Showing papers in "Hernia in 2014"

Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients

Abstract: Purpose In 2009, the European Hernia Society published the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. The guidelines expired January 1, 2012. To keep them updated, a revision of the guidelines was planned including new level 1 evidence.

Criteria for definition of a complex abdominal wall hernia

Abstract: Purpose A clear definition of “complex (abdominal wall) hernia” is missing, though the term is often used. Practically all “complex hernia” literature is retrospective and lacks proper description of the population. There is need for clarification and classification to improve patient care and allow comparison of different surgical approaches. The aim of this study was to reach consensus on criteria used to define a patient with “complex” hernia.

European Hernia Society classification of parastomal hernias

Abstract: Purpose A classification of parastomal hernias (PH) is needed to compare different populations described in various trials and cohort studies, complete the previous inguinal and ventral hernia classifications of the European Hernia Society (EHS) and will be integrated into the EuraHS database (European Registry of Abdominal Wall Hernias).

Surgical treatment for giant incisional hernia: a qualitative systematic review

Abstract: Introduction Repair for giant incisional hernias is a challenge due to unacceptable high morbidity and recurrence rates. Several surgical techniques are available, but all are poorly documented. This systematic review was undertaken to evaluate the existing literature on repair for giant incisional hernia.

Importance of recurrence rating, morphology, hernial gap size, and risk factors in ventral and incisional hernia classification.

Abstract: There is limited evidence on the natural course of ventral and incisional hernias and the results of hernia repair, what might partially be explained by the lack of an accepted classification system. The aim of the present study is to investigate the association of the criteria included in the Wuerzburg classification system of ventral and incisional hernias with postoperative complications and long-term recurrence. In a retrospective cohort study, the data on 330 consecutive patients who underwent surgery to repair ventral and incisional hernias were analyzed. The following four classification criteria were applied: (a) recurrence rating (ventral, incisional or incisional recurrent); (b) morphology (location); (c) size of the hernial gap; and (d) risk factors. The primary endpoint was the occurrence of a recurrence during follow-up. Secondary endpoints were incidence of postoperative complications. Independent association between classification criteria, type of surgical procedures and postoperative complications was calculated by multivariate logistic regression analysis and between classification criteria, type of surgical procedures and risk of long-term recurrence by Cox regression analysis. Follow-up lasted a mean 47.7 ± 23.53 months (median 45 months) or 3.9 ± 1.96 years. The criterion “recurrence rating” was found as predictive factor for postoperative complications in the multivariate analysis (OR 2.04; 95 % CI 1.09–3.84; incisional vs. ventral hernia). The criterion “morphology” had influence neither on the incidence of the critical event “recurrence during follow-up” nor on the incidence of postoperative complications. Hernial gap “width” predicted postoperative complications in the multivariate analysis (OR 1.98; 95 % CI 1.19–3.29; ≤5 vs. >5 cm). Length of the hernial gap was found to be an independent prognostic factor for the critical event “recurrence during follow-up” (HR 2.05; 95 % CI 1.25–3.37; ≤5 vs. >5 cm). The presence of 3 or more risk factors was a consistent predictor for “recurrence during follow-up” (HR 2.25; 95 % CI 1.28–9.92). Mesh repair was an independent protective factor for “recurrence during follow-up” compared to suture (HR 0.53; 95 % CI 0.32–0.86). The ventral and incisional hernia classification of Dietz et al. employs a clinically proven terminology and has an open classification structure. Hernial gap size and the number of risk factors are independent predictors for “recurrence during follow-up”, whereas recurrence rating and hernial gap size correlated significantly with the incidence of postoperative complications. We propose the application of these criteria for future clinical research, as larger patient numbers will be needed to refine the results.

Effect of botulinum toxin type A in lateral abdominal wall muscles thickness and length of patients with midline incisional hernia secondary to open abdomen management

Abstract: Abdominal wall hernia secondary to open abdomen management represents a surgical challenge. The hernia worsens due to lateral muscle retraction. Our objective was to evaluate if Botulinum Toxin Type A (BTA) application in lateral abdominal wall muscles modifies its thickness and length. A clinical trial of male trauma patients with hernia secondary to open abdomen management was performed from January 2009 to July 2011. Thickness and length of lateral abdominal muscles were measured by a basal Computed Tomography and 1 month after BTA application. A dosage of 250 units of BTA was applied at five points at each side between the external and internal oblique muscles under ultrasonographic guidance. Statistical analysis for differences between basal and after BTA application measures was performed by a paired Student’s t test (significance: p < 0.05). Seventeen male patients with a mean age of 35 years were included. There were muscle measure modifications in all the patients. Left muscle thickness: mean reduction of 1 ± 0.55 cm (p < 0.001). Right muscle thickness: mean reduction of 1.00 ± 0.49 cm (p < 0.001). Left muscle length: mean increase of 2.44 ± 1.22 cm (p < 0.001). Right muscle length: mean increase of 2.59 ± 1.38 cm (p < 0.001). No complications secondary to BTA or recurrences at mean follow-up of 49 months were observed. BTA application in lateral abdominal muscles decreases its thickness and increases its length in abdominal wall hernia patients secondary to open abdomen management.

A systematic review of randomised control trials assessing mesh fixation in open inguinal hernia repair.

Abstract: The technique for fixation of mesh has been attributed to adverse patient and surgical outcomes. Although this has been the subject of vigorous debate in laparoscopic hernia repair, the several methods of fixation in open, anterior inguinal hernia repair have seldom been reviewed. The aim of this systematic review was to determine whether there is any difference in patient-based (recurrence, post-operative pain, SSI, quality of life) or surgical outcomes (operative time, length of operative stay) with different fixation methods in open anterior inguinal hernioplasty. A literature search was performed in PubMed, EMBASE and the Cochrane Library databases. Randomised clinical trials assessing more than one method of mesh fixation (or fixation versus no fixation) of mesh in adults (>18 years) in open, anterior inguinal hernia repair, with a minimum of 6-month follow-up and including at least one of the primary outcome measures (recurrence, chronic pain, surgical site infection) were included in the review. Secondary outcomes analysed included post-operative pain (within the first week), quality of life, operative time and length of hospital stay. Twelve randomised clinical trials, which included 1,992 primary inguinal hernia repairs, were eligible for inclusion. Four studies compared n-butyl-2 cyanoacrylate (NB2C) glues to sutures, two compared self-fixing meshes to sutures, four compared fibrin sealant to sutures, one compared tacks to sutures, and one compared absorbable sutures to non-absorbable sutures. The majority of the trials were rated as low or very low-quality studies. There was no significant difference in recurrence or surgical site infection rates between fixation methods. There was significant heterogeneity in the measurement of chronic pain. Three trials reported significantly lower rates of chronic pain with fibrin sealant or glue fixation compared to sutures. A further three studies reported lower pain rates within the first week with non-suture fixation techniques compared to suture fixation. A significant reduction in operative time, ranging form 6 to 17.9 min with non-suture fixation, was reported in five of the studies. Although infrequently measured, there were no significant differences in length of hospital stay or quality of life between fixation methods. There is insufficient evidence to promote fibrin sealant, self-fixing meshes or NB2C glues ahead of suture fixation. However, these products have been shown to be at least substantially equivalent, and moderate-quality RCTs have suggested that both fibrin sealant and NB2C glues may have a beneficial effect on reducing immediate post-operative pain and chronic pain in at-risk populations, such as younger active patients. It will ultimately be up to surgeons and health-care policy makers to decide whether based on the limited evidence these products represent a worthwhile cost for their patients.

Evaluation of the contralateral inguinal ring in clinically unilateral inguinal hernia: a systematic review and meta-analysis.

Abstract: Purpose The management of the contralateral inguinal canal in children with clinical unilateral inguinal hernia is controversial. Our objective was to systematically review the literature regarding management of the contralateral inguinal canal.

Retrospective observational study on the incidence of incisional hernias after colorectal carcinoma resection with follow-up CT scan

Abstract: Incisional hernia (IH) is the most frequent complication after colorectal carcinoma (CRC) resection. The incidence depends on the method of follow-up, where ultrasound yields a significant number of additional hernias compared to clinical examination alone. Not many studies have evaluated the value of computed tomography (CT) to diagnose IH. The CorreCT study is a retrospective cohort study of IH after CRC surgery by clinical examination and by CT, as reported in the medical files. Additional independent reviewing of all CTs by two radiologists was performed. From the oncological database (2004–2008) of the hospital, 598 patients with CRC were identified. The data of 448 consecutive patients who underwent surgery were analyzed. Tumors were resected by laparotomy in 366 patients (81.7 %), by laparoscopy in 76 patients (17.0 %) and by laparotomy after conversion in 6 patients (1.3 %). A clinical follow-up by the surgeon in 282 patients (62.9 %) with a mean duration of 33 months, yielded 49 patients with IH (17.4 %). The mean time of IH diagnosis (T1) was 19 months. Only 16 patients (33 %) underwent a hernia repair. For 363 patients (81.0 %), CT follow-up was available for a mean period of 30 months. In 84 patients (23.1 %), an IH was diagnosed with a mean T1 of 21 months. The review of all CTs by two independent radiologists yielded additional IH in 19 and 21 patients, respectively, increasing the IH rate to 29.1 and 29.7 %, respectively, and with a decrease in mean T1 to 14 months. The inter-observer agreement between the radiologists had a Kappa-statistic of 0.73 (95 % CI 0.65–0.81). For those patients with disagreement between the radiologists, a final agreement was made during an additional reviewing session of both radiologists, increasing the IH rate to 35.0 %. Comparing clinical follow-up, routine CT follow-up, and reassessed CT follow-up we found a statistically significant difference between the three methods of IH detection (p < 0.0001). CT follow-up can identify significantly more IH than clinical examination alone, in particular if the radiologist focuses on IH development. Furthermore, we showed that focused CT evaluation diagnosed IH 7 months earlier than routine CT and 5 months earlier than clinical follow-up alone.

Outcome of patients with chronic mesh infection following abdominal wall hernia repair

Abstract: Purpose Mesh infection following incisional hernia repair has been reported at around 6–10 %. The aim of this study is to assess the outcome of patients following treatment for chronically infected mesh after repair of an abdominal wall hernia.

Inguinal hernia repair using a synthetic long-term resorbable mesh: results from a 3-year prospective safety and performance study

Abstract: Purpose Conventional meshes for hernia repair and abdominal wall reinforcement are usually made from polypropylene, polyester or other synthetic plastic materials known to promote foreign body reactions and a state of chronic inflammation that may lead to long-term complications. A novel approach is to use long-term resorbable implants like TIGR® Matrix Surgical Mesh. Preclinical studies have shown that this mesh maintains mechanical integrity beyond the point in time where newly formed tissue is capable of carrying the abdominal loads.

What do we know about titanized polypropylene meshes? An evidence-based review of the literature

Abstract: Purpose Despite the vast selection of brands available, nearly all synthetic meshes for hernia surgery continue to use one or other of three basic materials: polypropylene, polyester and ePTFE These are used in combination with each other or with a range of additional materials such as titanium, omega 3, monocryl, PVDF and hyaluronate This systematic review of all experimental and clinical studies is aimed at investigating whether titanized meshes confer advantages over other synthetic meshes in hernia surgery

Sports hernia or groin disruption injury? Chronic athletic groin pain: a retrospective study of 100 patients with long-term follow-up.

Abstract: Chronic groin pain (athletic pubalgia) is a common problem in sports such as football, hockey, cricket, baseball and athletics. Multiple co-existing pathologies are often present which commonly include posterior inguinal canal wall deficiency, conjoint tendinopathy, adductor tendinopathy, osteitis pubis and peripheral nerve entrapment. The mechanism of injury remains unclear but sports that involve either pivoting on a single leg (e.g. kicking) or a sudden change in direction at speed are most often associated with athletic pubalgia. These manoeuvres place large forces across the bony pelvis and its soft tissue supports, accounting for the usual clinical presentation of multiple symptomatic abnormalities forming one pattern of injury. The diagnoses encountered in this series of 100 patients included rectus abdominis muscle atrophy/asymmetry (22), conjoint tendinopathy (16), sports (occult, incipient) hernia (16), groin disruption injury (16), classical hernia (11) traumatic osteitis pubis (5), and avulsion fracture of the pubic bone (4). Surgical management was generally undertaken only after failed conservative therapy of 3–6 months, but some professionals who have physiotherapy during the football season went directly to surgery at the end of the football season. A variety of operations were performed including groin reconstruction (15), open hernia repair with or without mesh (11), sports hernia repair (Gilmore) (7) laparoscopic repair (3), conjoint tendon repair (3) and adductor tenotomy (3). Sixty-six patients were available for follow at an average of 13 years after initial consultation and the combined success rate for both conservative treatment and surgery was 94 %. The authors believe that athletic pubalgia or sports hernia should be considered as a ‘groin disruption injury’, the result of functional instability of the pelvis. The surgical approach is aimed at strengthening the anterior pelvic soft tissues that support and stabilise the symphysis pubis.

Beneficial effects of fibrin glue (Quixil) versus Lichtenstein conventional technique in inguinal hernia repair: a randomized clinical trial

Abstract: Introduction In inguinal hernia repair, many complications are due to mesh fixation technique. Therefore, new types of atraumatic methods of fixation have been proposed. In this article, we present the results of a prospective multicentric parallel randomized controlled trial aiming to compare two mesh fixation techniques: fibrin sealant (QUIXIL®, Omrix Biopharmaceuticals S.A., Belgium) and Lichtenstein technique.

Safety of polypropylene mesh for incarcerated groin and obturator hernias: a retrospective study of 110 patients.

Abstract: The purpose of this study was to evaluate the mesh repair for an incarcerated groin hernia. A total of 110 patients who underwent emergency surgery for incarcerated hernias were retrospectively analyzed using a multivariate analysis. The postoperative complications were associated with bowel resection, odds ratio (OR) 2.984, and 95 % confidence interval (CI) 1.273 to 6.994. The risk factors for bowel resection were femoral hernia, (OR 5.621, 95 % CI 2.243 to 14.082), and late hospitalization (24 h<), (OR 2.935, 95 % CI 1.163–7.406). The hernias were repaired with mesh in ten of the 39 (25.6 %) patients with bowel resection and sixty-four of the 71 (90.1 %) patients without bowel resection. The complication rate of the patients with bowel resection was 53.8 % and was 26.8 % in those without. The ratios of wound infection were 23.1 and 0.0 %, respectively. Wound infections were detected in two (20 %) of the ten patients who underwent bowel resection with mesh repair; however, there were no patients in whom the mesh was withdrawn due to infection. No wound infections in patients without bowel resection were detected, and mesh repair could be safely performed. Mesh repair for the patients with bowel resection is not contraindicated, as long as the clean-contamination of the wound was maintained during surgery.

Surgical morbidity and mortality in obturator hernia: a 10-year retrospective risk factor evaluation

Abstract: Obturator hernia is a rare condition occurring predominantly in elderly, thin, female patients and causes significant morbidity and mortality. Due to obscure presenting symptoms and signs, diagnosis and management are often delayed. While previous studies have attributed the high mortality to the delay in diagnosis, current literature remains controversial about this issue. The aim of this study was to identify peri-operative risk factors associated with mortality in patients with obturator hernia at our hospital. We retrospectively reviewed our series of 20 consecutive patients who underwent surgical repair of 21 obturator herniae and examined their clinical characteristics and post-operative outcomes. Overall mortality rate was 47.6 %. Survivors did not differ from non-survivors in terms of basic demographics and operative parameters (operative time, blood loss and the need for intestinal resection). The use of computed tomography for pre-operative diagnosis was associated with reduced need for bowel resection, but did not result in shorter time to operation or improved morbidity and mortality. Our series demonstrated that early timing of surgery alone did not improve operative outcome. The absence of bowel motion and a high serum urea level at the time of operation were independent factors for mortality. Obturator hernia remains a highly lethal surgical emergency. Adequate peri-operative resuscitation may be the key to further improvement in surgical outcomes.

Use of dynamic wound closure system in conjunction with vacuum-assisted closure therapy in delayed closure of open abdomen

Abstract: Aim Definitive abdominal closure may not be possible for several days or weeks after laparotomy in damage-control surgery, abdominal compartment syndrome and intraabdominal sepsis, until the patient has stabilized. Vacuum-assisted closure (VAC therapy®, KCI, San Antonio, TX, USA) and abdominal re-approximation anchor system (ABRA, Canica, Almonte, Ontario, Canada) are novel techniques in delayed closure of open abdomen. Our aim is to present the use of these strategies in the management of 7 patients with open abdomen.

Incisional hernia rate after open abdomen treatment with negative pressure and delayed primary fascia closure

Abstract: Various techniques for delayed primary fascia closure have been published in patients treated with open abdomen (OA) and application of negative pressure, but to date, no data are available on incisional hernia (IH) rate. The aim of this retrospective analysis was to investigate the long-term outcome of this patient population with special interest in IH development. Two hundred and nine consecutive patients, 90(43 %) female, were treated at our institution for various abdominal emergencies involving OA from June 2006 to June 2011. Mean age was 63(16–92) years. The indication was abdominal sepsis in 155(74 %) patients, ischemia in 24(12 %) and other reasons in 30(14 %). Hospital mortality was 21 %(n = 44); and planned ventral hernia was 7 %(n = 15); and mortality until follow-up was 16 %(n = 25), and 9 %(n = 13) patients were lost to follow-up, leaving 112 patients for evaluation of IH development. The rate of IH for patients with OA and delayed primary fascia closure was overall 35 % at a median (range) follow-up time of 26(12–81) months. Mean time for development of a ventral hernia was 11 months; 21(57 %) patients underwent surgery for symptomatic hernia (2 emergency operations for incarceration). Kaplan–Meier estimate for 5 years gave a 66 % IH rate. BMI, small bowel as source of infection and rapid adsorbable interrupted suture were identified risk factors. The rate of IH after open abdomen treatment with delayed primary fascia closure is high with a running suture with slow absorbable suture material showing the best results.

Central rupture and bulging of low-weight polypropylene mesh following recurrent incisional sublay hernioplasty.

Abstract: A recurrent incisional hernia resulting from the rupture of low-weight polypropylene mesh is rarely reported in the literature. Three patients with recurrent incisional hernia due to low-weight polypropylene mesh central rupture were operated 5, 7 and 13 months after initial sublay hernioplasty. The posterior myofascial layer was fully reconstructed in all patients during the hernioplasty, whereas the anterior myofascial layer was only partially reconstructed. The recurrent hernia was managed using heavy-weight polypropylene mesh; in two patients, a new sublay hernioplasty was performed and in one patient an “open preperitoneal flat mesh technique” was performed under local anaesthesia as a day case procedure. If closing of the anterior myofascial layer cannot be ensured during the incisional hernioplasty, the use of low-weight polypropylene meshes should be avoided; preference should be given to the heavy-weight polypropylene meshes.

Endoscopic repair of large inguinoscrotal hernias: management of the distal sac to avoid seroma formation

Abstract: The best approaches to repairing large inguinoscrotal hernias and handling of the distal sac are still debated. Complete dissection of a distal sac which extends deep into the scrotum carries a risk of orchitis and damage to the cord structures. However, failure to deal with the distal sac often results in the formation of a large and bothersome seroma or pseudohydrocele. We describe a technique for managing large distal sacs to avoid clinically important seromas when repairing large inguinoscrotal hernias, using the enhanced view totally extraperitoneal (e-TEP) endoscopic technique. From October 2010 to November 2011, 94 consecutive elective hernia repairs were performed using the e-TEP technique. Six of these patients had large inguinoscrotal hernias, defined as hernias extending deep into the scrotum with a distal sac not amenable to dissection. In these six patients, we managed the distal sac by pulling it out of the scrotum and fixing it high and laterally to the posterior inguinal wall. We prospectively followed these patients and examined them at 8 days and 1 and 3 months postoperatively, looking specifically for signs or symptoms of seroma. Ultrasonography was performed at each follow-up visit. Only one of the patients had developed a seroma by the eighth postoperative day. The seroma was drained and did not recur or produce symptoms during the following 3 months. There were no major complications or early recurrences in the series. Patients with large inguinoscrotal hernias and sacs extending deep into the scrotum can benefit from reduction and fixation of the distal sac high and laterally to the posterior inguinal wall. This technique lowers the risk of developing clinically significant seroma.

Skin as marker for collagen type I/III ratio in abdominal wall fascia

Abstract: Purpose An altered collagen metabolism could play an important role in hernia development. This study compared collagen type I/III ratio and organisation between hernia and control patients, and analysed the correlation in collagen type I/III ratio between skin and abdominal wall fascia.

Abdominal binders after laparotomy: review of the literature and French survey of policies.

Abstract: Background and aim The use of abdominal binders after laparotomy is a question of habit Scientific evidence of their usefulness is limited The aims of this work were to review the scientific literature and to depict the practices of French surgeons regarding the use of these devices

Relationship between Body Mass Index and the Incidence of Inguinal Hernia Repairs: A Population-Based Study in Olmsted County, MN

Abstract: Purpose The relationship between body mass index (BMI) and the risk of inguinal hernia development is unclear. To explore the relationship, we determined whether the incidence of inguinal hernia repairs (IHR) varied across patients with different BMI categories.

Mesh cancer: long-term mesh infection leading to squamous-cell carcinoma of the abdominal wall

Abstract: Purpose It is recognized that chronic inflammation can cause cancer. Even though most of the available synthetic meshes are considered non-carcinogenic, the inflammatory response to an infected mesh plays a constant aggression to the skin. Chronic mesh infection is frequently the result of misuse of mesh, and due to the challenging nature of this condition, patients usually suffer for years until the infected mesh is removed by surgical excision.

A comparison of outcomes and cost in VHWG grade II hernias between Rives-Stoppa synthetic mesh hernia repair versus underlay biologic mesh repair.

Abstract: The current literature is void of evidence-based guidelines regarding optimal choice of mesh. We aim to perform a comparative outcome analysis of synthetic mesh and acellular dermal matrix (ADM) in Ventral Hernia Working Grade (VHWG) grade II hernias with primary fascial closure. A retrospective review of patients undergoing ventral hernia repair (VHR) by the senior author (S.J.K.) from 2007 to 2012 was performed. Patients undergoing VHR with primary fascial closure were risk stratified using the VHWG defined grading system. Seventy-two patients met the abovementioned inclusion criteria with 45 receiving synthetic mesh and 27 receiving ADM. The mean length of follow-up was 12.1 ± 9.1 months. Patients were, on average, 53.2 ± 11.6 years of age with a BMI of 33.9 ± 10.6 kg/m2. The overall incidence of surgical site occurrence (SSO) in the cohort was 41.7 % and the incidence of hernia recurrence was 5.6 %. 30-day mortality was 1.2 %. Bivariate analysis demonstrated that obesity (P = 0.038) and number of comorbidities (P = 0.043) were associated with SSO. Bivariate analysis demonstrated that prior failed hernia, use of ADM, and operative time were associated with higher rates of hernia recurrence; however, adjusted multivariate regression found only prior failed hernia (OR = 4.1, P = 0.03) and biologic mesh (OR = 3.4, P = 0.046) to be independently associated with recurrent hernia. Comparison of mesh types revealed few differences in preoperative or operative characteristics between synthetic mesh and acellular dermal matrices (ADM). The rate of hernia recurrence was significantly higher with ADM (14.8 % vs. 0.0 %, P = 0.017). Patients receiving ADM repairs incurred significantly greater cost ($56,142.1 ± 54,775.5 vs. $30,599.8 ± 39,000.8, P < 0.001). These data suggest synthetic mesh is indicated in higher risk VHWG grade II repairs. In comparison to ADM, synthetic mesh was associated with significantly fewer hernia recurrences and lower cost utilization at 1-year. Prognostic/risk category, level III

Fifteen-year experience in managing obturator hernia: from open to laparoscopic approach

Abstract: Obturator hernia is a rare disease and preoperative diagnosis is always difficult. There are increasing reports employing laparoscopic approach in the recent literature. Our aim was to review and compare the open and laparoscopic approach in repairing obturator hernia. All patients with obturator hernia from 1997 to 2011 were recruited. Patient’s demographics, presentation, operative details, morbidity, and mortality were retrospectively collected and reviewed. There were 36 patients during the 15-year period. All of them were elderly ladies (median 83). Nineteen underwent open surgery while 16 received laparoscopic surgery. Both age and ASA were comparable. The median operative time was 68 and 65 min for laparoscopic and open group, respectively (p = 0.690). The median hospital stay was significantly longer in the open group (19 vs 5 days, p = 0.007). There were less major complications (p = 0.004) and mortality (p = 0.049) in the laparoscopic group. Two recurrences were reported in the laparoscopic group, although statistically not significant (p = 0.202). Laparoscopic repair can achieve a shorter hospital stay and has lesser major complications and mortality in selected patients.

The peritoneal flap hernioplasty for repair of large ventral and incisional hernias

Abstract: Mesh repair of large ventral or incisional hernias is problematic when primary fascial closure cannot be achieved, as this leaves mesh exposed, bridging the gap. We describe a modified retromuscular sublay repair which overcomes this problem and report a retrospective review of cases to assess outcome. Mesh is positioned between transposed flaps of preserved hernial sac and rectus sheath. Patients undergoing this repair by one author (BT) from 1 January 2004 to 31 December 2010 were identified, and clinical outcome was assessed by a combination of case-note review, outpatient consultation and telephone interview. Twenty-one ventral and incisional hernias were treated by this method. Eighteen were incisional (13 midline, three transverse and two oblique incisions), and three were primary paraumbilical hernias. Defect sizes ranged from 25 to 500 cm2 and mesh sizes from 300 to 900 cm2. Patients were reviewed at 6 weeks, 6 months and at a median of 37 months post-operatively. Three cases of superficial skin edge necrosis, two superficial wound infections and two sizeable seromas developed, but all had resolved within 6 months. One patient developed abdominal wall necrosis requiring mesh removal and eventual abdominal wall reconstruction without mesh, resulting in late recurrence. All other cases achieved excellent long-term outcomes with a high degree of patient satisfaction. This is a useful method for repairing large ventral and incisional hernias when primary fascial closure is not achievable, combining a sublay mesh repair with autologous tissue transposition across the fascial gap.

Optimal timeline for emergency surgery in patients with strangulated groin hernias.

Abstract: This retrospective study evaluates the clinical course and outcomes of patients who underwent surgery for strangulated hernias. Among 520 groin hernias from 2001 to 2012, 51 inguinal and 42 femoral hernias were strangulated and operated emergently at a tertiary referral center. Perioperative factors, patient profiles, and time interval to surgery (T total = time from onset to surgery, T 1 = time from onset to initial evaluation, T 2 = time from the first hospital to the tertiary center, T 3 = time from admission at the tertiary center to surgery, T total = T 1 + T 2 + T 3) were analyzed in patients with strangulation, then compared between two groups, the bowel resection (BR) group and the non-bowel resection (NBR) group. T 1, T 2 and T total in the bowel resection group were significantly longer than those in the non-bowel resection group (P < 0.05). Patients who presented initially to the tertiary center (T 2 = 0) had a significantly lower resection rate than patients transported from other hospitals (24 vs. 44 %, P = 0.048). There was no significant difference in morbidity between the BR and NBR groups (35 vs. 24 %, P = 0.231). The elapsed time from onset to surgery, especially T 1 and T 2, is the most important prognostic factor in patients with strangulated groin hernias. Early diagnosis and transportation are essential for good outcomes.

Potential benefits of single-port compared to multiport laparoscopic inguinal herniorraphy: a prospective randomized controlled study.

Abstract: Multiple prospective studies have confirmed safety and efficacy of laparoscopic inguinal herniorraphy with single-port compared to multiport surgery. This prospective randomized controlled trial aimed to assess safety, efficacy and potential benefits of single-port total extraperitoneal inguinal herniorraphy beyond the learning curve. All referred patients with inguinal/femoral hernias were enrolled from December 2011 to February 2013. Exclusion criteria included workers compensation cases. Identical balloon dissector, light-weight mesh and non-absorbable tacks were used in all cases. For single-port cases Triport™ was used while structural balloon trocar/inflation bulb for multiport cases. Results were analyzed with IBM® SPSS® version 22 for Windows. Participation rate was 100 % with 157 inguinal/femoral hernias in 100 patients: 51 randomized to single-port and 49 to multiport group. There was no conversion to open surgery/need for additional ports. There were no statistical differences between single-port and multiport groups with respect to age, sex, body mass index, American Society of Anesthesiologists scores, preoperative pain, hernia defect sizes and length of hospital stay. Operation times were equivalent for single-port and multiport 60.0 vs 61.0 min, P = 0.23, respectively. Significantly, single-port patients ingested fewer pain killers: 6 tablets vs 14 Dextropropoxyphene tablets, P < 0.001, experienced less pain (visual analog scores) on day 1 and 7 post-op op: 2.5 and 0, P < 0.001 compared to 4.5 and 2.5, P < 0.001, respectively, returned to work/normal physical activities 7 days quicker: 7.0 vs 14.0, P < 0.001 and had higher cosmetic scar scores at 6-week follow-up: 24 vs 21, P < 0.001, compared to multiport patients. There were no mortalities, morbidities or recurrences after follow-up of 6–21 months. Compared to multiport, single-port laparoscopic total extraperitoneal inguinal herniorraphy, when performed by a high-volume and highly dedicated hernia surgeon, resulted in significantly reduced postoperative pain, analgesic requirements, quicker return to work/normal activities, improved cosmesis, and equivalent safety and efficacy.