Prosthetic Mesh Repair for Incarcerated Inguinal Hernia

Suture repair versus mesh repair in elderly populations with incarcerated or strangulated groin hernia

Tension-free hernia repair is the gold standard for groin hernia repair. However, the optimal surgical treatment for incarcerated or strangulated groin hernia in elderly populations is controversial. The aim of this study is to compare the clinical efficacy of mesh repair and suture repair in the treatment of incarcerated or strangulated groin hernia in elderly patients. Patients ≥ 65 years who underwent urgent surgical repair for incarcerated or strangulated groin hernia from January 2012 to June 2022 were included. Patients' demographic data and postoperative outcomes were retrospectively analyzed. Patients with limited life expectancy were screened from the elderly population for subgroup analysis. A total of 103 patients (median age: 84 years old, range 65-96; mean follow-up time: 36.8 ± 24.8 months) were included, involving 42 cases in the suture repair group and 61 cases in the mesh repair group. Suture repair and mesh repair had similar lengths of ICU and hospital stay, and rates of small bowel resection, chronic pain, surgical site infection, and surgical-related death. However, suture repair had a significantly higher recurrence rate than mesh repair (7% vs. 2%, P = 0.04). In our subgroup analysis, for patients with limited life expectancy (41 patients; median age: 88 years old, range: 80-96), suture repair had no statistical difference in postoperative outcomes compared with mesh repair. Mesh repair is suitable for elderly patients with acutely incarcerated or strangulated groin hernias. However, for elderly patients with limited life expectancy, suture repair and mesh repair showed similar clinical outcomes.

The importance of predictive markers in incarcerated abdominal wall hernia

PURPOSE

Emergency abdominal wall hernia repairs play a significant role in general surgical emergencies. In such cases, the time taken to decide on surgery is crucial, as the situation may progress to necrosis, perforation, and organ resection due to strangulation following incarceration. To facilitate the early detection of this condition, studies have been conducted on various predictive markers, most of which are related to similar markers used in acute mesenteric ischemia. This study aims to assess the predictive significance of preoperative laboratory and imaging findings in incarcerated abdominal wall hernia with strangulation.

METHODS

Retrospectively, 122 patients who underwent emergency surgery for incarcerated abdominal wall hernias with a preoperative diagnosis between January 1, 2018, and September 1, 2023, at the General Surgery Clinic of Samsun University Education and Research Hospital were included in the study. According to the examination of the operation notes, Group I was designated for patients who underwent bowel resection, Group II for those who underwent omental resection, and Group III for those without resection. The study investigated the association between patients 'age, gender, hernia type and side, preoperative laboratory parameters (pH, Base Excess (BE), Lactate, White Blood Cell Count (WBC), Neutrophil (N), Lymphocyte (L), Monocyte (M), Platelet (P), C-Reactive Protein (CRP), and pH/BE, pH/Lactate, Lactate/BE, N/L, N/M, L/M, N/CRP, M/P, P/CRP ratios), physical examination (PE), and imaging findings among the resection groups.

RESULTS

Out of the 122 patients operated with a preliminary diagnosis of acute incarcerated abdominal wall hernia, 68 were female, 34 were male, and the median age was found to be 67.16 (30-99). In the conducted statistical analysis, mean values of Lactate (p = 0.007), WBC (White Blood Cell) (p = 0.001), Neutrophil (p < 0.001), and NLR (Neutrophil-to-Lymphocyte Ratio) (p = 0.003) were significantly different based on resection groups. Subsequent pairwise comparisons indicated that these differences were attributed to variations in mean values of Lactate, WBC, Neutrophil, and NLR between the Bowel Resection and Resectionless groups. Mean values of Monocytes were also significantly different among resection groups (p = 0.049), and pairwise comparisons revealed that this difference was due to variations in mean values of Monocytes between the Omental Resection and Resectionless groups. The cut-off values were determined as follows in the ROC analysis: 1.2 mmol/L for Lactate, 18.5 (10^9/L) for WBC, 8.1 (10^9/L) for Neutrophil and 10 mg/L for CRP concerning bowel resection.

CONCLUSION

In cases of abdominal wall hernia operations due to incarceration, bowel and/or intra-abdominal organ resections related to strangulation can lead to significant morbidity and mortality. Beyond the imaging methods available for preoperative assessment, high levels of laboratory parameters, including Lactate, WBC, Neutrophil, and NLR ratio, may primarily indicate the need for bowel resection, considering that omental resection is associated with lower morbidity and mortality compared to bowel resection, elevated levels of monocytes may primarily indicate the requirement for omental resection in emergency abdominal wall hernia surgery. We recommend that this be prioritized in emergency surgery to prevent complications such as bowel perforation and sepsis and improve clinical outcomes. The surgeon is advised to keep this in mind.

Mesh repair versus non-mesh repair for incarcerated and strangulated groin hernia: an updated systematic review and meta-analysis

BACKGROUND

Mesh repair in incarcerated or strangulated groin hernia is controversial, especially when bowel resection is required. We aimed to perform a meta-analysis comparing mesh and non-mesh repair in patients undergoing emergency groin hernia repair.

METHODS

We performed a literature search of databases to identify studies comparing mesh and primary suture repair of patients with incarcerated or strangulated inguinal or femoral hernias who underwent emergency surgery. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics.

RESULTS

1095 studies were screened and 101 were thoroughly reviewed. Twenty observational studies and four randomized controlled trials comprising 12,402 patients were included. We found that mesh-based repair had reduced recurrence (OR 0.36; 95% CI 0.19, 0.67; P = 0.001; I2 = 35%), length of hospital stay (OR - 1.02; 95% CI - 1.87, - 0.17; P = 0.02; I2 = 94%) and operative time (OR - 9.21; 95% CI - 16.82, - 1.61; P = 0.02; I2 = 95%) without increasing surgical site infection, mortality or postoperative complications such as seroma, chronic, ileus or urinary retention. In the subgroup analysis of patients that underwent bowel resection, we found that mesh repair was associated with an increased risk of surgical site infection (OR 1.74; 95% CI 1.04, 2.91; P = 0.04; I2 = 9%).

CONCLUSIONS

Mesh repair for incarcerated and strangulated groin hernias reduces recurrence without an increase in postoperative complications and should be considered in clean cases. However, in the setting of bowel resection, mesh repair might increase the incidence of surgical site infection.

Haematological inflammatory markers for indicating ischemic bowel in patients with incarcerated abdominal wall hernias

PURPOSE

To reveal the clinical significance of preoperative haematological inflammatory markers in the diagnosis of abdominal wall hernias with strangulation.

METHODS

The data of 200 patients who underwent surgery for incarcerated hernia were retrospectively analysed. The patients were grouped into three groups; Group 1; only surgical reduction and hernia repair, Group 2; small bowel resection and Group 3; omentum resection. Age, gender, hernia type, the presence of radiological bowel obstruction and preoperative complete blood count data were obtained. Neutrophil-leukocyte ratio (NLR), lymphocyte-monocyte ratio (LMR), platelet-lymphocyte ratio (PLR), haematological inflammatory index (HII) and systemic immune-inflammation index (SII) values were calculated.

RESULTS

The study was consisted of; Group 1: 119 patients (59.5%), Group 2: 46 patients (23%) and Group 3: 35 patients (17.5%). Advanced age (p = 0.001), female gender (p = 0.036), incisional hernias (p =  < 0.001) and the presence of bowel obstruction (p =  < 0.001) were found to be statistically significant in terms of strangulation. NLR, PLR and SII values were significantly higher in Group 2 compared to Group 1, and PLR values were significantly higher in Group 2 compared with Group 3 (p < 0.05).

CONCLUSION

The preoperative elevated NLR, PLR and SII values may indicate strangulation and possible intestinal resection, in incarcerated abdominal wall hernias.

The role of basic blood parameters in determining the viability of intestinal tissue in incarcerated hernias

OBJECTIVE

Abdominal hernia repair is a common surgery, with incarcerated hernias accounting for 15% of all cases. In these cases, early diagnosis of intestinal ischaemia and necrosis is crucial to prevent mortality and morbidity. Biomarkers that can predict ischaemic or necrotic status are of vital importance. The aim of this study was to reveal the roles of basic blood parameters in determining ischaemic or necrotic status.

METHODS

Patients were divided into three groups. Group I included 24 patients with normal bowels, Group II included 31 patients with intestinal ischaemia without necrosis, and Group III included 10 patients who underwent bowel resection for necrosis. Patients' demographic characteristics and blood parameters were retrospectively analysed.

RESULTS

A total of 65 patients were operated for incarcerated abdominal hernias. There was no significant difference between the groups in terms of age, sex, comorbidity or complications (P > .05). Group III had the longest length of hospital stay (P < .001). There were significant differences between the groups in terms of serum white blood cell (WBC), neutrophil, lymphocyte (LYM), neutrophil-lymphocyte ratio (NLR), urea, creatinine, total bilirubin, indirect bilirubin, lipase, C-reactive protein (CRP) and lymphocyte-to-C-reactive protein (CRP) ratio (LCR) values (P < .05).

CONCLUSION

Blood parameters combining with clinical symptoms and radiological examination may contribute to predicting intestinal resection. Preoperative WBC, neutrophil, NLR, urea, creatinine and total bilirubin levels can contribute to predict the onset of intestinal ischaemia. Serum creatinine, total bilirubin, indirect bilirubin, phosphorus, lactate dehydrogenase (LDH) and lipase levels can contribute to deciding on bowel resection.

Effectiveness and Safety of Mesh Repair for Incarcerated or Strangulated Hernias: A Systematic Review and Meta-Analysis

BACKGROUND

Hernia repair with mesh in patients with incarcerated or strangulated hernias is controversial. Moreover, the use of mesh for hernia repair with concomitant bowel resection poses a great dilemma. This study compared the outcomes of mesh and anatomic repairs in patients with acutely incarcerated or strangulated hernias.

METHODS

PubMed, Embase, and Cochrane databases were searched for studies published before November 2019. Randomized controlled trials (RCTs) and prospective studies were included. We conducted meta-analyses using a random-effects model. The treatment outcome was measured by the incidence of surgical site infection (SSI), seroma formation, and hernia recurrence postoperatively.

RESULTS

Two RCTs and six prospective studies with 978 patients were included. No significant difference in SSI incidence was observed between patients with incarcerated hernia from the mesh and anatomic repair groups. Recurrence was significantly lower in mesh repair group than in anatomic repair group (odds ratio, 0.08; 95% confidence interval, 0.01-0.45). Only two patients needed to have mesh explantation due to mesh infection. In the setting of hernia repair with concomitant bowel resection, the SSI rate with mesh repair was slightly higher, but most cases of infections were well controlled with conservative antibiotic therapy.

CONCLUSIONS

Mesh repair for incarcerated or strangulated hernias was feasible with a great benefit of lower recurrence rates. However, due to limited data, drawing conclusions regarding the use of mesh for hernia repair with concomitant bowel resection was difficult. Further studies with preset criteria for evaluating patients undergoing concomitant bowel resection may help elucidate this issue.

Analysis of risk factors associated bowel resection in patients with incarcerated groin hernia

BACKGROUND

Incarcerated groin hernia (IGH) is a common surgical emergency. However, there are few accurate and applicable predictors for differentiating patients with strangulated groin hernia from those with IGH. In this study, we aimed to identify the independent risk factors for bowel resection in patients with IGH.

METHODS

We retrospectively collected 323 patients who underwent emergency hernia repair surgery for IGH between January 2010 and October 2019. The patients were categorized into those who received bowel resection and those who did not require bowel resection. The receiver-operating characteristic curve was used to identify the best cutoff values for continuous variables. Following this, univariate and multivariate analyses were performed to identify potential risk factors for bowel resection in these patients.

RESULTS

Univariate analysis identified 6 variables that were significantly associated with bowel resection among patients with IGH. On multivariate analysis, neutrophil-to-lymphocyte ratio (NLR) (odds ratio [OR] = 3.362, 95% confidence interval [CI] 1.705-6.628, P = .000) and bowel obstruction (OR = 3.191, 95% CI 1.873-5.437, P = 0.000) were identified as independent risk factors for bowel resection among patients with IGH.

CONCLUSION

In this study, an elevated NLR and those with bowel obstruction are associated with an increased risk of bowel resection among patients with IGH. Based on our findings, surgeons should prioritize prompt emergency surgical repair for patients who present with elevated NLR and bowel obstruction concurrent with IGH.

Emergency TREPP for Strangulated Inguinal Hernia Repair: A Consecutive Case Series

Background  Patients with strangulated inguinal hernia (SIH) require emergency surgical treatment. International guidelines do not specify the surgical technique of preference. Frequently, an open anterior approach such as the Lichtenstein technique is used. The TransREctus sheath Pre-Peritoneal (TREPP) technique is an alternative, open posterior approach, which has shown promising results in the elective treatment of inguinal hernias. This study aims to evaluate the feasibility and safety of the TREPP technique in the emergency setting of SIHs. Materials and Methods  After medical ethical approval was warranted, all consecutive patients, who underwent emergency TREPP (e-TREPP) at a high-volume hernia institute, were retrospectively included from 2006 up to and including 2016. Data retrieved from the electronic patient files were combined with the findings during a long-term outcome physical investigation at an outpatient department visit. e-TREPP was, prior to the start of the study, defined as TREPP performed immediately at the operation room. Results  Thirty-three patients underwent e-TREPP for SIH. Ten patients were clinically evaluated, ten patients were deceased, nine patients could not be contacted, and four patients did not or could not consent. Of the ten deceased patients, one patient died perioperatively due to massive aspiration followed by cardiac arrest. Nine patients died due to other causes. Two patients developed a recurrence after (after 13 days and 16 months respectively). Two patients were surgically treated for a wound infection (mesh removal in one). No patient reported chronic postoperative inguinal pain. Conclusion  e-TREPP in experienced hands seems feasible and safe (Level of Evidence 4) for the treatment of patients with strangulated inguinal hernia, with percentages of postoperative complications comparable to other techniques.

The results of open preperitoneal prosthetic mesh repair for acutely incarcerated or strangulated inguinal hernia: a retrospective study of 146 cases

BACKGROUND

Tension-free hernia repair has been regarded as the gold-standard treatment for selected inguinal hernias, but the use of prosthetic mesh in acutely incarcerated or strangulated inguinal hernias is controversial. Our aim was to evaluate the safety and efficacy of open prosthetic mesh repairs for emergency inguinal hernias.

METHODS

Patients with acutely incarcerated or strangulated inguinal hernias who underwent open preperitoneal prosthetic mesh repairs during 2013 to 2016 at our department were included. Patients' characteristics, operative details, results, and complications were retrospectively analyzed.

RESULTS

During a 4-year period, 146 cases who met the inclusion criteria were enrolled in our study. There were 127 males and 19 females of median age 75 years (range 19-95 years). The hernia was indirect inguinal in 104 (71.2%) patients, direct inguinal in 18 (12.3%), and femoral hernia in 24 (16.5%). Bowel resection was necessary in 20 patients (13.7%). Complications occurred in 15 (10.3%) patients, including wound infection in 6 (4.1%), scrotal hematoma in 2 (1.4%), bleeding in 1 (0.7%), deep vein thrombosis (DVT) in 2 (1.4%), and chest infection in 4 (2.7%). No mesh-related infections were detected. There were 2 mortalities. During the median follow-up of 26 months (range 6-53 months) 2 recurrences occurred, but there were no deaths or further infections.

CONCLUSION

Open preperitoneal prosthetic mesh repair can be safely performed in patients with incarcerated or strangulated inguinal hernia without contaminated hernia content. Mesh repair is not contraindicated in patients with bowel resection.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Risk factors of postoperative complications after emergency repair of incarcerated groin hernia for adult patients: a retrospective cohort study

Purpose

This study aimed to explore risk factors of postoperative complications for adult patients with incarcerated groin hernia (IGH).

Methods

From January 2010 to December 2017, consecutive patients undergoing emergency hernia repair for IGH in our center were retrospectively reviewed. Postoperative complications, such as surgical site infection, seroma, hernia recurrence and mortality, were investigated, with risk factors for such complications analyzed using univariate and multivariate regressions.

Results

Sixty-four patients were included, with 51 males and 13 females (mean age 65.1, range 25–98 years). Ten patients (15.6%) underwent resection of necrotic bowel and anastomosis. 43 patients (67.2%) received open tension-free herniorrhaphy with polypropylene mesh, whereas the rest (32.8%) received herniorrhaphy without mesh. The overall postoperative complication rate was 40.6% (26/64), with an incisional complication rate of 31.2% (20/64) and an infection rate of 6.2% (4/64). At a median follow-up of 32 months, hernia recurrence and mortality were recorded in five cases each (7.8%). Mesh repair was associated with decreased recurrence rate compared with non-mesh repair (2.3% vs. 19.0%, p = 0.019). Diabetes mellitus (OR 8.611, 95%CI 1.292–57.405; p = 0.026) was an independent risk factor of postoperative complications, together with chronic obstructive pulmonary disease (COPD; OR 14.365, 95%CI 1.652–127.767, p = 0.016), intestinal necrosis (OR 14.260, 95%CI 1.079–188.460, p = 0.044), and general anesthesia (OR 14.543, 95%CI 1.682–125.711, p = 0.015) as risk for incisional complications after surgery.

Conclusions

Diabetes mellitus was an independent risk factor of postoperative complications for IGH, along with COPD, intestinal necrosis and general anesthesia associated with incisional complications. The use of polypropylene mesh did not increase infection or recurrence rate in this cohort.

Hernioscopy in Incarcerated Inguinal Hernia Spontaneously Reduced after General Anesthesia Induction

Hernioscopy is essentially hernia sac laparoscopy. Hernia repair has evolved over the years with better outcomes; however, strangulated inguinal hernias are acute surgical emergencies which require emergent operative intervention. During anesthesia induction and/or after incision, hernia self-reduction is possible, with or without compromised bowel, back into the abdominal cavity. It is pivotal to examine the bowel to decide on further operative course. A simple alternative to unnecessary laparotomy or standard laparoscopy is hernioscopy, which is quite uncommon. We present a case of an acute symptomatic strangulated left-sided inguinal hernia which got self-reduced during anesthesia induction and was successfully repaired after hernioscopy was used to evaluate the incarcerated hernia content. We provide a brief review of literature about hernioscopy and an algorithm to guide surgeons in emergent cases.

Prostheses Used in Laparoscopic Inguinal Hernia Repair: Biocompatibility, Postoperative Complications and Quality of Life - Review of the Literature

INTRODUCTION

There is a continuous concern about meshes used in laparoscopic inguinal hernia repair, which mainly relates to their biocompatibility and ability to decrease postoperative complications and recurrence rate; in other words, efforts are made to find the "ideal" prosthesis.

OBJECTIVES

To evaluate different prostheses used in laparoscopic inguinal hernia repair in terms of biocompatibility, postoperative complications, recurrence rate and quality of life, so that all the features could lead us to the "ideal" mesh.

MATERIAL AND METHOD

Randomized controlled trials, reviews, prospective and retrospective studies, retrospective cross-sectional and experimental studies on animals published between 2000 and 2016 were analysed with respect to several features of a mesh: biocompatibility, postoperative complications, recurrence rate and quality of life.

OUTCOMES

The most common comparison is between heavy-weight and light-weight mesh used in laparoscopic inguinal hernia repair. Experimental studies try to discover the "ideal" prosthesis, which could provide improved biocompatibility, low postoperative complications, decreased recurrence rate and good quality of life. The most commonly used mesh that meats the characteristics of an "ideal" prosthesis is a light-weight monofilament macroporous polypropylene mesh, with a minimum tensile strength >16 N/cm², measuring 10x15 cm.

CONCLUSIONS

Published data show that the "ideal" prosthesis used in laparoscopic inguinal hernia repair has not been discovered yet. Regarding heavy- or light-weight meshes, there is no significant effect on recurrence, acute or chronic pain, incidence of seroma or return to daily activity and quality of life (1).