Complications of open groin hernia repairs

Outcomes of primary and recurrent inguinal hernia repair with prosthetic mesh in a single region over 15 years

BACKGROUND

Sutured inguinal hernia repairs are now uncommon, with evidence suggesting that those augmented with mesh are associated with a lower recurrence rate. We aimed to explore the suggestion that the established use of mesh does indeed lower the rate of operation for recurrence in a single National Health Service region.

METHOD

We collected retrospective Office of Population Censuses and Surveys coded data across one region of all primary and recurrent inguinal hernia repairs over 15 years (2004-2019). Electronic records of recurrent repairs were scrutinised to identify year and type of previous primary repair.

RESULTS

In total, 7,234 repairs were performed during this time, of which 289 (4%) were for symptomatic recurrence. Operations for primary repair increased year on year (111 in 2004 to 402 in 2019). Frequency of operation for recurrent herniation declined with increasing use of mesh (8.8% in 2004 to 3.5% in 2019). The majority of repairs (73%) for recurrence were by an open approach. As opposed to an open mesh repair, a primary laparoscopic repair was associated with an earlier recurrence.

CONCLUSIONS

Inguinal hernia repairs are increasing in frequency but operations for later symptomatic recurrence following an open primary prosthetic mesh repair are not.

The Role of Antibiotic Prophylaxis in Lichtenstein Repair of Primary Inguinal Hernia: A Prospective Double-Blind Randomized Placebo-Controlled Trial

Objective:

The objective is to study the role of antibiotic prophylaxis, if any, in the prevention of wound infection after open mesh repair of primary inguinal hernias.

Materials and Methods:

Patients coming to outpatient department for open mesh repair of inguinal hernia were randomized into the placebo group and antibiotic group, a total of 150 patients were enrolled in the study. Follow-up was done up to 1 month to look for any evidence of surgical site infection using the criteria of Centers for Disease Control on wound infection.

Results:

Twelve patients in the antibiotic group and nine patients in the placebo group were found to have evidence of surgical site infection. This difference was found to be insignificant with P = 0.14. Three patients in the placebo group developed deep surgical site infection but on analysis, this difference was also found to be insignificant with P = 0.122.None of these patients required mesh removal.

Conclusion:

The result of the present study suggests that the use of prophylactic antibiotics during mesh repair of primary inguinal hernias does not give any extra protection from infections. Multicenter meta-analysis is required to give definite guidelines regarding the use of prophylactic antibiotics.

Antibiotic prophylaxis for prevention of postoperative wound infection in adults undergoing open elective inguinal or femoral hernia repair

BACKGROUND

Inguinal or femoral hernia is a tissue protrusion in the groin region and has a cumulative incidence of 27% in adult men and of 3% in adult women. As most hernias become symptomatic over time, groin hernia repair is one of the most frequently performed surgical procedures worldwide. This type of surgery is considered 'clean' surgery with wound infection rates expected to be lower than 5%. For clean surgical procedures, antibiotic prophylaxis is not generally recommended. However after the introduction of mesh-based hernia repair and the publication of studies that have high wound infection rates the debate as to whether antibiotic prophylaxis is required to prevent postoperative wound infections started again.

OBJECTIVES

To determine the effectiveness of antibiotic prophylaxis in reducing postoperative (superficial and deep) wound infections in elective open inguinal and femoral hernia repair.

SEARCH METHODS

We searched several electronic databases: Cochrane Registry of Studies Online, MEDLINE Ovid, Embase Ovid, Scopus and Science Citation Index (search performed on 12 November 2019). We also searched two trial registers and the reference list of included studies.

SELECTION CRITERIA

We included randomised controlled trials comparing any type of antibiotic prophylaxis versus placebo or no treatment for preventing postoperative wound infections in adults undergoing inguinal or femoral open hernia repair surgery (tissue repair and mesh repair).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed risk of bias. We separately analysed results for two different surgical methods (herniorrhaphy and hernioplasty). Several studies revealed infection rates that were higher than the expected 5% for clean surgery and we therefore divided studies into two subgroups: high infection risk environments (≥ 5% infection rate); and low infection risk environments (< 5% infection rate). We performed meta-analyses with random-effects models. We analysed three outcomes: superficial surgical site infections (SSSI); deep surgical site infections (DSSI); and all postoperative wound infections (SSSI + DSSI).

MAIN RESULTS

In this review update we identified and included 10 new studies. In total, we included 27 studies with 8308 participants in this review. It is uncertain whether antibiotic prophylaxis as compared to placebo (or no treatment) prevents all types of postoperative wound infections after herniorrhaphy surgery (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.56 to 1.33; 5 studies, 1865 participants; very low quality evidence). Subgroup analysis did not change these results. We could not perform meta-analyses for SSSI or DSSI as these outcomes were not reported separately. Twenty-two studies related to hernioplasty surgery (total of 6443 participants) and we analysed three outcomes: SSSI; DSSI; SSSI + DSSI. Within the low infection risk environment subgroup, antibiotic prophylaxis as compared to placebo probably makes little or no difference for the outcomes 'prevention of all wound infections' (RR 0.71, 95% CI 0.44 to 1.14; moderate-quality evidence) and 'prevention of SSSI' (RR 0.71, 95% CI 0.44 to 1.17, moderate-quality evidence). Within the high infection risk environment subgroup it is uncertain whether antibiotic prophylaxis reduces all types of wound infections (RR 0.58, 95% CI 0.43 to 0.77, very low quality evidence) or SSSI (RR 0.56, 95% CI 0.41 to 0.77, very low quality evidence). When combining participants from both subgroups, antibiotic prophylaxis as compared to placebo probably reduces the risk of all types of wound infections (RR 0.61, 95% CI 0.48 to 0.78) and SSSI (RR 0.60, 95% CI 0.46 to 0.78; moderate-quality evidence). Antibiotic prophylaxis as compared to placebo probably makes little or no difference in reducing the risk of postoperative DSSI (RR 0.65, 95% CI 0.26 to 1.65; moderate-quality evidence), both in a low infection risk environment (RR 0.67, 95% CI 0.11 to 4.13; moderate-quality evidence) and in the high infection risk environment (RR 0.64, 95% CI 0.22 to 1.89; low-quality evidence).

AUTHORS' CONCLUSIONS

Evidence of very low quality shows that it is uncertain whether antibiotic prophylaxis reduces the risk of postoperative wound infections after herniorrhaphy surgery. Evidence of moderate quality shows that antibiotic prophylaxis probably makes little or no difference in preventing wound infections (i.e. all wound infections, SSSI or DSSI) after hernioplasty surgery in a low infection risk environment. Evidence of low quality shows that antibiotic prophylaxis in a high-risk environment may reduce the risk of all wound infections and SSSI, while evidence of very low quality shows that it is uncertain whether antibiotic prophylaxis reduces DSSI after hernioplasty surgery.

Failure of talc seromadesis for the treatment of subcutaneous chronic seromas after incisional hernia surgery

BACKGROUND AND AIM

Talc poudrage has been used since many years for sclerosing chronic pleural effusion. Several reports have shown good results managing chronic seromas after breast, vascular, and incisional hernia surgeries. The purpose of this study is to determine the utility of talc seromadesis for the management of chronic seromas after incisional hernia surgery.

MATERIALS AND METHODS

Multicentric prospective observational study including patients diagnosed of chronic seromas after incisional hernia surgery. Under local anesthesia and ultrasonographic control, two percutaneous trocars were placed in the seroma, washing the seroma cavity with 0.9% saline solution and aspirating the remaining liquid. A sample of 4 g of talcum powder was introduced in the seroma cavity, and a 15-F drain was left in place. Patients were followed each week during at least 4 weeks after drainage removal.

RESULTS

Between January 2013 and December 2016, a total of six patients were enrolled in the study. Talc poudrage was performed without any complications. Drains were pulled out in a mean time of 3 (range: 2-4) weeks. One case of the chronic seromas was efficiently sclerosed with talc without recurrence in time. In three cases, the seroma recurred, and the final solution was surgical decortication of the seroma. In the other two cases, seroma also recurred and were managed with instillation of ethanol and iodine povidone.

CONCLUSION

In our experience, the management of chronic seromas after incisional hernia repair with talc seromadesis is ineffective and is associated with a high rate of seroma recurrence.

The Effect of Acupressure at PC6 and REN12 on Vomiting in Patients Undergoing Inguinal Hernia Repair: A Double-Blind Randomized Clinical Trial

BACKGROUND

Inguinal hernia surgery is one of the most commonly performed surgeries with complications such as postoperative nausea and vomiting (PONV).

AIM

This study aimed to evaluate the effect of acupressure at PC6 and REN 12 points on vomiting of patients undergoing inguinal hernia repair.

MATERIAL AND METHODS

This is a double-blind, randomised clinical trial performed on 60 patients undergoing inguinal hernia repair. Using permutation blocks, patients were allocated in two groups (acupressure at PC6 and REN12 points). After the surgery and full patient consciousness, acupressure was applied on PC6 and REN 12 points separately in each group for 5 minutes; 2, 4 and 6 hours later, acupressure was repeated on those points. Two hours after each acupressure, frequency and severity of vomiting were determined.

RESULTS

The results showed that there was no significant difference between the frequency of vomiting before the intervention and 2 hours after the intervention in the two intervention groups (P ≥ 0.05). Additionally, none of the two intervention groups experienced vomiting at 4, 6, and 8 hours after the intervention.

CONCLUSION

It seems that acupressure at PC6 and REN 12 points are not effective in reducing the frequency and severity of vomiting in patients after inguinal hernia surgery.

Benefits of pre-emptive analgesia by local infiltration at day-case general anaesthetic open inguinal hernioplasty

Introduction The open prosthetic repair of inguinal hernias under local anaesthesia (LA) is well established, with the concept of intraoperative 'pre-emptive analgesia' evolving so that patients are as comfortable as possible. We used a peri-incisional LA solution in patients undergoing day-case inguinal hernioplasty under general anaesthesia (GA) and recorded use of analgesia in the immediate postoperative period. Methods In this observational cohort study, 100 consecutive unselected men underwent open inguinal hernia repair as a day case. Of these, 75 underwent repair under GA and 25 with peri-incisional LA solution (equal mixture of 0.5% bupivacaine and 1% lignocaine with 1:200,000 adrenaline). Analgesia prescribed at induction, for maintenance and after cessation of anaesthesia was scored in accordance with the World Health Organization (WHO) analgesic ladder. Results The median age in the GA group was 59 years (range: 25-89 years) and in the GA+LA group, it was 62 years (range: 27-88 years). Of the 100 patients, 82 underwent a mesh plug repair by seven surgeons whereas 18 underwent a flat (Lichtenstein) mesh repair by two surgeons. WHO analgesic induction and postoperative scores were significantly lower in the GA+LA group (p=0.034 and p<0.001 respectively). There was also a significant difference in use of postoperative antiemetics (23% vs 0% in the GA only and GA+LA cohorts respectively, p=0.020). Six patients (8%) in the GA group failed day-case discharge criteria. Conclusions Patients undergoing contemporary day-case GA inguinal hernioplasty with pre-emptive LA solution infiltration require lower levels of postoperative opioid analgesia and antiemetics. These cases are less likely to fail discharge criteria for planned day surgery.

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.

Survey of Surgeons Regarding Prophylactic Antibiotic Use in Inguinal Hernia Repair

PURPOSE

The use of prophylactic antibiotics in the mesh repair of inguinal hernias remains controversial. The aim of this study was to determine the perception of surgeons about surgical site infection and how this affects their clinical practice.

METHODS

A SurveyMonkey of general surgeons and senior surgical trainees was conducted via the local trust network and the questionnaire was displayed on the website of the Association of Surgeons of Great Britain and Ireland and Association of Surgeons in Training.

RESULTS

Eighty-one responses were received from surgeons who perform an average of 75 hernia repairs per year - the majority by open technique. Thirty-six (44.4%) used routine antibiotic prophylaxis, 40 (49.4%) selectively, and five (6.2%) not at all as the five surgeons who did not use antibiotics perceived their surgical site infection rate to be <1% and have never removed an infected mesh from a hernia wound. There was no clear difference between those who use prophylactic antibiotics routinely or selectively as the experience of mesh explantation is similar (56% versus 55% had 2-10 meshes removed respectively). Seventy-seven (95%) of surgeons felt a new specific set of guidelines was required.

CONCLUSION

This study highlights the fact that in the absence of clear guidelines, most surgeons base their use of prophylactic antibiotics on their perceived risk or experience of surgical site infection. There is a strong need for a new set of guidelines to address the use of prophylactic antibiotics in groin hernia surgery.

Repair of groin hernia under local anaesthesia in secondary health facility

BACKGROUND

Repair of groin hernias is the most commonly performed elective procedure by general surgeons worldwide. The techniques of anaesthesia differ among surgeons and vary from one health facility to another. General anaesthesia is much favoured in spite of the lack of anaesthetists in our setting. We aim to determine the feasibility of groin hernia repair under local anaesthesia (LA) with respect to patients' morbidity, acceptability and satisfaction.

METHOD

Ninety-seven patients with uncomplicated groin hernias treated between July 2012 and June 2015, at the State Specialist Hospital, Ikere-Ekiti, Nigeria were recruited for the study.

RESULTS

One hundred and five hernias in 97 patients of American Society of Anesthesiologists categories I-III were successfully repaired under LA. Their ages ranged between 16 and 95 years with a median age of 52. There were 91 (93.8%) males and six (6.2%) females, giving a male to female ratio of 15:1. Most hernias were indirect (81.9%) and inguinoscrotal (65.7%) type. Nylon darn and modified Bassini were surgical techniques of repair in 60.9 and 36.2%, respectively. The mean operating time was 51.1 ± 11.2 min. Two patients (1.9%) developed scrotal haematoma while a patient each (1%) developed superficial surgical site infection and scrotal burns. Ninety (92.8%) patients were satisfied with anaesthesia technique. The mean follow-up was 8.9 ± 4.1 months and there was no recurrence.

CONCLUSION

Groin hernia repair under LA is safe, feasible with high patient's satisfaction and would be the most ideal technique in our local setting where anaesthetists are not readily available.

Antibiotic prophylaxis in open inguinal hernia repair: a literature review and summary of current knowledge

More than 1 million inguinal hernia repairs are performed in Europe and the US annually. Although antibiotic prophylaxis is not required in clean, elective procedures, the routine use of implants (90% of inguinal hernia repairs are performed with mesh) makes the topic controversial. The European Hernia Society does not recommend routine antibiotic prophylaxis for elective inguinal hernia repairs. However, the latest randomized controlled trial, published by Mazaki et al., indicates that the use of prophylaxis is effective for the prevention of surgical site infection. Unnecessary prophylaxis contributes to the development of bacterial resistance and significantly increases healthcare costs. This review documents clinical trials on inguinal hernia repairs with mesh and summarizes the current knowledge. It also tries to solve certain problems, namely: what constitutes a real risk factor, late-onset infection, and how the "surgical environment" impacts on the need to use antibiotic prophylaxis.

Comparison of inguinal hernia repairs performed with lichtenstein, rutkow-robbins, and gilbert double layer graft methods

Tension-free repairs are performed commonly in inguinal hernia operations. The objective of the present study is to compare the outcomes of three different tension-free repair methods known as Lichtenstein, Rutkow-Robbins, and Gilbert double layer. One-hundred and fifty patients diagnosed with inguinal hernia were randomly split into three groups. The comparisons across groups were carried out in terms of operation length, postoperative pain, femoral vein flow velocity, early and late complications, recurrence rates, length of hospital stay, time required to return to work, and cost analysis. No difference was found between the groups regarding age, gender, type and classification of hernia, postoperative pain, and late complications (p > 0.05). Operation length was 53.70 ± 12.32 min in the Lichtenstein group, 44.29 ± 12.37 min in the Rutkow-Robbins group, and 45.21 ± 14.36 min in the Gilbert group (p < 0.05). Mean preoperative and postoperative femoral vein flow velocity values were 13.88 ± 2.237 and 13.42 ± 2.239 cm/s for Lichtenstein group, 12.64 ± 2.98 and 12.16 ± 2.736 cm/s for Rutkow-Robbins group, and 16.02 ± 3.19 and 15.52 ± 3.358 cm/s for the Gilbert group, respectively. Statistical difference was found between all the groups (p < 0.001). However, no difference was determined between the groups regarding the decrease rates (p = 0.977). Among early complications, hematoma was observed in one (2 %) patient of Lichtenstein group, five (10 %) patients of Rutkow-Robbins group, and three (6 %) patients of Gilbert group (p = 0.033). Cost analysis produced the following results for Lichtenstein, Rutkow-Robbins, and Gilbert groups: US $157.94 ± 50.05, $481.57 ± 11.32, and $501.51 ± 73.59, respectively (p < 0.001). Lichtenstein operation was found to be more advantageous compared with the other techniques in terms of cost analysis as well as having unaffected femoral blood flow. Therefore, we believe that Lichtenstein repair is still the most appropriate surgical option in patients diagnosed with inguinal hernia.

Skin staples: a safe technique for securing mesh in lichtensteins hernioplasty as compared to suture

Background. Lichtenstein tension free repair is the most commonly used technique due to cost effectiveness, low recurrence rate, and better patient satisfaction. This study was done to compare the duration of surgery and postoperative outcome of securing mesh with skin staples versus polypropylene sutures in Lichtenstein hernia repair. Materials and Methods. A total of 96 patients with inguinal hernia undergoing Lichtenstein mesh repair were randomly assigned into two groups. The mesh was secured either by using skin staples (group I) or polypropylene sutures (group II). Results. The operation time was significantly reduced from mesh insertion to completion of skin closure in group I (mean 20.7 min) as compared to group II (mean 32.7 min) with significant P value (P < 0.0001) and less complication rate in group I as compared to group II. Conclusion. Mesh fixation with skin staples is as effective as conventional sutures with added advantage of significant reduction in the operating time and complications or recurrence. The staples can be applied much more quickly than sutures for fixing the mesh, thus saving the operating time. Infection rate is significantly decreased with staples.

Day-surgery inguinal hernia repair in the elderly: single centre experience

BACKGROUND

Inguinal hernioplasty is well established as a day-surgery procedure, our purpose is to assess the safeness of this approach in elderly patients.

METHODS

A total of 292 inguinal hernioplasty were performed between June 2009 and February 2013. Patients were divided into 3 groups depending on the age and postoperative complications were compared in these groups.

RESULTS

Despite of a large number of higher risk (ASA 3-4) patients and a higher rate of comorbidity in older patients, unplanned admission postoperative, symptoms and complications were comparable with those for the younger patients.

CONCLUSIONS

Ambulatory surgery is feasible also in older patients. Age, comorbidity and higher ASA risk should not be a barrier to elective day surgery.

Emergency groin hernia repair: implications in elderly

BACKGROUND

Groin hernia is one of the most frequently encountered pathologies occurring in old age and it is often the cause of emergency procedures. In our study we evaluate the impact of emergency procedures in over 75 patients compared to younger patients.

METHODS

We conducted a retrospective study about patients who underwent emergency hernioplasty between September 2007 and January 2013. Bilateral hernias and recurrences were excluded. We divided patients into two groups by age (under and over 75 years old) and then analyzed the early postoperative surgical complications.

RESULTS

A total of 48 patients were enrolled, 18 were included in under 75 group and 30 in over 75. In the older group we found a higher rate of comorbidity and also a significant higher rate of postoperative complications. Two patients of over 75 group died.

CONCLUSIONS

Our data suggests that a quick diagnosis and elective surgical procedures are desirable in order to avoid the complications that occur in emergency operations.

Inguinal hernias in patients of 50 years and above. Pattern and outcome

OBJECTIVE: to evaluate a one year experience with inguinal hernia repair, in patients of > 50years, with respect to the type of inguinal hernia, type of surgery, postoperative complications and recurrence. METHODS: a prospective descriptive study of patients (n=57) > 50 years operated for inguinal hernia during a one year period. Tension-free meshplasty and herniorrhaphy, using 3"x6" polypropylene mesh and 2-0 polypropylene suture, were performed in elective and emergency surgery respectively. Follow-up visits were scheduled at six weeks, three and six months postoperatively. RESULTS: the most representative age group was 61-70 years, and all patients were male. 52 (91.22%) patients had unilateral inguinal hernias, while five (8.77%) had bilateral hernias. In 50 (87.71%) patients, the hernia was uncomplicated, while seven (12.28%) patients presented with some complication such as obstruction or strangulation. Elective surgery was performed in 50 (87.71%) patients while seven (12.28%) patients were operated in emergency. Postoperatively, 50 (87.7%) patients had uneventful recovery, while seven (12.28%) patients developed some complications which were treated conservatively. Mean hospital stay was six days. One recurrence was observed and there was no peri/postoperative death. CONCLUSION: tension-free meshplasty and herniorrhaphy are safe, simple and applicable even in elderly patients after adequate pre-operative assessment and optimization. Although associated with longer hospital stay, the mortality rate is nil and complication as well as recurrence rate is low. Hence, timely repair is necessary in elderly patients even in those with comorbid conditions.

Do hernia operations in african international cooperation programmes provide good quality?

BACKGROUND

Hernia is especially prevalent in developing countries where the population is obliged to undertake strenuous work in order to survive, and International Cooperation Programmes are helping to solve this problem. However, the quality of surgical interventions is unknown. The objective of the present study was to evaluate the quality of hernia repair processes carried out by the Surgical Solidarity Charity in Central African States.

MATERIALS AND METHODS

A total of 524 cases of inguinal hernia repair carried out in Cameroon and Mali during 2005 to 2009 were compared with 386 cases treated in a Multicentre Spanish Study (2003). General data (clinical, demographic, etc.), type of surgery, complications, and effectiveness and efficiency indicators were collected.

RESULTS

Preoperative studies in the Spanish group were greater in number than in the African group. The use of local anesthesia was similar. Antibiotic prophylaxis was higher in the African group (100% to 75.4%). The use of mesh was similar. The incidence of hematomas was higher in the Spanish group (11.61% to 4.61%), but the incidence of infection of the wound and of hernia recurrence was similar, although follow-up was only carried out in 20.97% in the African group (70% in the Spanish group). Hospital stay of more than 24 h was higher in the Spanish group.

CONCLUSIONS

The standard quality of surgery for the treatment of hernia in developing countries with few instrumental means, and in sub-optimal surgical conditions is similar to that provided in Spain.

Low-density polypropylene meshes coated with resorbable and biocompatible hydrophilic polymers as controlled release agents of antibiotics

The application of bioactive meshes in abdominal surgery for the repair of hernias is an increasing clinical activity in a wide sector of the population. The main secondary effect is the appearance of infections from bacteria, specifically Staphylococcus aureus and S. epidermidis. This paper describes the development and application of low-density polypropylene meshes coated with a biocompatible and resorbable polymer as a controlled release system of the antibiotic vancomycin. The polymeric coating (a non-cross-linked copolymer of 2-hydroxyethyl methacrylate and 2-acrylamido-2-methylpropanesulfonic acid) has a thickness of 14-15μm and contains 0.32mgcm(-2) of the antibiotic vancomycin. The in vitro experiments demonstrate the excellent inhibitory character of the coated meshes loaded with the antibiotic, following the standard protocol of inhibition of halo in agar diffusion test. This inhibitory effect is maintained for a relatively long period (at least 14days) with a low concentration of antibiotic. The acrylic polymer system regulates the release of the antibiotic with a rate of 24μgh(-1), due to its slow dissolution in the medium. Experiments in vivo, based on the implantation of coated meshes, demonstrate that the system controls the infection in the animal (rabbits) for at least 30days. The concentration of antibiotic in the blood stream of the rabbits was below the detection limit of the analytical technique (<1-2μgml(-1)), which demonstrates that the antibiotic is released in the local area of the implant and remains concentrated at the implantation site, without diffusion to the blood stream. The systems can be applied to other medical devices and implants for the application of new-generation antibiotics in a controlled release and targeted applications.

Persistent inguinal seroma managed with sprinkling of talcum powder: a case report

Introduction

We present a new method to treat recurrent seromas, which is based on our experience with a patient who had recurrent groin seroma and was treated successfully with a sprinkling of talcum powder in the seroma cavity.

Case presentation

A 67-year-old Caucasian man with a suprapubic recurrent right groin hernia underwent inguinal hernioplasty with a polypropylene plug. Three days later the patient presented with a right groin fluctuating mass beneath the surgical wound with no signs of infection, and was discharged after seroma aspiration. After 23 days of increasing drainage, the seroma cavity was thoroughly dried with clean gauze swabs, and four g of sterilized dry talcum powder was sprinkled into the seroma cavity with a five-cc syringe. A compressive dressing was placed, and the patient was discharged. One week after the sprinkling of talcum powder, the surgical wound was almost closed with only minimal oozing from the drainage incision. The patient did not report any adverse effects. Two weeks later, the wound was fully healed.

Conclusion

Talcum powder sprinkling could be an effective, quick, and safe method for the treatment of inguinal seromas after inguinal hernioplasty when conservative management has failed. Nevertheless, larger series are needed before assessing this technique as the treatment of choice.

Risk factors for mesh-related infections after hernia repair surgery: a meta-analysis of cohort studies

Mesh infection, although infrequent, is a devastating complication of mesh hernioplasties. The aim of this study was to systematically review and synthesize the available evidence on risk factors for synthetic mesh infection after hernioplasty. A systematic search was performed in PubMed and Scopus databases. The extracted data were synthesized with the methodology of meta-analysis. We identified six eligible studies that reported on 2,418 mesh hernioplasties. The crude mesh infection rate was 5%. Statistically significant risk factors were smoking (risk ratio [RR] = 1.36 [95% confidence interval (CI): 1.07, 1.73]; 1,171 hernioplasties), American Society of Anesthesiologists (ASA) score ≥3 (RR = 1.40 [1.15, 1.70]; 1,682 hernioplasties), and emergency operation (RR = 2.46 [1.56, 3.91]; 1,561 hernioplasties). Also, mesh infections were significantly correlated with patient age (weighted mean difference [WMD] = 2.63 [0.22, 5.04]; 2,364 hernioplasties), ASA score (WMD = 0.23 [0.08, 0.38]; 1,682 hernioplasties), and the duration of the hernioplasty (WMD = 44.92 [25.66, 64.18]; 833 hernioplasties). A trend toward higher mesh infection rates was observed in obese patients (RR = 1.41 [0.94, 2.11]; 2,243 hernioplasties) and in patients operated on by a resident (in contrast to a consultant; RR = 1.18 [0.99, 1.40]; 982 hernioplasties). Mesh infections usually resulted in mesh removal, and common pathogens included Staphylococcus spp., Enterococcus spp., and gram-negative bacteria. Patient age, ASA score, smoking, and the duration and emergency setting of the operation were found to be associated with the development of synthetic mesh infection. The heterogeneity of the available evidence should be taken under consideration. Prospective studies with a meticulous follow-up are warranted to further investigate mesh-related infections.

Meta-analysis of the effectiveness of prophylactic antibiotics in the prevention of postoperative complications after tension-free hernioplasty

BACKGROUND

Previous reviews of the effectiveness of antibiotic prophylaxis for elective inguinal hernia repair were not conclusive owing to the limited number of patients enrolled in randomized controlled trials (RCTs). However, since new RCTs involving patients undergoing tention-free hernioplasty have been published in recent years, we performed a new meta-analysis to evaluate the effectiveness of antibiotic prophylaxisin the prevention of postoperative complications after this procedure.

METHODS

We performed a meta-analysis of RCTs studying the use of antibiotic prophylaxis to prevent postoperative complications in patients undergoing tension-free hernioplasty.

RESULTS

We included 6 RCTs conducted around the world in our analysis. Compared with the control condition, antibiotic prophylaxis was associated with a lower incidence of incision infection (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.26-0.77, p = 0.004). There were no significant differences in risk for incision hematoma (OR 1.57, 95% CI 0.60-4.10, p = 0.35), respiratory infection (OR 1.00, 95% CI 0.17-5.79, p > 0.99) or urinary tract infection (OR 1.81, 95% CI 0.38-8.52, p = 0.45) between the 2 conditions.

CONCLUSION

Antibiotic prophylaxis use in patients undergoing tension-free hernioplasty decreases the rate of incision infection by 55%.

Perception of semiquantitative terms in surgery

OBJECTIVE

To assess whether semiquantitative terms (eg, "often" or "rare"), which are often used for achieving informed consent, have the same meaning for laypersons and physicians.

BACKGROUND

To obtain informed consent, physicians have to make their patients aware of the risks of an operation. Thereby, semiquantitative terms are often used.

METHODS

Questionnaire interview among surgeons and randomly approached laypersons. A set of semiquantitative terms was presented to participants for quantification. Pertinent to 8 exemplary complications of common operations, these values were compared among the 2 interviewed groups and corresponding rates in scientific literature.

RESULTS

The questionnaire was completed by 48 surgeons and 582 laypersons in Switzerland. Confronted with corresponding complication rates in literature, laypersons underestimated the risk significantly in 6 of 8 cases. After a simulated informed consent conversation with a surgeon by using semiquantitative terms, laypersons overestimated the complication rate significantly in 7 of 8 cases. An interaction analysis did not show any significant difference between correct estimations of complication rates of respondents who graduated, who had a professional medical background or who had had prior contact with the health care system (eg, medical consultation, hospitalization, operation) compared with the others.

CONCLUSIONS

Laypersons overestimate probabilities of semiquantitative terms named by surgeons. We recommend using "percentages" or "odds ratios" to achieve a more reliable preoperative informed consent.

Antibiotic Prophylaxis in Patients Undergoing Open Mesh Repair of Inguinal Hernia: A Meta-Analysis

The use of antibiotic prophylaxis in hernia repair is still under debate. The aim of this meta-analysis was to assess the effect of antibiotic prophylaxis in patients undergoing open mesh repair of inguinal hernia with respect to incidence of postoperative surgical site infection (SSI). A literature search was conducted in databases of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. Study selection, data extraction, quality assessment, and meta-analysis were conducted according to the recommendations by Cochrane collaboration. Nine randomized controlled trials were included. Incidence of surgical site infection was 39/1642 (2.38%) in the antibiotic group and 70/1676 (4.18%) in the control group. Antibiotics showed a protective effect in preventing SSI after mesh inguinal hernia repair (odds ratio: 0.61, 95% confidence interval: 0.40–0.92, I2: 0%). Antibiotic prophylaxis did reduce the incidence of SSI in hernia patients undergoing mesh hernioplasty. The cost effectiveness of antibiotic prophylaxis needs further evaluation.

Cyclodextrin and maltodextrin finishing of a polypropylene abdominal wall implant for the prolonged delivery of ciprofloxacin

The aim of this work was to develop a polypropylene (PP) artificial abdominal wall implant for the prolonged release of ciprofloxacin (CFX). This sustained release effect was obtained by functionalization of the textile mesh with citric acid and hydroxypropyl-γ-cyclodextrin (HPγCD) or maltodextrin (MD). In both cases the textile finishing reaction yielded a cyclo- or malto-dextrin crosslinked polymer coating the fibers. The modified supports were characterized by thermogravimetric analysis (TGA), differential scanning calorimetry and scanning electron microscopy. The sorption capacities and the kinetics of CFX release were studied by batch tests coupled with spectrophotometric assays. Microbiological assays were carried out on Staphylococcus aureus, Staphylococcus epidermidis and Escherichia coli, while proliferation and viability tests used fibroblasts. The main results were as follows. (i) Due to the differences between the range of temperature of thermal degradation of the (cyclo)dextrins polymers and of the PP fibers TGA was a reliable method for quantifying the degree of functionalization of the textiles. (ii) Both modified supports showed improved sorption/desorption capacities for CFX, compared with the virgin mesh. The HPγCD-finished support showed an increased sorption capacity and a lower release rate of CFX compared with the MD modified support. (iii) Microbiological assays confirmed the latter result, with greater sustained antibacterial activity of the HPγCD treated support. These experiments have demonstrated the role of the cyclodextrin cavity in interactions with CFX: the antibiotic was not only adsorbed via hydrogen and acid-base interactions with the polyCTR-HPγCD network, but also via host-guest complexation. (iv) Biological tests revealed a slight decrease in fibroblast proliferation after 6 days on the modified supports, but cell viability tests showed that this was not due to toxicity of the (cyclo)dextrin polymer coatings.

Inguinal hernia repair in a community setting: implications for the elderly

OBJECTIVE

Inguinal hernia repair is thought to be a relatively low morbidity operation. This study examined whether this tenet hold true in patients who are elderly with significant comorbidity.

DESIGN

Case series. Retrospective review of a prospectively collected database.

SETTING

Single surgeon practicing in Vermont over a period of 9 years.

PATIENTS

Consecutive sample of 2,145 inguinal herniorraphies in 1,889 patients.

INTERVENTION

Patients underwent an open inguinal hernia repair with mesh placement. A total of 81% of the repairs were performed under local anesthesia with intravenous sedation.

MAIN OUTCOME MEASURE

Presence of comorbid conditions and complications were compared between patients younger and older than 65 years.

RESULTS

A total of 2,145 herniorraphies were performed on 1,889 patients (1,646 in younger patients and 499 in older patients). Hernia repairs in older patients were more likely associated with comorbid conditions than in their younger counterparts (74 vs 39%; OR = 4.55, P < 0.0001). Specifically, hypertension (26 vs 9%; OR = 3.5, P < 0.0001), coronary artery disease (34 vs 6%; OR = 8.4, P < 0.0001) and benign prostatic hypertrophy (26 vs 4%; OR = 8.2, P < 0.0001) were more commonly present in older individuals. The commonest postoperative complications in both groups were recurrence (3%), hematoma (1%) and nerve entrapment (1%). There were no deaths. There was no significant difference in the rate of postoperative complications (6 vs 7%; OR = 0.95, P = 0.88) or recurrence rates (2 vs 3%; OR = 0.82, P = 0.65) between groups.

CONCLUSION

Inguinal herniorrhaphy under local anesthesia is a safe operation with a high success rate in the elderly. Patients with significant comorbidities are not at higher risk of complications or recurrences.

Prophylactic antibiotics in open mesh repair of inguinal hernia - a randomized controlled trial

The role of prophylactic antibiotics in mesh repair of inguinal hernia is unclear. A Cochrane meta-analysis in 2005 concluded that "antibiotic prophylaxis for elective inguinal hernia repair cannot be firmly recommended or discarded" and "further studies are needed, particularly on the use for mesh repair." So, we designed a study to define the role of prophylactic antibiotics in mesh repair of inguinal hernia. We conducted a prospective, randomized, double-blind, trial comparing wound infection rates in 450 patients (225 received intravenous Cefazolin, 225 received a placebo) undergoing primary inguinal hernia repair electively using polypropylene mesh. 334 patients who completed a followup period of one month were analyzed. Age, American Society of Anesthesiologists class, type of hernia, type of anesthesia, grade of surgeon, pre and postoperative hospital stay and duration of operation were recorded. CDC criteria was used to define wound infection. Groups were well matched for all preoperative variables studied. The overall infection rate was 8.7% (29 out of 334). The incidence of wound infection in antibiotic group was 7% and 10.5% in control group. One from each group developed deep surgical site infection. Most of the infections occurred between the 7th and 12th post-operative day after discharge from the hospital. Antibiotic prophylaxis was associated with decreased incidence of wound infection when compared to control group, but the difference was not statistically significant. Based on our results we do not recommend the routine use of antibiotic prophylaxis in elective mesh repair of inguinal hernias.

Prophylactic antibiotic usage in patients undergoing inguinal mesh hernioplasty - A clinical study

BACKGROUND

There is ambiguity about the use of antibiotic prophylaxis in inguinal mesh hernioplasty. We have tried to assess the efficacy of antibiotic prophylaxis in this procedure.

MATERIALS AND METHODS

A randomized double blind placebo controlled study was conducted which included 55 patients who underwent an inguinal mesh hernioplasty over a 2 year period. The patients were evaluated for the status of the suture line as well as the presence of wound infection.

RESULTS

Out of 55 patients 29 were randomized to the antibiotic arm and 26 to the placebo group. The groups were well matched for all variables studied excluding wound infections, which occurred at a rate of 10.34% (n = 3) in the antibiotic group and 15.38% (n = 4) in the placebo arm, (p > 0.01).

CONCLUSION

This study did not document any statistically significant difference observed between those who received antibiotics and those receiving placebo in terms of any of the prognostic end points evaluated for Lichtenstein mesh hernioplasty.

Sensory disturbances and neuropathic pain after inguinal hernia surgery

Objectives The aim of this study was to explore how the handling of nerves affects the risk for developing sensory disturbances (SDs) following groin hernia surgery. Patients and methods All patients 18 years or older undergoing surgery for inguinal hernia at Mora Hospital, Sweden, during an eight-month period in 2006, were eligible for inclusion. The surgical procedure was recorded prospectively according to a standardised protocol. One year postoperatively all patients were requested to answer the Inguinal Pain Questionnaire as well as a set of 18 sensory and affective pain descriptors. They were also invited to clinical examination including sensory testing. Results Of the 157 hernia repairs in Mora during the period of study, 128 repairs in 116 patients, were registered prospectively according to the study protocol. Laparoscopic total extraperitoneal (TEP) repair was performed in 36 (28%) of the patients. Ninety-two (79%) patients, including five patients operated bilaterally, underwent postoperative examination. SDs were found in 33 (34%) of the groins examined. No descriptor was found that significantly predicted the presence of altered examination findings. No significant association between the intraoperative handling of nerves and SD was seen. In the TEP-group, no SDs were seen. Infiltration of local anaesthetic agents and blockade of the ilioinguinal nerve prior to surgery were found to be significantly associated with SD more than 2 cm away from the scar (both p < 0.05). The presence of SD was not associated with significant pain. Conclusions SDs are common after open hernia surgery, but are not associated with persistent postoperative pain.

A Strange Case of Left Bowel Ischemia after Right Hernioplasty

We report the first observed case of a young man who suffered of large and unsuspected left bowel ischemia following an elective right open hernioplasty. A 54-year-old man had a 2-year history of right inguinal reducible mass and was admitted to hospital for an elective day case open inguinal hernioplasty for a direct right inguinal hernia. Apart from mild hypertension controlled with ACE inhibitor, he was medically fit and well. The patient was submitted to open tension-free mesh repair with polypropylene preshaped mesh with local infiltration anesthesia and additive sedation with midazolam. The local anesthesia and surgery were uneventful and he was discharged home on the same day as per day case protocol. He was readmitted about 12 h after discharge with a history of central and left lower abdominal pain with palpable mass, and distension and fever (38°C). After imaging and laboratory studies the patient was submitted to explorative surgery with the suspicion of left colonic ischemia. After intraoperative confirmation we performed standard left hemicolectomy. The postoperative course was uneventful; the patient was discharged in good general condition on the 7th postoperative day. Actually, the patient is in follow-up, with normal coagulation and hemochromocytometric pattern, asymptomatic for hypercholesterolemia and atrial flutter/fibrillation. Complications relating to bowel during open techniques of hernia repair are limited to two situations: the freeing of an incarcerated or strangulated segment of bowel and inadvertent laceration of large bowel in the presence of a sliding hernia. Following this strange case of colonic ischemia, a boolean Medline search (terms: hernia, complication, repair, groin, herniorrhaphy, hernioplasty, all major MESH subjects without language restriction) revealed no previous similar cases reported. However, to our knowledge, there is another trouble hypothesis: not causality but casualty. In conclusion, to our knowledge this is the first reported case of large left bowel ischemia following right open hernioplasty. We can conclude that the presence of a dolichocolon is an added risk factor for this rare and uneventful complication, but further investigations and case reports are necessary to estabilish the real causality.

The role of antibiotic prophylaxis in mesh repair of primary inguinal hernias using prolene hernia system: a randomized prospective double-blind control trial

Antibiotic prophylaxis is being commonly used in mesh repair of inguinal hernia but its role has been questioned in a recent Cochrane analysis performed in 2003. Routine use of antibiotic prophylaxis in mesh repair of inguinal hernia can lead to bacterial resistance and increase in cost. In a present double-blind placebo controlled trial involving 120 patients undergoing inguinal hernia repair using prolene hernia system, we did not find any benefit of the routine use of antibiotic prophylaxis in terms of wound infection rate.

Re-operation due to severe late-onset persisting groin pain following anterior inguinal hernia repair with mesh

OBJECTIVES

Mild pain lasting for a few days is common following mesh inguinal hernia repair. In some patients however, severe groin pain may appear months or even years postoperatively. The aim of this study was to report our experience of late-onset persisting severe postoperative groin pain occurring years after mesh hernioplasty.

METHODS

In a 9-year period, 1,633 patients (1,073 men), median age 63 years (range 19-88), underwent mesh groin hernia repair. Between 1.5 and 4 years postoperatively, six patients (0.35%) presented with severe chronic groin pain unrelieved by conservative measures and surgical exploration was essential. The patients' records were retrospectively reviewed for the purpose of this study.

RESULTS

Ilioinguinal nerve entrapment was detected in four patients. The meshes appeared to be indistinguishable from the nerve and were removed along with the stuck nerve. New meshes were properly inserted. Mesh fixation on the periostium of the pubic tubercle by a staple was found in the other two patients. The staples were removed from the periostium in both patients. Neither hernia recurrence nor chronic groin pain was persisting in all six patients during a follow-up of 6-44 months postoperatively.

CONCLUSION

From the results of this study, it appears that ilioinguinal nerve entrapment and/or mesh fixation on the periostium of the pubic tubercle are the causes of late-onset severe chronic pain after inguinal mesh hernioplasty. Mesh removal, along with the stuck ilioinguinal nerve and staple detachment from the periostium, are the gold-standard techniques if conservative measures fail to reduce pain.

Mesh repair of common abdominal hernias: a review on experimental and clinical studies

Results on hernia surgery from numerous centers confirm that tensionless repair with various meshes reduces the complication rates and the frequency of recurrences. Some evidence on incisional hernias suggests, however, that the use of mesh seems to transfer the onset of recurrences by several years. Persistent pain and other discomfort is also an unpleasant complication of otherwise successful surgery in a number of patients. Thus, improved, slowly degrading, mesh materials, with strong connective tissue-inducing action, might be more optimal for hernia surgery. Accumulating evidence also suggests that recurrent hernias appear in patients having inherited weakness of connective tissues. Numerous tissue specific collagens, in addition to the classical fibrillar I-III collagens and numerous substrate specific matrix proteinases, have recently been described in biochemical literature, and their roles as possible causes of tissue weakness are discussed.

Prosthetic repair of prevascular femoral herniation

INTRODUCTION

In prevascular femoral hernias the sac is situated anterior to the femoral vessels in the groin. These hernias are rare and a preoperative diagnosis is seldom considered. Traditionally the surgeon had to do the best with the situation that confronted him/her. The aim of this study was to evaluate the use of a prosthetic mesh-plug via a low anterior groin approach.

METHODS AND RESULTS

Over a nine-year period, six patients (all men, aged 46-82 year) were treated for prevascular herniation using a mesh-plug. Five patients had previous groin surgery. Follow-up ranged from 15 months to nine years, during which no recurrence, infection or vascular compromise was detected.

DISCUSSION

Prevascular herniation is rare and the diagnosis may be difficult. Our results suggest that mesh-plug repair via a low approach is feasible and safe and may provide another option for a surgeon encountering a prevascular hernia.

The role of hernia sac ligation in postoperative pain in patients with elective tension-free indirect inguinal hernia repair: a prospective randomized study

BACKGROUND

Tension-free inguinal hernia repair is one of the so-called painless operations. Mild or medium postoperative pain, however, even in the mesh repair era, is common and usually due to ilioinguinal nerve entrapment or mesh fixation in the periostium of the pubic tubercle. Especially in indirect inguinal hernia repair, however, hernia sac ligation and excision may be the cause of pain. The aim of this study was to conduct a single-center prospective randomized trial with a view to clarify this issue on a scientific basis.

METHODS

In an 8-year period, all patients undergoing elective indirect inguinal hernia repair using a tension-free polypropylene mesh technique were randomized to induce high hernia sac ligation or not in a double blind manner. The main endpoint was to detect any difference in postoperative pain between the two groups.

RESULTS

Between January 1999 and December 2006, 477 patients with indirect inguinal hernia entered the study and were randomized to have high hernia sac ligation and excision (group A, n = 238) or not (group B, n = 239). The two groups were comparable regarding demographic data. Postoperative pain was associated with statistically significantly more episodes in group 1, 27% (65/238), than in group 2, 10% (24/239), on day 1, 9% (22/238), compared to 3% (8/239) on day 7, 2% (5/238), compared to 0% (0/239), on day 30, respectively, and these results were statistically significant (P <or= 0.05). All patients were treated conservatively.

CONCLUSION

From the results of this study, it appears that we are able to demonstrate a significant benefit from the omission of high hernia sac ligation and excision on postoperative pain in patients who undergo tension-free indirect inguinal hernia mesh repair.

The analysis of infection after polypropylene mesh repair of abdominal wall hernia

AIM

The aim of the study was to evaluate the frequency of superficial and prosthetic mesh infection following polypropylene mesh repair of different abdominal wall hernia in individual patients and to analyze the manifestation, clinical process and outcomes in patients with prosthetic mesh infection.

METHODS

This was a retrospective analysis of 375 patients with 423 implanted meshes for groin, femoral, umbilical, incisional and epigastric hernias, with a mean follow-up of 15 months (range: 3-73 months).

RESULTS

The total superficial infection rate was 1.65%, and the rate of mesh infection was 0.94%. There were no statistically significant differences in prosthetic mesh infection between monofilament and multifilament meshes as well as between the different repair groups of hernias. The deep incisional surgical site infection after previous operation was established as a significant risk factor for prosthetic mesh infection in incisional hernia repair (P < 0.0001). Five cases of prosthetic mesh infection were presented and analyzed.

CONCLUSIONS

There is no correlation between the superficial and prosthetic mesh infection. There may be difficulties in determining mesh infection and to choose the right tactic. The reconvalescence in all patients with mesh infection was achieved only after removal of the infected mesh.

Inguinal hernia treatment with the Prolene Hernia System in a Dutch regional training hospital

INTRODUCTION

In this retrospective study results from inguinal hernia repair with the Prolene Hernia System (PHS) in a regional training hospital were analysed.

PATIENTS AND METHODS

One-hundred and seventy-eight primary inguinal hernias and thirty-nine recurrent hernias (initial non-mesh repair) were treated with the PHS. The primary endpoint was the recurrence rate. Secondary endpoints were short-term and long-term complications. Pain was evaluated by use of a visual analog scale (VAS, 0-100), and a short-form 36-item questionnaire was used to assess postoperation quality of life. All patients visited the outpatient clinic for a physical examination (100% follow-up).

RESULTS

After a median follow-up of 32 months four patients were diagnosed with recurrent herniation (1.8%), three after primary hernia repair (1.6%) and one after recurrent hernia repair (2.6%). Three superficial wound infections (1.3%), three haematomas needing surgical evacuation (1.3%), and two lesions of the spermatic cord (0.9%) were diagnosed. Seven patients (3.2%) suffered from persistent pain (VAS > 40). Average VAS score was 13 (0-80) >24 months after surgery.

CONCLUSION

In a regional training hospital, primary and recurrent inguinal hernias were treated with low recurrence and few complications by use of the PHS.

Outcome of inguinal hernia repair at two rural hospitals in northern Scotland

INTRODUCTION

Audit of inguinal hernia repair is important in view of the magnitude of the problem and the fact that it is a common operation often performed by surgical trainees. Due to the disparity of the results of various workers with regard to the rate of complications, individual surgeons have been advised to audit their patients' outcomes.

METHOD

Retrospective audit was performed, of all the inguinal hernias repaired between 1997 and 2003 inclusive, at two rural hospitals in northern Scotland, under a single consultant. Data were gathered from a hospital database and by means of postal questionnaire specifically aimed at wound complications, recurrence and chronic groin pain.

RESULTS

One hundred and sixty-three inguinal hernias were repaired during this period. One hundred and fifty-eight questionnaires were sent to patients ascertained to be living at the time of audit initiation with a response from 129 (86%). At a mean follow-up of 4.34 years, no recurrences were noted and eight patients complained of chronic groin pain of whom only three (1.5%) were experiencing moderate to severe pain. The results achieved by senior house officers were comparable to those obtained by the senior surgeon.

CONCLUSION

The incidence of recurrence of hernia after open mesh repair of inguinal hernias is very low. Excellent outcomes can be obtained for inguinal hernia even at remote and rural hospitals in the hands of both experienced and trainee surgeons