Etiology of Inguinal Hernias: A Comprehensive Review

Two indirect sacs and one canal of Nuck in female inguinal hernia: a case report

BACKGROUND

Female inguinal hernias are rare to see. All inguinal hernias in females occur as indirect hernias. A single hernia sac is usually seen, but the occurrence of more than one sac in female indirect inguinal hernias is extremely rare.

CASE PRESENTATION

A 64-year-old female of Kashmiri ethnicity who had multiple comorbidities reported with right groin swelling. She had a diagnosis of a right indirect inguinal hernia. Intraoperatively, one canal of Nuck and two sacs of an indirect type were diagnosed.

CONCLUSION

Occurrence of two hernia sacs of an indirect type and canal of Nuck in female inguinal hernia is an extremely rare occurrence. This is the first case report in the world of a female indirect inguinal hernia being reported having two individual hernia sacs and a single canal of Nuck present. This hernia is named "the Srinagar" hernia after its region of origin.

A comparative study on trocar configurations and the use of steerable instruments in totally extraperitoneal inguinal hernia surgery training

BACKGROUND

Totally extraperitoneal (TEP) inguinal hernia surgery is a commonly performed but technically challenging procedure with a long learning curve. As TEP can be executed using two different trocar placements: a midline or a triangular configuration, the question remains which one is technically easier to master.

METHODS

In a multicenter crossover-study, medical students were randomised into two groups and executed tasks on a box trainer that measured time, volume and force parameters. Additionally, the study assessed whether the SATA instrument, a steerable laparoscopic instrument that articulates the instrument's tip, would reduce the difficulty of performing the tasks in the midline configuration. After training, all participants executed a first experiment using both trocar configurations, followed by a second experiment executed with steerable and non-steerable instruments in the midline configuration. Subjective and objective performances per condition and learning curves were assessed.

RESULTS

Participants were faster and showed lower peak forces in the triangulated configuration. Learning curve analysis showed a positive improvement in time and path length in the midline configuration. Although participants rated ergonomics and intuitiveness similarly between the instruments, they found the task easier with the SATA instruments, ranking the added value of the steering function as 5 out of 5. Objectively, time and path length showed no significant differences while exerted forces were lower when using conventional instruments.

CONCLUSION

Although the midline configuration is preferred in terms of comfort and posture, the findings indicate that, for inexperienced practitioners, performing TEP surgery in midline configuration is both subjectively and objectively more challenging, highlighting the need for extensive training to overcome its difficulties and possibly shorten its learning curve. Although instruments with additional steering functions were preferred over conventional instruments in the more challenging midline configuration, additional steering complexity did not result in better parameter outcomes, showing the need for more extensive training.

Penetrating versus non-penetrating mesh fixation in laparoscopic groin hernia repair

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms of penetrating versus non-penetrating mesh fixation in adults receiving laparoscopic groin hernia repair.

Outcomes of porcine small intestinal submucosa mesh compared to polypropylene mesh in laparoscopic transabdominal preperitoneal inguinal hernia repair: a retrospective cohort study

OBJECTIVE

To compare the long-term outcomes of porcine small intestinal submucosa (SIS) mesh and polypropylene (PP) mesh after an laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair.

BACKGROUND

Mesh-based surgical techniques for inguinal hernia repair are recommended in the guidelines due to the lower rate of recurrence. Biologic meshes (BMs) may have advantages in terms of chronic pain due to the different postoperative remodeling, without the disadvantages of a permanent implant. SIS mesh is the most commonly used BMs, mostly used for young male patients. Until now, the long-term efficacy of SIS mesh in laparoscopic inguinal hernia repair (LIHR) has rarely been reported and remains elusive.

METHODS

We retrospectively reviewed prospectively collected data from consecutive LIHR performed at Beijing Chaoyang Hospital between January 1, 2014 and December 31, 2018. Two groups of meshes were selected: SIS mesh and PP mesh. To reduce potential selection bias, patients were matched based on the logit of propensity scores through age, gender, and body mass index (BMI). Follow-up was until January 30, 2024. Long-term outcomes were analyzed, including the rate of recurrence, the rate of re-operation, and the postoperative discomfort.

RESULTS

A total of 2,348 patients with LIHR were eligible. After exclusion criteria, a total of 1,240 unilateral hernias treated using the TAPP approach were included for statistical analysis. Of these, 143 hernias (11.5%) were operated on with SIS mesh. Applying propensity score matching resulted in 115 matched pairs for comparative analysis. The mean operative time with the SIS mesh was 63.2 ± 18.5 min, which was longer than the operative time with PP mesh of 50.1 ± 17.6 min (P < 0.001). The SIS mesh was used more frequently to repair indirect hernias, while the PP mesh was more often employed to direct and femoral hernias at a higher rate (P = 0.009). The mean follow-up was 84.2 months and a total of seven patients (3%) were lost to follow-up. Overall, five (2.3%) patients experienced hernia recurrence postoperatively, all in the SIS group, but no statistical difference was observed between the two groups (4.4% vs. 0%; P = 0.06). All underwent a second operation, with three in TAPP approach and two in Lichtenstein approach, no recurrence was found afterward. More patients in the SIS group reported postoperative discomfort than those in the PP group (8.8% vs. 0.9%; P = 0.006), notably experiencing discomfort more frequently and to a greater degree during movement.

CONCLUSION

The SIS mesh in TAPP hernia repair leads to more frequent discomfort and a higher recurrence rate (though not statistically significant) compared to PP mesh. Continued follow-up and an increased sample size are needed to analyze the effectiveness of SIS mesh and to explore risk factors for recurrence.

Predictive factors of immediate continence after conventional robot-assisted radical prostatectomy: a single-institution retrospective study

BACKGROUND

To assess the predictive factors of immediate urinary continence after robot-assisted radical prostatectomy.

METHODS

This study included 282 patients who underwent conventional robot-assisted radical prostatectomy at our institution from April 2019 to March 2024. The primary outcome was immediate urinary continence, defined as the absence of urine leakage immediately after urinary catheter removal on postoperative day 6 or 7. In addition, the immediate urine loss rate, defined as the 24-h urine loss volume divided by the total urine volume after catheter removal, was calculated. The multivariable logistic model was used to assess the possible predictive factors of immediate continence (urine loss rate of 0%). The factors included age, body mass index, Charlson Comorbidity Index, pre-existing lower urinary tract symptoms, presence of an inguinal hernia, prostate volume, membranous urethral length, stratified cancer risk, surgeon's experience, and nerve-sparing procedure. In addition, a multiple linear regression model was established to investigate the associations of the same predictors with immediate urine loss rate (%). We also presented our techniques to achieve immediate continence.

RESULTS

The patients' median age was 70 (interquartile range: 63.0-73.0) years. Approximately 39% (n = 111) of patients presented with immediate continence. Age, inguinal hernia, membranous urethral length, and low risk for prostate cancer were associated with immediate continence. These were also statistically significant predictors of immediate urine loss rate.

CONCLUSION

Our study identified factors predicting immediate urinary continence after conventional robot-assisted radical prostatectomy. This information is potentially valuable for preoperative counseling in patients undergoing robot-assisted radical prostatectomy.

Hormonal Function of Undescended Testes Before Orchidopexy in Prepubertal Boys

Background/Objectives: The hormonal aspect of undescended testes (UDTs) in prepubertal boys, i.e., after mini-puberty, is poorly understood. The aim of this study was to evaluate the hormonal function of UDTs before orchidopexy in prepubertal boys and its correlation with testicular parameters. Methods: The study included 90 prepubertal boys (0.9-8.8 years) with UDTs and 57 age-matched boys with testes in the scrotum (control). The testicular volume (TV), testicular atrophy index (TAI), and testicular growth potential (TGP) of the UDTs were assessed before orchidopexy and 18-24 months after. The analysis included FSH, LH, T, DHT, E2, Inh B, INSL3, and AMH levels. Results: The UDT group demonstrated a significantly higher FSH level and lower Inh B/FSH ratio than controls. Boys with UDTs aged under six years exhibited significantly higher FSH and LH levels and lower Inh B/FSH and T/LH ratios. The TV level of descended and undescended testes, both before and after surgery, was significantly positively related to T and DHT levels, but negatively with Inh B, INSL3 levels, Inh B/AMH, and Inh B/FSH. Conclusions: Hormonal evaluation of the hypothalamus-pituitary-testicular axis and Sertoli and Leydig cell function in prepubertal boys (after mini-puberty) may predict the further development and function of UDTs and may serve as a diagnostic tool in testicular descent disorder.

Inguinal hernias in children: Update on management guidelines

Inguinal hernia repair is one of the most performed procedures in children, but aspects of care remain controversial. The aim of this review was to provide a critical appraisal of recently published guidelines on the management of inguinal hernias in children, by the American Academy of Pediatrics (2023) and the European Pediatric Surgeons' Association Evidence and Guideline Committee (2022). This was achieved by delineating areas of controversy and reviewing the most relevant recent literature on these topics. Currently available moderate-to-low quality evidence recommends postponing hernia repair in premature infants until after discharge, to reduce the risk of respiratory difficulties and recurrence. Laparoscopic repair provides similar outcomes to open but may shorten operative time in bilateral cases. No clear recommendation can be made for contralateral exploration, therefore should be evaluated case by case. In preterm infants, consideration of regional anaesthesia may reduce post-operative apnoea and pain, with no difference in neurodevelopment outcomes.

Incidence of groin hernia repairs in women and parity: a population-based cohort study among women born in Sweden between 1956 and 1983

INTRODUCTION

The aim of this study was to evaluate the association between parity and the incidence rate of groin hernia repair in women.

METHOD

This study was based on two Swedish national registers, the Medical Birth Register (MBR), and the Swedish Hernia Register (SHR). The cohort constituted of women born between 1956 and 1983. Data on vaginal and cesarean deliveries were retrieved from the MBR. The birth and hernia registers were cross matched to identify hernia repairs carried out after deliveries.

RESULTS

A total of 1,535,379 women were born between 1956 and 1983. Among these, 1,417,237 (92.3%) were registered for at least one birth. The incidence rate for Inguinal Hernia Repair (IHR) and Femoral Hernia Repair (FHR) was 10.7 per 100,000 person-year and 2.6 per 100,000 person-year, respectively. Compared with women registered for one delivery, the incidence rate ratio for IHR was 1.31 (95% Confidence Interval: 1.23-1.40) among women registered for two deliveries, 1.70 (1.58-1.82) among women registered for ≥ 3 deliveries. Additionally, the incidence rate ratios were higher 1.30 (1.14-1.49) and 1.70 (1.49-1.95) for FHR among women with two and  ≥ 3 registered deliveries, respectively.

CONCLUSION

In the present cohort, higher parity was associated with a higher incidence of inguinal as well as FHRs.

A new groin hernia classification with clinical relevance

INTRODUCTION

Groin hernia is one of the most commonly managed surgical diseases around the world. The typical question asked by patients is "Does my hernia require urgent surgery?". The currently available classifications are insufficient to stratify patients into different groups. We propose a new classification that incorporates diverse clinical elements together with anatomical and other vital information, which allows us to stratify patients into different groups.

METHOD

A task force was formed by the Hong Kong Hernia Society, working with international expert hernia surgeons. The framework of the classification system was formulated. Clinical elements that are important in groin disease stratification were identified. A comprehensive literature review was conducted using PubMed. Those which dictate the severity of the disease were selected and compiled to form the new proposed classification. Application of this classification model to a single hernia surgeon's registry in The Hong Kong Adventist Hospital Hernia Centre was done for initial evaluation.

RESULT

This new classification incorporates important clinical characteristics forming a total of nine grades of differentiation, together with the anatomical details and special information. This comprehensive system allows the stratification of patients into different groups based on disease severity. It also enables more accurate data collection for future audits, comparisons of disease progression over time, and the effect of different management strategies for different-stage patients.

CONCLUSION

This is the first classification system which incorporates essential clinical parameters, which allows the stratification of groin hernia into different stages. Further studies and validation should be performed to evaluate the usefulness and value of this classification in groin hernia management.

Evaluation of Open Rives-Stoppa and Lichtenstein Repair Methods for Bilateral Inguinal Hernias: A Single-Centre Comparative Analysis

Aim The purpose of the study is to compare the two common open surgical methods for bilateral inguinal hernias: bilateral Lichtenstein repair and Rives-Stoppa repair. It evaluates their benefits, drawbacks, and outcomes to improve the management of bilateral inguinal hernias and enhance patient care and results. Background Abdominal wall hernias are prevalent in the surgical field, and they occur when intra-abdominal organs protrude through weakened or torn regions in the abdominal wall. The Lichtenstein repair, also known as the tension-free mesh repair, is one of the most widely used techniques that involves placing a synthetic mesh over the hernia defect to reinforce the abdominal wall. The Rives-Stoppa technique takes the posterior approach, which involves placing a large mesh in the preperitoneal space, which provides broad coverage of the potential hernia sites. Method This retrospective study included 86 male patients from the Department of General Surgery at Indus Health Network, Karachi, Pakistan. Data were collected up to three months post-operation for all open bilateral inguinal hernia repairs performed between January 2017 and April 2021. The patients were divided into two groups: group A underwent Lichtenstein repair, while group B underwent Rives-Stoppa repair. The procedures were performed by different surgeons and surgical trainees under direct supervision. Results Regarding post-operative complications (scrotal swelling, epididymo-orchitis, seroma formation, ipsilateral testicular swelling, surgical site infection, erectile dysfunction, wound dehiscence, fever, hydrocele, sensory abnormality, hernia recurrence in 3 months, post-operative pain in 14 days), there was no significant difference observed between the two groups. There were two recurrences within three months after Lichtenstein repair and one recurrence after Stoppa repair, but no statistical difference was demonstrated. Conclusion Statistically, both the Lichtenstein repair and the Rives-Stoppa repair demonstrated similar outcomes. However, the Rives-Stoppa repair offers distinct advantages for bilateral inguinal hernia repair, making it a preferable option in many cases as this approach utilises a single midline incision, simultaneously facilitating access to both hernial sites. This method ensures complete coverage of the myopectineal orifices bilaterally, addressing all potential hernia sites in the lower abdomen. These features collectively contribute to the technique's efficacy in managing bilateral hernias.

Tailored treatment of female indirect inguinal hernias by using single-port laparoscopic percutaneous internal ring suture: a comparison between children and adults

PURPOSE

To compare the outcome of indirect inguinal hernias repaired by using single-port laparoscopic percutaneous internal ring suture (SPIRS) between the pediatric and adult females.

METHODS

The medical records of females who were clinically assessed to have inguinal hernia from Oct. 2016 to May 2022 were reviewed. Patients who received laparoscopy for the diagnosis of the hernia type and customized treatment according to their hernia type were included, while those who chose other operation methods initially were excluded. The patients were divided into the adult and pediatric groups based on their age. The demographic characteristics, hernia types, operation durations, and outcomes were analyzed between these two groups.

RESULTS

A total of 65 adults and 60 children were included in this study. The median age was 38 years. (range: 23-88) for group A and 3 years (range: 0.1-16) for group P. Indirect hernias were present in 85% of adults and 100% of children. All the indirect hernias were repaired by SPIRS uneventfully. Incidence of contralateral patent processus vaginalis was 24% in adults and 50% in children (p = 0.016). The average operation time was 22/46 min (one/two sides) for the adults and 9/15 min (one/two sides) for the pediatrics (p < 0.010 for both). The overall complication rates were 5.4% and 3.3% for the adult and pediatric group respectively (p = 0.106). No recurrence was observed in the pediatric group, but two adults experienced recurrence and another had chronic postoperative inguinal pain, necessitating reoperation. The mean follow-up period was 38.6 ± 15.4 months for adults and 42.8 ± 18.9 months for children (p = 0.198).

CONCLUSION

Our results support that the pathogenesis of indirect inguinal hernia for the female adults is due to the non-obliteration of a congenital processus vaginalis. Tailored treatment of the female IIH by using single-port laparoscopic percutaneous internal ring suture may be an alternative for the management of female IHs.

Incidence and risk factors of metachronous contralateral inguinal hernia development up to 25 years after unilateral inguinal hernia repair: a single-centre retrospective cohort study

BACKGROUND

Patients undergoing unilateral inguinal hernia repair (IHR) are at risk of metachronous contralateral inguinal hernia (MCIH) development. We evaluated incidence and risk factors of MCIH development up to 25 years after unilateral IHR to determine possible indications for concomitant prophylactic surgery of the contralateral groin at the time of primary surgery.

METHODS

Patients between 18 and 70 years of age undergoing elective unilateral IHR in the University Hospital of Leuven from 1995 to 1999 were studied retrospectively using the electronic health records and prospectively via phone calls. Study aims were MCIH incidence and risk factor determination. Kaplan-Meier curves were constructed and univariable and multivariable Cox regressions were performed.

RESULTS

758 patients were included (91% male, median age 53 years). Median follow-up time was 21.75 years. The incidence of operated MCIH after 5 years was 5.6%, after 15 years 16.1%, and after 25 years 24.7%. The incidence of both operated and non-operated MCIH after 5 years was 5.9%, after 15 years 16.7%, and after 25 years 29.0%. MCIH risk increased with older age and decreased in primary right-sided IHR and higher BMI at primary surgery.

CONCLUSION

The overall incidence of MCIH after 25-year follow-up is 29.0%. Potential risk factors for the development of a MCIH are primary left-sided inguinal hernia repair, lower BMI, and older age. When considering prophylactic repair, we suggest a patient-specific approach taking into account these risk factors, the surgical approach and the risk factors for chronic postoperative inguinal pain.

Obliteration of the Processus Vaginalis After Testicular Descent

The testis develops in the abdominal cavity and descends into the scrotum. Although numerous theories have been proposed, the mechanism of descent and the reason for its inhibition remain unknown. Furthermore, none of the explanations account for the other occurrences related to the descent, such as failed obliteration of the processus vaginalis, or the reasons for the decrease in fertility and increase in the risk of malignancy associated with an undescended testis. The gubernaculum is a primitive mesenchymal tissue that was first described in 1786. However, the role of the gubernaculum in the descent process remains obscure. The testis descends through the processus vaginalis. Although the processus vaginalis (PV) is usually defined as a simple peritoneal protrusion, it actively develops into the gubernaculum. The gubernaculum gives rise to the smooth muscles that surround the processus vaginalis. The striated cremaster muscle (CM) is also derived from the gubernaculum. Because the testis descends through the processus vaginalis, the muscles develop to propel the testis. After propelling the testis, the smooth muscle (SM) undergoes programmed cell death. The initiation of programmed cell death through the intrinsic pathway requires activation of phospholipase C. A transient shift in the autonomic balance via a decrease in the sympathetic tonus and an increase in the parasympathetic tonus is essential for initiating this programmed cell death. Programmed cell death in the SM is the physiological pathway for the obliteration of the processus vaginalis. Differences in the timing, intensity, or duration of this physiological pathway result in pathological conditions. A shift before testicular descent diminishes the SM content that is required to propel the testis, and thus inhibits descent. The early shift persists throughout childhood and results in the decrease in fertility and increase in the risk of malignancy because of the differences in signal transduction. Despite a successful descent, persistence of the shift alters the contractility of the CM by increasing the cytosolic calcium levels. Contracted CMs retracts or even ascends the testis. Inadequate intensity or duration of the shift of autonomic tonus causes failure of the programmed cell death. Persistence of the SM hinders the obliteration of PV and gives rise to hydroceles or inguinal hernias depending on the amount of residual smooth muscles. Similar findings from different countries support these explanations. Thus, our proposed mechanism satisfactorily explains the process of descent while considering all the factors related to the process of testicular descent.

Air pollution and human health: a phenome-wide association study

OBJECTIVES

To explore the associations of long-term exposure to air pollution with onset of all human health conditions.

DESIGN

Prospective phenome-wide association study.

SETTING

Denmark.

PARTICIPANTS

All Danish residents aged ≥30 years on 1 January 2000 were included (N=3 323 612). After exclusion of individuals with missing geocoded residential addresses, 3 111 988 participants were available for the statistical analyses.

MAIN OUTCOME MEASURE

First registered diagnosis of every health condition according to the International Classification of Diseases, 10th revision, from 2000 to 2017.

RESULTS

Long-term exposure to fine particulate matter (PM2.5) and nitrogen dioxide (NO2) were both positively associated with the onset of more than 700 health conditions (ie, >80% of the registered health conditions) after correction for multiple testing, while the remaining associations were inverse or insignificant. As regards the most common health conditions, PM2.5 and NO2 were strongest positively associated with chronic obstructive pulmonary disease (PM2.5: HR 1.06 (95% CI 1.05 to 1.07) per 1 IQR increase in exposure level; NO2: 1.14 (95% CI 1.12 to 1.15)), type 2 diabetes (PM2.5: 1.06 (95% CI 1.05 to 1.06); NO2: 1.12 (95% CI 1.10 to 1.13)) and ischaemic heart disease (PM2.5: 1.05 (95% CI 1.04 to 1.05); NO2: 1.11 (95% CI 1.09 to 1.12)). Furthermore, PM2.5 and NO2 were both positively associated with so far unexplored, but highly prevalent outcomes relevant to public health, including senile cataract, hearing loss and urinary tract infection.

CONCLUSIONS

The findings of this study suggest that air pollution has a more extensive impact on human health than previously known. However, as this study is the first of its kind to investigate the associations of long-term exposure to air pollution with onset of all human health conditions, further research is needed to replicate the study findings.

Inguinal hernia leads to worse immediate urinary continence after robot-assisted radical prostatectomy

OBJECTIVES

Patients with inguinal hernia (IH) may have voiding dysfunction and weak urethra-stabilizing periurethral fascial tissues, contributing to urinary incontinence. This study aimed to review the association between IH and urinary continence after robotic-assisted radical prostatectomy (RARP).

METHODS

This single-institution retrospective study included 251 consecutive cases of RARP between April 2019 and June 2022. Patients with concurrent IH or a history of adult IH repair were examined. The urine loss rate (ULR), defined as 24-h urine loss volume divided by the total urine volume immediately after urinary catheter removal (i.e., 6 or 7 postoperative days), was compared between the groups with (n = 33) and without IH (n = 214). Possible contributing factors for ULR were assessed, including age, body mass index (BMI), after benign prostatic hyperplasia surgery, prostate weight, and nerve-sparing. ULR was compared intergroup after propensity score matching countering selection biases.

RESULTS

Patients with IH were older (71.3 versus. 66.8 years, p < 0.01), had lower BMI (22.8 versus. 24.3, p < 0.01), and had higher ULR (14.5% versus. 5.1%, p < 0.01). In a multiple linear regression analysis (adjusted R2 = 0.084), IH (p < 0.01) was an independent contributing factor for ULR besides advancing age (p < 0.03). After propensity score matching adjusted for patient's age and nerve-sparing, patients with IH had higher ULR (14.1% versus. 5.7%, p < 0.03) as well.

CONCLUSIONS

This study first reported that IH may be one of the risk factors of urinary incontinence after RARP.

Comparison of Perioperative Complication Rates of Total Extraperitoneal and Transabdominal Preperitoneal Repairs in Primary Inguinal Hernia

Background

Hernia may be defined as a protrusion of viscus through layers anatomically designed to contain that viscus. Most abdominal hernias occur at well-described sites of potential weakness. Repair of inguinal hernia is one of the most common operations in general surgery. Objectives: To compare the perioperative complication rates of total extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) repairs of primary inguinal hernias.

Materials and Methods

It is a randomised comparative study, conducted at the department of general surgery. A total of 50 patients were included and divided into two groups with 25 in each. Group A represents the laparoscopic TEP repair and group B represents the laparoscopic TAPP repair. Patients above 18 years with primary unilateral inguinal hernia were included. Patients having complicated inguinal hernia and history of previous abdominal surgery were excluded.

Results

We observed that hernia occurrence is more common in the 31-50 years of age group and right-sided hernia is more common. Scrotal oedema and conversion to open surgery chances are similar in both TEP and TAPP groups. The duration of surgery in TEP is significantly higher as compared to TAPP. Patients who underwent TEP experienced less pain as compared to TAPP as per visual analogue scale. Postoperative hospital stay and time taken to resume the routine activity were significantly less in case of TEP.

Conclusion

TEP is preferred over TAPP for laparoscopic hernia repair because it preserves the peritoneal integrity and has lesser postoperative pain. The early recovery and return to the routine work were seen with the patient treated with the TEP and also showed better visual analogue score than the TAPP repair group.

The inheritance of groin hernias: an updated systematic review with meta-analyses

PURPOSE

The aim of this systematic review was to assess the inheritance of groin hernias.

METHODS

The primary outcome was to assess the inheritance based on the family history of groin hernias. We included studies that reported family history in patients with groin hernias, assessed the development of groin hernias in patients with a positive family history, or assessed the development of groin hernias in twins. Searches were conducted in PubMed, EMBASE, and Cochrane CENTRAL in November 2021. Results were synthesized narratively and with meta-analyses.

RESULTS

Twenty-two studies with unique participants were included. While two twin studies did not show convincing results of a genetic origin in children, database studies with low risk of bias showed that a positive history in parents or siblings increased the risk of inguinal hernia in children, and the risk was highest between mothers and daughters and between sisters. In adults, patients with inguinal hernia had higher odds of having a positive family history compared with patients without groin hernia (odds ratio 5.3, 95% confidence interval 3.3-8.7), and a nationwide study found the highest risk of inguinal hernia repair when a sister had been repaired compared with a brother. This study also found that having a sibling repaired for a groin hernia increased the risk of femoral hernia repair.

CONCLUSION

Despite studies being heterogeneous, there is overwhelming evidence that a positive family history is a risk factor for developing inguinal hernia in both children and adults, seemingly with a pronounced female-female inheritance pattern.

Risk factors for reoperation following inguinal hernia repair: results from a cohort of patients from an integrated healthcare system

PURPOSE

Inguinal hernia repair is one of the most common operations performed globally. Identification of risk factors that contribute to hernia recurrence following an index inguinal hernia repair, especially those that are modifiable, is of paramount importance. Therefore, we sought to investigate risk factors for reoperation following index inguinal hernia repair.

METHODS

125,133 patients aged ≥ 18 years who underwent their first inguinal hernia repair with mesh within a large US integrated healthcare system were identified for a cohort study (2010-2020). Laparoscopic, robotic, and open procedures were included. The system's integrated electronic health record was used to obtain data on demographics, patient characteristics, surgical characteristics, and reoperations. The association of these characteristics with ipsilateral reoperation during follow-up was modeled using Cox proportional-hazards regression. Risk factors were selected into the final model by stepwise regression with Akaike Information Criteria, which quantifies the amount of information lost if a factor is left out of the model. Factors associated with reoperation with p < 0.05 were considered statistically significant.

RESULTS

The cumulative incidence of reoperation at 5-year follow-up was 2.4% (95% CI 2.3-2.5). Increasing age, female gender, increasing body mass index, White race, chronic pulmonary disease, diabetes, drug abuse, peripheral vascular disease, and bilateral procedures all associated with a higher risk for reoperation during follow-up.

CONCLUSION

This study identifies several risk factors associated with reoperation following inguinal hernia repair. These risk factors may serve as targets for optimization protocols prior to elective inguinal hernia repair, with the goal of reducing reoperation risk.

A Rare Case of a Direct Incarcerated Inguinal Hernia Containing an Epiploic Appendage and a Literature Review

Inguinal hernias are a widespread condition, responsible for a large number of acute abdomen cases. Typically, indirect, rather than direct, hernias lead to complications, as a consequence of their narrower hernial defect. We report a 71-year-old male patient with a rather rare incidence of a direct incarcerated hernia who presented with acute pain in the left inguinal area at a university general hospital in Thessaloniki, Greece, in 2017. Upon clinical examination, an irreducible inguinal mass was palpated. Therefore, the existence of a complicated hernia was suspected. The patient underwent an emergency repair, during which it was established that the hernia was direct and incarcerated and that its sac contained an ischaemic epiploic appendage. The hernia was successfully repaired with mesh, the patient recovered uneventfully and was discharged five days later. Despite the rarity of complicated direct inguinal hernias, they should always be included in the differential diagnosis of irreducible groin masses as they can increase severe complications.

Primary Tissue Repair for Inguinal Hernias: The Shouldice Repair Technique and Patient Selection

It is estimated that approximately one in four men and one in 20 women will develop an inguinal hernia over the course of their lifetime. A non-mesh inguinal hernia repair via the Shouldice technique is a unique approach that necessitates dissection of the entire groin region as well as careful assessment for any secondary hernias. Subsequently, a pure tissue laminated closure allows the repair to be performed without tension. Herein, the authors describe a brief overview of inguinal hernias and discuss the relevant patient evaluation, operative steps of the Shouldice procedure, and postoperative considerations.

Administering prophylactic alpha-blockade to reduce urinary retention post inguinal hernia repair: A systematic review and meta-analysis of randomised control trials

Introduction

The incidence of post-operative urinary retention (POUR) following inguinal hernia repair (IHR) is approximately 0.4% - 22.0%. POUR may lead to patient discomfort and catheter-related complications including urinary tract infection, urethral trauma, bladder overdistension and subsequent permanent bladder dysfunction. We aimed to perform a systematic review and meta-analysis of randomised control trials (RCT) evaluating the impact of administration of perioperative alpha-blockade to reduce the incidence of acute POUR following IHR.

Methods

A systematic review was performed as per PRISMA guidelines. The incidence of POUR in the alpha-blocker and control groups were expressed as dichotomous outcomes, reported as odds ratios (ORs) expressed with 95% confidence intervals (CIs) following estimation using the Mantel-Haenszel method.

Results

Eight RCTs with a combined total of 918 patients were included. Of these, 53.7% (493/918) received alpha-blockers while 46.3% (425/918) did not. Five studies used tamsulosin, two used prazosin and one used phenoxybenzamine. Overall, the prescription of prophylactic alpha-blockers in the preoperative setting significantly reduced POUR compared to the control group (7.9% (39/493) vs 21.2% (90/425), OR: 0.31, 95% CI: 0.12-0.80, P = 0.020).

Conclusion

Preoperative prescription of alpha-blockers reduced the incidence of POUR following inguinal hernia repair. The next generation of prospective randomised trials may identify which patients should be prescribed this medication prior to surgery.

Lateral single incision laparoscopic totally extraperitoneal hernioplasty (L-SILTEP) after laparoscopic radical prostatectomy: A rare case report with literature review

INTRODUCTION

Single-incision laparoscopic totally extraperitoneal hernioplasty is a commonly used surgical procedure for the treatment of inguinal hernia. However, it is difficult to use traditional single incision laparoscopic totally extraperitoneal hernioplasty to treat inguinal hernia after laparoscopic radical prostatectomy. We successfully and smoothly cured a patient with left inguinal hernia after laparoscopic radical prostatectomy using lateral single incision laparoscopic totally extraperitoneal hernioplasty.

CASE PRESENTATION

We report the case of a 70-year-old man who underwent laparoscopic radical prostatectomy 2 years earlier and had an evanescent mass in the left inguinal region for 1 month.

DIAGNOSIS

On the basis of preoperative abdominal computed tomography and intraoperative findings, the patient was diagnosed with a left indirect inguinal hernia, and post-laparoscopic radical prostatectomy.

INTERVENTIONS

The patient underwent lateral single incision laparoscopic totally extraperitoneal hernioplasty.

OUTCOMES

The patient recovered well after the operation, and there were no postoperative complications or recurrence of inguinal hernia 3 months after the operation.

CONCLUSION

For patients who have undergone laparoscopic radical prostatectomy, lateral single-incision laparoscopic totally extraperitoneal hernioplastycan be performed.

Role of Collagen in the Etiology of Inguinal Hernia Patients: A Case-Control Study

Introduction Technical faults are no longer accepted as the sole reason for recurrence following inguinal hernia (InH) repairs. Medical literature has been studied to find any contributing factors and collagen has emerged as a promising marker. Owing to their long half-lives, it has been found to best reflect the process of scarring, which is central to ensuring the formation of a proper fibrous tissue that incorporates the mesh with the abdominal wall. Methods Sixty participants were divided into two groups. The case group were patients diagnosed with InH and the control group had patients undergoing abdominal surgeries for indications other than abdominal wall hernias. A 0.5x0.5cm specimen of skin and transversalis fascia were biopsied and subsequently stained to determine the amount of collagen I and III. Results Collagen I, collagen III and the ratio of collagen I to III was measured. Collagen I was normal in the skin of both groups but decreased in transversalis fascia of cases. Collagen III was found to be normal in transversalis fascia of both cases and controls, but increased in the skin of cases. Ratio of collagen I to III was decreased in both skin and transversalis fascia of cases. Statistical analysis was carried out using an unpaired t-test, non-parametric Mann-Whitney test, ANOVA and chi-square test. Conclusions Our study has reported that in patients with inguinal hernia, collagen III or immature collagen is increased in skin and collagen I or mature collagen is decreased in the transversalis fascia. The ratio of collagen I/III is decreased in both skin and transversalis fascia.

Laparoscopic Groin Hernia Repair Using the Totally Extraperitoneal Approach: A Retrospective Study and Our Experience

Background Recently, laparoscopic totally extraperitoneal (TEP) inguinal hernia repair has been considered one of the most effective and widely performed techniques for repairing inguinal hernias by avoiding entry into the peritoneal cavity. Its indications have evolved and expanded to almost encompass the entire range of groin hernias. This retrospective study aims to determine the outcomes and postoperative complications in patients undergoing TEP inguinal hernia repair performed by a single surgeon for groin hernias at a single center. Methodology We retrospectively evaluated the prospectively collected data of 900 patients who underwent elective TEP repair over 18 years at a single center performed by a single surgeon from April 2004 to February 2023. Patients were evaluated for age, sex, type of hernia, time taken for surgery, open from laparoscopy, intra and postoperative complications, hospital stay, and days taken to resume regular activity. Results The mean age of the 900 patients was 59 years (range = 21-83 years). The mean age of males and females was 59 and 56 years, respectively. The mean operative time was 40 and 55 minutes for a unilateral and bilateral hernia, respectively. In total, 369 (41%) patients had a right-sided groin hernia, 382 (42%) patients had a left-sided groin hernia, and 149 (16.5%) patients had bilateral groin hernias. A total of 121 (13%) patients had occult hernias, and 17 patients underwent concurrent TEP and transurethral resection of the prostate. Of the 900 patients, 20 (2.2%) had a recurrent hernia after a previous open inguinal hernia repair. Seven (0.8%) patients had a recurrence of hernias post-TEP and subsequently underwent open inguinal hernia repair. Seven (0.7%) patients needed conversion from TEP to the transabdominal pre-peritoneal approach. Only minor complications were noted intra and postoperatively. The average time of hospitalization was 24 hours. The time to resume normal activities was five (±1) days. Conclusions Our experience suggests that TEP repair with mesh fixation is a safe and effective procedure with a marginal recurrence rate. Apart from the obvious cosmetic benefits of minimal tissue invasion, a significant advantage of TEP is the visualization of the contralateral groin along with the surgical repair of a hernia, if required, in the same sitting and without the insertion of any extra trocars.

Rare Hernias as Surgical Emergencies: A Case Series of Five Cases

Hernia is one of the most common clinically diagnosed cases seen in day-to-day practice. But some of them might pose a challenge in diagnosing the condition and, thus, their further management. Some types of hernias are rare and mimic the common presentation of the acute abdomen, thus requiring extra caution to keep hernias as a differential diagnosis in the acute abdomen. In this series, we report five cases of rare hernias presented to a tertiary care center in northern India over the course of one year. Two cases of paraduodenal hernias (PHs), a right and left, respectively, a male femoral hernia, an Amayand hernia, and an obturator hernia presented as acute abdomen in the emergency department, with challenges in their diagnosis, intraoperative findings, and their outcomes. Computed tomography is a useful diagnostic tool for arriving at the diagnosis pre-operatively in these situations.

Study of Demographics, Clinical Profile and Risk Factors of Inguinal Hernia: A Public Health Problem in Elderly Males

BACKGROUND

Inguinal hernia repair is the most commonly performed elective surgery in India draining significant healthcare resources. This observational study was conducted at a tertiary-level institute in northern India to look into the demographics, clinical profile and risk factors of inguinal hernia.

METHOD

 This study was conducted as an observational study at the tertiary care centre of northern India, including 110 patients who had come to the surgical outpatient department for inguinal hernia repair. After obtaining informed consent from all the participants, demographic details, history and clinical examination were recorded. This was a prospective, single-centre, non-randomized, observational study.

RESULTS AND DISCUSSION

 In our study, 43 patients (39%) were >50 years of age. One hundred and seven patients (97.27%) were males, and three (2.72%) were females. Male: Female ratio was 32:1. The preponderance of males was due to their involvement in more strenuous exercises and lifting weights and the anatomical differences between them. The main risk factor in the present study was lifting heavy weights 55%, followed by altered bowel habits 36.36% and respiratory disease (chronic obstructive airway disease). Smoking and diabetes were also associated as risk factors for the hernia. In this study, the most common side of hernia was on the right side, 63%, on the left, 33% and bilateral in 4% of patients. The indirect hernia was the most common type.

CONCLUSION

Inguinal hernia is a surgical problem found commonly in the male elderly. Right-sided inguinal hernia is common, with the indirect type being more frequent. Heavy weight lifting and strenuous exercises were commonly found risk factors.

The plasticity of biocompatibility

Biocompatibility concerns the phenomena that occur within the interactions between biomaterials and human patients, which ultimately control the performance of many facets of medical technology. It involves aspects of materials science, many different forms of engineering and nanotechnology, chemistry, biophysics, molecular and cellular biology, immunology, pathology and a myriad of clinical applications. It is not surprising that an overarching framework of mechanisms of biocompatibility has been difficult to elucidate and validate. This essay discusses one fundamental reason for this; we have tended to consider biocompatibility pathways as essentially linear sequences of events which follow well-understood processes of materials science and biology. The reality, however, is that the pathways may involve a great deal of plasticity, in which many additional idiosyncratic factors, including those of genetic, epigenetic and viral origin, exert influence, as do complex mechanical, physical and pharmacological variables. Plasticity is an inherent core feature of the performance of synthetic materials; here we follow the more recent biological applications of plasticity concepts into the sphere of biocompatibility pathways. A straightforward linear pathway may result in successful outcomes for many patients; we may describe this in terms of classic biocompatibility pathways. In other situations, which usually command much more attention because of their unsuccessful outcomes, these plasticity-driven processes follow alternative biocompatibility pathways; often, the variability in outcomes with identical technologies is due to biological plasticity rather than material or device deficiency.

Association of Accelerometer-Measured Physical Activity Level With Risks of Hospitalization for 25 Common Health Conditions in UK Adults

Importance

Higher physical activity levels are associated with lower risks of cancer, cardiovascular disease, and diabetes, but associations with many common and less severe health conditions are not known. These conditions impose large health care burdens and reduce quality of life.

Objectives

To investigate the association between accelerometer-measured physical activity and the subsequent risk of hospitalization for 25 common reasons for hospitalization and to estimate the proportion of these hospitalizations that might have been prevented if participants had higher levels of physical activity.

Design, Setting, and Participants

This prospective cohort study used data from a subset of 81 717 UK Biobank participants aged 42 to 78 years. Participants wore an accelerometer for 1 week (between June 1, 2013, and December 23, 2015) and were followed up over a median (IQR) of 6.8 (6.2-7.3) years; follow-up for the current study ended in 2021 (exact date varied by location).

Exposures

Mean total and intensity-specific accelerometer-measured physical activity.

Main Outcomes and Measures

Hospitalization for the most common health conditions. Cox proportional hazards regression analysis was used to estimate hazard ratios (HRs) and 95% CIs for mean accelerometer-measured physical activity (per 1-SD increment) and risks of hospitalization for 25 conditions. Population-attributable risks were used to estimate the proportion of hospitalizations for each condition that might be prevented if participants increased their moderate to vigorous physical activity (MVPA) by 20 minutes per day.

Results

Among 81 717 participants, the mean (SD) age at accelerometer assessment was 61.5 (7.9) years; 56.4% were female, and 97.0% self-identified as White. Higher levels of accelerometer-measured physical activity were associated with lower risks of hospitalization for 9 conditions: gallbladder disease (HR per 1 SD, 0.74; 95% CI, 0.69-0.79), urinary tract infections (HR per 1 SD, 0.76; 95% CI, 0.69-0.84), diabetes (HR per 1 SD, 0.79; 95% CI, 0.74-0.84), venous thromboembolism (HR per 1 SD, 0.82; 95% CI, 0.75-0.90), pneumonia (HR per 1 SD, 0.83; 95% CI, 0.77-0.89), ischemic stroke (HR per 1 SD, 0.85; 95% CI, 0.76-0.95), iron deficiency anemia (HR per 1 SD, 0.91; 95% CI, 0.84-0.98), diverticular disease (HR per 1 SD, 0.94; 95% CI, 0.90-0.99), and colon polyps (HR per 1 SD, 0.96; 95% CI, 0.94-0.99). Positive associations were observed between overall physical activity and carpal tunnel syndrome (HR per 1 SD, 1.28; 95% CI, 1.18-1.40), osteoarthritis (HR per 1 SD, 1.15; 95% CI, 1.10-1.19), and inguinal hernia (HR per 1 SD, 1.13; 95% CI, 1.07-1.19), which were primarily induced by light physical activity. Increasing MVPA by 20 minutes per day was associated with reductions in hospitalization ranging from 3.8% (95% CI, 1.8%-5.7%) for colon polyps to 23.0% (95% CI, 17.1%-28.9%) for diabetes.

Conclusions and Relevance

In this cohort study of UK Biobank participants, those with higher physical activity levels had lower risks of hospitalization across a broad range of health conditions. These findings suggest that aiming to increase MVPA by 20 minutes per day may be a useful nonpharmaceutical intervention to reduce health care burdens and improve quality of life.

Novel modification of Marcy operation for indirect inguinal hernia reconstituting deep inguinal ring shutter action

PURPOSE

The two most frequent and significant complications after inguinal hernia repair are hernia recurrence and post-herniorrhaphy chronic pain. To add anatomic and physiologic strength to the tissue repair, especially in indirect inguinal herniorrhaphy, we devised a modification of Marcy operation that can reconstitute inguinal shutter action more efficiently by changing the direction of the sutures vertical to horizontal.

METHODS

During 36 months from 1st Jan. 2019, 148cases of 140 patients were operated for Indirect inguinal hernia or Pantaloon hernia (11 cases). 145 indirect inguinal herniorrhaphy were performed exclusively with author's modification of Marcy operation. Hernia recurrence during the follow-up period (3 months-36 months), and postoperative chronic pain at 3 months after herniorrhaphy were analyzed.

RESULTS

104 cases among the 145 indirect inguinal hernia (71.7%) were operated with only deep inguinal ring (DIR) reconstruction as author modified. In 41 cases (28.3%), posterior wall reconstruction was done simultaneously. There was no recurrence or reoperation case during the follow-up period. The incidence of postoperative chronic pain at postoperative 3 months of VAS greater than 3.0 was 2.2% (3 cases).

CONCLUSIONS

Author's modification of Marcy operation was feasible anatomically in all indirect inguinal hernia repair, which is theoretically superior to classic Marcy operation in that repositioning the DIR more laterally and securing the obliquity and shutter action of the DIR. Result is at least not inferior in the aspect of short-term recurrence and chronic post-herniorrhaphy pain.

Natural history and consequence of patent processus vaginalis: An interim analysis from a multi-institutional prospective observational study

BACKGROUND

The prevalence and natural history of patent processus vaginalis (PPV) are unknown. An interim analysis was performed of a multi-institutional, prospective, observational study in neonates undergoing laparoscopic pyloromyotomy during which bilateral inguinal canals were evaluated.

METHODS

Infants under 4 months undergoing laparoscopic pyloromyotomy were enrolled at 8 children's hospitals. The presence of a PPV was evaluated and measurements recorded. Patients with a PPV are undergoing annual phone follow-up to 18 years of age. Interim analysis was performed.

RESULTS

In a cohort of 610 patient, 80 did not have a PPV examined, 4 had consent issues and were excluded, leaving 526 patients. Of these, 433 (82%) were male, median age 1.2 months (IQR 0.9, 1.6), median weight 3.89 kg (IQR 3.4, 4.46), and EGA 39 weeks (IQR 37, 40). There were 283 PPVs, 132 bilateral (47%), 116 right (41%), and 35 left (12%). Patients with a PPV were significantly younger (1.1 months (IQR 0.9, 1.5) vs 1.3 months (IQR 0.9, 1.7), p=0.02), weighed less (3.76kg (IQR 3.35, 4.26) vs 3.9kg (IQR 3.4, 4.5) p=0.03) and had a significantly lower EGA at birth (38 weeks (IQR 37, 40) vs 39 weeks (IQR 38, 40) p=0.003). Of 246 eligible infants, 208 (85%) responded to at least one annual follow-up. Two patients had an inguinal hernia repair for a symptomatic hernia, 49- and 51-days post pyloromyotomy. One had an orchiopexy and incidental inguinal hernia repair 120 days post pyloromyotomy; for a total of 3 (1.2%) hernia repairs. No additional hernias were identified in 116 patients with the PPV patients who have been followed for > 1 year.

CONCLUSIONS

The presence of a PPV at the time of pyloromyotomy is common but the need for hernia repair is rare within the first year of life. Continued long-term longitudinal follow-up of this cohort is needed.

LEVEL OF EVIDENCE

II.

Combined pantaloon and femoral hernia: a common pathology in medicine occurring simultaneously

Inguinal hernias are typically classified based on their location and can be divided into two types. The most commonly seen inguinal hernias are direct and indirect, which can both potentially require surgical intervention. When both types of hernias are seen simultaneously, it is classified as a pantaloon hernia. This case describes an instance of a femoral hernia being found along with a pantaloon hernia. We present a case of what was projected to be a common inguinal hernia repair but progressed to a rare presentation of a femoral hernia superimposed on a pantaloon hernia. Pantaloon hernias plus a femoral hernia is a rare defect that does not present as often as the different types of isolated hernias.

Postoperative outcomes that matter to patients undergoing inguinal hernia repair: A qualitative study

Background

The purpose was to explore which postoperative outcomes are important to patients operated for inguinal hernia to gain a better insight into the patient experience going through surgery.

Methods

A qualitative study was performed using semistructured individual interviews. Participants were all male and had undergone inguinal hernia repair. Data were analyzed with directed content analysis.

Results

Ten patients were interviewed. Identified domains were function, sensation, expectations, appearance, social aspects, and satisfaction with surgeon/staff. Preoperative functional limitations were the main motivation for seeking surgery, and postoperative functional improvement seemed to be the most important factor determining overall patient satisfaction.

Conclusion

Patients consider a wide range of factors when assessing the outcome of their inguinal hernia repair. Our results suggest that the current practice of outcome assessment of inguinal hernia repair with focus on recurrence may be too narrow and may not adequately reflect the patients' experience.

Summary

This qualitative study explored patients' perspectives on postoperative outcome after inguinal hernia repair, and the identified domains of importance were function, sensation, expectations, appearance, social aspects, and satisfaction with surgeon/staff. These results highlight that patients emphasize a wide range of elements when assessing the outcome of their inguinal hernia repair that are important to acknowledge, as current practice of outcome assessment of inguinal hernia repair may be too narrow.

Laparoscopic versus open groin hernia repair in older adults: a systematic review and meta-analysis

BACKGROUND

Groin hernia repair is a common surgical procedure and includes both open and laparoscopic techniques. Studies comparing outcomes of laparoscopic versus open groin hernia repair specifically in the geriatric population are lacking. This study compares the outcomes of laparoscopic versus open groin hernia repair techniques in older adults.

METHODS

A literature search was conducted in each of the five selected databases up till June 2021: PubMed (MEDLINE), EMBASE, CINAHL, Cochrane and PsychInfo (OVID). Outcomes measured included but were not limited to total length of hospital stay, mean total operative time, intraoperative complications, post-operative complications such as wound infection, seroma formation, chronic pain, mesh infection and recurrence of inguinal hernia.

RESULTS

A total of five articles were included in the final analysis. The length of postoperative hospitalization stay was shorter in patients who underwent laparoscopic hernia repair (95% CI: -1.50 to -0.72; P < 0.01, I²  = 79%). The laparoscopic repair group had a significantly smaller number of patients who sustained postoperative wound infections (95% CI: 0.02 to 0.47; P = 0.003, I²  = 0%), and lower incidence of chronic pain (95% CI: 0.14 to 0.37, P < 0.01, I²  = 46%). Analysis of the remaining outcomes did not reveal any statistically significant differences between open and laparoscopic hernia repair.

CONCLUSIONS

The results of this analysis showed a shorter length of stay, lower wound infection rates and lower chronic pain with laparoscopic groin hernia repair as compared to open repair in older adults. Future prospective studies examining the impact of age on the relationship between surgical approach (open versus laparoscopic) and surgical outcomes are needed.

Laparoscopic extraperitoneal technique versus open inguinal herniotomy in children: historical controlled intervention study

Objective

To compare surgical outcomes of percutaneous extraperitoneal simple purse string method of laparoscopic hernia (LH) repair with a traditional open inguinal hernia (OH) repair in children with indirect inguinal hernia in a single center.

Methods

This study is a historical-controlled intervention study of two groups of patients: patients in the controlled group had OH repair performed from January 2016 to December 2017, and patients in the study group had LH repair from January 2018 to December 2019 at a single institution. Outcomes of the OH and LH groups, in terms of operative time, recurrence, complications, incidence of metachronous contralateral inguinal hernia (MCIH) and contralateral patent processus vaginalis (CPPV) were analyzed.

Results

Three hundred and five patients were enrolled in the study. Among them, 95 cases underwent laparoscopic percutaneous extraperitoneal closure herniotomy (LH group), and 210 cases underwent conventional open herniotomy (OH group). In terms of operative time, only unilateral herniotomy in females of the OH group was significantly less than that of the LH group (15.7±7.1 vs 20.5±7.4 min, p=0.004). No significant difference in overall complication was observed between the two groups of patients. The incidence of CPPV in the LH group was 15.7% (15/95), and MCIH in OH group was 10.9% (23/210).

Conclusions

Laparoscopic herniotomy may prevent the need for a second operation of metachronous contralateral hernia. Both open and laparoscopic techniques are equivalent in pro and cons.

Comprehensive genome-wide association study of different forms of hernia identifies more than 80 associated loci

Hernias are characterized by protrusion of an organ or tissue through its surrounding cavity and often require surgical repair. In this study we identify 65,492 cases for five hernia types in the UK Biobank and perform genome-wide association study scans for these five types and two combined groups. Our results show associated variants in all scans. Inguinal hernia has the most associations and we conduct a follow-up study with 23,803 additional cases from four study groups giving 84 independently associated variants. Identified variants from all scans are collapsed into 81 independent loci. Further testing shows that 26 loci are associated with more than one hernia type, suggesting substantial overlap between the underlying genetic mechanisms. Pathway analyses identify several genes with a strong link to collagen and/or elastin (ADAMTS6, ADAMTS16, ADAMTSL3, LOX, ELN) in the vicinity of associated loci for inguinal hernia, which substantiates an essential role of connective tissue morphology.

Inguinal Hernia in Nonhuman Primates: From Asymptomatic to Life-Threatening Events

In this study, a review of available data and literature on the epidemiology and anamnesis of inguinal hernias in nonhuman primates, as well as on their clinical evaluation and surgical management, was conducted. Inguinal hernias are assumed to be relatively common in male nonhuman primates. Clinical signs are usually limited to a visible or palpable mass in the groin region without pain or systemic illness. Most hernias contain omentum. Careful monitoring is an acceptable treatment option for those animals. Size, the danger of incarceration, and the presence of strangulation are important factors when considering surgical repair. A strangulated inguinal hernia is an emergency, requiring prompt surgery to avoid tissue necrosis and death. Imaging techniques, as well as computed tomography (CT), ultrasonography, and magnetic resonance imaging (MRI), provide information about the anatomical characteristics of the suspected region, allowing for a diagnosis and treatment. An inguinal hernia repair can be performed with either open surgery or laparoscopic surgery. The hernia repair can be achieved by mesh or suture. Decisions regarding which repair technique to use depend on the surgeon′s skill level and preference. Complication and recurrence rates are generally low. The most common postsurgical complication is a recurrence of the hernia. Contraceptive measures are not indicated in breeders, as there is no known hereditary component, and the presence of hernia does not appear to affect fertility, nor does it predispose to occurrence, recurrence, or incarceration.

Difficulties in Diagnosing Extraperitoneal Ureteroinguinal Hernias: A Review of the Literature and Clinical Experience of a Rare Encounter in Acute Surgical Care Settings

Although inguinal hernia repair is one of the most common surgical procedures, finding a retroperitoneal structure, such as the ureter, is a rather rare occurrence. Ureteroinguinal hernias may arise in the presence or absence of obstructive uropathy, the latter raising difficulties in diagnosis for the general surgeon performing a regular inguinal hernia surgery. This study aims to collect the relevant literature describing the diagnosis and management of ureteroinguinal hernias and update it with a case encountered in our clinic. The following study was reported following the SCARE guidelines. The relevant literature describes less than 150 cases of ureteroinguinal hernias overall, considering the 1.7% prevalence of inguinal hernias in the general population. With only 20% of these hernias being described as extraperitoneal, such an encounter becomes an extremely rare finding. Our clinical experience brings a case of a 75-year-old male with frequent urinary tract infections and a large irreducible inguinoscrotal hernia of about 20/12 cm located at the right scrotum. The patient underwent an open inguinal hernia repair technique under general anesthesia, incidentally finding an extraperitoneal ureteral herniation. Segmental ureterectomy was performed with uneventful recovery. Intraoperatively, finding an incidental ureteroinguinal hernia raises concerns about probable urinary tract complications during regular hernia repair surgery and whether the diagnosis is likely to happen prior to surgical intervention. Although imaging is rarely indicated in inguinal hernias, the case reports show that a pelvic CT scan with urography in symptomatic patients with urinary symptoms will provide accurate confirmation of the diagnosis. The relevant literature is limited due to the rarity of respective cases, thus making standardized management of such cases unlikely.

The relationship between glycine levels in collagen in the anterior rectus sheath tissue and the onset of indirect inguinal hernia: A cross-sectional study

Introduction

An inguinal hernia is a protrusion of abdominal-cavity contents through the inguinal canal. Protection against an inguinal hernia depends on the integrity of fascial tissue, which is maintained by collagen. Collagen is a structural protein consisting of amino acids, the most common of which is glycine. This study aimed to determine the relationship between glycine and the appearance of lateral inguinal hernias. To this end, the researchers examined the profile of collagen and glycine levels in the tissue of the sheath of the rectus femoris in patients with lateral inguinal hernia (indirect inguinal hernia).

Methods

The study used a cross-sectional design to determine glycine levels in rectus anterior sheath tissue in patients with indirect inguinal hernia. Examination of collagen glycine levels was conducted using the ELISA (Enzyme-Linked immunosorbent assay) method. Data were analyzed using the Statistical Package for the Social Science (SPSS) program. An ANOVA test, Pearson's correlation test, and Spearman's correlation test were also performed. A p-value <0.05 was said to be significant.

Results

Across 72 samples, the mean body mass index (BMI) was 22.5 kg/m2 and, the mean clinical onset was 28.02 months. Correlation tests showed a correlation between glycine levels and clinical onset (p = 0.026). The ANOVA test showed a difference between glycine levels with age group (p = 0.025) and BMI (p = 0.015). The correlation between glycine levels and clinical-grade (p = 0.416) was not statistically significant.

Conclusion

There is a significant relationship between glycine levels and age, BMI, and clinical onset of indirect inguinal hernia.

•

The stability of the abdominal wall depends on the integrity of muscle and fascial tissue.

•

Collagen is a structural protein that helps tissues maintain their mechanical characteristics, structure, and shape.

•

The collagen structure contains amino acids such as glycine, proline, hydroxyproline, alanine, and hydroxylysine.

•

The high glycine content of collagen is vital to promoting collagen turnover, as its deficiency reduces collagen turnover.

•

There is a relationship between glycine levels and age, body mass index, and clinical onset of indirect inguinal hernia.

Comparison of Preoperative and Postoperative Testicular Elasticity and Vascularity in Pediatric Patients With Inguinal Hernia

OBJECTIVES

Testicular complications after inguinal hernia (IH) operations can be overlooked because they are difficult to diagnose, but usually have a long-term effect. This study evaluates the effects of IH on preoperative and postoperative testicular elasticity and vascularity in children with unilateral hernias, examined using the superb microvascular imaging (SMI) and shear wave elastography (SWE) modalities.

METHODS

Forty-four male children with unilateral indirect IHs were included. Quantitative SMI and SWE examinations of the testicles were performed on the herniated and intact sides, both preoperatively and at 1, 3, and 6 months postoperatively. The SMI and SWE values of the testicles were compared between the herniated and intact sides, as well as with the opposite testicle.

RESULTS

Preoperative vascular index (VI) values were lower on the herniated side than on the intact side. Furthermore, preoperative kPa and m/s values were higher on the herniated side than on the intact side. In follow-up examinations performed at 6 months postoperatively, there was no equalization of kPa or m/s values, although VI values were equalized on both sides.

CONCLUSIONS

Testicular vascularization secondary to mechanical compression in testicles on the herniated side increased significantly in the postoperative period, and reached a level similar to that of the contralateral side. Mean SWE values decreased in testicles on the herniated side, but were not equal with those of contralateral testicles. Preoperative and postoperative evaluation of testicles using SMI and SWE is important for detecting possible advanced testicular complications in children with IH.

Comparison between TAPP & Lichtenstein techniques for inguinal hernia repair: A retrospective cohort study

Background

Worldwide, inguinal hernia repair is one of the commonest surgeries. The best treatment option to primary hernia has been investigated, but there still remains lack of evidence about the ideal approach. Therefore, this study aimed to compare the outcomes of inguinal hernia repair using transabdominal preperitoneal procedure (TAPP) & Lichtenstein techniques.

Materials and methods

This was a retrospective cohort study, conducted at Department of General & Minimal Invasive Surgery, SKIMS Medical College, Bemina, Srinagar. For performing the analysis, we used SPSS. Continuous variables were expressed as mean and standard deviation, and the categorical ones were presented as frequencies and percentages.

Results

A total of 60 patients were included (30 in each group). The mean age of the patients in both groups was around 54 years, and all patients were males. In unilateral cases the operating time was greater in the TAPP group than the Lichtenstein group (p < 0.001); however, in the bilateral cases, the operating time was significantly greater in the Lichtenstein than the TAPP group (p = 0.003). The pain scores, in unilateral cases, were significantly lower in the TAPP group than the Lichtenstein group (p < 0.001). The overall complication rate in the TAPP group was 6.7% while in the Lichtenstein group it was at 23.3%. In unilateral and bilateral cases, the patients significantly returned to work earlier in the TAPP group than those in the Lichtenstein group (p < 0.001).

Conclusion

TAPP and Lichtenstein techniques are both safe and reliable techniques for inguinal hernia repair. However, TAPP repair showed lesser post-operative pain, earlier discharge from the hospital, earlier return to usual activities, better cosmetic outcomes, and less persisting pain. However, there was no significant difference in the complication rate and TAPP repair was more costly for the patient.

•

In unilateral inguinal hernia, operating time was significantly greater in TAPP group.

•

In bilateral hernia, operating time was significantly greater in Lichtenstein group.

•

In all cases, pain was significantly lower with TAPP than Lichtenstein groups.

•

The overall complication rate was not significant between the two groups.

•

Occult hernias on the opposite side could be identified in the TAPP group.

Laparoscopic surgery: an effective and safe surgical method of pediatric inguinal hernia repair

Purpose

Inguinal hernia (IH) repair is very commonly performed in children. While open repair (OR) is the standard approach, laparoscopic repair is increasingly used. This study was aimed to investigate safety and feasibility of laparoscopic repair of pediatric IH compared to OR.

Methods

We retrospectively enrolled 105 pediatric patients with IH repair between January 2011 and October 2019. The laparoscopic procedures performed were laparoscopic percutaneous extraperitoneal closure (LPEC), and three-port mini-laparoscopic repair (TLR). The OR was performed as per usual technique.

Results

Thirty-nine patients underwent OR, 16 LPEC, and 50 TLR. The preoperative laterality of IH was 45 patients (42.9%) on the right side, 50 (47.6%) on the left side, and 10 (9.5%) on both sides. It was, however, diagnosed postoperatively in 27 patients (25.7%) on the right side, 38 (36.2%) on the left side, and 40 (38.1%) on both sides. Of the 63 patients who presented with unilateral IH in the laparoscopic groups, 32 (50.8%) had synchronous contralateral patent process vaginalis (PPV) which were simultaneously repaired. This was significantly more common in children under 3 years of age. Operative time in unilateral or bilateral repair was significantly shorter in the laparoscopic repair groups (p < 0.001). Ipsilateral recurrence was not observed in any group. Metachronous contralateral IH occurrence was not significantly different between groups.

Conclusion

Laparoscopic IH repair may have benefit in terms of shorter operation time and diagnosis of unpredicted contralateral PPV compared to OR.

New Insights into the Application of 3D-Printing Technology in Hernia Repair

Abdominal hernia repair using prosthetic materials is among the surgical interventions most widely performed worldwide. These materials, or meshes, are implanted to close the hernial defect, reinforcing the abdominal muscles and reestablishing mechanical functionality of the wall. Meshes for hernia repair are made of synthetic or biological materials exhibiting multiple shapes and configurations. Despite the myriad of devices currently marketed, the search for the ideal mesh continues as, thus far, no device offers optimal tissue repair and restored mechanical performance while minimizing postoperative complications. Additive manufacturing, or 3D-printing, has great potential for biomedical applications. Over the years, different biomaterials with advanced features have been successfully manufactured via 3D-printing for the repair of hard and soft tissues. This technological improvement is of high clinical relevance and paves the way to produce next-generation devices tailored to suit each individual patient. This review focuses on the state of the art and applications of 3D-printing technology for the manufacture of synthetic meshes. We highlight the latest approaches aimed at developing improved bioactive materials (e.g., optimizing antibacterial performance, drug release, or device opacity for contrast imaging). Challenges, limitations, and future perspectives are discussed, offering a comprehensive scenario for the applicability of 3D-printing in hernia repair.

Asymptomatic contralateral inguinal and ventral hernias among people with a workers' compensation claim for hernia

STUDY AIM

There is a gap in evidence that demonstrates an increased risk of hernia formation in laborers. A notable incidence of a second asymptomatic hernia among people making a workers' compensation claim for a hernia would suggest that the pathology is not acute and probably not related to work, or the performance of a single strenuous event.

PATIENTS AND METHODS

We performed a retrospective database study of a consecutive sample of 106 adults who claimed a work-related abdominal hernia between September 2016 and December 2018 and had a Computed Tomography (CT) scan as part of a diagnostic workup. Hernias were classified as incidental if patients had a contralateral inguinal hernia with unilateral groin symptoms, or if patients had a ventral hernia with only groin symptoms or vice versa.

RESULTS

Thirty-three percent of patients had an incidental hernia. No patient factors were associated with having an incidental hernia. Higher BMI and having a concurrent incidental hernia were associated with lower odds of surgical treatment under the injury claim.

CONCLUSION

Abdominal symptoms after a work event might lead to a diagnosis of hernia, and there is a notable likelihood that the hernia is incidental and unrelated to work. New symptoms at or near the site of an abdominal hernia may or may not be from the hernia, and very often are more consistent with an abdominal muscle strain. The clinical or imaging finding of an abdominal wall defect or the presence of a hernia may be incidental, unrelated to the physical activity.

Waist Circumference is not Superior to Body Mass Index in Predicting Groin Hernia Repair in Either Men or Women

Background and aims

A high body mass index (BMI) is considered a risk factor for ventral abdominal wall hernias but protective for the development of groin hernias. The reason for this is unclear. The surrounding abdominal fat in obesity might “protect” and limit the passage through the inguinal canal. The aim was to compare two different methods used for obesity registration in groin hernia patients and to investigate the hypothesis of high BMI/low groin hernia risk phenomenon.

Methods

This was a population-based observational study comparing BMI to waist circumference (WC) as well as their correlations to the quantity of groin hernia repair performed in either sex. Two national registers were crosslinked to a large regional register including information on WC.

Results

A larger WC and a higher BMI were associated with a lower risk of having groin hernia repair in both sexes. There was no difference using either WC or BMI as a risk factor for groin hernia repair in either sex. There was no advantage to using body composition based on WC rather than BMI for surgery indication.

Conclusions

Overweight patients, both men and women, have a lower risk of undergoing groin hernia repair regardless of fat distribution. BMI is a well-established method for obesity registration and is recommended in the evaluation of hernia patients.