Randomized clinical trial of non-mesh versus mesh repair of primary inguinal hernia

Ventral Hernia Repair With a Hybrid Absorbable-permanent Preperitoneal Mesh

OBJECTIVE

To analyze device safety and clinical outcomes of ventral hernia repair with the GORE SYNECOR Preperitoneal Biomaterial (PRE device), a permanent high-strength mesh with bioabsorbable web scaffold technology.

MATERIALS AND METHODS

This multicenter retrospective review analyzed device/procedure endpoints and patient-reported outcomes in patients treated for hernia repair ≥1 year from study enrollment.

RESULTS

Included in this analysis were 148 patients with a mean age of 56 years; 66.2% met the Ventral Hernia Working Group grade 2 classification. Median hernia size was 30.0 cm 2 and 58.8% of patients had an incisional hernia. Repairs were primarily a robotic (53.4%) or open approach (41.9%). All meshes were placed extraperitoneal. Procedure-related adverse events within 30 days occurred in 13 (8.8%) patients and included 7 (4.8%) patients with surgical site infection, 2 (1.4%) with surgical site occurrence (SSO), 4 (2.7%) requiring readmission, and 3 (2.0%) who had reoperation. The rate of SSO events requiring procedural intervention was 2.7% (4 patients) through 30 days and 3.4% (5 patients) at 12 months. The rate of procedure-related surgical site infection remained at 4.8% through 12 months (no further reports after 30 d) and 3.4% for SSO (2 reports after 30 d). There were no site-reported clinically diagnosed hernia recurrences throughout the study. Median patient follow-up including in-person visit, physical examination, reported adverse event, explant, death, and questionnaire response was 28 months (n = 148). Median patient follow-up with patient questionnaire was 36 months (n = 88).

CONCLUSIONS

Use of the PRE device, which incorporates the proven advantages of both an absorbable synthetic mesh and the long-term durability of a permanent macroporous mesh, is safe and effective in complex ventral hernia repairs. When used in the retromuscular space, the combination of these 2 materials had lower wound complications and recurrence rates than either type of material alone.

Incidence of contralateral metachronous inguinal hernia on long term follow-up after unilateral inguinal hernia repair: a systematic review and meta-analysis

BACKGROUND

The repair of inguinal hernias is a common surgical procedure. Some patients will need a second operation after developing a metachronous contralateral inguinal hernia (MCIH). The suggestion has been made to strengthen the contralateral side at the same time as primary unilateral surgery. In this systematic review we aim to determine how many adult patients with a unilateral inguinal hernia will develop a MCIH.

METHODS

This review was reported in line with PRISMA guidelines. We performed a literature review in PubMed Publisher, Embase, Google Scholar and Cochrane Library until May 2021, including articles reporting MCIH after unilateral inguinal hernia repair in adults. As outcome measure, the number of patients diagnosed with a MCIH was registered.

RESULTS

A total of 19 articles with a total of 277,288 patients were included. The combined estimate for MCIH after meta-analysis equaled 8.3% (95% CI 7.1%-9.5%), with a high index of heterogeneity (I2 = 97.9%). A random-effects meta-regression was performed to obtain the percentage of MCIH as a function of median follow-up time. The percentage of MCIH at 3, 5 and 10 years was estimated at 5.2%, 8.0% and 17.1%, respectively.

CONCLUSION

We suggest that there is insufficient clinical evidence to support prophylactic contralateral repair in all patients. We propose a patient-specific approach in the decision to perform prophylactic repair, taking into account potential risk factors for hernia development, type of surgical approach, and general risk factors for chronic postoperative inguinal pain. More long-term prospective data are needed to guide the decision for prophylactic contralateral mesh placement.

A multicenter randomized controlled trial comparing short- and medium-term outcomes of novel biologics and lightweight synthetic mesh for laparoscopic inguinal hernia repair

INTRODUCTION

The use of biological graft in laparoscopic inguinal hernia repair (LIHR) has been controversial, and there is a lack of high-level evidence to confirm the value of biological graft in LIHR. The purpose of this study is to evaluate the effectiveness of a novel composite biologics in LIHR.

METHODS

A multicenter, single-blinded, randomized controlled clinical trial was designed. Fifty patients with unilateral primary inguinal hernia were randomly assigned to the experimental and control group (1:1). The experimental group was repaired with a non-crosslinked composite extracellular matrix from porcine urinary bladder matrix and small intestinal submucosa (UBM/SIS). The control group was repaired with a lightweight, large-pore, synthetic mesh. The primary endpoint was the effectiveness rate of hernia repair.

RESULTS

The patients were followed up for four years. No significant difference was found between the experimental group and the control group in the effective rate of hernia repair (24/24[100%] vs 21/22[95.45%], RR, 0.4667; 95%CI, 0.3294-2.304; P = 0.4783). There was no fever, seroma, infection, groin pain, foreign body discomfort or recurrence in the experimental group during the follow-up. In the control group, there were 2 cases of seroma 14 days after operation, 1 case of groin discomfort 60 days after operation and one case of recurrence 410 days after surgery.

CONCLUSION

Compared with the lightweight synthetic mesh, the novel UBM/SIS graft has comparable short-term and medium-term effectiveness in LIHR, and the incidence of postoperative complications such as seroma groin discomfort is lower. Trial registration Clinical Trials Registry: ChiCTR1800020173.

Mesh shrinkage after transabdominal preperitoneal inguinal hernia repair

Synthetic mesh is now used for inguinal hernia repair in most cases. It is well known that the indwelling mesh contracts after placement in the body, regardless of the material. The aim of this study was to develop a method for indirect measurement of the mesh area postoperatively that allows for easy comparison with the condition of the mesh immediately after surgery. X-ray-impermeable tackers were used to fix the mesh, and changes of the indwelling mesh after surgery were measured indirectly using two mesh materials. This study involved 26 patients who underwent inguinal hernia repair with a polypropylene or polyester mesh (13 patients each). Polypropylene showed a stronger tendency to shrink, but there was no significant difference between the materials. For both materials, some patients showed relatively strong shrinkage and others showed relatively weak shrinkage. The group with the strong shrinkage had significantly higher body mass index. The results of the present study showed that mesh surly shrinked over time and there was no adverse effect of mesh shrinkage on the patients outcomes in this population. Mesh would shrink over time regardless of the sort of mesh but it did not affect the patients outcomes.

Concurrent Inguinal Hernia Repair During Robot-Assisted Transperitoneal Radical Prostatectomy: Single Center Experience

OBJECTIVE

To evaluate outcomes of concurrent inguinal hernia (IH) repair with mesh during transperitoneal robot-assisted radical prostatectomy (RARP).

MATERIAL AND METHODS

Data of 26 patients (31 procedures) undergoing IH repair concurrently with RARP between January 2017 and January 2020 were evaluated retrospectively. Patients' demographics, intraoperative and postoperative variables were recorded. Patients were assessed based on prostate-specific antigen recurrence, IH recurrence, mesh infection, seroma formation and groin pain quarterly in the first year, and every six month thereafter.

RESULTS

The median age was 64.5 years in our population. IH was detected preoperatively in 46.2% of patients (n = 12) and intraoperatively in 53.8% (n = 14). Twenty-one (80.8%) patients (11 of them had right IH and 10 of them had left IH) had unilateral hernias and 5 patients (19.2%) had bilateral hernias. Twenty-three (88.4%) IHs were direct, three (11.6%) were indirect. The median operative time and estimated blood loss were 192.5 (range: 140-250) min and 100 (range: 10-170) mL, respectively. The median duration of IH repair, time of drainage, length of hospitalization, and catheterization were 32.5 (range: 14-40) min. 2 (range: 2-6) days, 6 (range: 5-8) days and 7 (range: 5-7) days, respectively. No perioperative complication due to RARP or IH repair was observed. During a median follow-up time was 18 months, no scrotal hematoma, seroma formation or mesh infection was identified.

CONCLUSION

IH repair performed during the same session at RARP is a safe and applicable procedure.

Inguinoscrotal hernias containing stomach: risk of emergency presentation

INTRODUCTION

Inguinoscrotal hernias are the commonest form of abdominal wall hernia, but for them to contain stomach is extremely rare. The management of these hernias can be very challenging owing to their acute nature of presentation and distortion of anatomy. Our aim was to systematically review the literature for all reported cases of inguinoscrotal hernias containing stomach. In turn we analysed patient demographics, site of hernia, presentation and treatment. Outcomes were reviewed where available.

METHOD

We conducted a systematic search of the PUBMED, Embase and Medline databases with a combination of keywords: Hernia AND (inguin* OR scrot*) AND (gastric OR gastro*). An author's own case has also been included.

RESULTS

There were 20 case reports included in the review, plus the author's own case. They ranged in publication date from 1942 to 2020. Mean age at presentation was 71 years (range 49 to 87). All cases were male. In total, 62% (n = 13) of cases presented with combined symptoms of abdominal pain and vomiting, 48% (n = 10) presented with gastric outlet obstruction (GOO) and 48% (n = 10) presented with gastric perforation. All successfully treated cases with gastric perforation required a midline laparotomy approach, whereas 56% (n = 5) of patients in the GOO group were successfully treated conservatively. There were three deaths reported in this review, all in the gastric perforation group.

CONCLUSION

Stomach as a content of inguinoscrotal hernias is extremely rare. These hernias predominantly present acutely in the form of GOO or gastric perforation. All patients with gastric perforation will require a midline laparotomy. Patients with GOO can be successfully managed either surgically or in selective cases with conservative management.

Outcomes of 207 totally extraperitoneal hernia repairs using self-fixation mesh

Inguinal hernia (IH) repair is one of the most common procedures in general surgery around the world. Minimizing postoperative acute and chronic pain without increasing recurrence has been a critical point, giving place to different strategies like self-fixation mesh. The current study aimed to describe a group of patients who underwent IH repair by Totally Extraperitoneal (TEP) technique with self-gripping mesh at a fourth level hospital between 2012 and 2019. Retrospective review of a prospectively collected database including patients who underwent laparoscopic TEP approach with self-fixation mesh for IH repair. Follow up data was obtained at 12, 24, 36, 48, and 60 months post surgical intervention. 207 hernia repairs were performed in 142 patients, with a total of 66 patients with bilateral IH. 10.6% required hospitalization due to either concomitant procedure performed or cardiovascular comorbidities, with a mean hospital stay of 1.6 days. Median and late follow up was up to 5 years. 88.9% of patients complete a year, 86% two years, and 36.7% with a 5 year follow-up. IH repair using the TEP technique and self-fixation mesh showed to be an excellent approach, demonstrating satisfactory results in follow up and complications.

Mesh repair for lateral inguinal hernias: a non-evidence-based practice

INTRODUCTION

The EHS clinical guidelines recommend the use of mesh to repair symptomatic primary inguinal hernias (PIH) in adult males but, in spite of this, it begs the question as to why there is still place for tissue techniques. Lack of stratification of patients according to risk of recurrence in RCTs might be a cause of results disparity, since medial and mixed are hernias with higher risk of recurrence (HRRH), whereas lateral hernias present a lower risk (LRRH).

OBJECTIVE

To determine whether the lack of stratification may lead to questionable conclusions regarding the protective effect of mesh techniques and to identify other methodological flaws.

METHODS

In the RCTs included in the clinical guidelines that addressed recurrences of PIH after mesh and non-mesh techniques, we assessed the type of hernias classification used, the number needed to treat in LRRH and HRRH and the statistical power.

RESULTS

Most of trials were underpowered; five studies classified the hernia types; in the three studies that compared the recurrence rates of LRRH and HRRH the effect of mesh techniques was small; only two trials record data needed to calculate the NNT in LRRH (46 y 84 patients, respectively).

CONCLUSION

The idea that mesh techniques reduce the recurrence rate in all PIHs is not supported by high level of evidence. The NNT for pure lateral hernias was very high and should be interpreted taking into account chronic pain rates and costs.

Mesh in Elective Hernia Repair: 10-Year Experience with over 6,000 Patients

BACKGROUND

The use of mesh in hernia repair has faced intense scrutiny, leading patients to become fearful of its use, despite its benefits in reducing hernia recurrence. We report a single institutional experience in performing hernia repair with mesh in terms of hernia-specific outcomes, mesh-related complications, and patient-reported quality of life.

STUDY DESIGN

Patients who underwent abdominal wall hernia repair with mesh at a single institution were identified from a prospectively maintained quality database. Demographic, perioperative, and postoperative outcomes data were analyzed. Surgical Outcomes Measurements System (SOMS) and Carolinas Comfort Scale (CCS) surveys were administered pre- and postoperatively at 3 weeks, 6 months, 1, 2, and 5 years.

RESULTS

Between 2010 and 2020, a total of 6,387 patients underwent abdominal hernia repair with mesh. Inguinal hernia repairs made up the majority (65%) of the operations. Rates of mesh infection varied by hernia type, with lower rates after umbilical (0.0%) and inguinal (0.4%) repair, and highest after incisional repair (1.3%). Similarly, mesh explantation rates were low after umbilical and inguinal repair (0.0% and 0.4%, respectively) and highest after incisional repair (3.0%). Scores on all SOMS domains were significantly improved from baseline (all p < 0.05). On CCS, 2.9%, 3.3%, and 4.4% of patients reported severe or disabling symptoms postoperatively at 1, 2, and 5 years, respectively.

CONCLUSIONS

Rates of mesh-related complications vary by hernia type. A majority of patients report excellent long-term quality of life, although a relatively large percentage of patients experience severe or disabling symptoms at long-term follow-up.

Non-mesh Desarda Technique Versus Standard Mesh-Based Lichtenstein Technique for Inguinal Hernia Repair: A Systematic Review and Meta-analysis

BACKGROUND

The aims of the present systematic review and meta-analysis were to compare non-mesh Desarda technique with standard mesh-based Lichtenstein technique for inguinal hernia repair.

METHODS

A systematic literature search for RCTs comparing between DT and LT was conducted using electronic databases and Google scholar service. Studies were evaluated for recurrence and post-operative complications. We pooled the data using fixed effects model and random effects model after assessing the heterogeneity among the included studies.

RESULTS

A total number of 8 RCTs studies were included in this meta-analysis with total number of 3177 patients divided between Desarda group and Lichtenstein group as follows: 1551 patients and 1,626 patients, respectively. There was no difference in terms of recurrence between the Desarda repair and Lichtenstein repair groups [P = 0.44]. There was a lower rate of overall post-operative complications [P = 0.003], seroma [P = 0.0004] and surgical site infections (SSIs) [P = 0.04] in the Desarda group.

CONCLUSION

DT and LT were found to have comparable results in terms of recurrence rate, haematoma formation, testicular atrophy and time to return to normal daily activity/work. DT is superior to LT in terms of reducing post-operative mesh-attributed complications, such as SSI and Seroma formation.

Short- and Long-Term Outcomes of Transabdominal Preperitoneal, Open Mesh Plug and Open Tissue Inguinal Hernia Repair

BACKGROUND

There have been few comparisons of the postoperative outcomes of transabdominal preperitoneal (TAPP), open mesh plug (mesh plug) and open tissue (tissue) hernia repair. The objectives of this study were to compare these repair methods.

METHODS

This was a retrospective study of 1813 inguinal hernia patients between January 2008 and December 2016. Of these patients, 474 underwent TAPP repair, 1293 underwent mesh plug repair, and 46 underwent tissue repair. The short-term and long-term outcomes determined by questionnaire were compared among the three groups. In addition, risk factors for patient dissatisfaction were assessed.

RESULTS

In the TAPP group, the postoperative complications rate was the lowest at 4.6% (7.4% and 6.5% in the mesh plug and the tissue groups, respectively, P = 0.07), and recurrence rate was lower compared to the mesh plug group (0.8% vs. 3.3%, P = 0.002). As long-term outcomes, 92%, 88% and 75% of patients were satisfied in the TAPP, mesh plug and tissue groups, respectively (P = 0.03). The rate of patients with numbness was 3.1% in the TAPP group, 5.2% in the mesh plug group and 14% in the tissue group (P = 0.04). Predictive independent risk factors for patient dissatisfaction were complications (OR: 3.99, 95% CI: 1.35-11.8, P = 0.012) and infection (OR: 16.9, 95% CI: 1.25-229, P = 0.003).

CONCLUSIONS

TAPP repair is superior to mesh plug and tissue repairs in terms of complications, satisfaction and numbness, as determined by questionnaire. Complications and infection were independently associated with the patient dissatisfaction.

Postoperative Quality of Life after Open Transinguinal Preperitoneal Inguinal Hernia Repair Using Memory Ring or Three-dimensional Devices

A transinguinal preperitoneal (TIPP) approach has become a common technique for inguinal hernia repair. Our goal was to compare the impact of the two mesh designs for this operation: a flat mesh with a memory ring device (MRD) or a three-dimensional device (3DD) containing both onlay and preperitoneal mesh components. The prospective International Hernia Mesh Registry (2007 to 2012) was queried for MRD and 3DD inguinal hernia repairs. Outcomes and patient quality of life (QOL), using the Carolinas Comfort Scale (CCS), were examined at 1, 6, 12, and 24 months. Standard statistical methods were used, and multivariate logistic regression was performed using a forward stepwise selection method. TIPP was performed in 956 patients. Their average age 57.4 ± 15.3 years, 94.0 per cent were male, and mean body mass index was 25.7 ± 3.2 kg/m2. MRD was used in 131 and 3DD in 825. Follow-up was 97, 82, 87, and 80 per cent at 1, 6, 12, and 24 months, respectively. Complications were not significantly different ( P > 0.05). Recurrence was 0.8 per cent for MRD and 2.1 per cent for 3DD ( P = 0.45). Comparing patient outcomes of MRD with 3DD at 1 month, 18.9 versus 11.5 per cent had symptoms of mesh sensation ( P = 0.02); 28.7 versus 14.8 per cent had movement limitations ( P < 0.01). MRD use was a significant independent predictor of movement limitation (odds ratio, 2.3; confidence interval, 1.4 to 3.7). No significant differences in CCS scores were seen at 6, 12, and 24 months. TIPP repair is safe and has a low recurrence rate. Early postoperative QOL is significantly improved with a 3DD mesh compared with MRD.

Prospective, multicenter, pairwise analysis of robotic-assisted inguinal hernia repair with open and laparoscopic inguinal hernia repair: early results from the Prospective Hernia Study

PURPOSE

To evaluate and compare peri-operative outcomes through 30 days, including pain and quality of life (QOL) through 3 months across three cohorts of inguinal hernia repair (IHR) patients (robotic-assisted, laparoscopic, and open IHR).

METHODS

The Prospective Hernia Study is an ongoing, multicenter, comparative, open-label analysis of clinical and patient-reported outcomes from robotic-assisted surgery (RAS) versus open and RAS versus laparoscopic IHR procedures. Patient responses to the Carolinas Comfort Scale (CCS) questionnaire provided QOL outcomes.

RESULTS

504 enrolled patients underwent unilateral or bilateral IHR (RAS, n = 159; open, n = 190; laparoscopic, n = 155) at 17 medical institutions from May 2016 through December 2018. Propensity score matching provided a balanced comparison: RAS versus open (n = 112 each) and RAS versus laparoscopic (n = 80 each). Overall, operative times were significantly different between the RAS and laparoscopic cases (83 vs. 65 min; p < 0.001). Fewer RAS patients required prescription pain medication than either open (49.5% vs. 80.0%; p < 0.001) or laparoscopic patients (45.3% vs. 65.4%; p = 0.013). Median number of prescription pain pills taken differed for RAS vs. open (0.5 vs. 15.5; p = 0.001) and were comparable for RAS vs laparoscopic (7.0 vs. 6.0; p = 0.482) among patients taking prescribed pain medication. Time to return to normal activities differed for RAS vs. open (3 vs. 4 days; p = 0.005) and were comparable for RAS vs. laparoscopic (4 vs. 4 days; p = 0.657). Median CCS scores through 3 months were comparable for the three approaches. Postoperative complication rates for the three groups also were comparable. One laparoscopic case was converted to open.

CONCLUSION

This study demonstrates that IHR can be performed effectively with the robotic-assisted, laparoscopic, or open approaches. There was no difference in the median number of prescription pain medication pills taken between the RAS and laparoscopic groups. A difference was observed in the overall number of patients reporting the need to take prescription pain medication. Comparable operative times were observed for RAS unilateral IHR patients compared to open unilateral IHR patients; however, operative times for RAS overall and bilateral subjects were longer than for open patients. Operative times were longer overall for RAS patients compared to laparoscopic patients; however, there was no difference in conversion and complication rate in the RAS vs. laparoscopic groups or the complication rate in the RAS vs. open group. Time to return to normal activities for RAS IHR patients was comparable to that of laparoscopically repaired patients and significantly sooner compared to open IHR patients.

Network meta-analysis of urinary retention and mortality after Lichtenstein repair of inguinal hernia under local, regional or general anaesthesia

BACKGROUND

Urinary retention and mortality after open repair of inguinal hernia may depend on the type of anaesthesia. The aim of this study was to investigate possible differences in urinary retention and mortality in adults after Lichtenstein repair under different types of anaesthesia.

METHODS

Systematic searches were conducted in the Cochrane, PubMed and Embase databases, with the last search on 1 August 2018. Eligible studies included adult patients having elective unilateral inguinal hernia repair by the Lichtenstein technique under local, regional or general anaesthesia. Outcomes were urinary retention and mortality, which were compared between the three types of anaesthesia using meta-analyses and a network meta-analysis.

RESULTS

In total, 53 studies covering 11 683 patients were included. Crude rates of urinary retention were 0·1 (95 per cent c.i. 0 to 0·2) per cent for local anaesthesia, 8·6 (6·6 to 10·5) per cent for regional anaesthesia and 1·4 (0·6 to 2·2) per cent for general anaesthesia. No death related to the type of anaesthesia was reported. The network meta-analysis showed a higher risk of urinary retention after both regional (odds ratio (OR) 15·73, 95 per cent c.i. 5·85 to 42·32; P < 0·001) and general (OR 4·07, 1·07 to 15·48; P = 0·040) anaesthesia compared with local anaesthesia, and a higher risk after regional compared with general anaesthesia (OR 3·87, 1·10 to 13·60; P = 0·035). Meta-analyses showed a higher risk of urinary retention after regional compared with local anaesthesia (P < 0·001), but no difference between general and local anaesthesia (P = 0·08).

CONCLUSION

Local or general anaesthesia had significantly lower risks of urinary retention than regional anaesthesia. Differences in mortality could not be assessed as there were no deaths after elective Lichtenstein repair. Registration number: CRD42018087115 ( https://www.crd.york.ac.uk/prospero).

Resistance of Synthetic and Biologic Surgical Meshes to Methicillin-Resistant Staphylococcus aureus Biofilm: An In Vitro Investigation

Surgical meshes have become the standard procedure for a variety of surgical applications with 20 million meshes being implanted each year. The popularity of mesh usage among surgeons is backed by the multiple studies that support its functionality as a tool for improving surgical outcomes. However, their use has also been associated with infectious surgical complications and many surgeons have turned to biologic meshes. While there have been several studies investigating synthetic meshes, there is limited data comparing synthetic and biologic meshes in vitro in an infection model. This study evaluates the in vitro susceptibility of both synthetic and biologic meshes to single-species methicillin-resistant Staphylococcus aureus (MRSA) biofilms. This research compares biofilm biomass, average thickness, and coverage between the three meshes through florescent in situ hybridization (FISH), confocal scanning microscopy (CSLM), and image analysis. We also report the varying levels of planktonic and attached bacteria through sonication and cfu counts. While the data illustrates increased biofilm formation on biologic mesh in vitro, the study must further be investigated in vivo to confirm the study observations.

The Use of Prosthetic Mesh in the Emergency Management of Acute Incarcerated Inguinal Hernias

INTRODUCTION

Tension-free hernia repair has been regarded as a gold standard treatment for selected inguinal hernias, but the use of prosthetic mesh in acute incarcerated inguinal hernias is controversial. Our study focused on evaluating the safety and efficacy of the prosthetic mesh repair for emergency cases.

METHODS

Patients with acute incarcerated inguinal hernias who underwent emergency prosthetic mesh repair during 2009 to 2014 at our department were included. Patient characteristics, operative approaches and results, and complications were retrospectively analyzed.

RESULTS

A total of 167 patients were included in our study. One hundred and twenty-two patients underwent open surgery while the remaining 45 patients underwent transabdominal preperitoneal laparoscopic approach. The hernia was indirect inguinal in 133 patients (79.6%), direct inguinal in 15 patients (9.0%), and femoral in 19 patients (11.4%). The overall wound infection rate of these patients was 3%. Nonviable intestinal resection was performed in 25 patients (8.4%), only 2 of whom underwent wound infection. Another 3 patients who developed wound infection had viable hernia content. There was no mesh-related infection. There was no statistically significant difference in wound infection rates between patients with viable hernia contents and those with nonviable contents ( P < .05).

CONCLUSION

The use of the prosthetic mesh in the treatment of acute incarcerated inguinal hernia is safe and effective. Nonviable intestinal resection cannot be regarded as a contradiction of the mesh repair.

Open darn repair vs open mesh repair of inguinal hernia: a systematic review and meta-analysis of randomised and non-randomised studies

OBJECTIVES

To compare the outcomes of open darn repair vs open mesh repair in patients undergoing inguinal hernia repair.

METHODS

We performed a systematic review and conducted a search of electronic information sources to identify all observational studies and randomised controlled trials (RCTs) investigating outcomes of open darn repair vs open mesh repair for inguinal hernias. Hernia recurrence was considered as the primary outcome measure. The secondary outcome measures included surgical site infection (SSI), haematoma, seroma, neuralgia, urinary retention, length of hospital stay, time to return to normal activities or work, testicular atrophy, operative time and chronic pain. Random or fixed effects modelling was applied to calculate pooled outcome data.

RESULTS

Six RCTs, enrolling 1480 patients with 1485 hernias, and 4 observational studies, enrolling 1564 patients with 1641 hernias, were included. Meta-analysis of RCTs showed no significant difference in terms of recurrence (RD 0.00, 95% CI - 0.01 to 0.01, P = 0.86), SSI (OR 0.83, 95% CI 0.46-1.49, P = 0.52), haematoma (OR 1.21, 95% CI 0.62-2.38, P = 0.57), seroma (OR 0.83, 95% CI 0.42-1.65, P = 0.60), neuralgia (OR 1.05, 95% CI 0.29-3.73, P = 0.94), urinary retention (OR 1.44, 95% CI 0.64-3.21, P = 0.38), length of hospital stay (MD 0.09, 95% CI - 0.28 to 0.46, P = 0.63), time to return to normal activities or work (MD 0.88, 95% CI - 0.90 to 2.66, P = 0.33), testicular atrophy (RD 0.00, 95% CI - 0.02 to 0.02, P = 1.00), and operative time (MD 2.69, 95% CI - 1.75 to 7.14, P = 0.62) between the darn repair and mesh repair groups. Meta-analysis of observational studies also showed no significant difference in terms of recurrence (RD 0.00, 95% CI - 0.02 to 0.02, P = 0.99), SSI (OR 0.47, 95% CI 0.14-1.62, P = 0.23), haematoma (OR 1.07, 95% CI 0.45-2.55, P = 0.89), seroma (OR 0.12, 95% CI 0.01-2.27, P = 0.16), neuralgia (OR 0.25, 95% CI 0.05-1.21, P = 0.08), urinary retention (OR 1.53, 95% CI 0.20-11.96, P = 0.69), time to return to normal activities or work (MD 2.13, 95% CI - 2.18 to 6.44, P = 0.33), testicular atrophy (RD - 0.01, 95% CI - 0.02 to 0.01, P = 0.49), and operative time (MD - 4.76, 95% CI - 13.23 to 3.71, P = 0.27) between the two groups. The evidence was inconclusive for chronic pain. The quality of available evidence was moderate.

CONCLUSIONS

Our results suggest that open darn repair is comparable with open mesh repair for inguinal hernias. Considering that consequences of mesh complications in inguinal hernia repair, albeit rare, can be significant, open darn repair provides an equally credible alternative to open mesh repair for inguinal hernias. Further studies are required to investigate patient-reported outcomes and to elicit a superior non-mesh technique.

Outcome of the "Manchester Groin Repair" (Laparoscopic Totally Extraperitoneal Approach With Fibrin Sealant Mesh Fixation) in 434 Consecutive Inguinal Hernia Repairs

Introduction: This study looks at the outcome of 352 patients that underwent the "Manchester groin repair" in the period from 2007 to 2016. The effect of laterality on chronic groin pain and the reduction of pain scores post-surgery are evaluated as well as the rate of hernia recurrence for the inguinal hernia repairs. Methods: The "Manchester groin repair" is a modification of a laparoscopic totally extra-peritoneal approach with fibrin sealant mesh fixation. Data were collected prospectively. In addition to demographic data and the European Hernia Society classification grading of each hernia, pain scores were assessed prior to surgery and at 4-6 weeks post-operatively using a ten-point visual analog pain scale. Data were collected on a bespoke database and differences between time-points analyzed by non-parametric Wilcoxon signed rank tests with Kruskal-Wallis rank sum test for three-group comparisons. Significance was at the P < 0.05 level. The study was undertaken as an institutional audit. Results: Three hundred and fifty two patients underwent TEP repair as per the "Manchester Groin Repair" modification during the period of interest with a median follow-up period of 109.5 (IQR 57.0-318.5) weeks. Of these 274 (77.8%) were for the repair of true hernias and 78 (22.2%) were for inguinal disruptions. All inguinal hernia repairs patients were evaluated (254 m, 20 f); median [interquartile range] age 50 (39-65) years. There were 75 right inguinal hernias (27.4%), 39 Left inguinal hernias (14.2%), and 160 bilateral inguinal hernias (58.4%), giving a total of 434 hernia repairs. During follow-up there were 6 recurrences (1.4%).Of the 274 patients evaluated, 145 (52.9%) had both pre and post-operative pain scores available. Median pre-operative pain score was 5 [IQR 4-7]. Median post-operative pain score was 1 [IQR 1-2]. This difference was significant (P < 0.001). Pre-operative pain scores were higher for those with a bilateral hernia (median 6 vs. 5 and 4, respectively; P = 0.005), but there was no difference in post-operative scores (P = 0.347). One patient (0.3%) presented with chronic groin pain (pain after 3 months). Conclusion: This study demonstrates that the "Manchester groin repair" provides an excellent repair with a low rate of recurrence and low incidence of chronic pain. Longer-term evaluation and larger patient series will add to the understanding of the role of this procedure in groin hernia repair.

Mesh versus non-mesh for inguinal and femoral hernia repair

BACKGROUND

This is an update of a Cochrane Review first published in 2001.Hernias are protrusions of all or part of an organ through the body wall that normally contains it. Groin hernias include inguinal (96%) and femoral (4%) hernias, and are often symptomatic with discomfort. They are extremely common, with an estimated lifetime risk in men of 27%. Occasionally they may present as emergencies with complications such as bowel incarceration, obstruction and strangulation. The definitive treatment of all hernias is surgical repair, inguinal hernia repair being one of the most common surgical procedures performed. Mesh (hernioplasty) and the traditional non-mesh repairs (herniorrhaphy) are commonly used, with an increasing preference towards mesh repairs in high-income countries.

OBJECTIVES

To evaluate the benefits and harms of different inguinal and femoral hernia repair techniques in adults, specifically comparing closure with mesh versus without mesh. Outcomes include hernia recurrence, complications (including neurovascular or visceral injury, haematoma, seroma, testicular injury, infection, postoperative pain), mortality, duration of operation, postoperative hospital stay and time to return to activities of daily living.

SEARCH METHODS

We searched the following databases on 9 May 2018: Cochrane Colorectal Cancer Group Specialized Register, Cochrane Central Register of Controlled Trials (Issue 1), Ovid MEDLINE (from 1950), Ovid Embase (from 1974) and Web of Science (from 1900). Furthermore, we checked the WHO International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov for trials. We applied no language or publication restrictions. We also searched the reference lists of included trials and review articles.

SELECTION CRITERIA

We included randomised controlled trials of mesh compared to non-mesh inguinal or femoral hernia repairs in adults over the age of 18 years.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Where available, we collected information on adverse effects. We presented dichotomous data as risk ratios, and where possible we calculated the number needed to treat for an additional beneficial outcome (NNTB). We presented continuous data as mean difference. Analysis of missing data was based on intention-to-treat principles, and we assessed heterogeneity using an evaluation of clinical and methodological diversity, Chi² test and I² statistic. We used GRADE to assess the quality of evidence for each outcome.

MAIN RESULTS

We included 25 studies (6293 participants) in this review. All included studies specified inguinal hernias, and two studies reported that femoral hernias were included.Mesh repair probably reduces the risk of hernia recurrence compared to non-mesh repair (21 studies, 5575 participants; RR 0.46, 95% CI 0.26 to 0.80, I² = 44%, moderate-quality evidence). In absolute numbers, one hernia recurrence was prevented for every 46 mesh repairs compared with non-mesh repairs. Twenty-four studies (6293 participants) assessed a wide range of complications with varying follow-up times. Neurovascular and visceral injuries were more common in non-mesh repair groups (RR 0.61, 95% CI 0.49 to 0.76, I² = 0%, NNTB = 22, high-quality evidence). Wound infection was found slightly more commonly in the mesh group (20 studies, 4540 participants; RR 1.29, 95% CI 0.89 to 1.86, I² = 0%, NNTB = 200, low-quality evidence). Mesh repair reduced the risk of haematoma compared to non-mesh repair (15 studies, 3773 participants; RR 0.88, 95% CI 0.68 to 1.13, I² = 0%, NNTB = 143, low-quality evidence). Seromas probably occur more frequently with mesh repair than with non-mesh repair (14 studies, 2640 participants; RR 1.63, 95% CI 1.03 to 2.59, I² = 0%, NNTB = 72, moderate-quality evidence), as does wound swelling (two studies, 388 participants; RR 4.56, 95% CI 1.02 to 20.48, I² = 33%, NNTB = 72, moderate-quality evidence). The comparative effect on wound dehiscence is uncertain due to wide confidence intervals (two studies, 329 participants; RR 0.55, 95% CI 0.12 to 2.48, I² = 37% NNTB = 77, low-quality evidence). Testicular complications showed nearly equivocal results; they probably occurred slightly more often in the mesh group however the confidence interval around the effect was wide (14 studies, 3741 participants; RR 1.06, 95% CI 0.63 to 1.76, I² = 0%, NNTB = 2000, low-quality evidence). Mesh reduced the risk of postoperative urinary retention compared to non-mesh (eight studies, 1539 participants; RR 0.53, 95% CI 0.38 to 0.73, I² = 56%, NNTB = 16, moderate-quality evidence).Postoperative and chronic pain could not be compared due to variations in measurement methods and follow-up time (low-quality evidence).No deaths occurred during the follow-up periods reported in the seven studies (2546 participants) reporting this outcome (high-quality evidence).The average operating time was longer for non-mesh repairs by a mean of 4 minutes 22 seconds, despite wide variation across the studies regarding size and direction of effect, thus this result is uncertain (20 studies, 4148 participants; 95% CI -6.85 to -1.60, I²= 97%, very low-quality evidence). Hospital stay may be shorter with mesh repair, by 0.6 days (12 studies, 2966 participants; 95% CI -0.86 to -0.34, I² = 98%, low-quality evidence), and participants undergoing mesh repairs may return to normal activities of daily living a mean of 2.87 days sooner than those with non-mesh repair (10 studies, 3183 participants; 95% CI -4.42 to -1.32, I² = 96%, low-quality evidence), although the results of both these outcomes are also limited by wide variation in the size and direction of effect across the studies.

AUTHORS' CONCLUSIONS

Mesh and non-mesh repairs are effective surgical approaches in treating hernias, each demonstrating benefits in different areas. Compared to non-mesh repairs, mesh repairs probably reduce the rate of hernia recurrence, and reduce visceral or neurovascular injuries, making mesh repair a common repair approach. Mesh repairs may result in a reduced length of hospital stay and time to return to activities of daily living, but these results are uncertain due to variation in the results of the studies. Non-mesh repair is less likely to cause seroma formation and has been favoured in low-income countries due to low cost and reduced availability of mesh materials. Risk of bias in the included studies was low to moderate and generally handled well by study authors, with attention to details of allocation, blinding, attrition and reporting.

Chronic pain after mesh versus nonmesh repair of inguinal hernias: A systematic review and a network meta-analysis of randomized controlled trials

BACKGROUND

Chronic pain affects 10%-12% of patients after inguinal hernia repairs. Some have suggested that less foreign material may theoretically prevent pain. If the prevalence of chronic pain is less after nonmesh repairs, selected hernias might be repaired without mesh. Our aim was to clarify if nonmesh repairs are superior to mesh repairs regarding chronic pain.

METHODS

For this systematic review, searches were conducted in five databases. The main outcome was chronic pain reported a minimum of six months after mesh and nonmesh repair in adult patients with a primary inguinal hernia. Only randomized controlled trials (RCTs) were included.

RESULTS

A total of 23 RCTs with 5,444 patients were included. The median follow up was 1.4 years (range 0.5-10). Twenty-one studies reported crude chronic pain rates, and when considering moderate and severe pain, the prevalences of pain after nonmesh repairs and mesh repairs were similar: median 3.5% (0%-16.2%) versus median 2.9% (0%-27.6%), respectively. Both the meta-analyses and the network meta-analysis indicated no difference in chronic pain rates when comparing nonmesh repairs with open- and laparoscopic mesh repairs.

CONCLUSION

Mesh may be used without fear of causing a greater rate of chronic pain.

Mesh versus suture repair of umbilical hernia in adults: a randomised, double-blind, controlled, multicentre trial

BACKGROUND

Both mesh and suture repair are used for the treatment of umbilical hernias, but for smaller umbilical hernias (diameter 1-4 cm) there is little evidence whether mesh repair would be beneficial. In this study we aimed to investigate whether use of a mesh was better in reducing recurrence compared with suture repair for smaller umbilical hernias.

METHODS

We did a randomised, double-blind, controlled multicentre trial in 12 hospitals (nine in the Netherlands, two in Germany, and one in Italy). Eligible participants were adults aged at least 18 years with a primary umbilical hernia of diameter 1-4 cm, and were randomly assigned (1:1) intraoperatively to either suture repair or mesh repair. In the first 3 years of the inclusion period, blocked randomisation (of non-specified size) was achieved by an envelope randomisation system; after this time computer-generated randomisation was introduced. Patients, investigators, and analysts were masked to the allocated treatment, and participants were stratified by hernia size (1-2 cm and >2-4 cm). At study initiation, all surgeons were invited to training sessions to ensure they used the same standardised techniques for suture repair or mesh repair. Patients underwent physical examinations at 2 weeks, and 3, 12, and 24-30 months after the operation. The primary outcome was the rate of recurrences of the umbilical hernia after 24 months assessed in the modified intention-to-treat population by physical examination and, in case of any doubt, abdominal ultrasound. This trial is registered with ClinicalTrials.gov, number NCT00789230.

FINDINGS

Between June 21, 2006, and April 16, 2014, we randomly assigned 300 patients, 150 to mesh repair and 150 to suture repair. The median follow-up was 25·1 months (IQR 15·5-33·4). After a maximum follow-up of 30 months, there were fewer recurrences in the mesh group than in the suture group (six [4%] in 146 patients vs 17 [12%] in 138 patients; 2-year actuarial estimates of recurrence 3·6% [95% CI 1·4-9·4] vs 11·4% (6·8-18·9); p=0·01, hazard ratio 0·31, 95% CI 0·12-0·80, corresponding to a number needed to treat of 12·8). The most common postoperative complications were seroma (one [<1%] in the suture group vs five [3%] in the mesh group), haematoma (two [1%] vs three [2%]), and wound infection (one [<1%] vs three [2%]). There were no anaesthetic complications or postoperative deaths.

INTERPRETATION

This is the first study showing high level evidence for mesh repair in patients with small hernias of diameter 1-4 cm. Hence we suggest mesh repair should be used for operations on all patients with an umbilical hernia of this size.

FUNDING

Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands.

Prosthetic Mesh Repair in the Emergency Management of Acutely Strangulated Groin Hernias with Grade I Bowel Necrosis: A Rational Choice

The aim of this study was to determine the feasibility of prosthetic mesh repair according to the degree of bowel necrosis in the emergency management of acutely strangulated groin hernias. Emergency prosthetic mesh repair versus primary suture repair was randomly performed in 208 consecutive strangulated groin hernia patients with bowel necrosis between January 2005 and August 2016. The degree of bowel necrosis of each patient was determined according to a modified three-grade classification system. Patient characteristics sorted by repair method were analyzed by using Pearson's chi-squared tests. Correlations between mortality and wound-related morbidity with bowel necrosis grade and repair method were analyzed. There was no difference in gender, age, body mass index, comorbid diseases, hernia type (left or right, primary or recurrent), necrosis grade, and mortality between the mesh repair and suture repair groups (all P > 0.05). However, with regard to wound-related morbidity, there was significant difference between the two groups ( P < 0.05). Mortality and wound-related morbidity showed significant relationship with necrosis grade, especially with regard to postoperative wound infection ( P < 0.001). The wound infection rate with mesh repair was significantly higher than that with primary suture in Grade II and III necrosis patients ( P < 0.05), but there was no difference in Grade I patients ( P > 0.05). The use of prosthetic mesh in the emergency repair of acutely strangulated groin hernias seems to be as safe as suture-only repair in patients with noninfected strangulated bowel (Grade I necrosis). The use of prosthetic mesh repair is a rational choice made based on the degree of bowel necrosis in the emergency management of acutely strangulated hernias.

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.

Hernioplasty with and without mesh: analysis of the immediate complications in a randomized controlled clinical trial

Background:

Inguinal hernia repair is the most common procedure in general surgery and 80,000 operations are performed annually in Great Britain, 100,000 in France and 700,000 in the US. Given its high frequency has a major impact, both in the medical and economic aspects.

Aim:

Analyze the immediate postoperative complications comparing mesh versus non mesh hernioplasty.

Method:

Randomized control trial, with the enrollment of 263 patients underwent surgery for inguinal hernia randomized by randomization table. Treatment (mesh, Lichtenstein or without mesh, Bassini technique) was assigned using sequentially numbered opaque envelopes having fulfilled the inclusion criteria. The variables analyzed were: postoperative pain, seroma, hematoma, infection, return to normal activities and recurrence.

Results:

The mean age was 55.5 years, 88% patients were male and 12% female. The pain was higher in patients operated with mesh.

Conclusions:

The inguinal hernia repair mesh group had less immediate postoperative complications and significantly earlier return to work than hernioplasty without mesh, this being one of the most important conclusions.

Is the ligation of hernial sac necessary in herniotomy for children? A randomized controlled trial of evaluating surgical complications and duration

BACKGROUND

Herniotomy is a common operation done by pediatric surgeons. Recent studies have shown that high ligation in herniation in adult is not necessary, but this method was not fully evaluated in children. We compared non-ligation with high-ligation sac in herniotomy in terms of surgical complications and duration.

MATERIALS AND METHODS

This randomized controlled trial study was done on 104 children with inguinal hernia at Al-Zahra Hospital, Isfahan, Iran, between 2011 and 2013. Patients were equally randomized to undergo herniotomy with ligation of sac at the internal ring level or to undergo herniotomy without sac ligation. Patients were followed up just after the operation, and in the 1(st), 6(th), and 12(th) weeks postoperation to discover early (scrotal hematoma, edema, wound infection, and postoperation fever) and late (adhesion and recurrence) complications. Also, duration of operation was recorded for each group.

RESULTS

The incidence of early complications (nine cases in high-ligation and eight cases in non-ligation group) was the same in both groups (P = 0.402). No late complication was observed in any group. The mean duration of operation in high-ligation group (18.84 ± 5.47 min) was significantly shorter than non-ligation group (21.46 ± 9.03 min) (P < 0.001).

CONCLUSION

Complications are the same in herniotomy with or without ligation of the sac, but the duration of the non-ligation procedure is shorter than that of high-ligation. We suggest that herniotomy without sac ligation in children be the procedure of choice to save time and also to prevent any other possible complications such as nerve damage, spermatic cord injury, or peritoneal tearing.

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.

Clinical Implantation with the novel D-13 prosthesis for inguinal hernioplasty: A retrospective cohort study

INTRODUCTION

Using a mesh to repair inguinal hernias is now a standard procedure that is widely accepted as superior to primary suture repair. Although a variety of meshes are available, individual meshes may have their own unattractive features. This retrospective study examines the efficacy of our originally designed D-13 prosthesis, which is used in patients with inguinal hernias.

METHODS

A total of 305 patients who underwent a herniorrhaphy between January 2009 and March 2011 were included in this study. The recurrent rate, chronic pain and feeling of a foreign body were examined at a 3-year follow-up. The D-13 prosthesis, made from clear polypropylene monofilament mesh, was originally designed by the first author of this study and constructed with the upper and lower pieces of polypropylene mesh having different shapes and sizes. Both pieces are linked together by a connector.

RESULTS

The mesh is well tolerated. At a 3-year follow-up, only two patients had a foreign body sensation at the operative site, and three patients had recurrent hernias.

CONCLUSION

The unique design of the D-13 prosthesis with two pieces of mesh provided encouraging long-term outcome for hernia recurrence, chronic pain and the feeling of a foreign body.

Intrasaccular caecal adenocarcinoma presenting as enlarging right inguinoscrotal hernia

INTRODUCTION

Colorectal cancer and inguinal hernias are both common surgical pathologies in the elderly but rarely co-exist. Where the conditions overlap, there can be difficulties in both diagnosis and treatment.

PRESENTATION OF CASE

A 78 year old man with unexplained iron deficiency anaemia was investigated for gastrointestinal cancer. He was found to have enlarging bilateral inguinoscrotal hernias. CT colonoscopy revealed a herniated caecal carcinoma contained within the scrotum. An open excision was performed.

DISCUSSION

Iron deficiency anaemia without obvious bleeding is associated with colorectal cancer and should be thoroughly investigated. Asymptomatic inguinal hernias are often ignored by patients. However, a change in an existing hernia may be associated with neoplasia.

CONCLUSION

Dual pathology raises new difficulties in assessment, investigation and management of colorectal cancer.

Schley's inguinal hernia repair: a single unit's experience of a forgotten technique

BACKGROUND

This study was done to assess the effectiveness of Schley's inguinal hernia repair. It is a retrospective study analysing the outcome of patients who received the said technique over a period of 1 year at our institution. The minimum and the maximum follow-up periods were 2 and 3 years.

METHOD

The patients who underwent the above technique in 2011 were reviewed retrospectively in December 2013 by going through the hospital records and examining the patients in person.

RESULTS

105 patients had undergone surgery in 2011. The majority of them had right-sided hernias and were in 40-59 age group. Two cases of wound infection, one case of haematocele and one hernia recurrence were noted. Operating on the recurrent hernia was straightforward.

CONCLUSION

Schley's inguinal hernia repair is an effective technique with favourable outcome.

Reduced postoperative chronic pain after tension-free inguinal hernia repair using absorbable sutures: a single-blind randomized clinical trial

BACKGROUND

Chronic pain after inguinal hernia repair occurs in 16% to 62% of patients. The underlying mechanism probably involves sensory nerve damage and abnormal healing that might be influenced by the materials chosen for the procedure. We hypothesize that nonabsorbable sutures used for mesh fixation to the surrounding tissues are associated with higher rates of chronic groin pain after surgery.

STUDY DESIGN

We conducted a single-blind randomized clinical trial to compare the effect of absorbable braided sutures (Vycril; Ethicon) and nonabsorbable monofilament sutures (Prolene; Ethicon) used in inguinal hernia repair on the rate of chronic pain. We assessed chronic pain using a 4-point verbal-rank scale during a 1-year postoperative follow-up period.

RESULTS

Study groups included 100 patients in each group. No age, sex, or hernia-side differences were observed between the study groups. Chronic pain rate after surgery was higher in the nonabsorbable monofilament suture group compared with the absorbable braided suture group (37 vs 26 patients; p = 0.056). Time to pain disappearance was longer in the nonabsorbable monofilament suture vs the absorbable braided suture group (115.3 days; 95% CI, 88-142.7 vs 77.4 days; 95% CI, 54.3-100.3; p = 0.038, respectively). A 1-year age increment reduces the risk for chronic pain occurrence by 2.2% (odds ratio = 0.978%; 95% CI, 0.961-0.995; p = 0.013). The use of nonabsorbable sutures increases the risk for chronic pain in 94.9% compared with absorbable sutures (odds ratio = 1.949; 95% CI, 1.039-3.658; p = 0.038).

CONCLUSIONS

Nonabsorbable suture use in inguinal hernia repair is associated with a higher rate of chronic pain and a longer time to pain disappearance as compared with absorbable sutures.

Porcine incisional hernia model: Evaluation of biologically derived intact extracellular matrix repairs

We compared fascial wounds repaired with non-cross-linked intact porcine-derived acellular dermal matrix versus primary closure in a large-animal hernia model. Incisional hernias were created in Yucatan pigs and repaired after 3 weeks via open technique with suture-only primary closure or intraperitoneally placed porcine-derived acellular dermal matrix. Progressive changes in mechanical and biological properties of porcine-derived acellular dermal matrix and repair sites were assessed. Porcine-derived acellular dermal matrix–repaired hernias of additional animals were evaluated 2 and 4 weeks post incision to assess porcine-derived acellular dermal matrix regenerative potential and biomechanical changes. Hernias repaired with primary closure showed substantially more scarring and bone hyperplasia along the incision line. Mechanical remodeling of porcine-derived acellular dermal matrix was noted over time. Porcine-derived acellular dermal matrix elastic modulus and ultimate tensile stress were similar to fascia at 6 weeks. The biology of porcine-derived acellular dermal matrix–reinforced animals was more similar to native abdominal wall versus that with primary closure. In this study, porcine-derived acellular dermal matrix–reinforced repairs provided more complete wound healing response compared with primary closure.

Conservative management of an infected laparoscopic hernia mesh: A case study

INTRODUCTION

A dreaded complication of laparoscopic hernia repair is infection of the mesh. Traditionally mesh infection is managed by surgical removal of the mesh, an extensive procedure resulting in high re-herniation rates. A technique to treat such infections whilst salvaging the mesh is sorely needed. We describe a case in which a laparoscopic mesh infection was treated solely with drainage, parenteral antibiotics and antibiotic irrigation of the mesh.

PRESENTATION OF CASE

A 65 year old gentleman presented 11 months post laparoscopic repair of an inguinal hernia with malaise and an uncomfortable groin swelling. Computed tomography scanning revealed a collection surrounding the mesh which was drained and cultured to show heavy growth of Staphylococcus aureus. A pigtail drain on continuous drainage was inserted and kept in situ for 7 weeks.

The patient received one week of intravenous flucloxacillin and two gentamycin irrigations through the drain as an inpatient. He then received 6 weeks of oral flucloxacillin and bi-weekly saline flushes through the drain in the community. By 12 weeks an ultrasound scan showed resolution of the collection. At 7 months he remains clinically free from recurrence.

DISCUSSION

Here we report a novel conservative method used to treat a hernia mesh infection, preserve the mesh and avoid major surgery. Other reports exist suggesting variations in conservative methods to treat mesh infections, however ours is by far the most conservative.

CONCLUSION

Clearly, further research is required to identify which method is most effective and in which patients it is likely to be successful.

Meshless treatment of open inguinal hernia repair: a prospective study

Objective:

To evaluate two types of meshless open inguinal repair and to evaluate the recurrence rate.

Methods:

We operated on sequentially 98 men and 15 women with 144 unilateral or bilateral inguinal hernias between December 1988 and April 2007. The surgeries were performed by two experienced surgeons and divided into two groups: Bassini or McVay reconstructive surgery techniques. Bassini type reinforcements were employed for Nyhus II and IIIB with minor destruction of the posterior wall. Patients with Nyhus type IIIA, type IIIB with major destruction of the fascia transversalis, and type IIIC were subjected to the McVay technique.

Results:

Seventy-five hernias were corrected using the McVay technique. Only two recurrences (2.67%) were observed in this group. For group Bassini, two recurrences for 69 hernias (2.89%) were observed (p=0.658). Mean age for the recurrent group was 56 years. No differences were observed between the ages of males and females (52 years).

Conclusions:

Non-mesh repair in inguinal hernia can be safely used if performed by experienced surgeons.

Outcome of the patients with chronic mesh infection following open inguinal hernia repair

Purpose

Hernia repairs are the most common elective abdominal wall procedures performed by general surgeons. The use of a mesh has become the standard for hernia repair surgery. Herein, we discuss a management strategy for chronic mesh infections following open inguinal hernia repair with onlay prosthetic mesh.

Methods

In this study, 15 patients with chronic mesh infections following open inguinal hernia repairs were included. The medical records of these patients were retrospectively reviewed and information regarding presentation, type of previous hernia repair, type of mesh, operative findings and bacteriological examination results were obtained. In all cases, the infected mesh was removed completely and the patients were treated with antibiotic regimens and local wound care.

Results

Fifteen mesh removals due to chronic infection were performed between January 2000 and March 2012. The mean interval of hernia repair to mesh removal was 49 months. All patients were followed up for a median period of 62 months (range, 16 to 115 months). In all patients, the infections were resolved successfully and none were persistent or recurrent. However, one patient developed recurrent hernia and one developed nerve injury.

Conclusion

Chronic mesh infection following hernia repair mandates removal of the infected mesh, which rarely results in hernia recurrence.

Conservative management of mesh-site infection in hernia repair surgery: a case series

PURPOSE

The aim of this study is to assess the outcome of conservative management of infected mesh grafts following abdominal wall hernia repair.

METHODS

This study retrospectively examined the charts of patients who developed mesh-site infection following surgery for abdominal hernia repair to determine how effective conservative management in the form of antibiotics and wound management was on the resolution of infection and wound healing.

RESULTS

Over a period of 30 months, 13 patients developed infected mesh grafts post-hernia repair surgery. Twelve patients were successfully treated conservatively with local wound care and antibiotics if clinically indicated. One patient returned to theatre to have the infected mesh removed. Of the patients that healed eleven were treated with negative pressure wound therapy (VAC(®)).

CONCLUSION

This series of case studies indicate that conservative management of abdominal wall-infected hernia mesh cases is likely to be successful.

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

PURPOSE

Small mesh size has been recognized as one of the factors responsible for recurrence after Lichtenstein hernia repair due to insufficient coverage or mesh shrinkage. The Lichtenstein Hernia Institute recommends a 7 × 15 cm mesh that can be trimmed up to 2 cm from the lateral side. We performed a systematic review to determine surgeons' mesh size preference for the Lichtenstein hernia repair and made a meta-analysis to determine the effect of mesh size, mesh type, and length of follow-up time on recurrence.

METHODS

Two medical databases, PubMed and ISI Web of Science, were systematically searched using the key word "Lichtenstein repair." All full text papers were selected. Publications mentioning mesh size were brought for further analysis. A mesh surface area of 90 cm(2) was accepted as the threshold for defining the mesh as small or large. Also, a subgroup analysis for recurrence pooled proportion according to the mesh size, mesh type, and follow-up period was done.

RESULTS

In total, 514 papers were obtained. There were no prospective or retrospective clinical studies comparing mesh size and clinical outcome. A total of 141 papers were duplicated in both databases. As a result, 373 papers were obtained. The full text was available in over 95 % of papers. Only 41 (11.2 %) papers discussed mesh size. In 29 studies, a mesh larger than 90 cm(2) was used. The most frequently preferred commercial mesh size was 7.5 × 15 cm. No papers mentioned the size of the mesh after trimming. There was no information about the relationship between mesh size and patient BMI. The pooled proportion in recurrence for small meshes was 0.0019 (95 % confidence interval: 0.007-0.0036), favoring large meshes to decrease the chance of recurrence. Recurrence becomes more marked when follow-up period is longer than 1 year (p < 0.001). Heavy meshes also decreased recurrence (p = 0.015).

CONCLUSION

This systematic review demonstrates that the size of the mesh used in Lichtenstein hernia repair is rarely discussed in clinical studies. Papers that discuss mesh size appear to reflect a trend to comply with the latest recommendations to use larger mesh. Standard heavy meshes decrease the recurrence in hernia repair. Even though there is no evidence, it seems that large meshes decrease recurrence rates.

Open preperitoneal versus anterior approach for recurrent inguinal hernia: a randomized study

BACKGROUND

Inguinal herniorrhaphy remains one of the most common general surgical operations, with approximately 15% performed for recurrence. The repair of the resulting recurrent hernia is a daunting task because of already weakened tissues and obscured and distorted anatomy. The aim of this study is to compare the posterior preperitoneal versus anterior tension-free approach for repair of unilateral recurrent inguinal hernia regarding complications and early recurrence.

METHODS

120 Patients in this study were divided randomly into 2 main groups; Group A patients were subjected to posterior preperitoneal approach and those of group B were subjected to conventional anterior tension-free repair. The primary end point was recurrence and the secondary end points were time off from work, postoperative pain, scrotal swelling and wound infections.

RESULTS

The mean hospital stay was 1.2 days and 4.7, the mean time to return work was 8.2 and 11.2 days and the mean time off from work was 9.4 and 15.9 days in group A and B respectively. The maximum follow-up period was 48 months and the minimum was 14 months with a mean value as 37.11 ± 5.14 months. Only 2 recurrences (3.3%) in group A and 4 cases (6.25%) in group B were seen. The final pain score per patient and the overall complication rate were higher in group B.

CONCLUSIONS

The open preperitoneal repair offers the advantages of low recurrence rate and allows covering all potential defects with one piece of mesh and is far superior to the anterior approach.

TRIAL REGISTRATION

ACTRN12611000337976.

Use and indications of human acellular dermis in ventral hernia repair at a community hospital

Background. To evaluate the use, indications, and short-term outcomes for human acellular dermis. Methods. We retrospectively reviewed patients having human acellular dermis placed for ventral hernia repair from January 2008 through October 2009. Demographic information, operative details, and outcomes of patients with and without recurrences were compared; a P value <0.05 was considered significant. Results. 115 patients met inclusion criteria. The average age was 60 years (range, 24–89). The technique of repair included primary repair with overlay of mesh in 76%, bridge repair in 13%, and underlay in 11%. Average cost of mesh per operation was $3,709 (range $191–10,630). Open repairs were performed in 90% of patients with addition of component separation in 12%. At an average of 13 months, 58 patients were available for followup (50%), with a 47% recurrence rate. The morbidity rate was 48% and the mortality rate was 2%. Technique of repair was the only significant risk factor for recurrence with bridge repairs associated with a higher rate of recurrence (P < 0.05). Conclusions. The use of biologic grafts for ventral hernia repair is becoming more popular especially in clean cases. Although followup is limited, there remains a high recurrence rate associated with the use of human acellular dermis.

Feasibility of mesh repair for strangulated abdominal wall hernias

BACKGROUND

Prosthetic mesh reduces the risk of hernia recurrence. The use of mesh in patients with strangulated hernias requiring bowel resection is controversial.

PATIENTS AND METHODS

Patients with acutely incarcerated hernias (with small intestine contents) who underwent polypropylene mesh hernioplasty were included in this prospective study from June 2005 to Jan. 2011.

RESULTS

163 patients were included; 48 required intestinal resection and anastomosis (Group I) and 115 did not (Group II). Operative times and hospital stay were longer in Group I (P = 0.001). No significant difference was noted between both groups in terms of postoperative morbidities (16.6% vs 13% P = 0.5), wound infection (6% vs 4% P = 0.6), and recurrence rate (2% vs 2.8% P = 0.8), All cases of wound infection were successfully managed with drainage and local wound care and no mesh had to be removed. One patient in Group I and five patients in Group II died of concomitant diseases in the follow-up period (P = 0.5).

CONCLUSION

Mesh hernioplasty is crucial to prevent recurrence, and it is safe to utilize it in repair of acutely incarcerated hernias even if associated with intestinal resection.

Lysostaphin-Coated Mesh Prevents Staphylococcal Infection and Significantly Improves Survival in a Contaminated Surgical Field

Mesh and wound infections during hernia repair are predominantly caused by Staphylococcus aureus. Human acellular dermis (HAD) is known to lose its integrity in the face of large bacterial loads. The goal of this study was to determine if lysostaphin (LS), a naturally occurring anti-Staphylococcal protein, can protect HAD mesh from S. aureus infection. HAD samples, 3 cm X 3 cm, were implanted in the onlay fashion on the anterior abdominal wall of rats (n = 75). Subjects were grouped based on presence of antimicrobial bound to HAD (none or LS) and presence of S. aureus inoculum (sterile, 106, 108 CFU). At 60 days, meshes were explanted, and bacterial growth, histology, and mesh tensile strength were examined. None of the controls receiving bacterial inoculation without LS survived to 60 days. All LS-HAD sterile and LS-106 animals survived to explantation. The LS-HAD 108 group had a mortality rate of 50 per cent. All surviving LS-treated animals (n = 25) had negative wound and mesh cultures. Blinded gross and histologic evaluation and measured tensile strengths between all LS groups were comparable. Animals implanted with LS-HAD had a dramatically improved rate of survival. All animals surviving to 60 days had completely cleared S. aureus from their wounds with maintenance of mesh integrity and tensile strength. These findings strongly suggest the clinical use of LS-treated mesh in contaminated fields may translate into a more durable hernia repair.