[New prospects in the etiology of groin hernias]

The value of copper and zinc levels in hernia formation

BACKGROUND

A defect in collagen metabolism is suspected to be one of the factors responsible for hernia formation. Lysyl oxidase is a copper-dependent enzyme in the process that provides for the structural integrity of collagen molecules, while zinc is essential for tissue maintenance.

MATERIALS AND METHODS

In a prospective fashion, copper and zinc levels were measured in plasma and tissue specimens obtained from indirect (n=23), direct (n=20) and incisional hernia patients (n=19) and from healthy controls (laparoscopic cholecystectomy patients, n=15) by enzymatic colorimetric analysis.

RESULTS

Groups were similar in age, comorbid diseases and body mass index. Whereas plasma levels of Cu and Zn in hernia and control patients were similar, and tissue levels were significantly lower in all hernia groups (especially the incisional hernia group) compared to controls (P<0·001). The incisional hernia group had significantly lower tissue copper levels than direct hernia patients and lower zinc levels than indirect hernia patients.

CONCLUSIONS

Patients with all types of hernia, especially those with incisional hernias, have significantly lower tissue copper and zinc levels than control patients, despite having similar plasma levels. This finding might reflect excessive consumption or dysfunction of lysyl oxidase as playing a role in the aetiology of hernias.

Are collagens the culprits in the development of incisional and inguinal hernia disease?

Incidence curves for the development of inguinal hernia disease and recurrences thereof exhibit a linear rise over the years and therefore suggest multi-factorial underlying causes. Several studies have revealed marked changes in the abundance and composition of interstitial collagens in patients with (recurrent) hernia diseases, adult groin hernia and incisional hernia. These observations led to the hypothesis that hernia formation and the recurrence of incisional hernia may be explained by disordered tissue renewal and by abnormal wound healing, respectively. Interstitial collagens, owing to their long half-lives and biomechanical strength, are most likely critical components of the biological system of tissue remodelling. An overview of the literature is provided, and the consequences for surgical practice are discussed.

Evaluation of Skin Viscoelasticity in Type 1 Neurofibromatosis Patients

Neurofibromatosis type 1 (NF1) is a frequent autosomal dominant disease characterized by cutaneous benign tumors called neurofibromas. Surgery takes an important place in managing these skin disorders. However, skin distensibility and softness of NF1 patients quickly offset the surgical benefit. The aim of this study was to determine the rheological behavior of neurofibromas and compare it with healthy skin in an attempt to comprehend what leads to this phenomenon. Thirty patients were admitted to this study. A group of 24 healthy control subjects was also included. The skin elasticity was assessed by a noninvasive in vivo suction device (Cutometer) including 5 consecutive suctions. The assessments were performed on neurofibroma skin, the supposedly healthy skin around neurofibromas and the healthy skin of control subjects. The extensibility at the first and the fifth traction in NF1 patients (neurofibromas and the supposedly healthy skin around it) was significantly different compared to the healthy skin of control subjects. The viscoelastic parameters obtained from the neurofibromas were significantly different in comparison to those obtained from the supposedly healthy skin of NF1 patients and the healthy skin of control subjects. The rheological profiles of the neurofibromas and the apparent healthy skin of NF1 patients demonstrated a hyperextensibility behavior, but in neurofibromas, the skin was unable to return to its initial position at the end of the stretch.

A comparative histopathological evaluation of sacs from boys and girls with inguinal hernia

The purpose of this study is to determine and to compare histopathologic alterations of hernia sacs obtained from patients with inguinal hernia with those of the peritoneal tissue from patients operated on for other abdominal disorders. Samples were obtained from 42 pediatric patients with uni- or bilateral hernias, and from 30 pediatric control patients without hernia. Sections were stained with hematoxylin-eosin, Gomori's trichrome, and Gomori's reticulin. Furthermore, they were immunohistochemically stained with anti-synaptophysin for the quantification of neural structures. All the slides were examined for six parameters, including variations in tissue and collagen types, the presence of inflammation and proliferation of vessels, neural plexus, and mesothelial cells. The results were evaluated statistically using the independent T-test and the Mann-Whitney-U test. Parametric tests revealed a higher presence of large neural plexus (p = 0.003), increased proliferation of mesothelial cells (p = 0.009), and hypervascularization (p = 0.003) in sacs of the hernia group. There were also major changes that were dependent on the sex of the patients. Most part of hernia sacs tissue was found to be fibrous and adipose in most boy patients, but was fibro-muscular in girls with inguinal hernia (male/female p = 0.03), while the tissues were fibro-adipose in both sexes in the control group (inguinal hernia/control p = 0.016). Similarly, vascular proliferation was mainly encountered in hernia sacs of girls (p = 0.013). These features were not observed in the control groups. Therefore, on the basis of sex, we determined whether or not these findings could indicate the difference between the etiopathologic mechanisms of inguinal hernias. Furthermore, we went into the question of whether or not the comprehensive examination of hernia sacs sufficed to enlighten the etiology of hernias.

Umbilical and bilateral inguinal hernias in a veteran powerlifter: is it a pressure-overload syndrome?

Umbilical, inguinal and hiatal hernias are all thought to occur from basically the same etiology, a malformation in the tissue leading to herniation. The mechanisms for these malformations range from congenital to degenerative. Earlier studies proposed that hiatal hernias result from age-related degenerative changes in the phrenoesophageal ligament leading to subsequent herniation. We found that hiatal hernias occur in young power athletes secondary to intra-abdominal pressure overload of the phrenoesophageal ligament. We present a case of umbilical and bilateral inguinal hernias occurring in a veteran powerlifter. The pathogenesis of multiple hernias and the physiological pressure systems involved in the development of multiple hernias in a power athlete are discussed.