PROphylactic closed incision Negative-PRESSure treatment in open incisional hernia repair: Protocol for a multicenter randomized trial (PROPRESS study)

Background

Negative Pressure Therapy in closed incisions (ciNPT) after surgery has shown positive effects including reduction of Surgical Site Infection (SSI) incidence. In patients undergoing elective open incisional hernia repair, however, ciNPT is not standard care, perhaps due to high-quality evidence still not provided. This study hypothesizes that this patient group would benefit from ciNPT by reducing wound complications and improving postoperative quality of life.

Method

This is a multicenter Randomized Controlled Trial (RCT) including a total of 110 patients allocated in a 1:1 ratio with one intervention arm and one active control arm receiving ciNPT (i.e., Prevena™) and standard wound dressing, respectively. The primary outcome is the incidence of SSI at 30 days postoperatively and secondary outcomes are 1) pooled incidence of Surgical Site Occurrence (SSO), 2) patient-reported pain and satisfaction with the scar, and 3) hernia-related quality of life.

Conclusion

Patients undergoing elective open incisional hernia repair are fragile with a high risk of wound complication development. This multicenter RCT seeks to deliver the high-quality evidence needed to establish the role ciNPT must play for exactly this group with the aim of reducing SSI incidence and health economic costs, and finally improving quality of life. There are no theoretical or clinical experience of unwanted consequences of this treatment.

Chronic postsurgical pain (CPSP): an underestimated problem after incisional hernia treatment

BACKGROUND

Chronic postsurgical pain (CPSP) is a potential long-term problem following open incisional hernia repair which may affect the quality of life of patients despite successful anatomical repair of the hernia. The aim of this manuscript was to identify the incidence and outcome of patients following open incisional hernia repair in respect of risk factors to develop CPSP.

METHODS

A single-center retrospective analysis of patients who underwent open incisional hernia repair between 2015 and 2021 was performed. Pre-existing conditions (e.g., diabetes mellitus and malignancy), hernia complexity, postoperative complications, and postoperative pain medication were analyzed using the local database. Quality of life and CPSP were assessed using the EuraHS Quality of Life (QoL) questionnaire.

RESULTS

A total of 182 cases were retrospectively included in a detailed analysis based on the complete EuraHS (QoL) questionnaire. During the average follow-up period of 46 months, this long-term follow-up revealed a 54.4% incidence of CPSP and including a rate of 14.8% for severe CPSP (sCPSP) after open incisional hernia surgery. The complexity of the hernia and the demographic variables were not different between the group with and without CPSP. Patients with CPSP reported significantly reduced QoL. The analgesics score which includes the need of pain medication in the initial days after surgery was significantly higher in patients with CPSP than in those without (no CPSP: 2.86 vs. CPSP: 3.35; p = 0.047).

CONCLUSION

The presence of CPSP after open incisional hernia repair represents a frequent and underestimated long-term problem which has been not been recognized to this extent before. CPSP impairs QoL in these patients. Patients at risk to develop CPSP can be identified in the perioperative setting by the need of high doses of pain medication using the analgesics score. Possibly timely adjustment of pain medication, even in the domestic setting, could alleviate the chronicity or severity of CPSP.

A multi-center study on recurrent inguinal hernias: assessment of surgeons' compliance to guideline-based repair and evaluation of short-term outcomes

INTRODUCTION

As patients with recurrent inguinal hernia (RIH) are at a higher risk of perioperative complications, international guidelines have been developed to mitigate these risks by recommending the reverse approach for repair. We aim to study the characteristics of RIH, compliance to guidelines-based repair (GR) and determine factors influencing compliance to guidelines.

METHODS

A retrospective study of patients with RIH was carried out at two tertiary institutions in Singapore, over 10 years from January 2010 to 2020.

RESULTS

There were 16 patients with bilateral recurrences and 214 patients with unilateral recurrences. The characteristics of patients with non-guidelines-based repair (NGR) versus GR were similar, p > 0.05. GR was performed for 128 (52.1%) hernias as compared to NGR for 118 (47.9%) hernias. The open approach was more common in NGR than GR, 115/118 (89.8%) versus 58/128 (45.3%), p < 0.001. Forty (n = 40, 16.3%) RIH presented emergently, of which 37 underwent NGR while 3 underwent GR, p < 0.0001. More consultants were present during GR 103/128 (80.5%) as compared to NGR 78/118 (66.1%), p = 0.018. Emergency presentation of hernia recurrence, OR 7.74 (CI 6.11-9.20), p = 0.005, and open repair during the index repair were significantly associated with NGR, OR 6.63 (CI 4.42-8.84), p = 0.01. Median length of stay was shorter in the GR 1 day (IQR 1-2 days) versus 2 days (IQR 2-5 days) in the NGR group, p = 0.02.

CONCLUSION

The compliance rate of GR for RIH is 52%. NGR for RIH had acceptable short-term outcomes. For elective presentation of RIH, GR should be encouraged given a shorter length of hospital stay.

Management of lateral abdominal hernias

PURPOSE

Lateral abdominal wall hernias are rare defects but, due to their location, repair is difficult, and recurrence is common. Few studies exist to support a standard protocol for repair of these lateral hernias. We hypothesized that anchoring our repair to fixed bony structures would reduce recurrence rates.

METHODS

A retrospective review of all patients who underwent lateral hernia repair at our institution was performed.

RESULTS

Eight cases (seven flank and one thoracoabdominal) were reviewed. The median defect size was 105 cm² (range 36-625 cm²). The median operative time was 185 min (range 133-282 min). There were no major complications. One patient who was repaired without mesh attachment to bony landmarks developed a recurrence at ten months and subsequently underwent reoperation. Patients with mesh secured to bony landmarks were recurrence free at a median follow-up of 171 days.

CONCLUSIONS

Lateral hernias present a greater challenge due to their anatomic location. An open technique with mesh fixation to bony structures is a promising solution to this complex problem.

Evaluation of Mobility Status after Inguinal Hernia Surgery

Background

Many different studies have compared open and laparoscopic-endoscopic inguinal hernia repair techniques according to intraoperative and postoperative complications, recurrence rates, postoperative inguinal chronic pain, quality of life, and costs. Most of the researchers have compared these different inguinal hernia repair techniques using a visual analog scale, a short-form survey instrument, or patients' return-to-normal-activity time, but there is a lack of objective data concerning pelvic function recovery after these procedures.

Aim

To evaluate and compare real hip and leg function recovery times after the application of different inguinal hernia repair techniques using hip and leg mobility, strength, and stability testing for the first time.

Patients and Methods

This prospective nonrandomized clinical study included 33 male patients aged 18-75 years hospitalized for primary inguinal hernia repair surgery. The patients were divided into two groups: group 1 (Lichtenstein hernia repair) and group 2 (laparoscopic-endoscopic transabdominal preperitoneal/totally extraperitoneal hernia repair). The two groups were compared in terms of intraoperative and postoperative complications, postoperative recovery time, and hip and leg mobility, strength, and stability functional analysis on the first postoperative day as well as 1, 2, and 4 weeks after surgery.

Results

A total of 33 patients were included in the study: 13 in the open hernia repair group and 20 in the minimally invasive hernia repair group. There was no significant difference in early and late postoperative complications and recurrence rates. The surgery time and hospital stay were significantly shorter in the laparoscopic-endoscopic hernia repair group. All pelvic functions in the patients who underwent laparoscopic-endoscopic hernia repair recovered 2 or 3 weeks faster than after Lichtenstein repair.

Conclusions

Hip and leg mobility, strength, and stability tests are useful to evaluate the recovery time after inguinal hernia repair and could be used as objective tools for estimating recovery after the application of other inguinal hernia repair techniques. Hip and leg mobility, strength, and stability recover faster after minimally invasive inguinal hernia repair. There is no significant difference between the groups in early and late postoperative complications or recurrence rates.

The inguinal region revisited: the surgical point of view : An anatomical-surgical mapping and sonographic approach regarding postoperative chronic groin pain following open hernia repair

PURPOSE

Inguinodynia or chronic post-herniorrhaphy pain, defined as pain lasting longer than 3 months after open inguinal hernia repair, has become the most important complication after inguinal surgery and therefore compromises the patient´s quality of life. A major reason for inguinodynia might be the lack of neuroanatomical knowledge and suboptimal "management" of the nerves during surgery.

METHODS

We present a detailed neuroanatomic mapping of the inguinal region by dissection including the most important surgical landmarks with all nerves confirmed by immunohistochemistry, ultrasound guided visualization of the iliohypogastric, ilio-inguinal, and genital branch of the genitofemoral nerve, and a practical (preoperative) algorithm for clinical management.

RESULTS

Surgically and ultrasonographically relevant structures ("landmarks") in open hernia repair are the anterior-superior iliac spine, pubic tubercle, Camper´s fascia (superficial layer of the superficial abdominal fascia), External oblique aponeurosis, Internal oblique muscle, Transversus abdominis muscle, superficial inguinal ring, external spermatic fascia, cremasteric fascia with cremaster muscle fibers, internal spermatic fascia, cremasteric vein (=external spermatic vein = "blue line"), ductus deferens, pampiniform plexus, inguinal ligament and the inferior epigastric vessels.

CONCLUSION

A detailed understanding of inguinal anatomy is an indispensable basic requirement for all surgeons to perform inguinal ultrasonography as well as open inguinal hernia repair, avoiding complications, especially postoperative inguinodynia.

Current trends in laparoscopic groin hernia repair: A review

Hernia is a common problem of the modern world with its incidence more in developing countries. Inguinal hernia is the most common groin hernia repaired worldwide. With advancement in technology operative techniques of repair have also evolved. A PubMed and COCHRANE database search was accomplished in this regard to establish the current status of laparoscopic inguinal hernia repair in view of recent published literature. Published literature support that laparoscopic hernia repair is best suited for recurrent and bilateral inguinal hernia although it may be offered for primary inguinal hernia if expertise is available.

Intra Peritoneal Polypropylene Mesh and Newer Meshes in Ventral Hernia Repair: What EBM Says?

Incisional hernias and other ventral hernias are common surgical problems. It is estimated that incisional hernia complicates about 2 % to 10 % of laparotomies. Ventral and incisional hernia repairs are among the common surgeries done by a general surgeon. It is proven beyond any doubt that suture repair of these hernias should not be done as recurrence rates are unacceptably high, some series reporting as high as 54 % on long-term follow-up. A prosthetic mesh should always be used in ventral hernia repair (VHR). Now, the polypropylene mesh (PPM) has become the prosthetic mesh of choice in the repair of hernias, including inguinal hernia. However, with the advent of laparoscopic repair where the mesh is placed intraperitoneally, concerns regarding safety of PPM are raised. Newer meshes are introduced, claiming lesser complication rate. Many types of newer meshes are available now. Newer meshes are invariably costlier than PPM by 15-20 times. Is this extra cost worth? We looked in to available literature for an answer.