyl oxidase, and hypoxia-inducible factor 1 play significant role in the wound healing response. Thus, the ratio of tumor necrosis factorβ1: high-mobility group box 1 could be a critical determinant of the underlying pathology. Potential target sites for therapeutic intervention in the management of IH are recognized.