Showing papers in "Hernia in 2012"

Epidemiology and cost of ventral hernia repair: making the case for hernia research

Abstract: Purpose Ventral hernia repair (VHR) lacks standardization of care and exhibits variation in delivery. Complications of VHR, notably recurrence and infection, increase costs. Efforts at obtaining federal funding for VHR research are frequently unsuccessful, in part due to misperceptions that VHR is not a clinical challenge and has minimal impact on healthcare resources. We analyzed national trends for VHR performance and associated costs to demonstrate potential savings resulting from an improvement in outcomes.

EuraHS: the development of an international online platform for registration and outcome measurement of ventral abdominal wall hernia repair.

Abstract: Although the repair of ventral abdominal wall hernias is one of the most commonly performed operations, many aspects of their treatment are still under debate or poorly studied. In addition, there is a lack of good definitions and classifications that make the evaluation of studies and meta-analyses in this field of surgery difficult. Under the auspices of the board of the European Hernia Society and following the previously published classifications on inguinal and on ventral hernias, a working group was formed to create an online platform for registration and outcome measurement of operations for ventral abdominal wall hernias. Development of such a registry involved reaching agreement about clear definitions and classifications on patient variables, surgical procedures and mesh materials used, as well as outcome parameters. The EuraHS working group (European registry for abdominal wall hernias) comprised of a multinational European expert panel with specific interest in abdominal wall hernias. Over five working group meetings, consensus was reached on definitions for the data to be recorded in the registry. A set of well-described definitions was made. The previously reported EHS classifications of hernias will be used. Risk factors for recurrences and co-morbidities of patients were listed. A new severity of comorbidity score was defined. Post-operative complications were classified according to existing classifications as described for other fields of surgery. A new 3-dimensional numerical quality-of-life score, EuraHS-QoL score, was defined. An online platform is created based on the definitions and classifications, which can be used by individual surgeons, surgical teams or for multicentre studies. A EuraHS website is constructed with easy access to all the definitions, classifications and results from the database. An online platform for registration and outcome measurement of abdominal wall hernia repairs with clear definitions and classifications is offered to the surgical community. It is hoped that this registry could lead to better evidence-based guidelines for treatment of abdominal wall hernias based on hernia variables, patient variables, available hernia repair materials and techniques.

Modified classification of surgical meshes for hernia repair based on the analyses of 1,000 explanted meshes

Abstract: Background It is an undisputable fact that meshes have become standard for repair of abdominal wall hernias. Whereas in the late eighties there were only a couple of different devices available, today we have to choose among some hundreds, with lots of minor and major variations in polymer and structure. As most of the minor variations may not lead to significant change in clinical outcome and may be regarded as less relevant, we should focus on major differences. Eventually, this is used to structure the world of mesh by forming groups of textile devices with distinct biological response. Many experimental and some clinical studies have underlined the outstanding importance of porosity, which fortunately, in contrast to other biomechanical quanlities, is widely unaffected by the anisotropy of meshes.

A new classification for seroma after laparoscopic ventral hernia repair.

Abstract: Introduction Laparoscopic techniques are being used increasingly in the repair of ventral hernias, but different incidences and complications have been described as potential risks of this approach. Seroma formation has been documented as one of the most common complication, although most of the time remains asymptomatic and it can be considered just an incident. The incidence of seroma after laparoscopic ventral hernia repair has not been properly documented and analyzed since the definition used by different authors is not the same from one series to another. We present a new classification of clinical seroma in order to try to establish the real incidence of this potential complication.

Classification of prosthetics used in hernia repair based on weight and biomaterial

Abstract: The aim of this study was to classify the polymeric prosthetics used for hernia repair based on biomaterial composition and weight in an effort to clarify to surgeons what kinds of material they are dealing with and to provide a standardized system of categorization. An intensive research effort was carried out on prosthetics that are commercially available worldwide. We conducted a search of the medical literature and companies’ websites to find the weights and thicknesses of commercially available prosthetics. Where these data were lacking, we contacted manufacturers directly in order to render the research more complete. A total of 166 products were considered for classification based on biomaterial properties. Among these, a homogeneous group of 80 polypropylene monofilament knitted or woven prosthetics was selected for classification based on weight. Weights were provided for 70 prosthetics (87%), and both the weight and thickness was provided for 40 prosthetics (50%). Classification based on weight: Ultra-light <35 g/m2, Light ≥35 < 70 g/m2, Standard ≥70 < 140 g/m2, Heavy ≥140 g/m2. Classification based on biomaterial composition: simple (prosthetics made of one pure biomaterial); composite (prosthetics made of two or more different layers); combined (prosthetics made of two materials knitted or woven together); and biologic. Weight and biomaterial classifications were proposed after an extensive analysis of commercially available prosthetics. The need for a common terminology is important to avoid misunderstandings among clinicians and technicians.

Herniamed : an Internet-based registry for outcome research in hernia surgery

Abstract: Purpose Despite the high frequency of hernia surgery procedures and continuous improvements, thanks to new hernia meshes and fixation techniques, in Germany, for example, the recurrence rate and rate of chronic inguinal pain after inguinal surgery are more than 10% far too high. Introduction of a hernia register in Denmark led to a significant reduction in the recurrence rate.

Efficiency and safety of mesh fixation in laparoscopic inguinal hernia repair using n-butyl cyanoacrylate: long-term biocompatibility in over 1,300 mesh fixations

Abstract: Introduction In adult patients, most inguinal hernias are treated by implanting a prosthetic mesh. To prevent mesh dislocation and thus recurrence, different types of fixation have been proposed. In contrast to penetrating fixation known to cause acute chronic pain, adhesive fixation is becoming increasingly popular as it reduces markedly the risk of injury and chronic pain. Apart from the biological sealants (e.g., fibrin glue), surgical adhesives include a group of synthetic glues and genetically engineered protein glues. For example, cyanoacrylate is used in various medical and veterinary indications due to its fast action, excellent bonding strength and low price.

Use of a prosthetic mesh to prevent parastomal hernia during laparoscopic abdominoperineal resection: a randomized controlled trial.

Abstract: Prevention of parastomal hernia represents an important aim when a permanent stoma is necessary. The objective of this work is to assess whether implantation of a prophylactic prosthetic mesh during laparoscopic abdominoperineal resection contributed to reduce the incidence of parastomal hernia. Rectal cancer patients undergoing elective laparoscopic abdominoperineal resection with permanent colostomy were randomized to placement of a large-pore lightweight mesh in the intraperitoneal/onlay position by the laparoscopic approach (study group) or to the control group (no mesh). Parastomal hernia was defined radiologically by a CT scan performed after 12 months of surgery. The usefulness of subcutaneous fat thickness measured by CT to discriminate patients at risk of parastomal hernia was assessed by ROC curve analysis. Thirty-six patients were randomized, 19 to the mesh group and 17 to the control group. Parastomal hernia was detected in 50 % of patients in the mesh group and in 93.8 % of patients in the control group (P = 0.008). The AUC for thickness of the subcutaneous abdominal was 0.819 (P = 0.004) and the optimal threshold 23 mm. Subcutaneous fat thickness ≥23 mm was a significant predictor of parastomal hernia (odds ratio 15.7, P = 0.010), whereas insertion of a mesh was a protective factor (odds ratio 0.06, P = 0.031). Use of prophylactic large-pore lightweight mesh in the intraperitoneal/onlay position by a purely laparoscopic approach reduced the incidence of parastomal hernia formation. Subcutaneous fat thickness ≥23 mm measured by CT was an independent predictor of parastomal hernia.

Three-year results from a preclinical implantation study of a long-term resorbable surgical mesh with time-dependent mechanical characteristics

Abstract: Purpose The purpose of this study was to evaluate the biocompatibility, local tissue effects and performance of a synthetic long-term resorbable test mesh (TIGR® Matrix Surgical Mesh) compared to a non-resorbable polypropylene control mesh following implantation in a sheep model.

Evaluation of crosslinked and non-crosslinked biologic prostheses for abdominal hernia repair

Abstract: Introduction Abdominal wall defects and incisional hernias represent a challenging problem. Currently, several commercially available biologic prostheses are used clinically for hernia repair. We compared the performance and efficacy of two non-crosslinked meshes in ventral hernia repair to two crosslinked prostheses in a rodent model.

Randomized controlled multicenter international clinical trial of self-gripping Parietex™ ProGrip™ polyester mesh versus lightweight polypropylene mesh in open inguinal hernia repair: interim results at 3 months

Abstract: To compare clinical outcomes following sutureless Parietex™ ProGrip™ mesh repair to traditional Lichtenstein repair with lightweight polypropylene mesh secured with sutures. This is a 3-month interim report of a 1-year multicenter international study. Three hundred and two patients were randomized; 153 were treated with Lichtenstein repair (L group) and 149 with Parietex™ ProGrip™ precut mesh (P group) with or without fixation. The primary outcome measure was postoperative pain using the visual analog scale (VAS, 0–150 mm); other outcomes were assessed prior to surgery and up to 3 months postoperatively. Compared to baseline, pain score was lower in the P group at discharge (−10%) and at 7 days (−13%), while pain increased in the L group at discharge (+39%) and at 7 days (+21%). The difference between groups was significant at both time points (P = 0.007 and P = 0.039, respectively). In the P group, patients without fixation suffered less pain compared to those with single-suture fixation (1 month: −20.9 vs. −6.15%, P = 0.02; 3 months: −24.3 vs. −7.7%, P = 0.01). The infection rate was significantly lower in the P group during the 3-month follow-up (2.0 vs. 7.2%, P = 0.032). Surgery duration was significantly shorter in the P group (32.4 vs. 39.1 min; P < 0.001). No recurrence was observed at 3 months in both groups. Surgery duration, early postoperative, pain and infection rates were significantly reduced with self-gripping polyester mesh compared to Lichtenstein repair with polypropylene mesh. The use of fixation increased postoperative pain in the P group. The absence of early recurrence highlights the gripping efficiency effect.

Progressive preoperative pneumoperitoneum preparation (the Goni Moreno protocol) prior to large incisional hernia surgery: volumetric, respiratory and clinical impacts. A prospective study

Abstract: Progressive preoperative pneumoperitoneum (PPP) is used to prepare incisional hernias with loss of domain (IHLD) operations. The aim of the present study was to analyze the effect of PPP on peritoneal volume [measured using a new computed tomography (CT)-based method] and respiratory function. From July 2004 to July 2008, 19 patients were included in a prospective, observational study. The volumes of the incisional hernia (VIH), the abdominal cavity (VAC), the total peritoneal content (VP) and the VIH/VP ratio were measured before and after PPP using abdominal CT scan data. Spirometric parameters were measured before and after PPP, and postoperative clinical data were evaluated. Before and after PPP, the mean VIH was 1,420 cc and 2,110 cc (P < 0.01), and the mean VAC was 9,083 cc and 11,104 cc (P < 0.01). The VAC increased by 2,021 cc (P < 0.01) and was greater than the mean VIH before PPP. After PPP, the spirometric measurements revealed a restrictive syndrome. The overall postoperative morbidity rate was 37%. PPP increased the hernia and abdominal volumes. PPP induced a progressive, restrictive syndrome.

Prospective randomized trial comparing sutured with sutureless mesh fixation for Lichtenstein hernia repair: long-term results

Abstract: Background Following Lichtenstein hernia repair, up to 25% of patients experience prolonged postoperative and chronic pain as well as discomfort in the groin. One of the underlying causes of these complaints are the compression or irritation of nerves by the sutures used to fixate the mesh. We compared the level and rate of chronic pain in patients operated with the classical Lichtenstein technique fixated by sutures to patients with sutureless mesh fixation technique.

The endoscopic component separation technique for hernia repair results in reduced morbidity compared to the open component separation technique.

Abstract: Purpose The component separation technique for hernia repair results in significant wound morbidity due to the need for large undermining skin flaps. The endoscopic component separation technique allows for advancement of the abdominal wall while preserving the blood supply originating from the epigastric vessels. This study compares the outcomes following hernia repair utilizing these techniques.

Obturator hernia: the Mayo Clinic experience

Abstract: Obturator herniae (OH) are rare, with nonspecific signs and symptoms, and diagnosis is usually delayed until laparotomy. The added benefit of preoperative diagnosis with computed tomography (CT) remains unclear. We reviewed the clinical characteristics and outcomes of OH repairs performed at our institution over a 58-year period. Outcomes were compared between patients who did or did not have a preoperative CT. Between 1950 and 2008, 30 patients (median age 82 years, 29 women) underwent OH repair. The most common presenting signs and symptoms were bowel obstruction (63%), abdominal/groin pain (57%), and a palpable lump (10%). The pathognomonic Howship-Romberg sign was present in 11 patients (37%). The diagnosis was made preoperatively in nine patients: clinically in one (3%) and with CT in eight (27%). Nineteen patients (63%) presented emergently. Primary and prosthetic repair were performed in 23 (77%) and seven (23%) patients, respectively. Small-bowel resection was performed in 14 patients (47%). Perioperative morbidity (30%) and mortality (10%) rates were high. Patients with a preoperative CT were less likely to develop a postoperative complication of any type [odds ratio (OR) 0.8, P = 0.04]; however, time to operation, length of stay, need for bowel resection, and mortality rate did not differ (P = NS). No recurrences were detected at a median follow-up of 2 years (range 0–55). Although CT imaging provides an excellent means of preoperative diagnosis, suggestive signs and symptoms in a “skinny old lady” should prompt immediate operative intervention without delay.

Lightweight versus heavyweight in inguinal hernia repair: a meta-analysis

Abstract: Purpose The aim of this article is to compare the outcomes of lightweight mesh and heavyweight mesh in inguinal hernia repair.

Prospective randomized trial of laparoscopic (transabdominal preperitoneal-TAPP) versus open (mesh) repair for bilateral and recurrent inguinal hernia: incidence of chronic groin pain and impact on quality of life: results of 10 year follow-up.

Abstract: The incidence of chronic groin pain (CGP) and its impact on quality of life (QoL) after hernia repair are not clear with follow-up either being short or retrospective. We present 10-year prospective follow-up of a randomized trial for bilateral and recurrent hernia repair focusing on CGP and its impact on QoL. Patients enrolled between 1997 and 2000 were contacted by telephone and asked about the presence of CGP. Those patients with CGP were sent two validated questionnaires: a SF-12v2 Health Survey and a Pain Impact Questionnaire (PIQ-6) (QualityMetric, USA). One hundred and twenty patients were recruited into the original study, and of these, 14 complained of CGP and were sent a PIQ-6 and a SF-12 v2 health survey. Overall, there was a higher incidence of CGP in the laparoscopic group compared with the open group (15 vs. 8 %, ns), but the severity of the pain in the laparoscopic group was less (2 vs. 3.5, p = 0.0558). QoL was significantly reduced in patients with CGP compared with the US norm. The laparoscopic group scored higher in 5 out of 8 of the QoL categories compared with the open group, but this was not significant. Overall age-adjusted scores revealed those under 65 years of age felt they had poorer physical health, and this reduced their QoL compared to normal values. CGP following laparoscopic surgery for inguinal hernia repair is less severe than open repair, but this does not translate into a significant improvement in QoLin this study.

Meta-analysis of randomized controlled trials comparing lightweight and heavyweight mesh for Lichtenstein inguinal hernia repair.

Abstract: Lichtenstein inguinal hernia repair is associated with a low incidence of recurrence; however, the use of heavyweight mesh has been linked with chronic pain and foreign body sensation. It is hypothesized that the use of lightweight mesh may reduce these problems. This study aims to use meta-analysis to compare lightweight and heavyweight mesh for Lichtenstein inguinal hernia repair. Information was gathered from randomized controlled trials that compared lightweight and heavyweight mesh for Lichtenstein inguinal hernia repair. The Cochrane Library, Medline, EMBASE, trial registries, conference proceedings and reference lists were searched. Primary outcome measures were chronic pain, foreign body sensation and hernia recurrence. Secondary outcome measures were duration of surgery, mean visual analogue scale (VAS) pain scores, surgical-site infection, testicular atrophy and haematoma/seroma. The pooled Peto odds ratio (OR) was calculated for categorical data and weighted mean difference (WMD) for continuous data. Six trials with 1936 hernias were included. Lightweight mesh was associated with reduced chronic pain (OR = 0.67, 95% CI = 0.50–0.90; p < 0.01) and foreign body sensation (OR = 0.43, 95% CI = 0.21–0.93; p < 0.05). Lightweight mesh was also associated with lower VAS pain scores at 3 months after surgery (WMD = −0.35, 95% CI = −0.39 to −0.31; p < 0.0001). There were no differences in hernia recurrence (OR = 1.19, 95% CI = 0.54–2.64; p = 0.66) or other post-operative complications between the two groups. The use of lightweight mesh in Lichtenstein inguinal hernia repair is associated with less chronic pain, and foreign body sensation compared with heavyweight mesh without any difference in recurrence.

Incidence and risk factors for trocar site hernia following laparoscopic cholecystectomy: A long-term follow-up study

Abstract: The aim of this retrospective study was to assess the incidence of trocar site hernias (TSH) following laparoscopic cholecystectomy (LC) through a long-term follow-up and to elucidate the significance of several technical and patient-related factors. A total of 313 patients submitted to LC between 2000 and 2004 were included in our study. The pneumoperitoneum was always performed by means of Hasson’s technique at the umbilical site and the operative trocars were positioned using either the American technique or the French technique. Closure of the fascial defect was performed only at the umbilical site. The effects of several variables, including age, gender, size of gallstones, co-existing umbilical hernia, complexity of operation, diabetes, obesity, malnutrition, smoking, and heavy manual work on the development of TSH were assessed by univariate and multivariate models. Thirteen cases of TSH (4.1 %) were detected over a mean follow-up period of 89.8 months (range: 60–128). Of these, 11 (84.6 %) developed at the umbilicus and 2 at the 10 mm subxiphoid site (15.4 %). At univariate and multivariate analysis, gallstones ≥2 cm (p = 0.030; OR = 9.95, p = 0.01) and obesity (p = 0.002; OR = 22.93, p < 0.01) were found to increase the likelihood of TSH development. After long-term follow-up, the incidence of TSH following LC was higher than expected. The insertion of large trocars at the umbilical site plays a key role in the development of TSH. Other conditions such as obesity and large gallstones can be additional risk factors since the umbilical defect must often be widened in these cases.

Comparison of non-mesh (Desarda) and mesh (Lichtenstein) methods for inguinal hernia repair among black African patients: a short-term double-blind RCT

Abstract: Purpose This study compared the short-term outcomes of the non-mesh (Desarda) and mesh (Lichtenstein) methods of hernia repair among Black African patients, with regard to acute postoperative pain, day of return to normal gait, operative time and complications.

Late-presenting congenital diaphragmatic hernia: diagnostic pitfalls and outcome

Abstract: We sought to review the presentation, diagnosis, and outcome of a series of children with late-presenting, congenital diaphragmatic hernias (CDH). Bochdalek and Morgagni hernias that were diagnosed after 30 days of age, between January 1989 and December 2009, were reviewed retrospectively. A medical record review and telephone survey were conducted in 2010. Thirty-one subjects, diagnosed with CDH between 45 days and 13 years of age (mean, 16 months), were reviewed. Bochdalek hernias were present in 18 (58%) and Morgagni hernias in 13 (42%). There were twenty (64%) left-sided, eight (26%) right-sided, and three (10%) bilateral CDH. Five (16%) had other congenital anomalies. Eight (25.8%), including a subject with strangulated intestine that required resection, were initially misdiagnosed, due mostly to failure to obtain or correctly interpret a chest radiograph. Thirty (97%) were repaired by an abdominal approach, including seven laparoscopic closures. Follow-up ranged from 1 to 20 years (median, 7 years). All subjects survived without recurrence. Unlike neonatally diagnosed CDH, neither right-sided hernia, patch repair, nor associated esophageal atresia predicted morbidity. Although diagnostic delays may lead to morbidity, if late-presenting CDH are expeditiously identified and repaired, their outcome is very good, in contrast to those that present in neonates.

Systematic review and meta-analysis on heavy and lightweight polypropylene mesh in Lichtenstein inguinal hernioplasty.

Abstract: Background Recurrence and pain are the two most important outcomes after inguinal hernia surgery. The concept of lightweight or partially absorbable macroporous meshes was developed under the assumption that the observed pain rate could be decreased without increasing the number of recurrences. Few randomized trials were published to analyze their clinical value, and some concern was raised because of an increased risk of recurrence. A systematic review and a meta-analysis of RCTs were carried out to determine whether the use of lightweight meshes influenced the pain and recurrence rate after Lichtenstein hernioplasty.

The Endoloop technique for the primary closure of direct inguinal hernia defect during the endoscopic totally extraperitoneal approach.

Abstract: Seroma is a frequent complication of endoscopic totally extraperitoneal (TEP) mesh repair of direct inguinal hernia that may cause discomfort and anxiety. Its volume is proportional to the size of the preperitoneal dead space created after the reduction of the hernia. Attempts to reduce its incidence have included tacking the transversalis fascia (TF) to the pubic ramus or closed suction drainage of the preperitoneal space. Both of these techniques are not without problems. The aim of this study was to evaluate the efficiency of a new alternate technique that must be safe and easily reproducible, using a widely available and inexpensive pre-tied suture loop (Endoloop® Ligature) for plication of the weakened TF. This is a prospective study of consecutive patients diagnosed with inguinal hernia during a 33-month period and eligible for endoscopic TEP repair. A single surgeon performed all operations. Each of the M2 or M3 direct defects, according to the European Hernia Society (EHS), were systematically closed prior to the introduction of the prosthetic mesh and as follows: grasping and inversion of the attenuated TF at its apex, using a laparoscopic forceps and plication of the TF by placing a tight Endoloop of Polydioxanone (PDS) at its base. All meshes were secured with fibrin sealant only. Patients were reviewed in the clinic 2 and 6 weeks after the operation. Further follow-up was scheduled if it was deemed necessary. The primary post-operative outcome parameter was seroma formation; secondary outcome parameters included groin pain, surgical complications, and recurrence. Two hundred and fifty hernia repairs were prospectively recorded during this period. All procedures were carried out endoscopically. Seventy-nine patients with 94 direct inguinal hernias were selected in a sequential manner. There were 75 males and four females, with a median age of 57 years. Of those, 55 were combined with an indirect inguinal defect. In total, Endoloops of PDS were used to close the weakened TF in 76 cases (30 M3, 44 M2, and two M1). Only one patient (1.3%) complained of a residual seroma formation, which was still clinically present at 3 months post-operatively, but was not symptomatic. There were only two minor post-operative complications, which occurred in the same patient and were not related to the Endoloop technique. Finally, no patient complained of chronic groin pain and there was no hernia recurrence after a median follow-up of 18 months. The primary closure of direct inguinal hernia defects with a pre-tied suture loop during endoscopic TEP repair is safe, efficient, and very reliable for the prevention of post-operative seroma formation, without increasing the risk of developing chronic groin pain or hernia recurrence. This technique should be the preferred method over stapling of the TF or the insertion of a closed suction drainage device in such a situation.

Comparison of ultrasonography and physical examination in the diagnosis of incisional hernia in a prospective study

Abstract: Incisional hernia is a frequent complication of abdominal surgery (incidence 2–20%). Diagnosis by physical examination is sometimes difficult, especially in small incisional hernias or in obese patients. The additional diagnostic value of standardized ultrasonography was evaluated in this prospective study. A total of 456 patients participating in a randomized trial comparing two suture materials for closure of the abdominal fascia underwent physical examination and ultrasonography at 6-month intervals. Wound complaints and treatment of incisional hernia were also noted. Statistical analysis was performed using the Chi-squared and Fisher’s exact tests (SPSS). Interest variability analysis was performed. During a median follow-up of 31 months, 103 incisional hernias were found. A total of 82 incisional hernias were found by physical examination and an additional 21 with ultrasonography. Six of these additional hernias were symptomatic and only one of the additional hernias received operative treatment. The false-negative rates for physical examination and ultrasonography were 25.3 and 24.4%, respectively. Interest variability was low, with a Kappa of 0.697 (P < 0.001). There are no clear diagnostic criteria for incisional hernia available in the literature. Standardized combination of ultrasonography with physical examination during follow-up yields a significant number of, mostly asymptomatic, hernias, which would not be found using physical examination alone. This is especially relevant in research settings.

Biomechanical compatibility of surgical mesh and fascia being reinforced: dependence of experimental hernia defect repair results on anisotropic surgical mesh positioning

Abstract: Purpose We aimed to compare the effectiveness of experimental middle hernia defect repair in regard to the transverse and longitudinal positioning of anisotropic lightweight surgical mesh.

Muscle degeneration in inguinal hernia specimens

Abstract: There are few articles in the literature reporting the histological changes of groin structures affected by inguinal hernia. A deeper knowledge of this matter could represent an important step forward in the identification of the causes of hernia protrusion. This study aimed to recognise the pathological modifications of muscular structures in autopsy specimens excised from tissues surrounding the hernia orifice. Inguinal hernia was identified in 30 autopsied cadavers, which presented different varieties of hernia, including indirect, direct and mixed. Tissue specimens were resected for histological study from structures of the inguinal area surrounding the hernia opening, following a standardised procedure. The histological examination was focussed on the detection of structural changes in the muscle tissues. The results were compared with biopsy specimens resected from corresponding sites of the inguinal region in a control group of 15 fresh cadavers without hernia. Significant modification of the muscular arrangement of the inguinal area was recognized. Pathological alterations such as atrophy, hyaline and fibrotic degeneration, as well as fatty dystrophy of the myocytes were detected. These findings were observed consistently in the context of multistructural damage also involving vessels and nerves. In cadavers with hernia these alterations were always present independent of hernia type. No comparable damage was found in control cadavers without hernia. The high degree of degenerative changes in the muscle fibres in the inguinal area involved in hernia protrusion described in this report seems to be consistent with chronic compressive damage. These alterations could embody one important factor among the multifactorial sources of hernia genesis. Conjectures concerning its impact on the physiology and biodynamics of the inguinal region are made. The relationship between the depicted degenerative injuries and the genesis of inguinal hernia is also a focus of discussion in this article.

Trends in emergent inguinal hernia surgery in Olmsted County, MN: a population-based study.

Abstract: Evidence suggests that watchful waiting of inguinal hernias (IH) is safe because the risk of acute strangulation requiring an emergent repair is low. However, population-based incidence rates are lacking, and it is unknown whether the incidence of emergent inguinal hernia repairs (IHR) has changed over time. A retrospective review of all IHR performed on adult residents of Olmsted County, Minnesota from 1989 to 2008 was performed using the Rochester epidemiology project, a record-linkage system that covers more than 97 % of the population (2010 US Census = 146,466). Incidence rates/100,000 person-years were calculated, and trends over time were evaluated using Poisson regression. A total of 4,026 IHR were performed on 3,599 patients; 136 repairs (3.8 %) were emergent. Of these, 19 patients (14 %) had bowel resection and three (2 %) died within 30 days of the repair. Rates/100,000 person-years yielded an overall incidence of 7.6 for emergent IHR and 200.0 for elective IHR. Emergent IHR rates increased with age. Overall emergent IHR rates declined from 18.2 to 12.4 in men and from 6.4 to 2.4 in women from 1989 to 2008 (p > 0.05). Older age, obesity, a high ASA risk score, a femoral and/or a recurrent hernia were more likely to be associated with an emergent IHR (all p ≤ 0.05). The incidence of emergent IHR is low. This risk has decreased over the past 20 years. However, patients who are either ≥70 years old, obese, with a high ASA score, or with a femoral or recurrent hernias are more likely to require an emergent IHR and could benefit from elective operative intervention if deemed adequate surgical candidates.

Prevalence of adult paraumbilical hernia. Assessment by high-resolution sonography: a hospital-based study

Abstract: Abdominal wall hernias are a common imaging finding in the abdomen. Ultrasonography (US) is noninvasive and allows the examination of the patient in a physiological manner. High-frequency annular US probes have become an increasingly important diagnostic tool for detecting pathological lesions in superficial organs. To determine the prevalence of paraumbilical hernias among adult patients by abdominal sonography in a tertiary care hospital and to describe the sonographic technique and findings. During the 2-year period between January 2008 and December 2009, we performed high-resolution US of the anterior abdominal wall on 302 patients who were referred for different reasons other than the examination of the anterior abdominal wall. The images were taken by a radiologist with 12 years of experience in US, and the images were reviewed by three consultant radiologists with expertise in body imaging. A total of 302 patients [169 females (56.0%) and 133 males (44.0%)], ranging in age from 17 to 85 years, with a mean age of 53.5 years, were enrolled in the study. The number of positive cases among females was 42 (24.9%) and that among males was 31 (23.3%). High-resolution US is an efficient tool for detecting the presence of paraumbilical hernias and accurately verifying not only their content, but also the possible associated complications.

An incarcerated appendix: report of three cases and a review of the literature

Abstract: We came across three rare cases of incarcerated hernia, with different presentations. The first case was an elderly female, who presented with an incarcerated incisional hernia on the right lower iliac region diagnosed on contrast enhanced computed tomography (CT); the contents were the small bowel and the perforated tip of the appendix. In the second case of inguinal incarcerated hernia, ultrasonography showed the inflammed appendix in the subcutaneous plane of the hernial sac, which is very rarely diagnosed pre-operatively and was confirmed during surgery. Inflammed appendix with gangrenous tip was found in the inguinal hernial sac. In yet another case of incarcerated inguinal hernia, the contents were a gangrenous part of the ascending colon and transverse colon, with the tip of the inflamed appendix—also only rarely observed. The colon extended to the scrotum in this case. We could find no description within the existing medical literature on either transverse or ascending colon as contents in inguinal hernia although transverse colon alone has been reported in four cases. The surgical options for dealing with the appendix in an Amyand’s hernia depend on the mode of presentation. The presence of a normal appendix does not require an appendicectomy to be performed, but its removal is necessary if inflamed.

Irreducible indirect inguinal hernia containing uterus, ovaries, and Fallopian tubes

Abstract: An indirect inguinal hernia containing the entire uterus, ovaries, and Fallopian tubes is extremely rare in pediatrics. The present report describes the very rare case of a 1-month-old girl with an irreducible indirect inguinal hernia containing the entire uterus, ovaries, and Fallopian tubes, and the successful surgical treatment of simple herniorraphy. We review the literature on this type of relationship between indirect inguinal hernia and hernial visceras of the uterus, ovaries, and Fallopian tubes and discuss the clinical features of this complication. Furthermore, the possible cause of indirect inguinal hernia containing the uterus, ovaries, and Fallopian tubes was explored.