Perioperative opioid prescriptions associated with stress incontinence and pelvic organ prolapse surgery

BACKGROUND

There is an opioid epidemic in the United States with a contributing factor of opioids being prescribed for postoperative pain after surgery.

OBJECTIVE

Among women who underwent stress urinary incontinence and pelvic organ prolapse surgeries, our primary objective was to determine the proportion of women who filled perioperative opioid prescriptions and to compare factors associated with these opioid prescriptions. We also sought to assess the risk of prolonged opioid use through 1 year after stress urinary incontinence and pelvic organ prolapse surgeries.

STUDY DESIGN

Using a population-based cohort of commercially insured individuals in the 2005-2015 IBM MarketScan databases, we identified opioid-naive women ≥18 years who underwent stress urinary incontinence and/or pelvic organ prolapse procedures based on Current Procedural Terminology codes. We defined the perioperative period as the window beginning 30 days before surgery extending until 7 days after surgery. Any filled opioid prescription in this window was considered a perioperative prescription. For our primary outcome, we reported the proportion of opioid-naive women who filled a perioperative opioid prescription and reported the median quantity dispensed in the perioperative period. We also assessed demographic and perioperative factors associated with perioperative opioid prescription fills. Previous studies have defined prolonged use as the proportion of women who fill an opioid prescription between 90 and 180 days after surgery. We report this estimate as well as continuous opioid use, defined as the proportion of women with ongoing monthly opioid prescriptions filled through 1 year after stress urinary incontinence and/or pelvic organ prolapse surgery.

RESULTS

Among the 217,460 opioid-naive women who underwent urogynecologic surgery, 61,025 (28.1%) had pelvic organ prolapse and stress urinary incontinence surgeries, 85,575 (39.4%) had stress urinary incontinence surgery without pelvic organ prolapse surgery, and 70,860 (32.6%) had pelvic organ prolapse surgery without stress urinary incontinence surgery. Overall, 167,354 (77.0%) filled a perioperative opioid prescription, and the median quantity was 30 pills (interquartile range, 20-30). In a multivariate regression model, younger age, pelvic organ prolapse surgery with or without stress urinary incontinence surgery, abdominal route, hysterectomy, and mesh use remained significantly associated with opioid prescriptions filled. Among those with a filled perioperative opioid prescription, the risk of prolonged use defined as an opioid prescription filled between 90 and 180 days was 7.5% (95% confidence interval, 7.3-7.6). However, the risk of prolonged use defined as continuous use with at least 1 monthly opioid prescription filled after surgery was significantly lower: 1.2% (1.13-1.24), 0.32% (0.29-0.35), 0.06% (0.05-0.08), and 0.04% (0.02-0.05) at 60, 90, 180, and 360 days after surgery, respectively.

CONCLUSION

Among privately insured, opioid-naive women undergoing stress urinary incontinence and/or pelvic organ prolapse surgery, 77% of women filled an opioid prescription with a median of 30 opioid pills prescribed. For prolonged use, 7.5% (95% confidence interval, 7.3-7.6) filled an opioid prescription within 90 to 180 days after surgery, but the rates of continuously filled opioid prescriptions were significantly lower at 0.06% (95% confidence interval, 0.05-0.08) at 180 days and 0.04% (95% confidence interval, 0.02-0.05) at 1 year after surgery.

Complications Following the Use of Biologic Mesh in Ileostomy Closure: A Retrospective, Comparative Study

Prophylactic placement of mesh in the abdominal wall during ileostomy closure can decrease the rate of hernia formation. However, few studies have evaluated the safety of biologic mesh in ileostomy closure.

PURPOSE

This study aimed to investigate the safety of biologic mesh in ileostomy closure, specifically the need to remove the mesh due to infection. The rate of surgical site infection (SSI), incisional hernia, surgical site occurrence ([SSO] including seroma and hematoma), and wound pain between primary closure and mesh closure groups also were investigated.

METHODS

Using a retrospective study design, data from all consecutive patients who underwent ileostomy closure from January 2015 to June 2016 at the Hanyang University Hospital, Seoul, Republic of Korea, were analyzed. Patients with stage IV colorectal cancer, who were older than 85 years, or who experienced intestinal perforation during the procedure were excluded. Demographic (age, sex, body mass index [BMI], underlying disease) and clinical characteristics as well as SSI, SSO, length of hospital stay, use of additional analgesics, white blood cell count, C-reactive protein, and visual analog scale (VAS) pain scores (noted on days 1, 3, 5, and 14) were abstracted and compared. Clinical and surgical variables were compared using the Mann-Whitney U test, the χ2-test, or Fisher's exact test, depending on the nature of the data.

RESULTS

Of the 38 patients who underwent ileostomy closure, 33 (18 [54.5%] who received primary closure and 15 [45.5%] who received mesh closure) were included for analysis. Patient, surgical, and clinical characteristics were not significantly different, but the mean age of the primary closure group was significantly higher than that of the mesh closure group (71 ± 9 vs. 62 ± 10 years old; P = .014). The median follow-up duration was 25 months (interquartile range 18.0-31.5 months). Six (6) complications were observed in 5 patients in the primary closure group, and 8 complications in 5 patients were noted in the mesh closure group (27.8% vs. 33.3%; P = 1.000). None of the cases required removal of the biologic mesh due to mesh-related infectious complication. Two (2) SSIs occurred in the primary closure group (11.1% vs. 0%; P = .489). Three (3) patients experienced a postoperative incisional hernia (9.1%) - 1 in the primary closure group and 2 in the mesh closure group (5.6% vs. 13.3%; P = .579). No statistically significant differences in pain or length of hospitalization were noted.

CONCLUSION

No mesh-related infectious complications required biologic mesh removal, and no significant differences were noted in SSI, incisional hernia, and wound pain between the primary closure and mesh closure groups. Although not significantly different, the higher rates of hernia and SSOs in the mesh group require further study.

Evaluation of single-incision apical vaginal suspension for treatment of pelvic organ prolapse

OBJECTIVE

To present a comprehensive evaluation of anterior/apical and/or posterior prolapse repair systems with a focus on safety and surgical efficacy.

METHODS

Two hundred and twenty women with pelvic organ prolapse (POP) stage II-IV were referred for single-incision transvaginal mesh procedures in a single institution. Pre- and postoperative assessments included pelvic examination, urodynamic studies, and personal interviews about patients' quality of life and urinary symptoms.

RESULTS

The anatomical success rate was 92.3 % (203/220), regardless of primary or de-novo POP, at 12-38 month follow-up. The POP quantification parameters, except total vaginal length, improved significantly after surgery (p < 0.05). Complications included bladder injury (one case), mesh exposure (six cases) and urinary retention that required intermittent catheterization (five cases). There were no cases of bowel injury during surgery. The results indicated that 29 % of patients had de-novo stress urinary incontinence and 7.7 % of patients had de-novo POP after surgery.

CONCLUSION

The apical vaginal suspension system is a safe and effective procedure, creating good anatomical restoration and significant improvement in quality of life. However, the rate of de-novo POP in the anterior compartment of the vagina (31.8 %) seems high after treatment with apical and posterior prolapse repair systems.

Management of the uncomplicated primary inguinal hernia in 2019: the practice amongst members of the British Hernia Society

INTRODUCTION

The aim of this study was to survey the current practice of UK-based hernia surgeons in elective inguinal hernia repair.

MATERIALS AND METHODS

A questionnaire was created using SurveyMonkey™ and sent electronically to registered members of the British Hernia Society.

RESULTS

A total of 368 responses were obtained (a response rate of 55%); 83% were consultant surgeons, 91% were male and 91% stated that they had an interest in laparoscopic surgery. For an uncomplicated inguinal hernia in a male patient, 60% would perform an open Lichtenstein repair, 20% trans-abdominal pre-peritoneal repair and 20% totally extra-peritoneal repair. In a female patient, 54% would perform an open Lichtenstein repair, 25% trans-abdominal pre-peritoneal repair and 21% totally extra-peritoneal repair. 90% always use mesh in inguinal hernia repair. 93% of surgeons rarely or never perform a tissue repair.

CONCLUSIONS

Despite recent controversy, UK surgeons support the use of mesh in the repair of inguinal hernias with an open Lichtenstein repair being the most common choice. There has only been a modest increase in the use of laparoscopic surgery over the past 20 years.

Value Improvement and Resource Utilization in Complex Abdominal Wall Reconstruction

Although recommendations help guide surgeons' mesh choice in abdominal wall reconstruction (AWR), financial and institutional pressures may play a bigger role. Standardization of an AWR algorithm may help reduce costs and change mesh preferences. We performed a retrospective review of high- and low-risk patients who underwent inpatient AWR between 2014 and 2016. High risk was defined as immunosuppression and/or history of infection/contamination. Patients were stratified by the type of mesh as biologic/biosynthetic or synthetic. These cohorts were analyzed for outcome, complications, and cost. One hundred twelve patients underwent complex AWR. The recurrence rate at two years was not statistically different between high- and low-risk cohorts. No significant difference was found in the recurrence rate between biologic and synthetic meshes when comparing both high- and low-risk cohorts. The average cost of biologic mesh was $9,414.80 versus $524.60 for synthetic. The estimated cost saved when using synthetic mesh for low-risk patients was $295,391.20. In conclusion, recurrence rates for complex AWR seem to be unrelated to mesh selection. There seems to be an excess use of biologic mesh in low-risk patients, adding significant cost. Implementing a critical process to evaluate indications for biologic mesh use could decrease costs without impacting the quality of care, thus improving the overall value of AWR.

Primary Umbilical Hernia Repair: A Large-Volume Single-Surgeon Study

There are conflicting views regarding techniques for repair of small umbilical hernias (UHs). Here, we compare the recurrence rate in primary repair with that reported for mesh repair by examining a single surgeon's practice at a large medical center with a comprehensive electronic medical record. A six-year retrospective review of primary UH repairs between January 2012 and December 2017 at Kaiser Permanente Los Angeles Medical Center was undertaken. Patients were identified through a database search of the electronic medical record. The primary endpoint of UH recurrence was examined; median follow-up was 3.4 years. Primary, elective UH repair was performed in 244 patients; 71 per cent of hernias were small (<2 cm). The total number of recurrences was seven (3%). The t test analysis showed significant differences in the average size of hernia defects between those with recurrences (2 cm) and those without (1.4 cm), P < 0.05. Primary repair affords low infection and recurrence rates, comparable to those reported for mesh repair. Our single-surgeon/large-volume study contributes to the evidence that primary UH repair is a safe and durable method, with low risk of recurrence. The use of absorbable monofilament suture, and selection for lower BMI and smaller hernia sizes proved to be effective.

Worldwide hernia repair: variations in the treatment of primary unilateral inguinal hernias in adults in the United Kingdom and in low- and middle-income countries

INTRODUCTION

In this invited commentary, we aim to quantify and explain the variation between, and also within, developed healthcare systems (using the UK as an example) and low- to middle-income countries (LMICs). Rather than including complex cases, we have looked only at 'uncomplicated' primary unilateral inguinal hernias, an area where limited variation may be identified.

METHODS

Data were obtained from Hospital Episode Statistics and structured surveys in the United Kingdom and in low- and middle-income countries.

CONCLUSION

There is widespread variation in the repair of 'uncomplicated' primary inguinal hernias worldwide and within developed healthcare systems.

The management of perineal hernia following abdomino-perineal excision for cancer

PURPOSE

Perineal hernia (PH) is a tardive complication following abdomino-perineal resection (APR). Many repair methods are described and evidences are lacking. The aim of this study was to report PH management, analyze surgery outcomes and review the available literature.

METHODS

We retrospectively included all consecutive PH repair after APR performed between 2001 and 2017. We recorded data on APR surgery, PH symptoms and repair, and follow-up (recurrence and morbidity). Literature review included published articles on PubMed between 1960 and 2017.

RESULTS

24 PH repairs were included. The approach was perineal N = 16, abdominal N = 5 and combined N = 3. A biological mesh was used for 17, a synthetic for 5 and a flap for 2 patients. The median follow-up was 25 months. Overall morbidity was 37.5% (N = 9): 37.5% for the perineal, 20% for the abdominal, and 66.7% for the combined approach. Complications occurred in 35.3% of biological and 20% of synthetic mesh repairs. Recurrence rate was 41.7%, similar for biological (n = 8, 47.1%) and synthetic meshs (n = 2; 40%). No recurrence occurred in the flap group. Depending of the approach, we found 50% for perineal (n = 8) and 40% of the abdominal cohort (N = 2). Among twelve studies, recurrence rates ranged from 0 to 66.7%. Abdominal or laparoscopic approach with synthetic mesh was associated with less recurrences (0 and 12.5% respectively) and complications (37.5% and 9.5%).

CONCLUSIONS

Recurrences following PH repair are high irrespective of the repair technique. More studies are necessary to identify PH risk factors and decide the appropriate perineal reconstruction.

Repair of recurrent rectocele with posterior colporrhaphy or non-absorbable polypropylene mesh-patient-reported outcomes at 1-year follow-up

Introduction and hypothesis

The aim of this study was to compare the results of repair of isolated, recurrent, posterior vaginal wall prolapse using standard posterior colporrhaphy versus non-absorbable polypropylene mesh in a routine health care setting.

Methods

This cohort study was based on prospectively collected data from the Swedish National Register for Gynaecological Surgery. All patients operated for recurrent, posterior vaginal wall prolapse in Sweden between 1 January 2006 and 30 October 2016 were included. A total of 433 women underwent posterior colporrhaphy, and 193 were operated using non-absorbable mesh. Data up to 1 year were collected.

Results

The 1-year patient-reported cure rate was higher for the mesh group compared with the colporrhaphy group, with an odds ratio (OR) of 2.06 [95% confidence interval (CI) 1.03–4.35], corresponding to a number needed to treat of 9.7. Patient satisfaction (OR = 2.38; CI 1.2–4.97) and improvement (OR = 2.13; CI 1.02–3.82) were higher in the mesh group. However, minor surgeon-reported complications were more frequent with mesh (OR = 2.74; CI 1.51–5.01). Patient-reported complications and re-operations within 12 months were comparable in the two groups.

Conclusions

For patients with isolated rectocele relapse, mesh reinforcement enhances the likelihood of success compared with colporrhaphy at 1-year follow-up. Also, in our study, mesh repair was associated with greater patient satisfaction and improvement of symptoms, but an increase in minor complications. Our study indicates that the benefits of mesh reinforcement may outweigh the risks of this procedure for women with isolated recurrent posterior prolapse.

Trials of transvaginal mesh devices for pelvic organ prolapse: a systematic database review of the US FDA approval process

INTRODUCTION

Transvaginal mesh devices are approved in the USA by the Food and Drug Administration (FDA), through the 510(k) system. However, there is uncertainty about the benefit to harm balance of mesh approved for pelvic organ prolapse. We, therefore, assessed the evidence at the time of approval for transvaginal mesh products and the impact of safety studies the FDA mandated in 2012 because of emerging harms.

METHODS

We used FDA databases to determine the evidence for approval of transvaginal mesh. To create a 'family tree' of device equivalence, we used the 510(k) regulatory approval of the 1985 Mersilene Mesh (Ethicon) and the 1996 ProteGen Sling (Boston Scientific), searched for all subsequently related device approvals, and for the first published randomised trial evidence. We assessed compliance with all FDA 522 orders issued in 2012 requiring postmarketing surveillance studies.

RESULTS

We found 61 devices whose approval ultimately relied on claimed equivalence to the Mersilene Mesh and the ProteGen Sling. We found no clinical trials evidence for these 61 devices at the time of approval. Publication of randomised clinical trials occurred at a median of 5 years after device approval (range 1-14 years). Analysis of 119 FDA 522 orders revealed that in 79 (66%) the manufacturer ceased market distribution of the device, and in 26 (22%) the manufacturer had changed the indication. Only seven studies (six cohorts and new randomised controlled trial) covering 11 orders were recruiting participants (none had reported outcomes).

CONCLUSIONS

Transvaginal mesh products for pelvic organ prolapse have been approved on the basis of weak evidence over the last 20 years. Devices have inherited approval status from a few products. A publicly accessible registry of licensed invasive devices, with details of marketing status and linked evidence, should be created and maintained at the time of approval.

Long-term outcomes of robotic mesh sacrocolpopexy

The aim of the study is to evaluate anatomic and functional late-term outcomes of robotic mesh sacrocolpopexy (RMS) at a single tertiary-care institution. Following IRB approval, a retrospective chart review of a prospectively collected database on consecutive patients who underwent RMS for symptomatic pelvic organ prolapse and had 3 year minimum follow-up was performed. Data collected included physical examination, validated questionnaires including Urogenital Distress Inventory, Incontinence Impact Questionnaire, and global Quality of Life (QOL). The primary outcome was failure defined as the need for re-operation and/or prolapse recurrence by examination. Those with office follow-up < 36 months underwent structured phone interviews. Between 12/2007 and 2/2012, 56 women underwent RMS. Thirty women had follow-up ≥ 3 years (median 64 (IQR 48-85) months). Mean C-point went from - 2.33 (range 0 to - 5) to - 9.00 (0 to - 12) (p < 0.01), and mean QOL score from 3.93 (0-10) to 1.93 (0-8) (p < 0.01). Two developed recurrent vault prolapse later on at 26 and 34 months, respectively. Four women (13%) required surgery for secondary prolapses, with three for anterior compartment and one for posterior compartment. Sixteen of twenty six were contacted via structured phone interviews, with 14 doing well, one deceased, and one who underwent a secondary posterior compartment prolapse 6 years later at an outside facility. This long-term study indicates durability for RMS in the management of symptomatic pelvic organ prolapse.

Hiatal Hernia Repair: Current Evidence for Use of Absorbable Mesh to Reinforce Hiatal Closure

INTRODUCTION

There continues to be debate regarding the best surgical technique for the treatment of paraesophageal hernias. While laparoscopic and robotic approaches are widely employed around the world, the benefits of mesh use to reinforce hiatal closure are still not well established. The goal of this manuscript is to describe the currently available results with biologic and bioabsorbable meshes for treatment of paraesophageal hernias, particularly with reference to the rate of recurrence.

MATERIALS AND METHODS

A systematic review of the literature was conducted to identify studies describing treatment of hiatal hernias with biologic or bioabsorbable mesh. The available studies were categorized as comparative (when authors compared results with a different patient cohort undergoing suture repair of the hiatus without mesh reinforcement) and non-comparative, and organized by levels of evidence.

RESULTS

We identified two randomized control trials, a long-term follow-up to one of the trials, a prospective case control study, one retrospective case control study, two meta-analyses of the above-mentioned studies, as well as 11 non-comparative studies, which included two prospective, 10 retrospective, and two case series. Most studies involved the use of different biologic meshes, while bioabsorbable mesh use was only described in four of the retrospective studies mentioned. The results are variable, however, most authors found a benefit from hiatal closure reinforcement with mesh.

CONCLUSIONS

The available literature lacks definitive evidence to support the use of biologic or bioabsorbable materials to reinforce hiatal closure in the cure of paraesophageal hernias. Further studies are needed to assess newer materials and longer-term effects of existing products.

Explaining variation in ventral and inguinal hernia repair outcomes: A population-based analysis

BACKGROUND

No study has evaluated the relative importance of patient, surgeon, and hospital-level factors on surgeon and hospital variation in hernia reoperation rates. This population-based retrospective cohort study evaluated factors associated with variation in reoperation rates for recurrence after initial ventral hernia repair and inguinal hernia repair.

METHODS

The Statewide Planning and Research Cooperative System identified initial ventral hernia repairs and inguinal hernia repairs in New York state from 2003-2009. Mixed-effects Cox proportional hazards analyses were performed assessing factors associated with surgeon/hospital variation in 5-year reoperation rates for hernia recurrence.

RESULTS

Among 78,267 ventral hernia repairs and 124,416 inguinal hernia repairs, the proportion of total variation in reoperation rates attributable to individual surgeons compared with hospitals was 87% for ventral hernia repairs and 92% for inguinal hernia repairs. In explaining variation in ventral hernia repair reoperation between surgeons, 19% was attributable to patient-level factors, 4% attributable to mesh placement, and 10% attributable to surgeon volume and type of board certification. In explaining variation in inguinal hernia repair reoperation between surgeons, 1.1% was attributable to mesh placement and 10% was attributable to surgeon volume and years of experience. However, 67% of the variation between surgeons for ventral hernia repair and 89% of the variation between surgeons for inguinal hernia repair remained unexplained by factors in the models.

CONCLUSION

The majority of variation in hernia reoperation rates is attributable to surgeon-level variation. This suggests that hernia recurrence may be an appropriate surgeon quality metric. While modifiable factors such as mesh placement and surgeon characteristics play roles in surgeon variation, future research should focus on identifying additional surgeon attributes responsible for this variation.

Comparison between titanium mesh and autogenous iliac bone graft to restore vertebral height through posterior approach for the treatment of thoracic and lumbar spinal tuberculosis

Object

To compare the clinical efficacy of titanium mesh cages and autogenous iliac bone graft to restore vertebral height through posterior approach in patients with thoracic and lumbar spinal tuberculosis.

Method

59 patients with spinal tuberculosis underwent interbody fusion and internal fixation through posterior approach in our department from January 2011 to December 2013. In group A, 34 patients obtained titanium mesh for the reconstruction of vertebral height, among them 25 patients (group A1) suffered from single-segment spinal tuberculosis, and 9 patients, (group A2) had multi-segment spinal tuberculosis. In group B, 25 patients got autogenous iliac bone graft to restore vertebral height, including 24 patients with single-segment spinal tuberculosis (group B1), and 1 patient with multi-segment spinal tuberculosis (group B2). The clinical efficacy was evaluated based on average operation time, blood loss, hospital stays, hospitalization expenses, visual analog scale (VAS), Oswestry Disability Index (ODI), erythrocyte sedimentation rate (ESR), C-Reactive protein (CRP), neurological function recovery, bony fusion, intervertebral height, Cobb angle and postoperative complications.

Results

Final follow-up time was an average of 35.5 months ranging from 15 to 56 months. All patients were completely cured and obtained solid bone fusion. The bony fusion time was 9.4±6.1 months in group A1, 10.2±2.7 months in group A2 and 8.7±3.6 months in group B1. There were no significant difference among three groups (P>0.05). The Cobb correction and restoration of intervertebral height significantly improved compared with those in preoperation, but without significant difference among three groups (P>0.05). The loss of angular correction and intervertebral height in group A1 were found to be less than those in group B1 (P<0.05), but with no significant difference between group A1 and group A2, and between group A2 and group B1 (P>0.05). Patients in group B1 got the most loss of angular correction and intervertebral height. In addition, neurological function was revealed to be significantly improved after surgery. There were significant differences of VAS, ODI, ESR and CRP between preoperation and postoperation at the final follow-up time (P<0.05), with no significant difference among three groups (P>0.05). No statistically significant difference was found when analyzing blood loss, hospital stays, hospitalization expenses, and corrective cost among three groups (P>0.05). Complications included cerebrospinal fluid leakage (2 cases in group A1 and group A2), sinus formation (3 cases in group A1, group A2 and group B1), and intervertebral infection (1 case in group B1), but no implant failure or donor site complications was found in any patient.

Conclusions

Titanium mesh cages could obtain good clinical efficacy comparable to autogenous iliac bone graft when treating single-segment spinal tuberculosis, and may be better than autogenous iliac bone graft for treating multi-segment spinal tuberculosis.

Real-World Clinical Quality Improvement for Complex Abdominal Wall Reconstruction

INTRODUCTION

Traditional methods of clinical research may not be adequate to improve the value of care for patients undergoing abdominal wall reconstruction (AWR). These patients are prone to high complication rates and high costs. Here, we describe a clinical quality improvement (CQI) effort to enhance outcomes for patients undergoing AWR.

MATERIALS AND METHODS

CQI was applied for the entire care cycle for consecutive patients who underwent AWR from August 2011-September 2015. Initiatives for improving value during this period included use of long-term resorbable synthetic mesh as well as administration of preoperative bilateral transversus abdominus plane (TAP), and intraoperative abdominal wall blocks using long-acting bupivacaine as a part of a multimodal regimen. Outcomes data that measure value in the context of AWR were collected to compare outcomes for the patients who received TAP blocks only, TAP and intraoperative blocks, and those who received no block.

RESULTS

One hundred and two patients who had AWR for abdominal wall pathology were included. Outcomes including total opioid use, duration of stay and opioid use in the postanesthesia care unit (PACU), length of hospital stay (LOS), major wound complications, and costs, all improved over time. Specifically, PACU opioid use, total opioid use, and LOS were decreased in the two groups that received blocks versus a group that did not have any type of block.

CONCLUSIONS

CQI program implementation in patients undergoing AWR resulted in measurable improvement of value-based outcomes over time. A CQI effort applied to the entire patient cycle of care should be routinely utilized.

Hernioplasty: Tension free mesh repair versus Mayos repair for umbilical hernias

OBJECTIVE

To compare two different techniques of repairing umbilical hernia.

METHODS

The comparative study was conducted from April 2009 to December 2011 at the Gambat Institute of Medical Sciences, Gambat, Pakistan, and comprised hernia patients who were randomly allocated to group A and group B. In group A, repair was carried with tension free hernioplasty, while group B underwent Mayo's repair. All patients were operated by the same consultant surgeon. All patients were followed up for 36 months.

RESULTS

The 86 patients were divided into two groups of 43(50%) each. There were 18(20.9%) males and 68(79%) females. Patients in group A needed less post-operative analgesics 4.3±7.49 (p<0.05) and short hospital stay 6.14±1.3 days (p<0.05). Postoperative complications were more in group B (p<0.05). There was 1(2.3%) recurrence in group A and 3(7%) in group B over the 36-month follow-up.

CONCLUSIONS

Tension free mesh repair was found to be a better technique than Mayo's repair for umbilical hernia.

Hypertrophic scarring: the greatest unmet challenge after burn injury

Improvements in acute burn care have enabled patients to survive massive burns that would have once been fatal. Now up to 70% of patients develop hypertrophic scars after burns. The functional and psychosocial sequelae remain a major rehabilitative challenge, decreasing quality of life and delaying reintegration into society. Approaches to optimise healing potential of burn wounds use targeted wound care and surgery to minimise the development of hypertrophic scarring. Such approaches often fail, and modulation of the established scar is continued although the optimal indication, timing, and combination of therapies have yet to be established. The need for novel treatments is paramount, and future efforts to improve outcomes and quality of life should include optimisation of wound healing to attenuate or prevent hypertrophic scarring, well-designed trials to confirm treatment efficacy, and further elucidation of molecular mechanisms to allow development of new preventive and therapeutic strategies.

Early safety and efficacy outcomes of a novel technique of sacrocolpopexy for the treatment of apical prolapse

OBJECTIVE

To assess the safety and efficacy of a modified technique of bilateral abdominal sacrocolpopexy in which both uterosacral ligaments are replaced with polyvinylidene fluoride mesh to provide support to the cervix (cervico-sacropexy [CESA]) or vaginal vault (vagino-sacropexy [VASA]).

METHODS

A retrospective observational study was undertaken of women with posthysterectomy vault prolapse or recurrent apical prolapse following previous prolapse repair who underwent bilateral sacrocolpopexy between July 1, 2013, and December 31, 2014, in a tertiary referral unit in the UK. Before surgery and 3 months afterwards, prolapse was assessed using the Pelvic Organ Prolapse Quantification scale and functional outcomes were recorded using the International Consultation on Incontinence Questionnaire for vaginal symptoms and urinary incontinence.

RESULTS

Fifty women were included. At 3 months, 47 (94%) patients reported no bulge symptoms and the mean point C was -7.6. Complications comprised bladder injury in 1 (2%) and minor wound problems in 3 (6%) patients. No mesh erosion was reported.

CONCLUSION

Bilateral abdominal sacrocolpopexy seems to be a safe and effective option for apical prolapse. Longer-term follow-up is needed to detect prolapse recurrence and mesh-related complications.

Initial Experience with a New Macroporous Partially Absorbable Mesh: Introducing Ultrapro® Advanced™

INTRODUCTION

The Ultrapro® Advanced™ mesh (Ethicon, Sommerville, NJ) is a new mesh design, using the best characteristics from the previous platform, while adding new, advanced features. Our centre, Imelda Hospital, Bonheiden, Belgium, was chosen as one of the first clinical testing sites. The aim of this study was to present our preliminary data on complication rate and patient satisfaction.

MATERIALS AND METHODS

From October 1, 2015 until January 31, 2016, we treated 57 patients, implementing 67 Ultrapro® Advanced™ meshes. One patient was excluded due to postoperative cerebral haemorrhage with aphasia. Only patients with more than one-month follow-up were included for further analysis, resulting in a population of 41 patients with 51 meshes. Of them, 35 were male and only 6 were female, with an average age of 61.4 years and an average BMI of 25.9. The indications were uni- and bilateral laparoscopic inguinal hernia repair (n = 23 and 10 respectively), open inguinal hernia repair (n = 3), and open incisional hernia repair (n = 5). Quality of life was measured preoperatively and at four weeks postoperatively, using the hernia specific Carolina Comfort Scale (CCS) questionnaire.

RESULTS

The primary endpoint was complication rate. Only two patients (4.8%) mentioned a mild scrotal hematoma and two patients (4.8%) demonstrated a seroma. There were no superficial wound infections nor early recurrent hernias. Our secondary endpoint was quality of life, measured by the CCS questionnaire, which differentiates between a symptomatic and an asymptomatic group. A total of 13 patients were asymptomatic, whilst 28 patients reported some sort of discomfort, ranging from mild (n = 25) to moderate and/or daily symptoms (n = 3). No patients were disabled by their symptoms.

CONCLUSION

The Ultrapro® Advanced™ is a sequel of the classic Ultrapro® mesh with similar characteristics: it is a "lightweight", macroporous, partially absorbable mesh built out of thin filaments, while maintaining sufficient strength. Its improvement is due to incorporation of evidence-based characteristics such as an increased mesh elasticity. Furthermore, the surgical manipulation is improved thanks to the increased mesh memory. Our prospective cohort study shows good initial and short-term results after implementation of the Ultrapro® Advanced™. However, further prospective research is mandatory on the long-term outcomes.

Polyvinylidene Fluoride Mesh (PVDF, DynaMesh®-IPOM) in The Laparoscopic Treatment of Incisional Hernia: A Prospective Comparative Trial versus Gore® ePTFE DUALMESH® Plus

BACKGROUND

Laparoscopic approach is now generally accepted for the treatment of incisional hernia. The ideal mesh is still to be found. The aim of this study is to compare the well-known Gore® DUALMESH® Plus (WL Gore & Associates, Flagstaff, AZ) to a new prosthesis, the DynaMesh®-IPOM (FEG Textiltechnik GmbH, Aachen, Germany), to clinically verify its potential benefits in the laparoscopic treatment of incisional hernia.

MATERIALS AND METHODS

Comparing the results of the laparoscopic treatment of two groups of patients affected by incisional hernia using Gore® DUALMESH® Plus and DynaMesh®-IPOM.

RESULTS

There were 45 females and 31 males, with age variable from 21 to 84 years of age. The two groups were well matched for age (median age 60 years for group A and 57.6 years for group B-p=0.44) and sex (28F and 17M group A and 13 F and 18 M group B-p=0.008), while median BMI resulted slightly higher in group B (26.12 group A and 29.74 group B-p=0.001). The median size of the defect was similar in the two groups (87.5 mm group A and 83.4 mm for group B-p=0.83), while the median operating time was slightly longer in group A (77 min group A and 67 min group B-p=0.44). No difference in the length of hospital stay was evidenced between the two groups (3.19 days for group A and 3 days for group B-p=0.74). Time to return to physical activity was similar between the two groups (13.46 days for group A and 12.7 days for group B-p=0.32). Minor complications occurred in 15 cases (19.7%): seromas (7 cases), prolonged ileus (6 cases), and hemoperitoneum (2 cases), without significant difference in the incidence of such complications in the two groups. Five recurrences (6.5% of cases) occurred. No differences in the recurrence rate was noted between the two groups (3 cases/7% for group A and 2 cases/6% for group B-p=00.7).

CONCLUSIONS

DynaMesh®-IPOM proved to be a safe and effective mesh for the laparoscopic repair of incisional hernia even when compared to DUALMESH® Plus.

Clinical Importance and Surgical Outcomes of Green Type III Cystocele in Women With Anterior Vaginal Prolapse

OBJECTIVES

To explore the clinical importance and surgical outcomes of Green type III cystocele in women with anterior vaginal prolapse.

METHODS

A database of 336 women with a Ba point higher than -3 cm on the Pelvic Organ Prolapse Quantification system was retrospectively reviewed. Investigated data comprised those obtained from a clinical interview, the Pelvic Organ Prolapse Quantification system, and sonography. Initially, the baseline data between women with (n = 126) and without (n = 210) Green type III cystocele on sonography were compared. Subsequently, 6-month postoperative data between women who had Green type III cystocele on sonography and underwent either anterior colporrhaphy (n = 25) or a Perigee procedure (n = 76) were compared.

RESULTS

Women with Green type III cystocele had symptoms of voiding dysfunction more frequently, stress urinary incontinence less frequently, and more bulging (mean ± SD, 2.7 ± 1.2 versus 1.9 ± 1.5 for women with versus without Green type III cystocele; P = .001), a greater likelihood of stage II or higher cystocele (86.5% versus 60.0% for women with versus without Green type III cystocele; P < .001), as well as more caudodorsal bladder neck and genitohiatal positions and a wider genital hiatus on sonography. Women with Green type III cystocele had a greater likelihood of stage 0 cystocele (64.0% versus 89.5% for anterior colporrhaphy versus Perigee; P< .001) and more ventral bladder neck positions after Perigee procedures.

CONCLUSIONS

The presence of Green type III cystocele in women with anterior vaginal prolapse is associated with more functional impairments and anatomic defects. Despite comparable functional outcomes, Perigee procedures provide better anatomic outcomes for the anterior vagina in women with Green type III cystocele than anterior colporrhaphy does in the short term.

Suture, synthetic, or biologic in contaminated ventral hernia repair

BACKGROUND

Data are lacking to support the choice between suture, synthetic mesh, or biologic matrix in contaminated ventral hernia repair (VHR). We hypothesize that in contaminated VHR, suture repair is associated with the lowest rate of surgical site infection (SSI).

METHODS

A multicenter database of all open VHR performed at from 2010-2011 was reviewed. All patients with follow-up of 1 mo and longer were included. The primary outcome was SSI as defined by the Centers for Disease Control and Prevention. The secondary outcome was hernia recurrence (assessed clinically or radiographically). Multivariate analysis (stepwise regression for SSI and Cox proportional hazard model for recurrence) was performed.

RESULTS

A total of 761 VHR were reviewed for a median (range) follow-up of 15 (1-50) mo: there were 291(38%) suture, 303 (40%) low-density and/or mid-density synthetic mesh, and 167(22%) biologic matrix repair. On univariate analysis, there were differences in the three groups including ethnicity, ASA, body mass index, institution, diabetes, primary versus incisional hernia, wound class, hernia size, prior VHR, fascial release, skin flaps, and acute repair. The unadjusted outcomes for SSI (15.1%; 17.8%; 21.0%; P = 0.280) and recurrence (17.8%; 13.5%; 21.5%; P = 0.074) were not statistically different between groups. On multivariate analysis, biologic matrix was associated with a nonsignificant reduction in both SSI and recurrences, whereas synthetic mesh associated with fewer recurrences compared to suture (hazard ratio = 0.60; P = 0.015) and nonsignificant increase in SSI.

CONCLUSIONS

Interval estimates favored biologic matrix repair in contaminated VHR; however, these results were not statistically significant. In the absence of higher level evidence, surgeons should carefully balance risk, cost, and benefits in managing contaminated ventral hernia repair.

Trends in management of pelvic organ prolapse among female Medicare beneficiaries

OBJECTIVE

In the last decade, many new surgical treatments have been developed to achieve less-invasive approaches to prolapse management. However, limited data exist on how the patterns of care for women with pelvic organ prolapse (POP) may have changed over the last decade, and whether mesh implantation techniques have influenced the type of specific compartment repair performed. We used a national data set to analyze the temporal trends in patterns of care for women with POP.

STUDY DESIGN

Data were obtained from Public Use Files from the Centers for Medicare and Medicaid Services for a 5% random sample of national beneficiaries with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of POP from 1999 through 2009. Current Procedural Terminology, 4th Edition and International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes were used to evaluate nonsurgical and surgical management trends for this cohort. Types of surgery were categorized by prolapse compartment and combinations of repairs. After 2005, when applicable codes became available, mesh or graft repairs were also analyzed.

RESULTS

Over the study time period, the number of women with a diagnosis of POP in any 1 year in our 5% sample of Medicare beneficiaries remained relatively stable (range, 21,245-23,268 per year). Rates of pessary insertion were also consistent at 11-13% over the study period. Of the women with a prolapse diagnosis, 14-15% underwent surgical repair, and there was little change over time in surgical management patterns based on compartment. Most commonly, multiple compartments were repaired simultaneously. There was a rapid increase in mesh use such that in 2009, 41% of all women who underwent surgery (5.8% of the total cohort) had mesh or graft inserted in their repair. Hysterectomy rates for prolapse decreased over time. Rates of vault suspension at the time of hysterectomy for prolapse were low; however, they showed a relative increase over time (22% in 1999 to 26% in 2009).

CONCLUSION

Patterns and rates of prolapse repairs remained relatively unchanged from 1999 through 2009, with an exception of a rapid rise in mesh use. These data suggest that the majority of mesh techniques were used for augmentation purposes only, but did not result in an increase in apical repairs performed in the United States. There remains a disappointingly low rate of vault suspension repairs concomitantly at time of hysterectomy for POP.

A belgian multicenter prospective observational cohort study shows safe and efficient use of a composite mesh with incorporated oxidized regenerated cellulose in laparoscopic ventral hernia repair

BACKGROUND

A variety of anti-adhesive composite mesh products have become available to use inside the peritoneal cavity. However, reimbursement of these meshes by the Belgian Governemental Health Agency (RIZIV/INAMI) can only be obtained after conducting a prospective study with at least one year of clinical follow-up. This -Belgian multicentric cohort study evaluated the experience with the use of Proceed®-mesh in laparoscopic ventral hernia repair.

METHODS

During a 25 month period 210 adult patients underwent a laparoscopic primary or incisional hernia repair using an intra-abdominal placement of Proceed®-mesh. According to RIZIV/INAMI criteria recurrence rate after 1 year was the primary objective, while postoperative morbidity, including seroma formation, wound and mesh infections, quality of life and recurrences after 2 years were evaluated as secondary endpoints (NCT00572962).

RESULTS

In total 97 primary ventral and 103 incisional hernias were repaired, of which 28 (13%) were recurrent. There were no conversions to open repair, no enterotomies, no mesh infections and no mortality. One year cumulative follow-up showed 10 recurrences (n = 192, 5.2%) and chronic discomfort or pain in 4.7% of the patients. Quality of life could not be analyzed due to incomplete data set.

CONCLUSIONS

More than 5 years after introduction of this mesh to the market, this prospective multicentric study documents a favorable experience with the Proceed mesh in laparoscopic ventral hernia repair. However, it remains to be discussed whether reimbursement of these meshes in Belgium should be limited to the current strict criteria and therefore can only be obtained after at least 3-4 years of clinical data gathering and necessary follow-up.

Mesh or no mesh: a hamletic dilemma to prevent Renal Allograft Compartment Syndrome (RACS)

Tension-free muscle closure is essential in kidney transplantation, both in adult and pediatric patients. Tight muscle closure may lead to renal allograft compartment syndrome either due to compression of the renal parenchyma or due to kinking of the renal vessels. It may also cause kinking of the transplant kidney ureter, wound dehiscence and incisional hernia. Many techniques have been proposed in an attempt to achieve tension-free closure. There is a wrong belief among surgeons that using prosthetic mesh may increase the incidence of infective complications in these immunosuppressed patients. Also, there is fear that one is not able to monitor the renal graft by ultrasound and perform biopsy in the presence of a mesh. Other alternative techniques to mesh closure include subcutaneous placement and intraperitonealization of the kidney transplant. These techniques however, are valuable when mesh closure is unfavorable or contraindicated as in case of a potential source of infection, like a stoma. Abdominal wall fasciotomy can be adjunctive to the various techniques of muscle closure.

KEY WORDS

Abdominal mesh closure, Post transplant incisional hernia, Renal transplantation, Renal Allograft Compartment syndrome (RACS).

Prospective, single center, single surgeon's experience with an atraumatic self-adhering mesh in 100 consecutive patients

The purpose of this study was to show the short- and long-term results of a lightweight self-adhering mesh, Adhesix®. Between February 2011 and April 2013, we prospectively collected data of 100 consecutive patients who underwent incisional or inguinal hernia repair. Mean follow-up time was 23 months (range 7-33 months). Mean length of hospital stay was 1.7 days (range 0.5-16 days). No recurrences occurred. Pain was significantly reduced after 1 month (4.1 vs 1.6; 95% confidence interval [CI] 1.9-3.1; P < 0.0001) as well as at the last follow-up visit (1.6 vs 0.48; 95% CI 0.6-1.7; P < 0.0001). SF 36 scaled scores, as an indicator of quality of life, were good with 86, 84, 86, 84, 83, 88, 92, 87. Only 2 patients developed clinically significant seromas. No clinically significant hematomas were observed. Neither mesh nor wound infections occurred. Four patients developed urinary retention immediately postoperative, while 2 were hospitalized 2 weeks after discharge because of pneumonia. Two patients died because of unrelated causes. Based on these results, use of the Adhesix mesh seems to be safe, feasible, and efficient in hernia repair.

Biological mesh in contaminated fields--overuse without data: a systematic review of their use in abdominal wall reconstruction

Ventral hernia repair in contaminated fields is a significant problem for surgeons. We performed a systematic review regarding the use of biological mesh in contaminated fields for abdominal wall reconstruction. The primary end points were recurrence and infection of the hernia repair. An independent search of scientific papers in the English language was performed by three reviewers. Articles were chosen based on reference to ventral hernias, their use in infected fields, and in human subjects. Papers were scored using the Methodological Index for Non-Randomized Studies and those with a score of 8 or more were combined to evaluate the end points. A total of 16 studies from six different mesh products met our criteria. These papers comprised 554 patients with an overall infection rate of 24 per cent and a recurrence rate of 20 per cent. The largest study used 116 patients. All papers were case series. Overall the data for use of biological mesh products in contaminated fields are limited. Further controlled studies are needed to address this important and clinically relevant question. Caution should be used when using biological mesh products in infected fields because there is a paucity of controlled data and none have U.S. Food and Drug Administration approval for use in infected fields.

Mesh fixation compared with nonfixation in transabdominal preperitoneal laparoscopic inguinal hernia repair

This study was conducted to compare laparoscopic inguinal hernia repair with or without mesh fixation regarding recurrence rate and duration of operation time. A sample of 73 patients who underwent laparoscopic transabdominal pre-peritoneal (TAPP) inguinal hernia repair from January 2002 to January 2010 were derived from the medical records of university hospitals including Ekbatan, Beasat, and Shaheed Beheshti, as well as private hospitals. MERSILENE™ Mesh (Johnson & Johnson Medical GmbH, Norderstedt, Germany) fixation was performed for 23 cases and polypropylene mesh without fixation for the rest. The recurrence rate was followed in both groups for two years. The patients ages were from 7 to 64 years, 70 patients (95%) were male. Operation time for mesh fixation and nonfixation was 68.09 and 21.10 minutes, respectively (P < 0.001). Two recurrences occurred in the mesh fixation group versus no recurrence in the nonfixation group (P = 0.096). The results of this study revealed that laparoscopic TAPP inguinal hernia repair without mesh fixation is safe and feasible with no increase in recurrence rate. In addition, it offers a significantly shorter operation time than TAPP mesh fixation. However, we need more evidence based on randomized clinical trials to compare the benefits and harm of the two methods.

Abdominal wall closure in neonates after congenital diaphragmatic hernia repair

PURPOSE

Repair of Congenital Diaphragmatic Hernia (CDH) abruptly increases intra-abdominal pressure. This study sought to characterize the incidence and significance of ACS and delayed fascial closure (DFC) after CDH repair.

METHODS

We reviewed the CAPSNet database from 2006 to 2011, identifying the subset of patients that developed ACS or required DFC. Prenatal and demographic information, operative and physiologic details, and outcomes were investigated.

RESULTS

Of 349 patients with CDH, 3 (0.8%) were diagnosed with ACS, while 43 patients (12%) had DFC at the time of CDH repair. Patients more often had right-sided defects (26% vs 13%, p=0.04) and trended toward requiring a patch repair (41% vs 31.2%, p=0.23) and having a liver lobe above the diaphragmatic rim (47% vs 32.7, p=0.09). Patients with ACS or DFC had increased length of stay (47.5 vs 33.9, p=0.01), days fasting (8.2 vs 5.8, p=0.01), days on parenteral nutrition (23.6 vs 15.5, p=0.003), and days on mechanical ventilation (16.3 vs 9.0, p=0.001).

CONCLUSIONS

While ACS in neonates after CDH repair is rare (<1%), DFC is required relatively commonly (>10%) and is associated with right-sided diaphragmatic hernias. Inability to close abdominal fascia is associated with increased morbidity. Clinicians caring for neonates with CDH should be facile with strategies to manage delayed abdominal fascia closure.

Retrospective study on the use of a composite mesh (Physiomesh) in laparoscopic ventral hernia repair

The ideal mesh suited for intraperitoneal placement should address both requirements of tissue separation on the visceral surface and tissue integration on the parietal surface. Meshes with bioresorbable coatings have recently been demonstrated to be successful. In this article, the results are shown of a study with a new type of tissue-separating lightweight mesh with a bioresorbable coating (Physiomesh; Ethicon, Somerville, NJ) in laparoscopic ventral hernia repair. In this single-center retrospective analysis, 88 patients (50 men, 38 women) undergoing hernia surgery between November 16, 2010 and August 10, 2012 at the Imelda Hospital Bonheiden were included. Patients were asked to score their pre- and postoperative pain (1 month after surgery) on a visual analogue scale (VAS), as well as the chronic postoperative pain (pain at more than 6 months after surgery). The time period after which patients were pain free and after which they could return to work was also noted. Our results demonstrate that Physiomesh is a good alternative to the existing meshes leading to significant pain reduction, early return to work, acceptable complications, and low recurrence and reintervention rates.

Preliminary results of surgical and quality of life outcomes of Physiomesh in an international, prospective study

Physiomesh is a novel, lightweight, large pore, polypropylene mesh designed to have flexibility that matches the compliance of the abdominal wall in an effort to improve patient quality of life (QOL). The International Hernia Mesh Registry was queried for ventral hernia repair (VHR) and inguinal hernia repair (IHR) with Physiomesh. Demographics, operative and postoperative details, and the Carolinas Comfort Scale (CCS) as a measure of QOL were recorded. Physiomesh was used in 100 patients, 29 IHR and 71 VHR. Their average age was 56.8 +/- 13.7, and BMI was 34.0 +/- 21.0 kg/m2. For IHR, preoperative pain (CCS > or = 2) was present in 41%, but decreased at 1, 6, and 12 months postoperatively to 25.9%, 0%, and 1.6%, while movement limitation decreased from 42.9% to 18.5%, 1.6%, and 3.1%. There were no complications or recurrences. The average VHR measured 66.4 cm2; 93% underwent a laparoscopic repair. Pain was present in 59.1% preoperatively but 21% at 12 months. Movement limitations reduced from 43.2% to 15.8% at 12 months. Mesh sensation was reported in only 10.5% at 1 year. There was 1 recurrence. Physiomesh is well tolerated by patients undergoing IHR and VHR. It is associated with a very favorable long-term QOL.

Self-gripping Parietene and Parietex Progrip mesh laparoscopic hernia repair: have we found the ideal implant?

INTRODUCTION

The goal of modern laparoscopic hernia repair is to achieve a high standard of patient safety with a low threshold of hernia recurrence and chronic inguinal pain. In the absence of fixating devices and the use of the self-gripping Parietene and Parietex ProGrip mesh (Covidien AG, Zurich, Switzerland) was evaluated in this prospective clinical study. The incidence of chronic pain, postoperative complications, patient satisfaction, and hernia recurrence at follow-up after 12 and 24 months was recorded.

METHODS

Data were collected retrospectively from patient files and were analyzed for 405 male and female patients with 483 primary inguinal hernias. All patients included had undergone surgical repair for inguinal hernia by the laparoscopic transabdominal preperitoneal (TAPP) approach using Parietex ProGrip meshes performed in the same clinical center in Germany. Pre-, peri-, and postoperative data were collected and a follow-up after 12 and 24 months was performed prospectively. Complications, pain scored on a 0 to 10 NRS scale, patient satisfaction, and hernia recurrence were assessed.

RESULTS

The only complications were minor and were postoperative: hematoma/seroma (nine cases), secondary hemorrhage through the trocar's site (eight cases), hematuria, emphysema in the inguinal regions (both sides), and swelling above the genital organs (one case for each). Two patients had to be reoperated due to a hematoma in inguinal canal. At mean follow-up at 22.8 months, there were only eight reports of hernia recurrence: 1.9% of the hernias. Most patients (94.9%) were satisfied or very satisfied with their hernia repair with only 1.2% reporting severe pain (NRS score 7 to 10) and 3.6% reported mild pain.

CONCLUSION

This study demonstrates that, in experienced hands, inguinal hernia repair surgery performed by laparoscopic transabdominal preperitoneal hernioplasty using Parietene and Parietex ProGrip self-gripping meshes is rapid, efficient, and safe with low pain and low hernia recurrence rate. Since no fixating device or glue is necessary for the procedure, additional cost-effectiveness is achieved.

Reducing postoperative pain: the use of Tisseel for mesh fixation in inguinal hernia repair

INTRODUCTION

The new objective in primary hernia surgery should be the reduction of disabling chronic pain. This article will discuss the safety, efficacy, and reduction of pain of a sutureless glue mesh procedure for primary uncomplicated inguinal hernia repair.

METHODS

We began performing sutureless glue mesh repairs in 2004 for primary uncomplicated inguinal hernias with good results. After reduction of the hernia sac, polypropylene medium-weight preshaped flat mesh is fixed to the posterior inguinal wall with 0.5 mL of fibrin glue on the pubic tubercle; another 1.5 mL is sprayed on the entire mesh surface. The cord is positioned in subcutaneous space. The TI.ME.LI (Tissucol/Tisseel for MEsh fixation in LIchtenstein hernia repair) trial was planned and conducted based on this experience.

RESULTS

In two years, we treated more than 600 primary inguinal hernias with fibrin glue mesh fixation repair. At follow-up (2 to 96 months after surgery), no patients presented with severe pain, 2.7% of patients complained of moderate pain.

CONCLUSION

Fibrin sealant for mesh fixation in open repair is well tolerated and it should be considered as a first-line option for mesh fixation in open inguinal hernia repair.

One-year objective and functional outcomes of a randomized clinical trial of vaginal mesh for prolapse

OBJECTIVE

The purpose of this study was to show 12-month outcomes of a randomized trial that compared vaginal prolapse repair with and without mesh.

STUDY DESIGN

Women with stage ≥2 prolapse were assigned randomly to vaginal repair with or without mesh. The primary outcome was prolapse stage ≤1 at 12 months. Secondary outcomes included quality of life and complications.

RESULTS

All 65 evaluable participants were followed for 12 months after trial stoppage for mesh exposures. Thirty-two women had mesh repair; 33 women had traditional repair. At 12 months, both groups had improvement of pelvic organ prolapse-quantification test points to similar recurrence rates. The quality of life improved and did not differ between groups: 96.2% mesh vs 90.9% no-mesh subjects reported a cure of bulge symptoms; 15.6% had mesh exposures, and reoperation rates were higher with mesh.

CONCLUSION

Objective and subjective improvement is seen after vaginal prolapse repair with or without mesh. However, mesh resulted in a higher reoperation rate and did not improve 1-year cure.

[The benefits of tension-free methods with prosthetic materials in inguinal hernia repair]

Recurrences after inguinal hernia repair represent a significant problem for both surgeons and patients.

MATERIAL AND METHODS

This study tries to evaluate operations that were performed in Clinical Emergency Hospital Oradea, II-nd Surgical Department, between September 2007 and December 2009, using polypropylene meshes. The operations were performed using the Lichtenstein technique in loco-regional or general anesthesia. The follow up was performed at one month after surgery and then at 3, 6, 12 months with a compliance rate of 80%.

RESULTS

were similar to the results found in literature.

CONCLUSIONS

The technique is easy to learn and to perform and the benefits for patients are represented by the low recurrence rates, comfort due to low levels of postoperative pain, early discharge and early socio-professional reintegration.

Use of vaginal mesh in the face of recent FDA warnings and litigation

Choosing to use mesh in vaginal reconstructive surgery for pelvic organ prolapse or stress urinary incontinence is perplexing in the face of recent US Food and Drug Administration (FDA) warnings. In October 2008, the FDA alerted practitioners to complications associated with transvaginal placement of surgical mesh. Litigation is another concern. A Google search of "transvaginal mesh" results in numerous hits for plaintiff attorneys seeking patients with complications related to use of mesh. In light of a recent decision by the US Supreme Court and strategies by manufactures of medical devices to escape liability, it is imperative that gynecologic surgeons using transvaginal mesh document proper informed consent in the medical records. The purpose of this commentary is not to deter gynecologic surgeons from using transvaginal mesh when appropriate, but to provide an overview of current medical-legal controversies and stress the importance of documenting informed consent.

Clinical audit of the use of tension-free vaginal tape as a surgical treatment for urinary stress incontinence, set against NICE guidelines

Urinary incontinence affects a large proportion of adult women and is associated with considerable distress and social disability. In February 2003 the UK National Institute for Clinical Excellence (NICE) published new clinical guidelines on the use of tension free vaginal tape (TVT) for surgical treatment of stress urinary incontinence. Against these guidelines we have conducted a retrospective audit of patient care by the Oxford Radcliffe NHS Trust over 3 years, using the BFLUTS questionnaire in conjunction with patient records. This is believed to be the first such audit. Our results show overall performance to be satisfactory with no major problems. For all women the type of incontinence was confirmed by urodynamic investigation and in 92% of cases conservative management was tried and had failed before surgery was considered. For the TVT operation patients reported a high subjective cure rate, with 95% either fully cured or showing substantial improvement in their condition. Incidences of the main complications of TVT were found within statistical limits to be low (bladder/urethral perforation 4%; haemorrhage 1%; long-term voiding dysfunction 2%; tape rejection 0%; defective healing 0%; de novo urine retention 12%). These levels are similar to those reported elsewhere in the literature. However, a quarter of patients either did not receive full information about the TVT procedure in order to make an informed choice, or this was not documented. To improve care we recommend that local agreement should be reached between clinicians on information that will be provided to the patient as part of the consent process.

Tension-free vaginal tape: 162 cases in a district general hospital

From March 1999 to July 2002 a prospective study was carried out of 162 consecutive cases of urodynamically confirmed stress and mixed incontinence who underwent the tension-free vaginal tape (TVT) procedure. Patients were followed up at 6 weeks and 6 months and with a quality of life questionnaire at 1 year. The intraoperative complication rate was 7.6% and the postoperative complication rate was 18.8%. The subjective cure rate for patients suffering from urodynamic stress incontinence was 85%, with a further 11% experiencing significant improvement in their symptoms. The subjective cure rate for patients with mixed incontinence was 88%, with a further 9% experiencing significant improvement. The TVT procedure appears to be safe and effective for both stress and mixed incontinence for up to three years in a district general hospital. Complications in the short term are uncommon and can be managed easily.

Contemporary approaches to cystocele repair: a survey of AUGS members

INTRODUCTION

To assess practice patterns in the management of cystoceles among American Urogynecologic Society (AUGS) members.

STUDY DESIGN

A 22-question survey regarding various cystocele repair techniques was delivered to AUGS members via e-mail.

RESULTS

Of 963 members surveyed, there were 315 respondents. For the treatment of primary cystocele, 77% of respondents used midline vaginal plication; 40% used this approach for management of recurrent cystocele. At the time of abdominal sacrocolpopexy, most considered the anterior vaginal graft sufficient to address cystocele. At the time of uterosacral suspension, midline plication was the most common approach to address cystocele. The most commonly used graft material was synthetic mesh (67%). Almost half of respondents used minimally invasive transobturator devices for cystocele repair.

CONCLUSION

The wide variety of surgical approaches likely reflects the absence of a clearly defined best practice for cystocele repair, underscoring the need for rigorous surgical trials.

[16-year experience with one-day surgery inguinal hernia repair]

AIM OF THE STUDY

Evaluation of inguinal hernia repair techniques and results.

MATERIAL

Study group consist of patients undergoing inguinal hernia repair between 1990-1998 326 patients (305 men, 21 women, mean age 45.5 yrs), and between 1999-2006 693 patients (662 men, 31 women, mean age 48.5 yrs).

METHOD

Inguinal hernia repair techniques and anesthesia: 1990-1998: Bassini--234 (47.7%), Girard--52 (15.9%), Shouldice--36 (11.8%), PHS--2 (0.6%); general anesthesia--140 (430%), spinal anesthesia--186 (57%), 1999-2006: Lichtestein--207 (30.0%). Robbins-Rutkow--299 (43.1%), PHS--148 (21.3%), Shouldice--39 (5.6%); general anesthesia--28 (4%), spinal anesthesia--665 (96%).

RESULTS AND CONCLUSION

1. The use of synthetic mesh significant reduces inguinal hernia recurrences. 2. Returning to normal daily activities within short time after surgery. 3. The use of lowered doses of analgesics after surgery. 3. The use of lowered doses of analgesics after surgery. 4. After the use of synthetic hernia mesh the number of wound infections, hametaomas or seromas did not increase. 5. There were no differences in the intensity of postoperative pain related to synthetic mesh used. Inguinal hernia repair-management diagram. 1. Patients operated on through one-day surgery. 2. Hospital stay--12 hours. 3. Spinal anaesthesia. 4. The administration of antibiotic prophylaxis for elective inguinal hernia repair cannot be universally recommended. 5. We prefer Lichtenstein repair ("gold standard"). 6. Patient fully ambulated 4-6 hours after surgery. 7. Returning to normal daily activities after 2 weeks.

[Differentiated approach to surgical treatment of inguinal hernia recurrence in accordance with morphologic characteristics of musculo-aponeurotic structures of inguinal channel]

In 44 patients, ageing 39-73 yrs and suffering inguinal hernia recurrence, the investigation of musculo-aponeurotic structures of inguinal region was conducted. In 21 patients, suffering primary inguinal hernia recurrence, in concurrence with the connective tissue complex degeneration the pronounced atrophy of tissues was revealed. In 23 patients, suffering multiple inguinal hernia recurrence, the tissues degeneration and atrophy were manifested significantly. The results of investigation trust the necessity of additional plastic material application while performing hernioplasty for inguinal hernia recurrence. To optimize the primary inguinal hernia recurrence, the combined hernioplasty, applying polypropylene mesh, was performed, and for secondary recurrence--preperitoneal allohernioplasty, using operative access through the inguinal channel.

Long-term follow-up of a randomized clinical trial of non-mesh versus mesh repair of primary inguinal hernia

BACKGROUND

Prospective studies and meta-analyses have indicated that non-mesh repair is inferior to mesh repair based on recurrence rates in inguinal hernia. The only reliable way to evaluate recurrence rates after hernia surgery is by long-term follow-up.

METHODS

Between September 1993 and January 1996, a multicentre clinical trial was performed, in which 300 patients with unilateral primary inguinal hernia were randomized to non-mesh or mesh repair. Long-term follow-up was carried out from June 2005 to January 2006.

RESULTS

Median follow-up was 128 months for non-mesh and 129 months for mesh repair. The 10-year cumulative hernia recurrence rates were 17 and 1 per cent respectively (P = 0.005). Half of the recurrences developed after 3 years' follow-up. There was no significant correlation between hernia recurrence and age, level of expertise of the surgeon, contralateral hernia, obesity, history of pulmonary disease, constipation or prostate disease.

CONCLUSION

After 10 years mesh repair is still superior to non-mesh hernia repair. Recurrence rates may be underestimated as recurrences continue to develop for up to 10 years after surgery.

Use of synthetic mesh in pelvic reconstructive surgery: a survey of attitudes and practice patterns of urogynecologists

This study surveyed attitudes and practice patterns of urogynecologists regarding the use of synthetic mesh in pelvic reconstructive surgery. A web-based survey was administered to members of the American Urogynecologic Society. The survey evaluated the use of the mesh for sacrocolpopexy, suburethral sling, and vaginal pelvic reconstructive surgery. The survey had a 30.5% response rate. One hundred one (39%) respondents were women, and 158 (61%) were men. One hundred forty-seven (56.8%) participated in fellowship training. Two hundred forty-seven (99.5%) currently perform procedures using synthetic mesh, including 93% who perform sacrocolpopexy and 93% who perform suburethral slings. In a logistic regression model including gender, fellowship training, and practice setting, male surgeons and those who had not undergone fellowship training were more likely to use the mesh than those who were fellowship trained. Respondents use the mesh most commonly when performing sacrocolpopexies and suburethral slings. The use of the mesh for anterior and posterior colporrhaphy is less common.