Is contralateral exploration necessary in girls with unilateral inguinal hernia?

Background/Purpose: Routine contralateral groin exploration in girls with unilateral inguinal hernia (UIH) continues to be controversial. The aim of this study was to determine the incidence of contralateral hernia development in girls after UIH repair. Methods: Between 1972 and 2000, 391 girls underwent repair of UIH. Ninety-one (23%) of the 391 girls underwent routine contralateral exploration during UIH repair and were excluded from the study. The median age at operation in the remaining 300 girls was 3.3 years (range, 1 month to 14 years). Two hundred ten (70%) girls had right-sided and 90 (30%) had left-sided UIH. Familial history of hernia was identified in 8 (3%) patients. The follow-up ranged from 1.5 to 14 years. Mann-Whitney U test was used for intergroup comparison. Results: A contralateral hernia developed in 24 (8%) of the 300 patients who had unilateral repair of inguinal hernia. Median time from operation to occurrence of the contralateral hernia was 3 years (range, 1 to 4 years). Age at operation, side of hernia, and familial history did not influence the development of contralateral hernia. Conclusions: These data suggest that the low incidence of contralateral hernia development in girls undergoing UIH repair does not justify routine contralateral groin exploration. J Pediatr Surg 38:756-757. [copy ] 2003 Elsevier Inc. All rights reserved.     

Is contralateral exploration necessary in preterm infants with unilateral inguinal hernia?

Purpose

Contralateral inguinal exploration has been the preferred approach to preterm infants with unilateral inguinal hernia. There is no literature evidence to justify this. The aim of this prospective study is to analyze the incidence and to determine any risk factors for the development of contralateral metachronous hernia (MH) in the preterm when compared with term infants.

Methods

Preterm and term infants with unilateral inguinal hernia younger than 6 months who underwent surgery were included. Those infants who subsequently developed MH were analyzed.

Results

Two hundred sixty-six patients met the inclusion criteria. One hundred five were preterm and 161 were term. Ten preterm (10.31%) and 9 term infants (5.92%) presented subsequently with MH (P =.18). All but 1 were male. There was no relation between the side of hernia, presentation with incarceration, age at surgery, sex of the patient, and the development of MH. However, a trend toward a higher incidence of MH in very low birth weight and early gestational age preterms was noted.

Conclusion

There is no significant difference between the occurrence of MH in preterm when compared with term infants. Routine contralateral exploration in preterm infants with its associated risks is therefore not justified in unilateral hernia.     

Are there any predictive factors of metachronous inguinal hernias in children with unilateral inguinal hernia?

Purpose  

This study was done to identify risk factors for metachronous manifestation of contralateral inguinal hernia in children with unilateral inguinal hernia.     

Risk of contralateral manifestation in children with unilateral inguinal hernia: should hernia in children be treated contralaterally?

PURPOSE: This study was done to identify risk factors for metachronous manifestation of contralateral inguinal hernia in patients with unilateral inguinal hernia. METHODS: Characteristics of 156 patients with metachronous contralateral hernia were compared with those of 156 patients with unilateral hernia who were ascertained not to have presented with contralateral hernia. RESULTS: There was a tendency for the hernia to be more often on the left side in 88 of 156 patients (56.4%) with contralateral manifestation compared with 70 of 156 patients (44.9%) in the control group (P =.054). The age at hernia repair of the patients with contralateral manifestation, 1 to 120 months (median, 14 months), was significantly younger than the 1 to 149 months (median, 20 months) of the control patients (P =.016). More patients with contralateral manifestation had a family history of inguinal hernia, and the percentage, 24.4%, was significantly higher than the 14.7% in the control group (P =.046). A univariate analysis with the Cox regression models found that hernia on the left side and a positive family history were significantly associated with the metachronous manifestation of contralateral hernia (hazard ratio [HR], 1.40; P =. 037 and HR, 1.59; P =.013, respectively). CONCLUSION: The risk of metachronous manifestation of contralateral hernia is high in patients with left-side hernia and in those with a family history, and the incidence of contralateral hernia is at most 10% in these patients. The authors think that the incidence is still too low to justify routine exploration and surgery for a patent processus vaginalis. Contralateral exploration should therefore be reserved for high-risk patients in whom second anesthesia and surgery have to be avoided.     

A case report of incarcerated inguinal hernia: Amyand’s hernia with adenocarcinoma tumor

IntroductionInguinal hernia is one of the most common surgical problems, often posing technical challenges even to expert surgeons. Amyand’s hernia (AH) is an inguinal hernia whose sac contains the vermiform appendix. Primary appendiceal neoplasms are rare. We report the case of an appendiceal adenocarcinoma within an Amyand’s hernia, presenting as an incarcerated right inguinal hernia.Presentation of caseA 87-year-old male presented in the emergency department due to a persistent right inguinal pain. Clinical examination revealed a tender right groin mass. Under the diagnosis of an right inguinal hernia, an operation was taken. Intraoperatively, an inflamed appendix and a part of the cecum were found in the hernia sac. The operation was completed with an ileocecal resection and a modified Bassini hernia repair. Histological examination revealed a adenocarcinoma of the appendix.DiscussionAmyand’s hernia is an inguinal hernia that contains vermiform appendix in its sac. It consists 1% of all inguinal hernias while appendicitis in an Amyand’s hernia accounts for 0.1% of all appendicitis cases. Adenocarcinomas of the appendix are even rarer, accounting for 0.2% to 0.5% of all intestinal malignancies, and 4%–6% of primary appendiceal neoplasms. Diagnosis is usually established intraoperatively.ConclusionA malignancy of the appendix should always be in the differential diagnosis of a right inguinal mass, in order to provide optimum surgical treatment.     

Difference in outcome of shoulder surgery between workers’ compensation and nonworkers’ compensation populations

The purpose of this study was to review the association between compensation status and surgical outcome especially of the shoulder. Given the high prevalence of shoulder injuries in the workplace and the large proportion of workers compensation (WC) claims involving such injuries, it is worth examining the correlation between WC status and surgical outcome of the shoulder. All studies published in journals (MEDLINE and PubMed) from 1980 through 2007 on surgical interventions performed on the shoulder in which workers compensation status was documented and the postoperative functional outcome was compared according to that status were pooled for meta-analysis. This systematic review shows that compensation status of an individual receiving shoulder surgery is a consistent positive predictor of poor functional outcome. The majority of questions posed in the most commonly adopted shoulder-specific functional outcome measurement tools were subjective in nature and may account for part of the phenomenon.

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Résumé  Analyser l’effet du statut d’accident du travail sur les résultats de la chirurgie au niveau de l’épaule. Etant donnée la fréquence élevée des traumatismes de l’épaule sur le lieu de travail et la part importante de demandes d’indemnisation chez les travailleurs avec ce type de blessures, il est intéressant d’étudier la corrélation entre le statut accident du travail et les résultats de la chirurgie de l’épaule. Toutes les études publiées dans les journaux médicaux (MEDLINE et PUBMED) de 1980 à 2007 concernant des interventions réalisées au niveau de l’épaule dans lesquelles le statut accident du travail était documenté et le résultat post opératoire étudié en fonction de ce statut ont été réunis pour une méta analyse. Cette revue systématique montre que le statut accident du travail d’un individu opéré de l’épaule est un facteur prédictif d’un mauvais résultat. La majorité des questions posées dans les tests spécifiques de l’épaule les plus couramment utilisés sont de nature subjective et cela pourrait expliquer en partie ce phénomène.

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An erratum to this article can be found at     

Preperitoneal gridiron hernia repair for inguinal hernia: Single-center experience with 2 years of follow-up

The optimal operation technique for groin hernia repair has not been established. This study evaluates the long-term recurrence rate and perioperative complications after posterior inguinal mesh hernia repair using a gridiron incision described by Frans Ugahary. A retrospective analysis was performed of the medical records of 366 patients who underwent Ugahary hernia repair. Operative results and perioperative morbidity were evaluated retrospectively. Follow-up was done by clinical examination. The main outcome measure was recurrence rate at a mean follow-up of 2 years. Of the 386 groin hernia repairs, 263 hernia repairs were examinated in the outpatient clinic. The overall recurrence rate was 6.5% with a mean follow-up of 2 years, and 10.1% of the patients had minor complications. This retrospective study demonstrates that the repair according to Ugahary is a safe technique for operating on groin hernia. However, the procedure is difficult to reproduce in nonexpert hands. This technique must be compared to other inguinal hernia operation techniques in the near future.     

Pediatric inguinal hernias,are they all the same? A proposed pediatric hernia classification and tailored treatment

Purpose

To propose a new clinical classification for pediatric inguinal hernias modified from a similar classification system for adult inguinal hernia and to propose a tailored repair for each type. The impact of this approach on hernia recurrence will be assessed.

Methods

This prospective and retrospective cross-sectional study was conducted in two tertiary teaching university hospitals in Egypt (Alexandria and Tanta University Children’s Hospitals) from January 2013 to December 2014 on children below 12 years of age with indirect inguinal hernias who were divided into two groups: (a) prospective group I, classified according to our proposed pediatric hernia classification and tailored treatment (PHCTT) into types: pediatric Nyhus 1 (PNI) assigned for herniotomy alone, pediatric Nyhus II (PNII) assigned for herniotomy plus deep ring narrowing, and type pediatric Nyhus III (PNIII) assigned for herniotomy plus posterior wall repair. (b) Retrospective unclassified group II where all cases were assigned to herniotomy alone (open). Data about patient characteristics, assigned hernia type, operative findings, procedures done, and postoperative complications were documented and analyzed by comparing the outcomes of the two groups.

Results

A total of 371 patients were included in this study with 401 hernias (30 bilateral); group I included of 217 patients, while group II included 154 patients. There was a male preponderance in group I (173/217?=?80%) and in group II (130/154?=?85%); the majority in both groups were less than 12 months of age, in group I (132/217?=?66%) and in group II (120/154?=?85%). The median age was 4 months and the median duration of symptoms was 2 months. For group I, PNII hernias formed the predominant cluster making 40% (94/235) followed by PNI hernias making 34.8% (82/235), while PNIII hernias were the least group being 25% (59/235) only. The mean follow-up period was 9.2 months?±?4.8 SD (and 9.1 months?±?2 SD in group II). The pooled recurrence rate was 1.9% (8/401) of the whole series, a weighted mean of the individual recurrence rates of 0% (0/235) of group I and 4.8% (8/166) of group II patients, all males. This difference in the recurrence rates between the two groups was statistically significant (P?=?0.004).

Conclusions

Pediatric inguinal hernias are not the same and there is extreme variation in the presentation regarding the size of the defect. We proposed a nouvelle pediatric hernia classification modified from the original Nyhus classification for adult inguinal hernia with tailored surgical approach to each type (PHCTT). Applying this (PHCTT), it has the benefit of a significant reduction of recurrence rate.

     

A new approach for transversalis fascia reinforcement in Lichtenstein’s inguinal hernia repair

Operations undertaken for inguinal hernia repair are the most common elective surgical procedures. According to the current guidelines, Lichtenstein’s tension-free method is the gold standard for elective hernia operations. The most common types of implanted mesh are polypropylene and composite mesh. We herein present Lichtenstein’s operation using a biological hemostatic mesh (Tachosil) used for transversalis fascia reinforcement, and our results after a 3-year follow-up period for 52 patients implanted with Tachosil mesh are reported. According to our results, the biological mesh can be safely implanted during hernia repair with the same recurrence rate and lower postoperative pain and complications compared to hernia repair with polypropylene mesh implantation.     

Endoscopic surgeons’ preferences for inguinal hernia repair: TEP, TAPP, or OPEN

Introduction

The use of endoscopic inguinal hernia repair has slowly increased in the past years, but the indications have remained vague. Some surgeons perform a tailored approach depending on patient or hernia characteristics, whereas others perform the same approach and technique for all hernias.

Methods

Based on these principles, a survey of 19 questions was conducted during the 18th Congress of the European Association of Endoscopic Surgeons, which took place in Geneva, Switzerland, in 2010, to determine surgeons’ preference depending on the hernia and the patient.

Results

All surgeons who attended the session (N?=?100) responded to all questions. Eighty two percent of surgeons preferred a tailored approach, whereas 18?% used the same technique in all cases. Endoscopic techniques are used more frequently than the open approach in bilateral (7 vs. 93?%) and recurrent hernias (19 vs. 81?%), whereas in primary unilateral hernias all three techniques were used with almost similar frequency (32?% open, 39?% TAPP vs. 29?% TEP). TAPP was used more frequently than TEP, and even those surgeons who are expert in TEP preferred to perform a TAPP in difficult hernias, such as in obese patients and large scrotal hernias. Based on the age of patients, the open approach is preferred in patients younger than 18 years and older than 70 years, whereas the endoscopic approach is preferred in young active males and females, with a trend to use TAPP (44?%) more frequently than TEP (40?%) in females. Surgeons tended to use the open (vs. endoscopic) approach in patients with hematologic disorders (58?% open vs. 42?% endoscopic), previous laparotomy (59?% open vs. 41?% endoscopic) or emergency surgery (66 vs. 33?% in incarcerated hernias and 74 vs. 26?% in strangulated hernia).

Conclusions

This survey showed that most surgeons who perform an endoscopic approach for inguinal hernia as the first option are convinced that not all hernias are good indications for this approach. On the other hand, most surgeons think that it is better to be able to offer patients an endoscopic technique or an open approach depending on the case.     

Decreased hernia recurrence using autologous platelet-rich plasma (PRP) with Strattice™ mesh in a rodent ventral hernia model

Background

Recurrence after ventral hernia repair (VHR) remains a multifactorial problem still plaguing surgeons today. Some of the many contributing factors include mechanical strain, poor tissue-mesh integration, and degradation of matrices. The high recurrence rate witnessed with the use of acellular dermal matrices (ADM) for definitive hernia repair has reduced their use largely to bridging repair and breast reconstruction. Modalities that improve classic cellular metrics of successful VHR could theoretically result in improved rates of hernia recurrence; autologous platelet-rich plasma (PRP) may represent one such tool, but has been underinvestigated for this purpose.

Methods

Lewis rats (32) had chronic ventral hernias created surgically and then repaired with Strattice? mesh alone (control) or mesh + autologous PRP. Samples were harvested at 3 and 6 months postoperatively and compared for gross, histologic, and molecular outcomes of: neovascularization, tissue incorporation, peritoneal adhesions, hernia recurrence, and residual mesh thickness.

Results

Compared to control at 3 months postoperatively, PRP-treated rats displayed significantly more neovascularization of implanted mesh and considerable upregulation of both angiogenic genes (vEGF 2.73-fold, vWF 2.21-fold) and myofibroblastic genes (αSMA 9.68-fold, FSP-1 3.61-fold, Col1a1 3.32-fold, Col31a1 3.29-fold). Histologically, they also showed enhanced tissue deposition/ingrowth and diminished chronic immune cell infiltration. Peritoneal adhesions were less severe at both 3 (1.88 vs. 2.94) and 6 months (1.63 vs. 2.75) by Modified Hopkins Adhesion Scoring. PRP-treated rats experienced decreased hernia recurrence at 6 months (0/10 vs. 7/10) and had significantly improved ADM preservation as evidenced by quantification of residual mesh thickness.

Conclusions

PRP is an autologous source of pro-regenerative growth factors and chemokines uniquely suited to soft tissue wound healing. When applied to a model of chronic VHR, it incites enhanced angiogenesis, myofibroblast recruitment and tissue ingrowth, ADM preservation, less severe peritoneal adhesions, and diminished hernia recurrence. We advocate further investigation regarding PRP augmentation of human VHR.

     

Desarda’s technique versus Lichtenstein technique for the treatment of primary inguinal hernia: a systematic review and meta-analysis of randomized controlled trials

Purpose

The Lichtenstein technique (LT) has been recognized as the standard treatment for inguinal hernia in adults owing to the high recurrence rates of tissue-based repairs. However, Desarda technique (DT) appeared as promising tissue-based repair that provided low incidence of recurrence without the need for implanting prosthetic or foreign materials in the inguinal canal. This meta-analysis of randomized controlled trials (RCTs) comparing DT and LT for primary inguinal hernia in adults aimed to determine which technique had better clinical outcome regarding recurrence and complication rates.

Methods

A systematic literature search for RCTs comparing between DT and LT was conducted using electronic databases and Google scholar service. Patients’ characteristics, technical details, recurrence and complication rates, and time to resume daily activities were extracted from the original studies and analyzed.

Results

Six RCTs comprising 2159 patients (89% males) were included. No significant difference in the incidence of recurrence between both techniques was detected (OR = 0.946; P = 0.91). The overall complication rate of LT was significantly higher than DT (OR = 1.86; P < 0.001). LT had significantly higher rates of seroma formation and surgical site infection (OR = 2.17; P = 0.007) and (OR = 2.17; P = 0.029), respectively. Postoperative pain, operation time, and time to resume normal activities were comparable in both groups.

Conclusion

Both DT and LT provided satisfactory treatment for primary inguinal hernia with low recurrence rates and acceptable rates of complications that were significantly less after DT. More well-designed RCTs with longer follow-up are required for further validation of the DT.

     

Appendicitis and Meckel’s diverticulum in a femoral hernia: simultaneous De Garengeot and Littre’s hernia

This report presents the case of a 73-year-old woman who was admitted with sepsis, cachexia and confusion secondary to a strangulated femoral hernia containing both the appendix (De Garengeot hernia) and a Meckel??s diverticulum (Littre??s hernia). She underwent successful operative management and was discharged from hospital on the 10th post-operative day. This is the first report in the literature of a combined De Garengeot and Littre??s hernia within a femoral hernia sac.     

Validation of a questionnaire for the assessment of pain following ventral hernia repair—the VHPQ

Purpose

The aim of this study was to create and evaluate the validity and reliability of a novel ventral hernia pain questionnaire (VHPQ) to assess pain following surgery for ventral hernia.

Methods

The questionnaire was constructed using focus groups and patient interviews. Validity was tested on 51 patients who responded to the VHPQ and brief pain inventory (BPI) 1 and 4?weeks following surgery. Reliability and internal consistency was tested on 74 patients who had surgery 3?years earlier and received the VHPQ and BPI on two separate occasions. Pain not related to surgery was examined on one occasion using the VHPQ on 100 non-operated people.

Results

For pain intensity items, a significant decrease was seen from week 1 to week 4 postoperative (p?<?0.05). Spearman rank correlations were significant between the pain intensity items of the VHPQ and the BPI, tested 1?week postoperative (p?<?0.05). Kappa levels for test?Cretest of items for interference with daily activities were higher than 0.5 for all items except one. Intra-class correlation was significant for pain intensity items (p?<?0.05) in the test?Cretest group. Three years after surgery, the operated group stated more pain in the pain intensity items (p?<?0.05) and more interference with daily activities (p?<?0.05) than a non-operated group from the general population.

Conclusion

The validity and reliability of the VHPQ make it a useful tool in assessing postoperative pain and patient satisfaction.