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PPP technique (plane polypropylene prosthesis): quick and safe procedure to repair recurrent inguinal hernia in high-risk patients
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Introduction
The Accreditation and Certification of Hernia Centers and Surgeons (ACCESS) Group of the European Hernia Society (EHS) recognizes that there is a growing need to train specialist abdominal wall surgeons. The most important and relevant argument for this proposal and statement is the growing acceptance of the increasing complexity of abdominal wall surgery due to newer techniques, more challenging cases and the required ‘tailored’ approach to such surgery. There is now also an increasing public awareness with social media, whereby optimal treatment results are demanded by patients. However, to date the complexity of abdominal wall surgery has not been properly or adequately defined in the current literature.
Methods
A systematic search of the available literature was performed in May 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, with 75 publications identified as relevant. In addition, an analysis of data from the Herniamed Hernia Registry was performed. The percentage of patients with hernia- or patient-related characteristics which unfavorably impacted the outcome of inguinal and incisional hernia repair was also calculated.
Results
All present guidelines for abdominal wall surgery recommend the utilization of a ‘tailored’ approach. This relies on the prerequisite that any surgical technique used has already been mastered, as well as the recognized learning curves for each of the several techniques that can be used for both inguinal hernia (Lichtenstein, TEP, TAPP, Shouldice) and incisional hernia repairs (laparoscopic IPOM, open sublay, open IPOM, open onlay, open or endoscopic component separation technique). Other hernia- and patient-related characteristics that have recognized complexity include emergency surgery, obesity, recurrent hernias, bilateral inguinal hernias, groin hernia in women, scrotal hernias, large defects, high ASA scores, > 80 years of age, increased medical risk factors and previous lower abdominal surgery. The proportion of patients with at least one of these characteristics in the Herniamed Hernia Registry in the case of both inguinal and incisional hernia is noted to be relatively high at around 70%. In general surgery training approximately 50–100 hernia repairs on average are performed by each trainee, with around only 25 laparo-endoscopic procedures.
Conclusion
A tailored approach is now employed and seen more so in hernia surgery and this fact is referred to and highlighted in the contemporaneous hernia guidelines published to date. In addition, with the increasing complexity of abdominal wall surgery, the number of procedures actually performed by trainees is no longer considered adequate to overcome any recognized learning curve. Therefore, to supplement general surgery training young surgeons should be offered a clinical fellowship to obtain an additional qualification as an abdominal wall surgeon and thus improve their clinical and operative experience under supervision in this field. Practicing general surgeons with a special interest in hernia surgery can undertake intensive further training in this area by participating in clinical work shadowing in hernia centers, workshops and congresses.
Despite evidence suggesting race and ethnicity are important factors in responses to environmental exposures, drug therapies, and disease risk, few studies focus on the health needs of racially- and ethnically-diverse aging adults.
The objective of this study was to determine the burden of 10 health conditions across race and ethnicity for a nationally-representative sample of aging Americans.
Data from the 1998 to 2014 waves of the Health and Retirement Study, an ongoing longitudinal-panel study, were analyzed.
Those aged over 50 years who identified as Black, Hispanic, or White were included. There were 5510 Blacks, 3423 Hispanics, and 21,168 Whites in the study.
At each wave, participants reported if they had cancer, chronic obstructive pulmonary disease, congestive heart failure, diabetes, back pain, hypertension, a fractured hip, myocardial infarction, rheumatism or arthritis, and a stroke. Disability-adjusted life years (DALYs) were calculated for each health condition by race and ethnicity. Ranked DALYs determined how race and ethnicity was differentially impacted by the burden of each health condition. Sample weights were utilized to make DALY estimates nationally-representative.
Weighted DALY estimates (in thousands) ranged from 1405 to 55,631 for Blacks, 931 to 28,442 for Hispanics, and 15,313 to 295,623 for Whites. Although the health conditions affected each race and ethnicity differently, hypertension had the largest number of DALYs, and hip fractures had the fewest across race and ethnicity. In total, there were an estimated 198,621, 101,462, and 1,187,725 DALYs for older Black, Hispanic, and White aging adults.
Our findings indicate that race and ethnicity may be influential on health and disease for aging adults in the United States. Monitoring DALYs may help guide the flow of health-related expenditures, improve the impact of health interventions, advance inclusive health care for diverse aging adult populations, and prepare healthcare providers for serving the health needs of aging adults.
Background-purpose:
Totally extraperitoneal (TEP) endoscopic hernioplasty and Lichtenstein hernioplasty are the most commonly used approaches for inguinal hernia repair. However, current evidence on which is the preferred approach is inconclusive. This updated meta-analysis was conducted to track the accumulation of evidence over time.
Methods:
Studies were identified by a systematic literature search of the EMBASE, PubMed, Cochrane Library, and Google Scholar databases. Fixed- and random-effects models were used to cumulatively assess the accumulation of evidence over time.
Results:
The TEP cohort showed significantly higher rates of recurrences and vascular injuries compared to the Lichtenstein cohort; [Peto Odds ratio (OR) = 1.58 (1.22, 2.04), p = 0.005], [Peto OR = 2.49 (1.05, 5.88), p = 0.04], respectively. In contrast, haematoma formation rate, time to return to usual activities, and local paraesthesia were significantly lower in the TEP cohort compared to the Lichtenstein cohort; [Peto OR = 0.26 (0.16, 0.41), p ≤ 0.001], [mean difference = - 6.32 (- 8.17, - 4.48), p ≤ 0.001], [Peto OR = 0.26 (0.17, 0.40), p ≤ 0.001], respectively.
Conclusions:
This study, which is based on randomised-controlled trials (RCTs) of high quality, showed significantly higher rates of recurrences and vascular injuries in the TEP cohort than in the Lichtenstein cohort. In contrast, rate of postoperative haematoma formation, local paraesthesia, and time to return to usual activities were significantly lower in the TEP cohort than in the Lichtenstein cohort. Future multicentre RCTs with strict adherence to the standards recommended in the Consolidated Standards of Reporting Trials guidelines will shed further light on the topic.
Purpose
Work relative value units (wRVUs) can be used as a compensation model based on the effort required for providing a service and helps to determine adequate compensation for physicians. Thus, more complex surgical procedures that require greater technical skills and time should yield greater compensation. There are limited data comparing wRVUs and operative times within common general surgery procedures such as inguinal hernia repair. This study aims to compare mean operative times and wRVUs per minute between primary and recurrent inguinal hernia repairs, the latter being considered as a more difficult procedure to perform.
Methods
A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was performed to identify all patients undergoing primary inguinal hernia repair and recurrent inguinal hernia repair by general surgeons over a 6-year period (2012–2017). Calculation and comparison of mean operative times, wRVUs, and wRVU per minute were performed.
Results
A total of 134,391 patients were included in the analysis. 121,235 underwent primary inguinal repair and 13,156 patients underwent repair of recurrent inguinal hernia. Patients were distributed within open/reducible, open/incarcerated and laparoscopy groups. Mean operative time and RVUs were greater for recurrent inguinal procedures (p < 0.0001). Consistently, RVU per minute was also found to be higher for recurrent procedures within the different groups analyzed.
Conclusion
Appropriately, general surgeons are reimbursed at a higher rate per minute in recurrent cases, regardless of the technique used.
Purpose
This study aimed to determine if the prognoses of inguinal hernia patients improved with the application of lightweight mesh (LWM).
Methods
Medline, Embase, and Cochrane library were searched for randomized controlled trails related to laparo-endoscopic inguinal hernia repair with different prosthetic meshes. Data were extracted and analyzed using the guidelines of the Cochrane handbook. The primary endpoints were recurrence and chronic postoperative inguinal pain. The second endpoints encompassed acute postoperative pain, foreign body sensation, seroma, infection, and numbness. Data were processed using Review Manager 5.3.
Results
The heavyweight mesh (HWM) had a distinctive advantage for recurrence (RR 2.30; 95% CI 1.21–4.38; P = 0.01), with comparable results for postoperative pain (RR 0.91; 95% CI 0.37–2.22; P = 0.83), foreign body sensation (RR 1.18; 95% CI 0.91–1.51; P = 0.21), seroma(RR 0.87; 95% CI 0.75–1.01; P = 0.06), infection (RR 0.85; 95% CI 0.31–2.34; P = 0.75), and numbness, compared to LWM.
Conclusion
HWM had a distinctive advantage over LWM with regard to recurrence. The two types of prosthetic meshes had equivalent outcomes for postoperative pain, seroma, foreign body sensation, infection, and numbness. Studies focused on defect sizes and fixation methods are warranted for further stratification.
Purpose
The Open Lichtenstein technique, the Laparoscopic Trans-Abdominal PrePeritoneal (TAPP), the Totally Extra Peritoneal (TEP), and the robotic TAPP (rTAPP) are commonly performed. The aim of the present network meta-analysis was to globally compare short-term outcomes within these major surgical techniques for primary unilateral inguinal hernia repair.
Methods
PubMed, EMBASE, and Web of Science were consulted. A fully Bayesian network meta-analysis was performed.
Results
Sixteen studies (51.037 patients) were included. Overall, 35.5% underwent Open, 33.5% TAPP, 30.7% TEP, and 0.3% rTAPP. The postoperative seroma risk ratio (RR) was comparable considering TAPP vs. Open (RR 0.91; 95% CrI 0.50–1.62), TEP vs. Open (RR 0.64; 95% CrI 0.32–1.33), TEP vs. TAPP (RR 0.70; 95% CrI 0.39–1.31), and rTAPP vs. Open (RR 0.98; 95% CrI 0.37–2.51). The postoperative chronic pain RR was similar for TAPP vs. Open (RR 0.53; 95% CrI 0.27–1.20), TEP vs. Open (RR 0.86; 95% CrI 0.48–1.16), and TEP vs. TAPP (RR 1.70; 95% CrI 0.63–3.20). The recurrence RR was comparable when comparing TAPP vs. Open (RR 0.96; 95% CrI 0.57–1.51), TEP vs. Open (RR 1.0; 95% CrI 0.65–1.61), TEP vs. TAPP (RR 1.10; 95% CrI 0.63–2.10), and rTAPP vs. Open (RR 0.98; 95% CrI 0.45–2.10). No differences were found in term of postoperative hematoma, surgical site infection, urinary retention, and hospital length of stay.
Conclusions
This study suggests that Open, TAPP, TEP, and rTAPP seem comparable in the short term. The surgical management of inguinal hernia is evolving and the effect of the adoption of innovative minimally invasive techniques should be further investigated in the long term. Ultimately, the choice of the most suitable treatment should be based on individual surgeon expertise and tailored on each patient.
Objectives
To compare the outcomes of open darn repair vs open mesh repair in patients undergoing inguinal hernia repair.
Methods
We performed a systematic review and conducted a search of electronic information sources to identify all observational studies and randomised controlled trials (RCTs) investigating outcomes of open darn repair vs open mesh repair for inguinal hernias. Hernia recurrence was considered as the primary outcome measure. The secondary outcome measures included surgical site infection (SSI), haematoma, seroma, neuralgia, urinary retention, length of hospital stay, time to return to normal activities or work, testicular atrophy, operative time and chronic pain. Random or fixed effects modelling was applied to calculate pooled outcome data.
Results
Six RCTs, enrolling 1480 patients with 1485 hernias, and 4 observational studies, enrolling 1564 patients with 1641 hernias, were included. Meta-analysis of RCTs showed no significant difference in terms of recurrence (RD 0.00, 95% CI − 0.01 to 0.01, P = 0.86), SSI (OR 0.83, 95% CI 0.46–1.49, P = 0.52), haematoma (OR 1.21, 95% CI 0.62–2.38, P = 0.57), seroma (OR 0.83, 95% CI 0.42–1.65, P = 0.60), neuralgia (OR 1.05, 95% CI 0.29–3.73, P = 0.94), urinary retention (OR 1.44, 95% CI 0.64–3.21, P = 0.38), length of hospital stay (MD 0.09, 95% CI − 0.28 to 0.46, P = 0.63), time to return to normal activities or work (MD 0.88, 95% CI − 0.90 to 2.66, P = 0.33), testicular atrophy (RD 0.00, 95% CI − 0.02 to 0.02, P = 1.00), and operative time (MD 2.69, 95% CI − 1.75 to 7.14, P = 0.62) between the darn repair and mesh repair groups. Meta-analysis of observational studies also showed no significant difference in terms of recurrence (RD 0.00, 95% CI − 0.02 to 0.02, P = 0.99), SSI (OR 0.47, 95% CI 0.14–1.62, P = 0.23), haematoma (OR 1.07, 95% CI 0.45–2.55, P = 0.89), seroma (OR 0.12, 95% CI 0.01–2.27, P = 0.16), neuralgia (OR 0.25, 95% CI 0.05–1.21, P = 0.08), urinary retention (OR 1.53, 95% CI 0.20–11.96, P = 0.69), time to return to normal activities or work (MD 2.13, 95% CI − 2.18 to 6.44, P = 0.33), testicular atrophy (RD − 0.01, 95% CI − 0.02 to 0.01, P = 0.49), and operative time (MD − 4.76, 95% CI − 13.23 to 3.71, P = 0.27) between the two groups. The evidence was inconclusive for chronic pain. The quality of available evidence was moderate.
Conclusions
Our results suggest that open darn repair is comparable with open mesh repair for inguinal hernias. Considering that consequences of mesh complications in inguinal hernia repair, albeit rare, can be significant, open darn repair provides an equally credible alternative to open mesh repair for inguinal hernias. Further studies are required to investigate patient-reported outcomes and to elicit a superior non-mesh technique.
The new guidelines of the HerniaSurge group recommend that only an expert hernia surgeon should repair a re-recurrent inguinal hernia. We report the efficacy of the hybrid method with explorative laparoscopy and anterior open approach for re-recurrent inguinal hernia repair. A 61-year-old man underwent anterior open preperitoneal mesh repair for right inguinal direct hernia and laparoscopic transabdominal preperitoneal repair for recurrence. Two years after the second surgery, re-recurrent inguinal hernia was confirmed. We carried out explorative laparoscopy for the re-recurrent inguinal hernia, which revealed a re-recurrent hernia orifice. We performed the anterior open approach while observing from the abdominal cavity. Explorative laparoscopy can help in accurately determining the orifice of the re-recurrent inguinal hernia. Based on that information, the hernia sac can be reached through the shortest route using the anterior open approach.
Purpose
Deciding between surgery and non-operative management of a non-obstructive ventral hernia (VH) in a high-risk patient often poses a clinical challenge. The aim of this study is to evaluate a national series of open and laparoscopic ventral hernia repair (VHR), and to assess predictors of mortality after elective VHR.
Methods
A retrospective analysis of 2008–2014 data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample was performed. All patients with a primary diagnosis of abdominal wall hernia were included. Inguinal, femoral, or diaphragmatic hernias were excluded. Patients were stratified by elective versus emergent repair. Factors associated with mortality after elective VHR were analyzed.
Results
103,635 patients were studied, including 14,787 (14.3%) umbilical, 63,685 (61.5%) incisional, and 25,163 (24.3%) other ventral hernias. Operative procedures included 59,993 (57.9%) elective and 43,642 (42.1%) emergent VHR. 21.3% elective VHRs were laparoscopic versus 13% in emergent cases (P < 0.001). Mesh was used in 52,642 (87.7%) elective versus 27,734 (63.5%) emergent VHR (P < 0.001). Median (interquartile range) length of stay was 2(3) days in laparoscopic and 3(3) days in open group (P < 0.001). Mortality was 0.2% (n = 135) in elective and 0.6% (n = 269) in emergent group (P < 0.001). In elective group, mortality rates were equal among laparoscopic and open VHR (0.2%), while in emergent group, it was lower in laparoscopic VHR (0.4% vs 0.6%, P = 0.028). Multivariate analysis of elective VHR showed that the following factors were associated with mortality during hospitalization: age > 50 years [Odds ratio (OR) = 1.96], male gender (OR = 2.37), congestive heart failure (OR = 2.15), pulmonary circulation disorders (OR = 5.26), coagulopathy (OR = 3.93), liver disease (OR = 1.89), fluid and electrolyte disturbances (OR = 8.66), metastatic cancer (OR = 4.66), neurological disorders (OR = 2.31), and paralysis (OR = 5.29).
Conclusions
VHR has a low mortality, especially when performed laparoscopically. In patients undergoing elective VHR, higher age and some comorbidities are predictors of mortality. These include congestive heart failure, pulmonary circulation disorders, coagulopathy, liver disease, metastatic cancer, neurological disorders, and paralysis. Conservative management should be considered for these high-risk subgroups in context of the overall clinical presentation.
Background:
This is an update of a Cochrane Review first published in 2001.Hernias are protrusions of all or part of an organ through the body wall that normally contains it. Groin hernias include inguinal (96%) and femoral (4%) hernias, and are often symptomatic with discomfort. They are extremely common, with an estimated lifetime risk in men of 27%. Occasionally they may present as emergencies with complications such as bowel incarceration, obstruction and strangulation. The definitive treatment of all hernias is surgical repair, inguinal hernia repair being one of the most common surgical procedures performed. Mesh (hernioplasty) and the traditional non-mesh repairs (herniorrhaphy) are commonly used, with an increasing preference towards mesh repairs in high-income countries.
Objectives:
To evaluate the benefits and harms of different inguinal and femoral hernia repair techniques in adults, specifically comparing closure with mesh versus without mesh. Outcomes include hernia recurrence, complications (including neurovascular or visceral injury, haematoma, seroma, testicular injury, infection, postoperative pain), mortality, duration of operation, postoperative hospital stay and time to return to activities of daily living.
Search methods:
We searched the following databases on 9 May 2018: Cochrane Colorectal Cancer Group Specialized Register, Cochrane Central Register of Controlled Trials (Issue 1), Ovid MEDLINE (from 1950), Ovid Embase (from 1974) and Web of Science (from 1900). Furthermore, we checked the WHO International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov for trials. We applied no language or publication restrictions. We also searched the reference lists of included trials and review articles.
Selection criteria:
We included randomised controlled trials of mesh compared to non-mesh inguinal or femoral hernia repairs in adults over the age of 18 years.
Data collection and analysis:
We used standard methodological procedures expected by Cochrane. Where available, we collected information on adverse effects. We presented dichotomous data as risk ratios, and where possible we calculated the number needed to treat for an additional beneficial outcome (NNTB). We presented continuous data as mean difference. Analysis of missing data was based on intention-to-treat principles, and we assessed heterogeneity using an evaluation of clinical and methodological diversity, Chi2 test and I2 statistic. We used GRADE to assess the quality of evidence for each outcome.
Main results:
We included 25 studies (6293 participants) in this review. All included studies specified inguinal hernias, and two studies reported that femoral hernias were included.Mesh repair probably reduces the risk of hernia recurrence compared to non-mesh repair (21 studies, 5575 participants; RR 0.46, 95% CI 0.26 to 0.80, I2 = 44%, moderate-quality evidence). In absolute numbers, one hernia recurrence was prevented for every 46 mesh repairs compared with non-mesh repairs. Twenty-four studies (6293 participants) assessed a wide range of complications with varying follow-up times. Neurovascular and visceral injuries were more common in non-mesh repair groups (RR 0.61, 95% CI 0.49 to 0.76, I2 = 0%, NNTB = 22, high-quality evidence). Wound infection was found slightly more commonly in the mesh group (20 studies, 4540 participants; RR 1.29, 95% CI 0.89 to 1.86, I2 = 0%, NNTB = 200, low-quality evidence). Mesh repair reduced the risk of haematoma compared to non-mesh repair (15 studies, 3773 participants; RR 0.88, 95% CI 0.68 to 1.13, I2 = 0%, NNTB = 143, low-quality evidence). Seromas probably occur more frequently with mesh repair than with non-mesh repair (14 studies, 2640 participants; RR 1.63, 95% CI 1.03 to 2.59, I2 = 0%, NNTB = 72, moderate-quality evidence), as does wound swelling (two studies, 388 participants; RR 4.56, 95% CI 1.02 to 20.48, I2 = 33%, NNTB = 72, moderate-quality evidence). The comparative effect on wound dehiscence is uncertain due to wide confidence intervals (two studies, 329 participants; RR 0.55, 95% CI 0.12 to 2.48, I2 = 37% NNTB = 77, low-quality evidence). Testicular complications showed nearly equivocal results; they probably occurred slightly more often in the mesh group however the confidence interval around the effect was wide (14 studies, 3741 participants; RR 1.06, 95% CI 0.63 to 1.76, I2 = 0%, NNTB = 2000, low-quality evidence). Mesh reduced the risk of postoperative urinary retention compared to non-mesh (eight studies, 1539 participants; RR 0.53, 95% CI 0.38 to 0.73, I2 = 56%, NNTB = 16, moderate-quality evidence).Postoperative and chronic pain could not be compared due to variations in measurement methods and follow-up time (low-quality evidence).No deaths occurred during the follow-up periods reported in the seven studies (2546 participants) reporting this outcome (high-quality evidence).The average operating time was longer for non-mesh repairs by a mean of 4 minutes 22 seconds, despite wide variation across the studies regarding size and direction of effect, thus this result is uncertain (20 studies, 4148 participants; 95% CI -6.85 to -1.60, I2= 97%, very low-quality evidence). Hospital stay may be shorter with mesh repair, by 0.6 days (12 studies, 2966 participants; 95% CI -0.86 to -0.34, I2 = 98%, low-quality evidence), and participants undergoing mesh repairs may return to normal activities of daily living a mean of 2.87 days sooner than those with non-mesh repair (10 studies, 3183 participants; 95% CI -4.42 to -1.32, I2 = 96%, low-quality evidence), although the results of both these outcomes are also limited by wide variation in the size and direction of effect across the studies.
Authors' conclusions:
Mesh and non-mesh repairs are effective surgical approaches in treating hernias, each demonstrating benefits in different areas. Compared to non-mesh repairs, mesh repairs probably reduce the rate of hernia recurrence, and reduce visceral or neurovascular injuries, making mesh repair a common repair approach. Mesh repairs may result in a reduced length of hospital stay and time to return to activities of daily living, but these results are uncertain due to variation in the results of the studies. Non-mesh repair is less likely to cause seroma formation and has been favoured in low-income countries due to low cost and reduced availability of mesh materials. Risk of bias in the included studies was low to moderate and generally handled well by study authors, with attention to details of allocation, blinding, attrition and reporting.
Introduction:
Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.
Methods:
An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.
Conclusions:
The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.
Surgeons occasionally encounter a case of recurrent hernia in adult patients after the primary repair, and these cases are challenging to manage appropriately. This study was conducted to describe the clinical nature of recurrent inguinal hernia, compare the results of management, and identify the relationship between the specific risk factors and the occurrence of recurrent hernia. Retrospectively reviewed 58 patients who underwent the inguinal herniorrhaphy for recurrent hernia in a single institution. Analyzed clinical characteristics of recurrent hernia and tried to verify the relationship between smoking, obesity, and occurrence of recurrent hernia. Recurrent inguinal hernia was 13.5 per cent of all hernia repairs in the study period. Most of the recurrence was the first event (74.1%) and showed an interval to recurrence with a mean duration of 40.7 months. There was no significant difference in procedure time, development of postoperative complications, and duration of hospital stay according to the procedure. Compromise of smoker and overweight was significantly higher in the recurrent group (P < 0.05). Surgeons should be aware of the increased risk for recurrence in adult inguinal hernia patients when they smoke or are overweight (body mass index ≥ 25 kg/m2), also it needs to follow-up during the adequate period.
Despite all the progress made in inguinal hernia surgery driven by the development of meshes and laparoendoscopic operative techniques, the proportion of recurrent inguinal hernias is still from 12% to 13%. Recurrences can present very soon after primary inguinal hernia repair generally because of technical failure. However, they can also develop much later after the primary operation probably due to patient-specific factors. Supported by evidence-based data, this review presents the surgical risk factors for recurrent inguinal hernia after the primary operation. The following factors are implicated here: choice of operative technique and mesh, mesh fixation technique, mesh size, management of medial and lateral hernia sac, sliding hernia, lipoma in the inguinal canal, operating time, type of anesthesia, participation in a register database, femoral hernia, postoperative complications, as well as the center and surgeon volume. If these surgical risk factors are taken into account when performing primary inguinal hernia repair, a good outcome can be expected for the patient. Therefore, they should definitely be observed.
Purpose:
Many surgeons are reluctant to offer elective inguinal and femoral hernia repair (IHR) to the elderly due to concerns of increased risk. The authors sought to evaluate the outcomes of elderly patients undergoing IHR compared to the general population.
Methods:
We performed a retrospective review of the 2011 NSQIP database evaluating 19,683 patients undergoing IHR. Patients were divided by age into three categories: <65, 65-79 and >80. Logistic regression analysis was used to assess impact of comorbid conditions and type of surgery on outcomes. Patients were analyzed for mortality and complications based on their age and the types of surgery (elective, urgent, emergent, laparoscopic versus open) and comorbid conditions.
Results:
There were 17,375 male patients (88 %). 92.7 % were elective. 70 % were performed using an open technique. Age distribution was 63.4 % < 65, 26.6 % 65-79, 10 % >80. Mortality was similar across age groups in elective repair. Mortality was increased in emergency repair in all age groups (p < 0.001). Mortality was increased in emergency surgery compared to elective surgery in patients >80 (OR = 57, p < 0.001). Mortality was similar between laparoscopic and open in <65 (OR = 0.96, p = 0.97) and unable to be assessed in other age groups. Dyspnea and COPD predicted higher mortality and complications with emergency surgery in the elderly (age 65-79 OR 15.3 and 14.9, respectively, age >80 OR 56.5 and 14.9, respectively).
Conclusions:
Elective inguinal hernia repair carries a similar mortality in the elderly compared to the general population. Emergent IHR carries a very high risk of death in the elderly. The authors recommend considering elective IHR regardless of age.
Aim:
identifying the variables that can help in quantifying/ predicting duration of hospital stay after inguinal hernia surgery.
Method:
257 patients who were diagnosed with inguinal hernia underwent surgery between January 2013 and October 2014 and were prospectively registered and statistically analyzed by using linear regression with the aim of emphasizing, calculating and validating the predictors for duration of hospital stay.
Results:
out of 257 patients, 50,7% underwent laparoscopic surgery (TAPP and TEP) and 49,7% had an anterior approach by using the technique described by Lichtenstein in most of the cases. From the variables registered in the study (age, recurrence, emergency surgery, ASA [American Society of Anesthesiologists] risk classification, surgery duration, local and general complications) only the age and presence/absence of complications were statistically associated with the modification of the duration of hospital stay in this pathology.
Conclusions:
the duration of hospital stay can be evaluated preoperatory by using a mathematical model, which takes into consideration factors that depend on the patient or the procedure, with results that can have a significant impact on planning the local resources.
It is known that recurrences continue to occur after the follow-up period of 1-5 years usually used in most hernia studies. By reviewing the data in the Herniamed Hernia Registry documenting the time interval between the recurrent operation and previous inguinal hernia repair, the present study identifies the temporal course of onset of recurrence.
Prospective data were recorded in the Herniamed Registry between 1 September 2009 and 4 May 2015 on a total of 145,590 patients with 171,143 inguinal hernia operations. These included 18,774 operations due to an inguinal hernia recurrence (10.94%). During the same period, prospective data were collected on 24,385 incisional hernia operations. The latter cases included 5,328 patients with a recurrent incisional hernia (21.85%).
Only 57.46% of all inguinal hernia recurrences occurred within 10 years of the previous inguinal hernia operation. Some of the remaining 42.54% of all recurrences occurred only much later, even after more than 50 years. The course of onset of recurrence is markedly different for incisional hernia. About 91.87% of such recurrences occur already within 10 years of the last operation.
Ascertainment of the actual recurrence rate after hernia repair calls for a follow-up of 10 years for incisional hernia and of 50 years for inguinal hernia. The data collected can be used to give an approximate estimate with a shorter follow-up.
Background:
Recurrence after inguinal hernia surgery is a considerable clinical problem, and several risk factors of recurrence such as surgical technique, re-recurrence, and family history have been identified. Non-technical patient related factors that influence the risk of recurrence after inguinal hernia surgery are sparsely studied. The purpose of the studies included in this PhD thesis, was to describe the epidemiologic characteristics of inguinal hernia occurrence and recurrence, as well as investigating the patient related risk factors leading to recurrence after inguinal hernia surgery. Four studies were included in this thesis.
Methods and results:
Study 1: The study was a nationwide register-based study combining the Civil Registration System and the Danish National Hospital Register during a five-year period. We included a total of 46,717 persons operated for a groin hernia from the population of 5,639,885 people (2,799,105 males, 2,008,780 females). We found that 97% of all groin hernia repairs were inguinal hernias and 3% femoral hernias. Data showed that inguinal hernia surgery peaked during childhood and old age, whereas femoral hernia surgery increased throughout life. Study 2: Using data from the Danish Hernia Database (DHDB), we included all male patients operated for elective primary inguinal hernia during a 15-year period (n = 85,314). The overall inguinal hernia reoperation rate was 3.8%, and subdivided into indirect inguinal hernias and direct inguinal hernias, the reoperation rates were 2.7% and 5.2%, respectively (p <0.001, chi-square). In the multivariate Cox proportional hazards analysis of factors predicting reoperation, we found that a direct inguinal hernia at primary operation was a substantial risk factor for recurrence with a Hazard ratio of 1,90 (CI 95% 1.77-2.04) compared with an indirect inguinal hernia at primary operation (p < 0.001). We found that there was a significant relationship between the type of hernia at the primary operation and reoperation, when controlling for the effect of the operation method, r = 0.45 (p < 0.001). This corresponded to odds ratios (OR) of 7.1 (CI 95% 6.0-8.4) of being reoperated for a direct inguinal hernia if the hernia at the primary operation was a direct inguinal hernia, and an OR of 3.0 (CI 95% 2.7-3.3) of being reoperated for an indirect inguinal hernia if the primary operation was for an indirect inguinal hernia. As subsequent findings, we saw that the frequency of laparoscopic hernia repair increased during the study period and that the laparoscopic repair of indirect inguinal hernias recurred more often than indirect inguinal hernias operated by Lichtenstein's technique (p < 0.001). Study 3: Using data from the DHDB, we included all female patients operated for elective primary inguinal hernia during a 15-year period (n = 5,893). Of those, a total of 305 operations for recurrences were registered (61 % inguinal recurrences, 38 % femoral recurrences, 1 % no hernial), which corresponded to an overall crude reoperation rate of 5.2%. A noticeable difference was found in reoperation rates after primary operation for direct inguinal hernias (DIH), indirect inguinal hernias (IIH) and combined IIH+DIH of 11.0%, 3.0%, and 0.007% respectively (p < 0.001, chi-square). In the multivariate Cox proportional hazards analysis of factors predicting reoperation, we found that a direct inguinal hernia at primary operation was a substantial risk factor for recurrence with a Hazard ratio of 3.1 (CI 95% 2.4-3.9) compared with an indirect inguinal hernia at primary operation (p < 0.001). Laparoscopic operation was found to give a lower risk of recurrence with a Hazard ratio of 0.57 (CI 95% 0.43-0.75) compared with Lichtenstein's technique (p < 0.001). We found that all femoral recurrences (n = 116) occurred after Lichtenstein's procedure and none occurred after laparoscopic operation (p < 0.001, Log Rank test). Study 4: This study was a systematic review and meta-analysis of non-technical patient-related risk factors for recurrence after inguinal hernia surgery. From a total of 5,061 potentially relevant records we included 40 studies in the review covering 719,901 procedures in 714,167 patients and of those 14 studies covering 378,824 procedures in 375,620 patients were included into meta-analysis of eight risk factors (gender, age, hernia type, hernia size, re-recurrence, bilaterality, mode of admission and smoking). We found that female gender (RR 1.38, 95% CI 1.28-1.48, I2 = 0%), direct inguinal hernias at primary procedure (RR 1.91, 95% CI 1.62-2.26, I2 = 10%), operation for a recurrent inguinal hernia (RR 2.2, 95% CI 2.0-2.42, I2 = 6%), and smoking (OR 2.53, 95% CI 1.43-4.47, I2 = 0%) were risk factors for recurrence after inguinal hernia surgery. Furthermore, emergency admission; connective tissue composition and degradation; and positive family history were found to have an impact on the risk of recurrence, while post-operative convalescence and age had no impact on the risk of recurrence.
Conclusion:
The studies included in the thesis have studies the natural history of groin hernias on a nationwide basis; have identified the epidemiologic distribution of groin hernias and the non-technical risk factors associated with recurrence. Data showed that non-technical patient-related risk factors have great impact on the risk of recurrence after inguinal hernia surgery. The reason to why inguinal hernias recur is most likely multifactorial and lies in the span of technical and non-technical patient-related risk factors and it is possible that the different groin hernia subtypes have different pathophysiology. This knowledge should be implemented into clinical practice in order to reduce the risk of recurrence and in future research design examining recurrence after inguinal hernia surgery as outcome.
The aim of the study was to determine risk factors for morbidity and mortality in patients older than 80 years, compared to younger patients, who undergo emergency strangulated groin hernia repair.
This is a retrospective study of patients who underwent emergency surgery for strangulated groin hernia repair during 14 years. Patients were divided by age into three groups: younger than 59 (group A), 60-79 (group B), and older than 80 years (group C). Patient data included age, gender, hernia type, sac content, comorbidities, and surgical outcomes.
Two hundred patients were included in the study. There was no difference between groups in sex, hernia localization, and the type of repair. More comorbidities were found in octogenarians compared to the younger patients [group C vs. D (A + B)]. Small bowel resections and ICU admissions were more frequent in patients over 60 years compared to younger patients, 19.6 and 32.7 % vs. 1.7 and 0 %, respectively. Surgery was longer in group B. The rate of postoperative complications, repeated surgery, length of admission, and mortality were significantly higher in octogenarian (group C). Multivariate analysis found that age is a significant factor in the occurrence of non-surgical postoperative complications, but not in surgical complications.
Emergency surgery for strangulated hernia repair in patients over 80 years is more complicated than in younger patients, mostly due to the existing comorbidities. In order to reduce the high morbidity and mortality rates in emergency surgery associated with this age group, elective hernia surgery in elderly should be considered in selected patients with severe symptoms affecting their daily life.
Nowadays, hernia is considered as a disturbance of homeostasis of cellular or matrix extracellular components in fascias and muscles. Any damage to the extracellular matrix facilitates the hernia. Hyperfunction of renin-angiotensin system will result in fibrosis; many drugs consumed by people with hypertension disrupt homeostasis of the extracellular matrix.
Our objectives were to assess whether there is association between hernia and hypertension, to analyze drugs consumed by hypertensive patients and to compare the prevalence of hypertension to that of other risk factors for hernia.
The sample had 1818 patients, with an average age 64 years, underwent surgery between 1998 and 2012. We compared the prevalence of hypertension between herniated people and general population. We verified the use of antifibrotic drugs by all patients in the sample. We estimated the prevalence of several risk factors for hernia.
The prevalence of hypertension in the sample is 55.1%, higher than in the general population. It is also higher in all age groups. Hypertensive and herniated patients consumed 3.3 antifibrotic drugs on average; herniated non-hypertensive patients consumed on average 1.1 drugs. The prevalence of hypertension is similar to or higher than the herniosis, smoking, family history, obesity, diabetes or cancer.
Hypertension, due of their means of treatment, should be considered as a acquired agent in the genesis of hernia. The risk have the same strength that other factors known to cause hernia.
Background:
Inguinal herniorrhaphy remains one of the most common general surgical operations, with approximately 15% performed for recurrence. The repair of the resulting recurrent hernia is a daunting task because of already weakened tissues and obscured and distorted anatomy. The aim of this study is to compare the posterior preperitoneal versus anterior tension-free approach for repair of unilateral recurrent inguinal hernia regarding complications and early recurrence.
Methods:
120 Patients in this study were divided randomly into 2 main groups; Group A patients were subjected to posterior preperitoneal approach and those of group B were subjected to conventional anterior tension-free repair. The primary end point was recurrence and the secondary end points were time off from work, postoperative pain, scrotal swelling and wound infections.
Results:
The mean hospital stay was 1.2 days and 4.7, the mean time to return work was 8.2 and 11.2 days and the mean time off from work was 9.4 and 15.9 days in group A and B respectively. The maximum follow-up period was 48 months and the minimum was 14 months with a mean value as 37.11 ± 5.14 months. Only 2 recurrences (3.3%) in group A and 4 cases (6.25%) in group B were seen. The final pain score per patient and the overall complication rate were higher in group B.
Conclusions:
The open preperitoneal repair offers the advantages of low recurrence rate and allows covering all potential defects with one piece of mesh and is far superior to the anterior approach.
Trial registration:
ACTRN12611000337976.
Hernia surgery continues to draw the attention of surgeons, patients, and the industry. This strong interest has driven the establishment of professional medical societies with the sole purpose of furthering the understanding of hernias and hernia repair. In the more than 100 years of development, industry has played a major role in advancing the technology to perfect the performance of hernia repair with the hope of establishing the "best" technique and its associated technology. However, with the development of newer prosthetics and approaches to hernia repair, many surgeons do not fully understand the properties of the available prosthetics. The goal of this review is to highlight the different types of meshes in an effort to clarify to surgeons what types of materials are available to them and how to select an appropriate one for a given case.
Emergency hernia surgery, in contrast to elective hernia surgery, is associated with appreciable mortality. Incarcerated hernia is the second most common cause of small bowel obstruction after adhesions, and the leading cause of bowel strangulation.
Information on patients who died within 30 days of groin hernia surgery was retrieved from the Swedish Hernia Register, from the Cause-of-Death Register, and from hospital notes.
Of 103,710 groin hernia operations between 1992 and 2004, 292 patients died within 30 days of surgery. Hospital notes and cause of death were retrieved for 242 cases (82%). In 5 of these patients, the hernia operation was done in addition to more urgent surgery and therefore excluded from further analyses; 152 patients were admitted as emergency cases and 55 of these patients underwent bowel resection. A total of 107 patients had signs of bowel obstruction when admitted. For 37% of these patients, physical examination of the groin was not documented. Patients with bowel obstruction without a note on a palpable groin lump were more likely to undergo imaging investigation preoperatively (P < 0.001) and they had an increased time to surgery compared to patients with a palpable lump. Women and patients with femoral hernia were significantly less likely to undergo a groin examination compared to other patients. Local anaesthesia was used in 7% of all patients who died postoperatively, and in 3% of emergency cases. Pulmonary disease, sepsis and malignant disease were more common as causes of death after emergency surgery than after elective surgery.
Groin examination of patients presenting with bowel obstruction is of utmost importance in order to minimise delay to hernia surgery.
Family history, male gender and age are significant risk factors for inguinal hernia disease. Family history provides evidence for a genetic trait and could explain early recurrence after inguinal hernia repair despite technical advance at least in a subgroup of patients. This study evaluates if age and family history can be identified as risk factors for early recurrence after primary hernia repair.
We performed an observational cohort study for 75 patients having at least two recurrent hernias. The impact of age, gender and family history on the onset of primary hernias, age at first recurrence and recurrence rates was investigated.
44% (33/75) of recurrent hernia patients had a family history and primary as well as recurrent hernias occurred significantly earlier in this group (p = 0.04). The older the patients were at onset the earlier they got a recurrent hernia. Smoking could be identified as on additional risk factor for early onset of hernia disease but not for hernia recurrence.
Our data reveal an increased incidence of family history for recurrent hernia patients when compared with primary hernia patients. Patients with a family history have their primary hernias as well as their recurrence at younger age then patients without a family history. Though recurrent hernia has to be regarded as a disease caused by multiple factors, a family history may be considered as a criterion to identify the risk for recurrence before the primary operation.
Background:
In a recent publication, the International Guidelines for Groin Hernia Management by the European Hernia Society (EHS) recognized the need to individualize and tailor the surgical approach for hernia repair. There may be different opportunities for optimization of the surgical technique for surgeons performing open, laparoscopic, or robotic-assisted hernia repair. Robotic-assisted hernia repair is a relatively new minimally invasive surgical approach compared to laparoscopic and open repair. Currently, there is a lack of comparative prospective studies designed to evaluate long-term outcomes of patients undergoing robotic-assisted, laparoscopic, or open hernia repair.
Materials & methods:
This manuscript presents an innovative study design with two study cohortss (incisional and inguinal hernia repair) that contain three arms (robotic-assisted, laparoscopic, and open). The trial objective is to collect short-term and long-term outcomes for patients undergoing robotic-assisted, laparoscopic, or open hernia repair. The present publication will discuss the trial design, methods used to ensure consistency in surgeon expertise, and provides strategies to obtain long-term (> 3 months) follow-up data for enrolled patients.
Results:
One hundred subjects underwent incisional and one hundred underwent inguinal hernia repair at the time of this manuscript. Surgeon experience was analyzed across the three surgical techniques and follow-up compliance was assessed through 1 year. The follow-up completion rates for both study cohortss were >80% for all visits.
Conclusions:
The innovative trial design helped to improve the quality and quantity of long-term follow-up. More innovative options to improve patient retention may be tested in future trials of similar design.
Introduction
Elective and emergency inguinal hernia surgery is a central task for general and abdominal surgeons. As a standard procedure it is regarded as having a relatively low income in the German diagnosis-related groups (DRG) system. This can lead to an economic imbalance, especially in a cost-intensive environment of a university hospital. The aim of this analysis was to investigate the influence of clinical factors on costs and the contribution margin as well as the overall economic evaluation of elective inguinal hernia surgery at a university hospital.
Material and methods
All patients undergoing elective inguinal hernia surgery at two locations of the Charité University Medicine Berlin in 2014 and 2015 were included in the analysis. The influence of clinical, patient and surgical factors on the economic outcome of the cases was evaluated.
Results
A total of 419 patients were included, mostly after a Lichtenstein operation (44.9%) and laparoscopic transabdominal preperitoneal (TAPP) surgery (53.9%). The greatest impact on the economic outcome was the occurrence of postoperative complications. Also, a patient clinical complexity level (PCCL) value of >1, more than 8 encoded secondary diagnoses and a duration of hospital stay of less than 2 days had a significantly negative impact on the contribution margin. Overall, elective inguinal hernia surgery led to a negative contribution margin of € 651 per case.
Conclusion
Elective inguinal hernia surgery in the environment of a university hospital has a high financial deficit; however, since a complete discontinuation of this treatment is not an alternative multifactorial approaches are required to improve the economic outcome.
The extracellular matrix (ECM) provides the environment for many cells types within the body and, in addition to the well recognised role as a structural support, influences many important cell process within the body. As a result, age-related changes to the proteins of the ECM have far reaching consequences with the potential to disrupt many different aspects of homeostasis and healthy function. The proteins collagen and elastin are the most abundant in the ECM and their ability to function as a structural support and provide mechanical stability results from the formation of supra-molecular structures. Collagen and elastin have a long half-life, as required by their structural role, which leaves them vulnerable to a range of post-translational modifications. In this chapter the role of the ECM is discussed and the component proteins introduced. Major age-related modifications including glycation, carbamylation and fragmentation and the impact these have on ECM function are reviewed.
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.
With more than 20 million patients annually, inguinal hernia repair is one of the most often performed surgical procedures worldwide. The lifetime risk to develop an inguinal hernia is 27-43% for men and 3-6% for women. In spite of all advances, 11% of all patients suffer from a recurrence and 10-12% from chronic pain following primary inguinal hernia repair. By developing evidence-based guidelines and recommendations, the international hernia societies aim to improve the outcome of inguinal hernia repair due to standardization of care. From a total of more than 100 different repair techniques for inguinal and femoral hernias, classified as tissue repair, open mesh repair, and laparo-endoscopic mesh repair, the new International Guidelines of the Hernia-Surge Group only recommend the totally extraperitoneal patch plasty (TEP), transabdominal preperitoneal patch plasty (TAPP), and Lichtenstein techniques. Since a generally accepted technique suitable for all inguinal hernias does not exist, surgeons should provide both an anterior open (Lichtenstein) and a posterior laparo-endoscopic (TEP or TAPP) approach option. The guidelines strongly recommend that surgeons tailor the treatment of inguinal hernias based on expertise, local/national resources, and patient- and hernia-related factors. A tailored approach in inguinal hernia repair should pay heed to the patient- and hernia-related factors, unilateral hernia in men and women, bilateral hernia, recurrent hernia, scrotal hernia, previous pelvic and lower abdominal surgery, severe cardiac or pulmonary comorbidities, and incarcerated hernia.
Background:
One of the main complications of inguinal hernia repair continues to be recurrence. Commonly cited prior reports from relatively small studies estimate this rate to be 1% to 5% in the United States. Although some reports have found higher recurrence rates, they get little attention on the national stage or in other large studies. We sought to determine the trend of inguinal hernia repairs performed for recurrence over time using large national databases.
Methods:
We identified patients aged ≥18 years who underwent inguinal hernia repair from three sources: the Premier database (January 2010 to September 2015), the American College of Surgeons National Surgical Quality Improvement Program database (January 2005 to December 2014), and the Mayo Clinic institutions (January 2005 to December 2014). We evaluated the incidence of primary and recurrent inguinal hernia repairs stratified by sex over time using one-tailed Cochran-Armitage tests.
Results:
In the Premier database, of the 317,636 inguinal hernia repairs, the proportion performed for recurrence had a small decrease in males from 11.4% in 2010 to 10.5% in 2015 (P < .0001); however, it remained constant in females (6.5% in 2010 to 6.7% in 2015, P = .46). In the National Surgical Quality Improvement Program database, of the 180,512 inguinal hernia repairs, there was no change for either sex: 10.5% to 11.2% (2005-2014, P = .12) in males and 6.2% to 7.1% (2005-2014, P = .11) in females. Within our institution, in the 9,216 patients identified, there was no change in the proportion of inguinal hernia repairs for recurrence in males: 13.3% to 11.5% (2005-2014, P = .25). In females, the proportion increased from 1.3% to 12.0% during the study period (P = .006).
Conclusion:
Based on these larger evaluations of recurrent inguinal hernia surgery, the current literature on inguinal hernia repair recurrence is skewed and overly optimistic.
Purpose:
To present a new and alternative method for surgical treatment of recurrent inguinal hernia after total extraperitoneal patch plastic (TEP).
Methods:
From January 2005 to September 2015, 35 patients (34 male, 1 female; mean age 65 ± 12.6 years) with recurrent inguinal hernia following TEP were operated at the Kliniken Essen-Mitte using a simplified method consisting of re-fixation of the primary mesh to the inguinal ligament by an anterior approach.
Results:
The mean operating time was 47 ± 22 min. All complications were minor with an overall incidence of 6%. After a mean follow-up of 54 months one re-recurrence was observed.
Conclusions:
This Simplified Hernia Repair is safe and avoids additional foreign body implantation. Therefore, it is our method of choice for recurrent inguinal hernias after TEP.
Background
Whether total extraperitoneal inguinal hernia repair (TEP) is associated with worse outcomes compared to transabdominal preperitoneal inguinal hernia repair (TAPP) for the treatment of recurrent inguinal hernia continues to be a matter of debate. The objective of this large cohort study is to compare complications, conversion rates and postoperative length of hospital stay between patients undergoing TEP or TAPP for unilateral recurrent inguinal hernia repair.
Method
Based on prospective data of the Swiss Association of Laparoscopic and Thoracoscopic Surgery, all patients who underwent elective TEP or TAPP for unilateral recurrent inguinal hernia between 1995 and 2006 were included. The following outcomes were compared: conversion rates, intraoperative complications, surgical postoperative complications and duration of operation.
Results
Data on 1309 patients undergoing TEP (n = 1022) and TAPP (n = 287) for recurrent inguinal hernia were prospectively collected. Average age, BMI and ASA score were similar in both groups. Patients undergoing TEP had a significantly increased rate of intraoperative complications (TEP 6.3 % vs. TAPP 2.8 %, p = 0.0225). Duration of operation was longer for patients undergoing TEP (TEP 80.3 vs. TAPP 73.0 min, p < 0.0023) while postoperative length of hospital stay was longer for patients undergoing TAPP (TEP 2.6 vs. TAPP 3.1 day, p = 0.0145). Surgical postoperative complications (TEP 3.52 % vs. TAPP 2.09 %, p = 0.2239), general postoperative complications (TEP 1.47 % vs. TAPP 0.7 %, p = 0.3081) and conversion rates (TEP 2.15 % vs. TAPP 1.39 %, p = 0.4155) were not significantly different.
Conclusion
This study is the first population-based analysis comparing outcomes of patients with recurrent inguinal hernia undergoing TEP versus TAPP in a prospective cohort of over 1300 patients. Intraoperative complications were significantly higher in patients undergoing TEP. The TEP technique was associated with longer operating times, but a shorter postoperative length of hospital stay. Nonetheless, the absolute outcome differences are small and thus, on a population-based level, both techniques appear to be safe and effective for patients undergoing endoscopic repair for unilateral recurrent inguinal hernia.
Background: Inguinal hernia repair is the most common general surgical procedure in industrialized countries, with a frequency of about 200 operations per 100 000 persons per year. Suture- and mesh-based techniques can be used, and the procedure can be either open or minimally invasive.
Method: This review is based on a selective search of the literature, with interpretation of the published findings according to the principles of evidence-based medicine.
Results: Inguinal hernia is diagnosed by physical examination. Surgery is not necessarily indicated for a primary, asymptomatic inguinal hernia in a male patient, but all inguinal hernias in women should be operated on. For hernias in women, and for all bilateral hernias, a laparoscopic or endoscopic procedure is preferable to an open procedure. Primary unilateral hernias in men can be treated either by open surgery or by laparoscopy/endoscopy. Patients treated by laparoscopy/endoscopy develop chronic pain less often than those treated by open surgery. A mesh-based repair is generally recommended; this seems reasonable in view of the pathogenesis of the condition, which involves an abnormality of the extracellular matrix.
Conclusion: The choice of procedure has been addressed by international guidelines based on high-level evidence. Surgeons should deviate from their recommendations only in exceptional cases and for special reasons. Guideline conformity implies that hernia surgeons must master both open and endoscopic/laparoscopic techniques.
The objective of this article is to systematically analyse the randomized, controlled trials comparing open (OPPR) versus laparoscopic (LPPR) preperitoneal mesh repair of inguinal hernia. Randomized, controlled trials comparing OPPR versus LPPR of inguinal hernia were analysed systematically using RevMan®, and combined outcomes were expressed as odds ratio (OR) and standardized mean difference (SMD). Ten randomized trials evaluating 1286 patients were retrieved from the electronic databases. There were 606 patients in the OPPR repair group and 680 patients in the LPPR group. There was significant heterogeneity among trials (p < 0.0001). Therefore, in the random effects model, LPPR was associated with longer operative time and relatively lesser postoperative pain in the case of the trans-abdominal preperitoneal approach. Statistically, both OPPR and LPPR were equivalent in terms of developing chronic groin pain, recurrence and postoperative complications. OPPR of inguinal hernia is associated with shorter operative time and comparable with LPPR (both total extraperitoneal and trans-abdominal preperitoneal approaches) in terms of risk of chronic groin pain, recurrence and complications.
Key Clinical PointsGroin Hernias in Adults Groin hernias are much more common in men than in women.Patients with symptoms of acute incarceration and strangulation require emergency surgery.Watchful waiting is a safe approach for asymptomatic male patients with inguinal hernia, but data from randomized trials suggest that the majority of men will ultimately be referred for surgery, primarily because of pain, within 10 years.For an uncomplicated unilateral inguinal hernia, open repair has the advantages of potentially being performed under local anesthesia and incurring lower initial costs; laparoscopic repair results in less postoperative pain and an earlier return to normal activities, but it requires general anesthesia routinely and carries a small risk of major intraabdominal injury.Femoral hernias occur more often in women than in men, are associated with much higher risk of strangulation, and can be difficult to distinguish from inguinal hernias; watchful waiting is not recommended in women.
A patient presented with a recurrent incarcerated inguinoscrotal hernia requiring urgent surgery. The defect was through the gap in the mesh left originally for the cord structures. As a result, a modified funnel repair was performed. An innovative approach was adopted that was best suited to tackling and reducing the risk of recurrence.
To assess the long-term crossover (CO) rate in men undergoing watchful waiting (WW) as a primary treatment strategy for their asymptomatic or minimally symptomatic inguinal hernias.
With an average follow-up of 3.2 years, a randomized controlled trial comparing WW with routine repair for male patients with minimally symptomatic inguinal hernias led investigators to conclude that WW was an acceptable option [JAMA. 2006;295(3):285-292]. We now analyze patients in the WW group after an additional 7 years of follow-up.
At the conclusion of the original study, 254 men who had been assigned to WW consented to longer-term follow-up. These patients were contacted yearly by mail questionnaire. Nonresponders were contacted by phone or e-mail for additional data collection.
Eighty-one of the 254 men (31.9%) crossed over to surgical repair before the end of the original study, December 31, 2004, with a median follow-up of 3.2 (range: 2-4.5) years. The patients have now been followed for an additional 7 years with a maximum follow-up of 11.5 years. The estimated cumulative CO rates using Kaplan-Meier analysis was 68%. Men older than 65 years crossed over at a considerably higher rate than younger men (79% vs 62%). The most common reason for CO was pain (54.1%). A total of 3 patients have required an emergency operation, but there has been no mortality.
Men who present to their physicians because of an inguinal hernia even when minimally symptomatic should be counseled that although WW is a reasonable and safe strategy, symptoms will likely progress and an operation will be needed eventually.
Background: We investigated the epidemiology of nosocomial bloodstream infection in elderly intensive care unit (ICU) patients.
Methods: In a single-center, historical cohort study (1992–2006), we compared middle-aged (45–64 years; n = 524), old (65–74 years; n = 326), and very old ICU patients (≥75 years; n = 134) who developed a nosocomial bloodstream infection during their ICU stay.
Results: Although the total number of ICU admissions (patients aged ≥45 years) decreased by ∼10%, the number of very old patients increased by 33% between the periods 1992–1996 and 2002–2006. The prevalence of bloodstream infection (per 1,000 ICU admissions) increased significantly over time among old (p = 0.001) and very old patients (p = 0.002), but not among middle-aged patients (p = 0.232). Yet, this trend could not be confirmed with the incidence data expressed per 1,000 patient days (p > 0.05). Among patients with bloodstream infection, the proportion of very old patients increased significantly with time from 7.2% (1992–1996) to 13.5% (1997–2001) and 17.4% (2002–2006) (p < 0.001). The incidence of bloodstream infection (per 1000 patient days) decreased with age: 8.4‰ in middle-aged, 5.5‰ in old, and 4.6‰ in very old patients (p < 0.001). Mortality rates increased with age: 42.9%, 49.1%, and 56.0% for middle-aged, old, and very old patients, respectively (p = 0.015). Regression analysis revealed that the adjusted relationship with mortality was borderline significant for old age (hazard ratio, 1.2; 95% confidence interval, 1.0–1.5) and significant for very old age (hazard ratio, 1.8; 95% confidence interval, 1.4–2.4).
Conclusion: Over the past 15 years, an increasing number of elderly patients were admitted to our ICU. The incidence of nosocomial bloodstream infection is lower among very old ICU patients when compared to middle-aged and old patients. Yet, the adverse impact of this infection is higher in very old patients.
The authors reviewed the records of 2,468 operations of groin hernia in 2,350 patients, including 277 recurrent hernias updated to January 2005. The data obtained - evaluating technique, results and complications - were used to propose a simple anatomo-clinical classification into three types which could be used to plan the surgical strategy:
Type R1: first recurrence ‘high,’ oblique external, reducible hernia with small (<2 cm) defect in non-obese patients, after pure tissue or mesh repairType R2: first recurrence ‘low,’ direct, reducible hernia with small (<2 cm) defect in non-obese patients, after pure tissue or mesh repairType R3: all the other recurrences - including femoral recurrences; recurrent groin hernia with big defect (inguinal eventration); multirecurrent hernias; nonreducible, linked with a controlateral primitive or recurrent hernia; and situations compromised from aggravating factors (for example obesity) or anyway not easily included in R1 or R2, after pure tissue or mesh repair.
Research by herniologists from around the world has shown that abdominal defects, in the adult, are not caused by wear and tear but systemic hernial disease (herniosis), a disorder of connective tissue which affects the extracellular matrix (ECM). Wound healing may be affected, leading to recurrences after hernia repair or primary incisional herniation. Women with genitourinary prolapse show signs of herniosis in the pelvis. Diverticulosis coli, commonly seen in the elderly, like hernia, was once attributed to stress and strain from constipation. It is now suspected that herniosis weakens the colonic ECM, allowing the mucosa to form diverticula by herniating alongside the vasa recta. Remarkably, clinical studies of Saint's triad extending over the past 60 years have repeatedly demonstrated a highly significant relationship between colonic diverticula and abdominal herniae. Krones et al. (Int J Colorectal Dis 21:18-24, 2006) reported that diverticula and cancer are rarely coincident in the colon, despite aging. Their data indicate that the two pathologies arise in different ECMs. Klinge et al. (Int J Colorectal Dis 22:515-520, 2007), quoting Paget (Lancet 1:571-573, 1889), "Tumor cells can like seeds only grow if they fall on congenial soil," suggested that certain genes prevent stromal malignancy by influencing the microenvironment to stop epithelia from becoming cancerous. Thus, damage to the colonic ECM from hernial disease is conducive to diverticulosis, but hostile for cancer. Hernial disease being systemic, a similar ECM should be present throughout the body. Coincident diverticulosis and herniae support this hypothesis. Its validation requires further research involving the lifetime risk of cancer in patients with and without hernia. Since smoking causes both herniation and cancer, data from indulgers will have to be analyzed separately from abstainers.
This study aimed to compare the outcome and morbidity parameters of laparoscopic total extraperitoneal (TEP) repair for recurrent and primary inguinal hernias.
A retrospective analysis was conducted over a 3-year period. The recurrence rate; pain scores at 24 h, 1 week, and 4 weeks; hospital stay; days to resumption of normal activities; seroma formation; and urinary retention rates were noted.
Of 937 patients, 52 underwent recurrent and 885 underwent primary hernia repair. The follow-up period was 12 to 40 months (median, 25 months). The mean operating time was longer in the recurrent group (32.7 +/- 6.3 min) than in the primary group (30.1 +/- 6.1 min; p = 0.015). The mean pain scores at 24 h were similar in the two groups (2.28 +/- 0.5 for the recurrent group vs. 2.20 +/- 0.4 for the primary group; nonsignificant difference). However the pain scores at 1 week were significantly higher in the recurrent group (1.35 +/- 0.5) than in the primary group (1.20 +/- 0.4; p = 0.017). The hospital stay (1.19 +/- 0.4 vs. 1.07 +/- 0.3 days; p = 0.002) and the time to resumption of normal activities (8.62 +/- 2.6 vs. 7.67 +/- 1.4 days; p < 0.0001) were significantly longer in the recurrent group than in the primary group. The urinary retention (9.6% vs. 5.4%; nonsignificant difference) and seroma formation (3.8% vs. 3.5%; p = 0.5) were similar in the recurrent and the primary groups, respectively. There were two recurrences and two conversions to open procedure in the primary group and none in the recurrent group.
Laparoscopic TEP repair of recurrent inguinal hernia is safe and effective, with recurrence and conversion rates similar to those for primary hernia repair. However, the operative time, pain at 1 week and 1 month postoperatively, hospital stay, and time to resumption of normal activities with recurrent repair were significantly greater than with laparoscopic primary hernia repair.
Abnormal systemic collagen metabolism is thought to dispose to the development of hernias. Studies have shown that a reduced type-I/III collagen ratio predisposes to the development of hernias. Patient groups with reduced type-I/III collagen ratio and consequently increased risk of herniation include patients with Ehlers-Danlos, Marfans syndrome, osteogenesis imperfecta, cutis laxa, and patients with abdominal aortic aneurysms, colonic diverticula or stress urinary incontinence. Looking ahead, the perspective may be individualization of the operative technique for patients with a hernia, depending on their collagen profile.
Prosthetic mesh in the form of a plug has been used extensively in the United States for hernia repair. It has been popular for all types of femoral hernias and for the majority of recurrent inguinal hernias. It follows the basic principle of 'tension-free' repair and permits unrestricted postoperative physical activity. The method has resulted in a long-term success rate better than the many modifications of the Bassini repair.
Since 1984 we have completed 3897 inguinal herniorrhaphies. This article compares our results with a conventional Cooper ligament repair versus the "mesh hernia plug" method.
From 1984 through 1988 we performed 2886 conventional Cooper ligament repairs. From 1989 through 1991 we completed 1011 mesh hernia plug repairs.
Despite an acceptable recurrence rate (1.8%), we abandoned the Cooper ligament technique because of persistent difficulties with immediate postoperative pain, inability to reasonably resume day-to-day activities, delayed capacity regarding return to work, and four cases of femoral vein compression. Of the hernias repaired by the mesh plug method, the recurrence rate remains remarkably low (0.2%), and except for four superficial infections and three cases of urinary retention, no other significant complications have been reported.
Compared with conventional sutured surgical techniques, a plug repair uses less overall dissection and ensures a "tension-free" hernioplasty. We believe that the two factors of no tissue tension and decreased dissection are the most important reasons for greater patient comfort, rapid rehabilitation, decreased recurrence, and lessened overall complication rates with the mesh hernia plug technique.
Inguinal herniorrhaphy remains one of the most common general surgical operations, with approximately 10 to 20 per cent performed for recurrence. Subsequent repairs provide considerable technical challenge, as well as substantially greater risk of developing further recurrence. Mesh repair is advocated by several specialized hernia centers, demonstrating re-recurrence rates less than 2 per cent. Detractors of this repair include cost, technical difficulty, and risk for infection. The purpose of this study was to compare results of mesh and nonmesh repairs for recurrent inguinal hernia, either using an anterior or posterior approach, at a large teaching institution. From January 1, 1985, to December 31, 1994, 146 patients underwent repair for recurrent inguinal hernia at the Veterans Administration Hospital at Memphis, Tennessee. Patients were stratified by type of repair: Lichtenstein (Mesh), open anterior (OA), Bassini, Marcy, McVay, Shouldice, and preperitoneal with or without mesh. Patient ages and weights were similar between groups. Mean operative time for Mesh repair (104 +/- 4 minutes) was longer than that for OA repairs (80 +/- 5 minutes, P < 0.05) or preperitoneal without mesh repairs (92 +/- 5 minutes, P < 0.05). Mesh-based posterior repairs had the longest operative times (116 +/- 5 minutes). Hospital stay averaged 2.8 +/- 0.3 days, similar among all groups. One wound infection (1.0%) occurred in patients undergoing Mesh repair, which required operative drainage. No patient required removal of mesh. Two patients in the Mesh group (5.9%) developed recurrence compared with four recurrences (18.0%) in patients undergoing OA repairs. Only one patient with a mesh-based posterior repair recurred (1.9%) compared to eight without mesh (21.6%, P < 0.01). Follow-up ranged from 2 to 12 years. Repair of recurrent inguinal hernia using either an anterior or posterior mesh repair technique, performed at a teaching facility, provides superior recurrence rates without increasing risk for infection or length of stay. Preperitoneal mesh based repair is the preferred technique.
Recurrent inguinal hernias can be repaired efficaciously by mesh plug techniques, which have had better results than traditional tissue-based repairs in several small studies. This report provides a detailed description and assessment of the anterior, tension-free, "umbrella" mesh plug method for recurrent groin herniorrhaphy.
We performed a retrospective analysis of 407 patients with recurrent inguinal and femoral hernias treated with an umbrella mesh plug repair since 1989. Information was recorded about postoperative recovery and complications, and patients were examined for rerecurrences 1 week after operation and annually thereafter.
Of the 320 patients with a first-time recurrence, 6 (2%) had a recurrence after placement of a mesh plug. Of the 87 patients who had undergone 2 or more prior repairs, 8 (9%) had a rerecurrence subsequent to a mesh plug hernioplasty. Nine (64%) of the 14 rerecurrences were noted within 1 year of operation; 4 (29%) were found 2 years after operation and 1 (7%) during postoperative year 3. During the 9 years of follow-up study, a mesh plug has not been involved in any infectious process requiring removal. There have been no instances of draining sinus tracts, ischemic orchitis, long-term pain, vascular and embolic phenomena, or plug erosion and migration. Two hundred fifteen (53%) of the patients took no pain medication. One hundred fifty-nine patients (39%) used nothing more than nonprescription pain medicine. Three hundred seventy-five patients (92%) returned to normal daily activities within 4 days of the herniorrhaphy.
Patients with recurrent groin hernias, who undergo a minimal-dissection umbrella mesh plug repair, have a rapid recovery and few postoperative complications.
To describe a 7-year experience with recurrent inguinal hernia repair performed mainly with tension-free mesh or plug technique under local anesthesia through the anterior approach, and to evaluate the safety and effectiveness of this method of treatment.
One hundred forty-five elective and 1 emergency herniorrhaphies for recurrent groin hernia were performed in 141 subjects (134 men and 7 women) with a mean age of 65 years (range 30-89). Concomitant medical and surgical problems were present in 73% and 8% of subjects, respectively. In 28 instances, the relapsed hernia had already been operated on once or twice for recurrence. A traditional hernioplasty had been previously performed in the vast majority of cases (136). Tension-free mesh or plug techniques through an anterior approach under local anesthesia were performed in 144 reoperations. Preperitoneal mesh repair and general or spinal anesthesia were used in all but one case when herniorrhaphy was performed during simultaneous operations.
Mean hospital stay after surgery was 1.5 days (range 3 hours-14 days). No perioperative deaths occurred in this series. General complications were one case of acute intestinal bleeding and two cases of urinary retention. Local complications consisted of eight (5.5%) minor complications and one case of orchitis (0.7%) followed by testicular atrophy. In no instance was postoperative neuralgia or chronic pain reported. Two re-recurrences occurred.
Given the low complication rate in this and other reported series and the absence of surgical or general complications described after preperitoneal open or laparoscopic repair and after general and spinal anesthesia, anterior mesh repair under local anesthesia seems to be a low-cost surgical technique that can be safely and effectively used even in a teaching hospital for the treatment of the majority of patients with recurrent groin hernias.
The history of open surgery for groin hernia has gone through many stages of development, including the ancient era (ancient times to the fifteenth century), the era of the start of herniology (fifteenth to seventeenth centuries), the anatomic era (seventeenth to nineteenth centuries), the era of repair under tension (nineteenth to mid-twentieth century), and the era of tensionless repair (mid-twentieth century to the present). Five principles of modern hernia repair developed through these periods of development: antiseptic/aseptic hernia operation, high ligation of the sac, tightening of the internal ring, reconstruction of the posterior inguinal floor, and tensionless repair. Interestingly, many of the initial attempts at laparoscopic hernia repair did not adhere to the recognized principles of hernia surgery learned from open surgery. It is only when the transabdominal preperitoneal mesh repair and the totally extraperitoneal approach, which adhere to the basic principles, are considered that the results of laparoscopic hernia repair procedures can improve and the recurrence of hernia decrease.
To audit the effect of changes in treatment of inguinal hernias on recurrence rate.
Retrospective analysis of consecutive patients operated on in 1990 and prospective analysis of consecutive patients operated on in 1996. Follow up with questionnaire followed by selective clinical examination.
County hospital, Sweden.
144 patients with 147 inguinal hernias operated on in 1990 and 154 patients with 165 inguinal hernias operated 1996. on in
In 1993, we changed many aspects of the treatment of inguinal hernia. We introduced new techniques such as Shouldice, Lichtenstein, and laparoscopic hernia repair. Non-absorbable polypropylene sutures replaced the braided absorbable sutures previously used. Inguinal herniorrhaphy went from a "low status" operation to a high status operation and became a primary teaching operation for surgical residents.
Recurrence rate at 5 year follow up.
The 5 year recurrence rate decreased from 28% in 1990 to 3% in 1996 (p < 0.001). The m edian operating time increased from 35 minutes in 1990 to 78 minutes in 1996 (p < 0.001).
Changing the strategy of inguinal hernia surgery by introducing uniform operating techniques and new materials dramatically improved the results and allowed us to achieve recurrence rates comparable to those seen in specialised hernia centres.