Randomized clinical trial comparing inguinal hernia repair with Lichtenstein technique using non-absorbable or partially absorbable mesh. Preliminary report

Selective anterior annuloplasty during inguinal herniotomy in boys: an approach to further reduce hernia recurrence

BACKGROUND

Hernia recurrence is one of the most common complications after inguinal herniotomy (IH) in children. We describe a novel approach that involves adding anterior annuloplasty (AAP) during IH for selective high recurrence-risk children.

OBJECTIVES

Evaluate the initial safety and effectiveness of selective AAP during IH in boys.

DESIGN

Retrospective SETTING: Tertiary care center.

PATIENTS AND METHODS

The study included boys younger than 15 who were selected to undergo either IH with or without AAP between January 2011 and January 2022. The preoperative recurrence risks were compared for the two groups. Cases who underwent other forms of hernia repair were excluded.

MAIN OUTCOME MEASURES

The frequency of recurrence and other postoperative complications and the distribution of high recurrence-risks.

SAMPLE SIZE

315 boys; 143 underwent IH and AAP, while 172 had IH only.

RESULTS

Among all the cases, only one recurrence was reported (0.3%). Other complications were hydrocele in 29 (9.2%), scrotal hematoma/inflammation in 9 (2.9%), and wound infection in 8 (2.6%), which resolved spontaneously in all cases. Compared to IH only, those selected for an additional AAP were significantly younger (3 [16%] vs. 12 [46%] months, P=.038) and more likely to be premature (35 [24.5%] vs. 15 [8.7%], P<.0001), frequently had extensive cremasteric adhesions (39.2% versus 3.5%, P<.0001) and had a higher rate of incarcerated hernia at presentation (6.3% versus 1.2%, P=.026). The high-recurrence risk group was almost twice as likely to be selected for an additional AAP compared to the low-risk group (143 vs. 75, P<.0001).

CONCLUSION

Adding simple AAP to conventional hernia repair for high-recurrence risk boys can be a safe and effective step to reduce the overall risk of recurrence without increasing the incidence of other postoperative complications.

LIMITATIONS

The study lacked a control group of patients to whom selective AAP would not be offered despite a high-recurrence risk. A prospective, controlled trial with a longer follow-up would lead to a stronger conclusion.

Definition of Mesh Weight and Pore Size in Groin Hernia Repair: A Systematic Scoping Review of Randomised Controlled Trials

Introduction: Groin hernia literature often uses the terms light- and heavyweight and small or large pores to describe meshes. There is no universal definition of these terms, and the aim of this scoping review was to assess how mesh weight and pore sizes are defined in the groin hernia literature. Methods: In this systematic scoping review, we searched PubMed, Embase, and Cochrane CENTRAL. We included randomised controlled trials with adults undergoing groin hernia repair with the Lichtenstein or laparoscopic techniques using a flat permanent polypropylene or polyester mesh. Studies had to use the terms lightweight, mediumweight, or heavyweight to be included, and the outcome was to report how researchers defined these terms as well as pore sizes. Results: We included 48 studies with unique populations. The weight of lightweight meshes ranged from 28 to 60 g/m2 with a median of 39 g/m2, and the pore size ranged from 1.0 to 4.0 mm with a median of 1.6 mm. The weight of heavyweight meshes ranged from 72 to 116 g/m2 with a median of 88 g/m2, and the pore size ranged from 0.08 to 1.8 mm with a median of 1.0 mm. Only one mediumweight mesh was used weighing 55 g/m2 with a pore size of 0.75 mm. Conclusion: There seems to be a consensus that meshes weighing less than 60 g/m2 are defined as lightweight and meshes weighing more than 70 g/m2 are defined as heavyweight. The weight terms were used independently of pore sizes, which slightly overlapped between lightweight and heavyweight meshes.

Varying convalescence recommendations after inguinal hernia repair: a systematic scoping review

PURPOSE

The most recent international guideline on inguinal hernia management recommends a short convalescence after repair. However, surgeons' recommendations may vary. The objective of this study was to give an overview of the current convalescence recommendations in the literature subdivided on the Lichtenstein and laparoscopic inguinal hernia repairs.

METHODS

In this systematic review, three databases were searched in August 2021 to identify studies on inguinal hernia repairs with a statement about postoperative convalescence recommendations. The outcome was convalescence recommendations subdivided on daily activities, light work, heavy lifting, and sport.

RESULTS

In total, 91 studies fulfilled the eligibility criteria, and 50 and 58 studies reported about convalescence recommendations after Lichtenstein and laparoscopic repairs, respectively. Patients were instructed with a wide range of convalescence recommendations. A total of 34 Lichtenstein studies and 35 laparoscopic studies recommended resumption of daily activities as soon as possible. Following Lichtenstein repairs, the patients were instructed to resume light work after median 0 days (interquartile range (IQR) 0-0), heavy lifting after 42 days (IQR 14-42), and sport after 7 days (IQR 0-29). Following laparoscopic procedures, the patients were instructed to resume light work after median 0 days (IQR 0-0), heavy lifting after 14 days (IQR 10-28), and sport after 12 days (IQR 7-23).

CONCLUSION

This study revealed a broad spectrum of convalescence recommendations depending on activity level following inguinal hernia repair, which likely reflects a lack of high-quality evidence within this field.

Hybrid: Evolving techniques in laparoscopic ventral hernia mesh repair

Introduction

Laparoscopic repair is now the treatment of choice for most cases of ventral/incisional hernia. Although the technique has undergone many refinements, there is no standard technique for difficult or complicated hernias.

Aim

The aim of this study was to show the different innovative methods used to treat difficult ventral hernia through hybrid techniques.

Materials and Methods

A total of 75 (n = 75) patients underwent Laparoscopic Ventral Hernia Hybrid Mesh Repair (LVHHMR) by our surgical unit between January 2014 and December 2016. Three different techniques of repairing the defects were used. Mesh fixation time, post-operative pain score (visual analogue score) and follow-up for pain and recurrence (at 6 months, 12 months and 24 months) were recorded and analysed.

Results

Out of 75 patients (20 men and 55 women), the median age was 45 years and body mass index of the patients was 25-35. Types of hernias operated were paraumbilical hernias, incisional and recurrent hernias. The techniques used were (1) laparoscopic adhesiolysis, open sac excision with closure of defect and laparoscopic mesh placement, (2) laparoscopic adhesiolysis, omphalectomy with closure of defect and laparoscopic mesh placement and (3) open adhesiolysis, sac excision with closure of defect and laparoscopic mesh placement. Five patients required analgesics for 48 h. No patients complained of pain at follow-ups (1 month, 6 months, 12 months and 24 months). Mean hospital stay postoperatively was 2-3 days.

Conclusion

LVHHMR is safe and feasible approach for complicated/difficult ventral hernias. However, further larger studies are required to establish these methods as gold standard.

Uniformity of Chronic Pain Assessment after Inguinal Hernia Repair: A Critical Review of the Literature

BACKGROUND

Chronic postoperative inguinal pain (CPIP) is the most common long-term complication of inguinal hernia repair. As such procedures are routinely performed, CPIP can be considered a significant burden to global health care. Therefore, adequate preventative measures relevant to surgical practice are investigated. However, as no gold standard research approach is currently available, study and outcome measures differ between studies. The current review aims to provide a qualitative analysis of the literature to seek out if outcomes of CPIP are valid and comparable, facilitating recommendations on the best approach to preventing CPIP.

METHODS

A systematic review of recent studies investigating CPIP was performed, comprising studies published in 2007-2015. Study designs were analyzed regarding the CPIP definitions applied, the use of validated instruments, the availability of a baseline score, and the existence of a minimal follow-up of 12 months.

RESULTS

Eighty eligible studies were included. In 48 studies, 22 different definitions of CPIP were identified, of which the definition provided by the International Association for the Study of Pain was applied most often. Of the studies included, 53 (66%) used 33 different validated instruments to quantify CPIP. There were 32 studies (40%) that assessed both pain intensity (PI) and quality of life (QOL) with validated tools, 41% and 4% had a validated assessment of only PI or QOL, respectively, and 15% lacked a validated assessment. The visual analog scale and the Short Form 36 (SF36) were most commonly used for measuring PI (73%) and QOL (19%). Assessment of CPIP was unclear in 15% of the studies included. A baseline score was assessed in 45% of the studies, and 75% had a follow-up of at least 12 months.

CONCLUSION

The current literature addressing CPIP after inguinal hernia repair has a variable degree of quality and lacks uniformity in outcome measures. Proper comparison of the study results to provide conclusive recommendations for preventive measures against CPIP therefore remains difficult. These findings reaffirm the need for a uniform and validated assessment with uniform reporting of outcomes to improve the burden that CPIP poses to a significant surgical patient population.

Lichtenstein Mesh Repair (LMR) v/s Modified Bassini's Repair (MBR) + Lichtenstein Mesh Repair of Direct Inguinal Hernias in Rural Population - A Comparative Study

INTRODUCTION

Lichtenstein's tension free mesh hernioplasty is the commonly done open technique for inguinal hernias. As our hospital is in rural area, majority of patients are labourers, open hernias are commonly done. The present study was done by comparing Lichtenstein Mesh Repair (LMR) v/s Modified Bassini's repair (MBR) + Lichtenstein mesh repair (LMR) of direct Inguinal Hernias to compare the technique of both surgeries and its outcome like postoperative complications and recurrence rate.

MATERIALS AND METHODS

A comparative randomized study was conducted on patients reporting to MNR hospital, sangareddy with direct inguinal hernias. A total of fifty consecutive patients were included in this study of which, 25 patients were operated by LMR and 25 patients were operated by MBR+LMR and followed up for a period of two years. The outcomes of the both techniques were compared.

RESULTS

Study involved 25 each of Lichtenstein's mesh repair (LMR) and modified bassini's repair (MBR) + LMR, over a period of 2 years. The duration of surgery for lichtenstein mesh repair is around 34.56 min compared to LMR+MBR, which is 47.56 min which was statistically significant (p-value is <0.0001). In this study the most common complication for both the groups was seroma. The pain was relatively higher in LMR+MBR group in POD 1, but not statistically significant (p-value is 0.0949) and from POD 7 the pain was almost similar in both groups. The recurrence rate is 2% for LMR and 0% for MBR+LMR.

CONCLUSION

LMR+MBR was comparatively better than only LMR in all direct inguinal hernias because of low recurrence rate (0%) and low postoperative complications, which showed in our present study.

Combination of liechtenstein repair with herniorrhaphy in open inguinal hernia repair- a prospective observational single center study

CONTEXT

This study is about documentation of a technique which includes a combination of both hernioplasty and Herniorrhaphy, and its outcome in terms of recurrence rate and postoperative complications. It also compares the outcome of this method with routinely used techniques reported in the literature.

MATERIALS AND METHODS

LR with Herniorrhaphy was performed in the patients admitted with inguinal hernia under concerned surgeon. Their follow-up was assessed after 12 months. Incidences of recurrence rate and other postoperative complications like painful scar, atrophy of testis, urinary retention, hematoma, sinus and infection were noted and compared with other techniques of repair from published data.

STATISTICAL ANALYSIS

was carried out by calculating the mean, standard deviation (SD), percentage and incidence rates.

RESULTS

LR with Herniorrhaphy performed in 475 patients showed recurrence rate of <<0.01% (n=1) and very low incidences of other postoperative complications like painful scar (0.01%, n=5), sinus (0%, n=0), atrophy of testis (0%, n=0), retention of urine (0.01%, n=6), hematoma (<<0.01%, n=1) and infection (0%, n=0); as compared to published data with different techniques.

CONCLUSION

LR with Herniorrhaphy can be used for open inguinal hernia repair as the gold standard procedure as it has got low recurrence rate and other postoperative complications as compared to other techniques. However, the result of this study is based on the data from a single center, thus we recommend multicentric trials to test the efficacy of this technique.

An innovative repair for a re-recurrence of an incarcerated inguinal hernia

A patient presented with a recurrent incarcerated inguinoscrotal hernia requiring urgent surgery. The defect was through the gap in the mesh left originally for the cord structures. As a result, a modified funnel repair was performed. An innovative approach was adopted that was best suited to tackling and reducing the risk of recurrence.

Single incision approach to totally extraperitoneal inguinal hernia repair

Introduction

Nowadays the vast majority of inguinal hernia repairs are laparoscopically assisted. Single incision laparoscopy aims to accelerate recovery and provide a better cosmetic outcome after the operation.

Aim

To present our own modification of the totally extraperitoneal (TEP) procedure with a single incision and without a multiport, and compare the results with those obtained in the classic three-trocar TEP method.

Material and methods

The study group comprised 61 males. The first group consisted of 35 males who underwent single incision videoscopic alloplasty TEP. The second group comprised 26 males who underwent videoscopic alloplasty using the classic approach. The study assessed the time of operation, complications and postoperative pain based on the VAPS scale.

Results

The operation time in the first group was statistically longer compared with the time in the second group. The assessment of differences in postoperative pain in both the examined groups on the first and seventh day after the operation was considered statistically insignificant. In both the studied groups there was no recurrence of hernia established on the first and seventh day after the operation.

Conclusions

The reduced number of incisions in the TEP method with a single incision approach without a multiport involves a decrease in the number of postoperative scars, and thus offers a better cosmetic outcome compared with the classic TEP procedure. The time of TEP operation performed with a single incision approach without a multiport is statistically longer than the duration of the classic laparoscopic TEP procedure.

Laparoscopic repair of incisional and ventral hernias with the new type of meshes: randomized control trial

Introduction

Laparoscopic incisional and ventral hernia repair (LIVHR) was first reported by Le Blanc and Booth in 1993. Many studies are available in the literature that have shown that laparoscopic repair of incisional and ventral hernia is preferred over open repair because of lower recurrence rates (less than 10%), less wound morbidity, less pain, and early return to work.

Aim

To identify the long-term outcomes between the different types of meshes and two techniques of mesh fixation, i.e., tacks (method Double crown) and transfascial polypropylene sutures.

Material and methods

A total of 92 patients underwent LIVHR at our department between January 2009 and August 2012. The hernias were umbilical in 26 patients, paraumbilical in 15 patients and incisional in 51 patients. All patients admitted for LIVHR were randomized to either group I (tacker fixation of ePTFE meshes) or group II (suture fixation of meshes with nitinol frame) using computer-generated random numbers with block randomization and sealed envelopes for concealed allocation.

Results

The mean mesh fixation time was significantly higher in the tacker fixation group (117 ±15 min vs. 72 ±6 min, p < 0.01). There were no conversions in either group. The median postoperative hospital stay was 3.5 ±1.5 days. All patients were followed up at 1, 3, 6, 12 and every 6 months thereafter postoperatively. There were 5 recurrences in the study population. In group I there were 4 patients with recurrence, and only 1 patient in the group with meshes with a nitinol frame.

Conclusions

Meshes of the new generation with a nitinol framework can significantly improve laparoscopic ventral hernia repair. The fixation of these meshes is very simple using 3–4 transfascial sutures. The absence of shrinkage of these meshes makes the probability of recurrence minimal. Absence of tackers allows postoperative pain to be minimized. We consider that these new meshes can significantly improve laparoscopic ventral hernia repair.

Effect of mesh type, surgeon and selected patients' characteristics on the treatment of inguinal hernia with the Lichtenstein technique. Randomized trial

Introduction

Though not entirely free of complications, the Lichtenstein technique is still considered the “gold standard” for inguinal hernia repair due to the low recurrence rate.

Aim

In our study we determined the effect of mesh type, surgeon and selected patients’ characteristics on treatment results. The latter were determined by the frequency of early complications, recovery time and return to normal activities, chronic pain and hernia recurrence.

Material and methods

Tension-free hernia repair with the Lichtenstein technique was performed in 149 male patients aged 20-89 years randomized to two trial groups. One group comprised 76 patients with heavyweight non-absorbable polypropylene mesh (HW group) and the other included 73 patients with lightweight partially absorbable mesh (LW group). The control schedule follow-up took place on the 7^th day as well as in the 3^rd and 6^th month after the operation. Statistical analysis was performed with multi-factor regression models.

Results

In the LW group patients returned to normal activity faster (p = 0.031), experienced less intensive chronic pain (p = 0.01) and expressed higher treatment satisfaction (p = 0.024) than the patients from the HW group. The type of mesh had an insignificant influence on the risk of early complications and hernia recurrence. Statistically significant differences were observed however with regard to surgeon, type and hernia duration, patient's general condition and body mass.

Conclusions

Both types of mesh are equally effective for prevention of hernia recurrence. Lightweight partially absorbable meshes are more beneficial to patients than the heavyweight non-absorbable type. The surgeon and patients’ characteristics have a significant impact on the treatment outcome.