Complications in groin hernia surgery and the way out

Ventral hernia repair in India: a Delphi consensus

PURPOSE

While research on inguinal hernias is well-documented, ventral/incisional hernias still require investigation. In India, opinions on laparoscopic ventral hernia repair (LVHR) techniques are contested. The current consensus aims to standardize LVHR practice and identify gaps and unfulfilled demands that compromise patient safety and therapeutic outcomes.

METHODS

Using the modified Delphi technique, panel of 14 experts (general surgeons) came to a consensus. Two rounds of consensus were conducted online. An advisory board meeting was held for the third round, wherein survey results were discussed and the final statements were decided with supporting clinical evidence.

RESULTS

Experts recommended intraperitoneal onlay mesh (IPOM) plus/trans-abdominal retromuscular/extended totally extraperitoneal/mini- or less-open sublay operation/transabdominal preperitoneal/trans-abdominal partial extra-peritoneal/subcutaneous onlay laparoscopic approach/laparoscopic intracorporeal rectus aponeuroplasty as valid minimal access surgery (MAS) options for ventral hernia (VH). Intraperitoneal repair technique is the preferred MAS procedure for primary umbilical hernia < 4 cm without diastasis; incisional hernia in the presence of a vertical single midline incision; symptomatic hernia, BMI > 40 kg/m2, and defect up to 4 cm; and for MAS VH surgery with grade 3/4 American Society of Anaesthesiologists. IPOM plus is the preferred MAS procedure for midline incisional hernia of width < 4 cm in patients with a previous laparotomy. Extraperitoneal repair technique is the preferred MAS procedure for L3 hernia < 4 cm; midline hernias < 4 cm with diastasis; and M5 hernia.

CONCLUSION

The consensus statements will help standardize LVHR practices, improve decision-making, and provide guidance on MAS in VHR in the Indian scenario.

Fluorescence-guided laparoscopic inguinal hernia repair using indocyanine green angiography to prevent iatrogenic vascular injury: A case report and video

INTRODUCTION

Laparoscopic inguinal hernia repair (LIHR) is one of the most common surgical procedures performed worldwide, associated with a roughly 10 % rate of complications, most commonly iatrogenic injury to blood vessels, sometimes necessitating conversion to open surgery. Fluorescence-guided laparoscopic surgery using indocyanine green fluorescence angiography (ICG-FA) facilitates the precise identification of numerous anatomical structures, especially vascular, reducing their risk of iatrogenic injury. We present the first published case and video demonstrating LIHR with ICG-FA to prevent intra-operative vascular injury.

PRESENTATION OF CASE

A 46-year-old, otherwise-healthy male with a right inguinal hernia underwent fluorescence-guided LIHR using ICG-FA. Before peritoneal dissection, 2 ml ICG was administered intravenously, followed by 10 ml physiological solution. The surgical field was then illuminated using the Stryker fluorescence system. Once vascular structures were located, the sac was dissected. After reversing the peritoneum, but before placing the extraperitoneal mesh, another dose of ICG was administered intravenously to aid in safely securing the mesh. Both times after ICG injection, both the iliac artery and spermatic arteries were clearly visible throughout their course in the surgical field within 45 s. The hernia was repaired successfully with no complications.

DISCUSSION

ICG-FA appears to facilitate inguinal hernia repair by enabling real-time visualization of anatomical structures, theoretically reducing the risk of complications, particularly vascular injuries. It is particularly helpful identifying the inguinal area's highly-vascular 'triangle of doom'.

CONCLUSIONS

Further studies are warranted to evaluate short- and the long-term outcomes and cost-effectiveness of ICG-fluorescence angiography during laparoscopic inguinal hernia repair.

Comparing stapler and sutured mesh fixation techniques for laparoscopic TAPP repair: a study on chronic groin pain on 3-year follow-up

Trans-abdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repairs are the available surgeries for inguinal hernias, with both methods of laparoscopic repairs requiring mesh applications. This study analyzes the correlation between sutured versus stapler mesh fixation in a laparoscopic TAPP for unilateral groin hernia regarding chronic pain during 3-year follow-up. A total of 130 patients with laparoscopic hernia undergoing TAPP repair were randomized into 2 groups based on their fixation technique-one with sutures and the other with stapler. Postoperative complications and chronic groin pain were noted for each technique. Equal number of participants was present in the stapler and suture groups, with the majority having an ASA score of one. The mean age was 42.50 ± 13.86 years, and the body mass index (BMI) was 27.47 ± 5.88. The stapler group presented a shorter mean operative time than the suture group. However, the stapler group had a significantly higher mean VAS score than the suture group. Most participants in the suture group (89.2%) had LOS for 1 day, while a 2-day LOS was significantly higher in the stapler group (12.3%) than in the suture group (9.2%). No patient reported mesh erosion, conversion, recurrence, testicular atrophy, and mesh infection. Early postoperative pain was more in stapler group along with long hospital stay, but both were non-significant. Chronic postoperative pain results and recurrence incidences over 3-year follow-up were also similar. Re-admission rates were minimal, no significant complications occurred.

Outcome of the incarcerated abdominal wall hernias managed by open and laparoscopic approaches

Background & Objective

Laparoscopic surgery is generally considered as better than open surgery in terms of less complications, minimal hospital stays and quick healing of the wounds. Our objective was to compare the immediate and early outcome of the different incarcerated hernias of anterior abdominal wall operated on as emergency cases by open and laparoscopic approach.

Methods

This is a retrospective comparative study which was conducted at two hospitals of AlAhsa city of the Eastern region of the Kingdom of Saudi Arabia from July, 2017 to June, 2022. The data were retrieved from the medical records of the hospitals. All male and female patients having different types of incarcerated hernias of anterior abdominal wall presenting to the emergency room were included in the study. The patients were divided in two groups; those who were operated on by open approach (Group-I) and those who were operated on by laparoscopic approach (Group-II).

Results

Out of total 70 male and female patients, 42 were in Group-I and 28 in Group-II. The variety of the incarcerated hernias in both groups overall was para-umbilical 26(37.14%), incisional 18(25.71%), inguinal (right & left) 17(24.28%) and epigastric 9(12.86%). The mean operative time taken by Group I and II was 126.07 (±9.728) and 98.57 (±10.079) minutes respectively with a difference of 27.50 minutes (p=0.807). The mean hospital stay of the patients in Group I and II was 1.36(±0.719) and 1.57(±0.997) days respectively (p=0.482). The post-operative complications rate in Group-I was 6(14.28%) and in Group-II, 6(21.43%) (p=0.658). Overall, 12(17.14%) patients developed the complications in both groups. When the number of the complications is compared, it shows that there was no significant difference between the two groups (p=0.583).

Conclusion

Laparoscopic approach is not superior to the open approach in the terms of the immediate and early outcome/complications of the incarcerated hernias of the anterior abdominal wall operated as emergency cases in this study.

The burden of Chronic Pelvic Pain (CPP): Costs and quality of life of women and men with CPP treated in outpatient referral centers

INTRODUCTION

Chronic Pelvic Pain (CPP) is a complex, multifaceted condition that affects both women and men. There is limited literature on the cost utilization the healthcare system and CPP patients incur. The purpose of this analysis is to characterize the overall healthcare utilization, cost burden, and quality-of-life restrictions experienced by CPP patients using data from an outpatient pelvic rehabilitation practice.

METHODS

Healthcare utilization data was gathered by systematically reviewing and analyzing data from new patient visit progress notes stored in the clinic's electronic health records (EHR). We obtained in-network costs by using the FAIR Health Consumer online database. Overall costs were then calculated as the utilization times the per-unit costs from the FAIR database. Additionally, data on patients' visual analogue scale (VAS), absenteeism, presenteeism emergency room visits, usage of common pain medications, use of diagnostics, and participation in common treatment modalities was gathered.

RESULTS

Data from 607 patients was used. The overall cost burden per patient for all surgeries combined was $15,750 for in-network services. The cost burden for diagnostics was $5,264.22 and treatments was $8,937 per patient for in-network treatments.

CONCLUSION

Chronic Pelvic Pain was found to have a large cost burden of $29,951 for in-network services which includes treatments, diagnostics, and surgeries. This analysis sets the stage for future investigations involving data on costs of medications that patients have tried prior to presenting to us and costs associated with work hours lost.

Management of iliofemoral vein injury during open inguinal hernia repair

BACKGROUND

Vascular injuries during inguinal hernia repair are rarely reported. Especially in children, we have little information about vascular management.

CASE REPORT

In this article, we present a 6-year-old girl with right iliac vein ligation during inguinal hernia repair who was referred to our center and managed at the day of surgery. We recommended prior surgeon to order therapeutic heparin in dispatch time. The patient was treated with primary anastomosis of iliac vein and was admitted to pediatric intensive care unit (PICU). On the day following the operation, she had minimal dyspnea with low oxygen saturation and the investigations revealed pulmonary micro-embolization. Blood flow in lower extremity was normal and after a few days, she was discharged with good health and oral anticoagulation.

CONCLUSION

Any unusual bleeding at the time of inguinal hernia repair should be considered as major vascular injury by the surgeon, and to prevent more injuries, minimum attempt must be performed to control the bleeding.

Entrapped appendicitis in post TAPP mesh repair

Transabdominal preperitoneal (TAPP) repair is a common laparoscopic inguinal hernia repair technique performed worldwide. A rare long-term complication of TAPP is mesh-induced appendicitis, of which only four cases have been described in the literature to date. We report a case of appendicitis due to appendix entrapped in the TAPP mesh.

Closed non-suction drain placement as haematoma and seroma formation preventive measure post-nylon darn surgery for inguinoscrotal hernias in adults

Purpose

Inguinal hernia is a common male surgical disease. Intervention carries a wide range of complications such as scrotal haematoma and seroma which may require surgical re-intervention or predispose patients to developing infections, pains or feeling of mass. This could lead to long hospital stay. Scrotal tamponade by bandaging or wearing of tight pants and elevation are practiced to reduce bleeding and haematoma formation. These methods require prolong use. Closed suction drains are scarcely used in resource-deprived communities due to high cost and non-availability.

Aim

This study was to determine the effectiveness of a closed non-suction drain in preventing scrotal collection requiring further surgical intervention and the predisposition to developing surgical site infection following nylon darn repair of inguinoscrotal hernia.

Methods

Forty (40) participants were recruited for a preliminary study and assigned into control and interventional groups (CG, IG) for purposes of inserting flexible feeding tube (FFT) wound drain after nylon darn (ND) repair. Daily measurement of drained scrotal collection was carried out in the IG till the day drainage was zero. Residual volumes in IG and wound collection in the CG who were not candidates for re-intervention were determined at 14th and 28th post-operative days using ultrasound scan. Data were analyzed using SPSS version 25.

Results

Three (3) patients (15.8%) in the CG required re-intervention. Surgical site infection rates for the CG and IG were, respectively, 2/19 versus 0/21 (ρ = 0.134).There was a numerical significant difference in the mean volumes of scrotal collections between the control (0.95 ± 0.42 ml) and the intervention group (0.44 ± 0.33 ml) [p value of 0.041] but with no clinical impact.

Conclusion

Simple inexpensive flexible feeding tube placement significantly reduced scrotal collection which forms a base for larger sample size in subsequent studies. This could reduce the feared risk of re-intervention, wound infection and long hospital stay post-operative.

Laparoscopic versus open inguinal hernia repair in children: which is the true gold-standard? A systematic review and meta-analysis

PURPOSE

Hernia repair is one of the most common operations performed in children. Traditionally, an open surgical approach has been utilized; however, laparoscopic repair has been gaining favour within the surgical community. We aimed to determine whether open or laparoscopic hernia repair is optimal for pediatric patients by comparing recurrence rates and other outcomes.

METHODS

We searched CENTRAL, MEDLINE, and EMBASE from 1980 onwards, including studies that compared laparoscopic and open repair for pediatric inguinal hernia.

RESULTS

Our initial search yielded 345 unique citations. Of these, we reviewed the full text of 28, and included 21 in meta-analysis. The results showed that patients who underwent laparoscopic surgery were more likely to experience wound infection (p = 0.003), but less likely to experience ascending testis (p = 0.05) and metachronous hernia (p = 0.0002). There were no differences in recurrence rates (p = 0.95), surgical time (p = 0.55), length of hospitalization (p = 0.50), intra-operative injury, bleeding, testicular atrophy, or hydrocele.

CONCLUSION

Laparoscopic and open surgeries are equivalent in terms of recurrence rates, surgical time, and length of hospitalization. Laparoscopic repair is associated with increased risk of wound infection, but decreased risk of ascending testis. Laparoscopic surgery allows the opportunity to explore and repair the contralateral side, preventing metachronous hernia.

LEVEL OF EVIDENCE

III.

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

BACKGROUND

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

AIM

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Prevalence and Cost Analysis of Chronic Pain After Hernia Repair: A Potential Alternative Approach With Neurostimulation

OBJECTIVES

Chronic pain (CP) affects a significant number of patients following hernia repair, ranging from 11 to 54% in the literature. The aim of this study was to assess the prevalence, overall costs, and health care utilization associated with CP after hernia repair.

MATERIALS AND METHODS

A retrospective longitudinal study was performed using the Truven MarketScan® data base to identify patients who develop chronic neuropathic posthernia repair pain from 2001 to 2012. Patients were grouped into CP and No Chronic Pain (No CP) cohorts. Patients were excluded if they 1) were under 18 years of age; 2) had a previous pain diagnosis; 3) had CP diagnosed <90 days after the index hernia repair; 4) had less than one year of follow-up; or 5) had less than one-year baseline record before hernia repair. Patients were grouped into the CP cohort if their CP diagnosis was made within the two years following index hernia repair. Total, outpatient, and pain prescription costs were collected in the period of five years prehernia to nine years posthernia repair. A longitudinal multivariate analysis was used to model the effects of chronic neuropathic posthernia repair pain on total inpatient/outpatient and pain prescription costs.

RESULTS

We identified 76,173 patients who underwent hernia repair and met inclusion criteria (CP: n = 14,919, No CP: n = 61,254). There was a trend for increased total inpatient/outpatient and pain prescription costs one-year posthernia repair, when compared to baseline costs for both cohorts. In both cohorts, total inpatient/outpatient costs remained elevated from baseline through nine years posthernia repair, with the CP cohort experiencing significantly higher cumulative median costs (CP: $51,334, No CP: $37,388). The CP diagnosis year was associated with a 1.75-fold increase (p < 0.001) in total inpatient/outpatient costs and a 2.26-fold increase (p < 0.001) in pain prescription costs versus all other years. In the longitudinal analysis, the CP cohort had a 1.14-fold increase (p < 0.001) in total inpatient/outpatient costs and 2.00-fold increase (p < 0.001) in pain prescription costs.

CONCLUSIONS

Our study demonstrates the prevalence of CP after hernia surgery to be nearly 20%, with significantly increased costs and healthcare resource utilization. While current treatment paradigms are effective for many, there remains a large number of patients that could benefit from an overall approach that includes nonopioid treatments, such as potentially incorporating neurostimulation, for CP that presents posthernia repair.

An Analysis of Early Postoperative Returns after Inguinal Hernia Surgery

Although inguinal herniorrhaphy is low risk, patients still return to the urgent care or ED. We performed a retrospective study on 19,296 inguinal hernia operations across 14 Southern California Kaiser Permanente medical centers over five years. Unplanned returns within the first postoperative week were evaluated focusing on four potentially avoidable diagnoses (AD): pain, constipation, urinary retention, and nausea/vomiting. Overall, 1370 (7%) patients returned to the urgent care/emergency department, of which 537 (39%) had an AD. There was no difference in total returns (7.1 vs 7.4%, P = 0.33) or AD returns [2.8 vs 2.6%, ( P = 0.44)] for males vs females. Of the 537 total AD returns, there were 205 (38%) patients with pain, 191 (36%) with urinary retention, 112 (21%) with constipation, and 29 (5%) with nausea/vomiting. Most AD returns (78%) occurred within the first three postoperative days. Pain was greater in open operations [44 vs 26%, ( P < 0.05)], and urinary retention was greater in the laparoscopic group [27 vs 55%, ( P < 0.05)]. The overall rate of return was higher for laparoscopic compared with open unilateral operations [8 vs 6%, ( P < 0.05)], but similar between approaches for bilateral operations [11 vs 10%, ( P = 0.32)].

Quality of life after laparoscopic totally extraperitoneal repair of an asymptomatic inguinal hernia

BACKGROUND

When considering an asymptomatic inguinal hernia, surgeons must weigh the risks of watchful waiting against the risk of operative complications. Laparoscopy offers the benefit of reduced postoperative pain, which, for appropriate surgical candidates, may strengthen the case for repair. This study compares general and disease-specific quality of life following totally extraperitoneal (TEP) laparoscopic inguinal hernia repair (LIHR) of asymptomatic and symptomatic hernias.

METHODS

We summarize prospective data from 387 patients who underwent TEP LIHR between 2009 and 2015 by four surgeons at a single institution. Asymptomatic individuals were identified by pain scores of zero at preoperative clinic visits. Validated quality of life (QOL) measurements were administered preoperatively and at 3 weeks, 6 months, and 1-year postop. Comparisons were made using Chi-square test, t test, or Mann-Whitney U test. Changes over time were assessed using longitudinal mixed effects models.

RESULTS

A cohort of 79 asymptomatic cases were compared to 308 symptomatic individuals. The asymptomatic cohort had larger median hernia defects (2.5 vs 2 cm, p < 0.01), was older (mean 63.0 vs 58.9 years, p = 0.03), included fewer indirect hernias (57.7 vs 74.9%, p < 0.01), took pain medication for fewer days (mean 1.2 ± 1.5 vs 2.2 ± 3.0 days, p = 0.02), returned to baseline activities of daily living earlier (median 3 vs 5 days, p < 0.01), and reported decreased postoperative pain (p = 0.02). There was no significant difference in general QOL. There was one recurrence in the asymptomatic group and were two in the symptomatic cohort.

CONCLUSIONS

Asymptomatic individuals undergoing TEP LIHR reported less postoperative pain, returned to baseline activities, and discontinued pain medication sooner than symptomatic patients. These results are encouraging and may inform patient-centered discussions about asymptomatic hernia repair.

Slit versus non-slit mesh placement in total extraperitoneal inguinal hernia repair

BACKGROUND

The goal of the present research was to study patients who underwent laparoscopic total extraperitoneal repair using slit and non-slit mesh placement.

METHODS

Patients who underwent laparoscopic inguinal hernia repair in our hospital between 2005 and 2009 were interviewed and examined. Surgery outcome, hernia recurrence, postoperative pain and time to return to normal physical activities, and surgery satisfaction were compared.

RESULTS

During the study period 389 consecutive patients underwent laparoscopic groin hernia repair: 387 by the total extraperitoneal (TEP) approach and 2 by the TAPP approach. Six of the TEP patients were converted to TAPP. Eighty-seven patients in the TEP group had slit mesh placement and 300 had non-slit mesh placement. Mean follow-up was 36 months (range: 6-66 months). At follow-up, 387 patients responded to a request for interview and 277 were examined. The overall recurrence rate was 4.7%, the incidence of constant postoperative pain was 1.3%, the presence of permanent testicular pain was 2.8%, and patient satisfaction with the surgery was 94.5%. A significantly lower recurrence rate was found in the slit mesh group than in the non-slit group (0.6% versus 5.9%; p < 0.003). There was no difference in the length of time until return to normal activities, patient satisfaction, and postoperative pain between the groups. Surgery time and the occurrence of testicular pain were significantly greater in the anatomic group.

CONCLUSIONS

Total extraperitoneal inguinal hernia repair with slit mesh placement is a safe technique with a very low recurrence rate and is superior to non-slit mesh positioning.