Longterm results of a prospective study of 225 femoral hernia repairs: indications for tissue and mesh repair

BACKGROUND: Femoral hernias are uncommon, and there are relatively few clinical studies of longterm outcomes after repair. Although the McVay repair has been classically described, the infrainguinal plug technique has gained popularity in recent years. Evidence supporting these repairs is sparse. STUDY DESIGN: A prospective study of elective femoral hernia repairs was done at the Shouldice Hospital from June 1999 until June 2003. The tissue-based complete groin repair (CGR) and a preperitoneal mesh repair were performed for specific indications. Patients were followed annually for 5 years to examine for recurrences and complications. RESULTS: Two hundred fifty-six patients were enrolled, with 225 completing 5 years of followup. Median age was 55 years, and hernias on the right side were more common (63.1%). Concurrent inguinal hernias were found in 115 patients (51%), and 41 (18.2%) had a previous inguinal hernia repair. A complete groin repair was performed in 120 patients and a preperitoneal mesh repair in 78. The remaining had an infrainguinal mesh repair. The overall recurrence rate was 3.1%, with a median time to recurrence of 12 months. There was no significant difference between mesh and suture repairs. Chronic postoperative pain was experienced by 20 patients (8.9%). CONCLUSIONS: Femoral hernias can be repaired electively with a tissue-based or a preperitoneal mesh technique, with durable longterm results. Mesh repair is indicated for recurrent femoral hernias, inguinofemoral hernias, prevascular hernias, association with concurrent direct hernias, and, if tension is anticipated, with complete groin repair. Infrainguinal mesh repair is used only when there has been a successful previous inguinal hernia repair.     

Hernia repair in elderly patients

Background This study evaluates a 5-year experience of the management of the most frequent abdominal wall hernias in an elderly population. Methods From April 1990 to December 1995, 231 inguinal, 12 femoral and seven umbilical hernias were repaired in 221 patients (mean age 74 (range 66–93) years). Concomitant diseases were present in 157 patients, A mesh repair was performed with ‘tension-free’ or ‘plug’ techniques in all but 23 inguinal and two femora! hernia repairs, in which the Bassini or Shouldice procedures were adopted. Ten emergency hernia repairs were performed for strangulation. A total of 232 operations, including four emergency hernia repairs, were carried out under local anaesthesia. Results There was no perioperative mortality. Acute intestinal bleeding occurred 2 days after surgery in a patient with colonic diverticular disease. Urinary retention occurred once following emergency hernia repair under general anaesthesia and twice after elective hernia repair under local anaesthesia. Local complications included four scrotl haematomas (2 per cent), three wound infections (1 per cent) and one case of orchitis with atrophy after repair of a recurrent hernia. There was one recurrence after a Bassini repair and one after Shouldice inguinal herniorrhaphy. No recurrence was observed after mesh repair. Conclusion Local anaesthetic mesh hernia repair is safe and effective in elderly patients. Age should be no bar to elective hernia repair. This policy should avoid the complications of emergency operation.     

Rezidivleistenhernienreparation nach vorangegangener Netzimplantation

INTRODUCTION: Since the use of prosthetic mesh for the surgical repair of inguinal hernias has become increasingly popular, mesh material introduced during a previous operation is being detected in a growing number of patients undergoing surgery for recurrent hernia. This applies to at least 10% of recurrences. Needed is a therapeutic algorithm for the surgical management of recurrent hernias after previous mesh repair. MATERIAL AND METHODS: A total of 672 recurrent hernia repairs performed in hospitals in the German cities Aachen and Koblenz were analysed in order to review clinical practice. In 92 patients (13.7%) who underwent surgery for recurrent hernia, mesh had been used in the previous hernia repairs. Attention was focused on the location of the recurrence in relation to the site of mesh implantation and on the advantages and disadvantages of the various surgical procedures for repairing recurrent hernias. Re-examination was performed with a mean follow-up of 3 years. RESULTS: Surgeons mostly decided during operation which procedure to use. A transinguinal approach was preferred for patients presenting with recurrent hernia and pain, and mesh material introduced during a previous operation was then explanted. In the case of multiple recurrences, a minimal direct suture repair was used for small defects or a preperitoneal approach for inserting a new, large mesh. The majority of recurrences were medial or suprapubic, especially those occurring after a Lichtenstein repair. After re-examining 87 of 92 patients, nine recurrences (10.3%) were found. Mesh-free suturing methods were affected most frequently. Moderate complaints were reported by 39.1%, and 4.6% suffered from medical chronic pain. CONCLUSION: The surgical management of recurrent hernias after previous mesh repair is a particular challenge for surgeons. We introduce a therapeutic algorithm for recurrent hernia surgery after previous mesh implantation based on analysis of clinical practice.     

Laparoscopic versus open inguinal hernia repair

Inguinal hernias are common, with a lifetime risk of 27% in men and 3% in women. Inguinal hernia repair is one of the most common operations in general surgery. Despite more than 200 years of experience, the optimal surgical approach to inguinal hernia remains controversial. Surgeons and patients face many decisions when it comes to inguinal hernias: repair or no repair, mesh or no mesh, what kind of mesh, open or laparoscopic, extraperitoneal or transabdominal, and so forth. Inguinal hernia repairs have morbidity and recurrence rates that are not inconsequential. The search for the gold standard of repair continues.     

Cost-effective laparoscopic TEP inguinal hernia repair: the Portsmouth technique

NICE (UK) has not recommended unilateral primary laparoscopic inguinal hernia repair because of its expense. A two-port technique without balloon inflator or routine tacking was developed, which helped reduce costs to just ￡35 more than day-case open hernia repair. Over a 6-month period, 40 patients underwent 60 TEP repairs with a 6-month follow up. Zero degree laparoscope (10 mm) and blunt graspers (5 mm) created the pre-peritoneal space, identified landmarks and completed the dissection. Trimmed 15×15 cm mesh was placed over each defect. Operating times for unilateral and bilateral hernias for consultants and supervised trainees were 30*, 42.5* and 40*, 55* min (*: Median) respectively. Verbal rating pain scores at 24 and 72 h were 1* (0–3) and 0* (0–2) respectively. Patients returned to activity, driving and work in 5*, 7* and 14* days respectively. Cost of laparoscopic hernia repair was calculated at ￡105. A two-port laparoscopic hernia repair can be performed effectively and safely, in reasonable time and at a low cost. These data support the use of this technique in primary unilateral inguinal hernia. European Association for Endoscopic Surgery, Barcelona, 9th–12th June 2004 Association of Surgeons of Great Britain and Ireland, Harrogate, 28th–30th April 2004     

Is laparoscopic umbilical hernia repair with mesh a reasonable alternative to conventional repair?

BACKGROUND: Laparoscopic mesh repair has been advocated as treatment of choice for ventral hernias. The term "ventral hernia" refers to a variety of abdominal wall defects and laparoscopic papers have not reported defect specific analysis. The purpose of this study was to determine any advantages to laparoscopic mesh repair of umbilical hernias. METHODS: A retrospective review (January 1998 to April 2001) was made of patients undergoing umbilical hernia repair. Patients were categorized into three groups: laparoscopic repair with mesh, open repair with mesh, and open repair without mesh. Comparative analysis was performed. RESULTS: One-hundred and sixteen umbilical hernia repairs were performed in 112 patients: 30 laparoscopic mesh repairs, 20 open mesh repairs, and 66 open nonmesh repairs. The laparoscopic technique was used for larger defects and took more time with a trend toward fewer postoperative complications and recurrences. CONCLUSIONS: Laparoscopic umbilical hernia repair with mesh presents a reasonable alternative to conventional methods of repair.     

Preperitoneal prosthetic mesh hernioplasty during radical retropubic prostatectomy

PURPOSE: The number of radical retropubic prostatectomies performed in the United States has increased during the last decade. There are 5 to 10% of candidates for radical retropubic prostatectomy who have a detectable inguinal hernia on physical examination. Furthermore, recent data suggest that there is an increased incidence of inguinal hernia after radical retropubic prostatectomy. We evaluated the role of simultaneous inguinal hernioplasty during radical prostatectomy. MATERIALS AND METHODS: During 575 radical prostatectomy procedures from June 1991 to June 1997, 70 hernioplasties were performed in 48 patients. Retrospective chart review was performed for all men who underwent simultaneous hernia repair. Mean patient age was 60.9 years (range 43 to 73). Polypropylene or polyester fiber prostheses were used for mesh hernioplasty. All repairs were performed using a preperitoneal approach during radical retropubic prostatectomy. RESULTS: There were 35 hernioplasties performed without and 35 with mesh. Mean postoperative followup was 24 months (range 6 to 66). Of the hernias 71% were indirect and 29% were direct. No recurrence was detected after mesh hernioplasty, whereas 5 hernias (14%) recurred in the nonmesh group. In this group 2 men (4%) also had de novo hernias on the contralateral side during followup. All recurrent hernias were diagnosed within 1 year of the initial operation. No patient had wound infection, persistent neuralgia or ischemic orchitis. CONCLUSIONS: Simultaneous repair of inguinal hernias during radical retropubic prostatectomy is effective and technically feasible. There is convenient access to the preperitoneal space during radical retropubic prostatectomy and hernia repair adds only 5 to 10 minutes of operative time. Mesh repair appears to offer optimized results compared to the nonmesh technique. Despite the use of prosthetic material, no complications were attributable to its application during these genitourinary procedures.     

Inguinal hernia repair in Hospital Authority hospitals: The role of laparoscopic hernioplasty

Objective: Two major changes have occurred in inguinal hernia repair during the last two decades: (i) the use of tension‐free mesh repair; and (ii) the application of laparoscopic technique for repair. The aims of the present study were to study: (i) how inguinal hernia repair was carried out; and (ii) the outcome of inguinal hernia repair in Hospital Authority (HA) hospitals. Methodology: This was a retrospective analysis on 8311 elective inguinal hernia repairs performed in 16 HA hospitals from January 2001 to December 2003. The mean age was 63.9 ± 14.2 years, and the male to female ratio was 22.0 : 1.0. Among these, 869 (10.5%) repairs were performed with the laparoscopic approach and 7442 (89.5%) repairs with the open approach. The proportion of laparoscopic hernia repair increased from 8.7% to 12.6%. Results: For open repair, 39% of cases were carried out with regional anaesthesia, 32% with general anaesthesia and 29% with local anaesthesia (LA). Furthermore, mesh repair was used in 88% of the patients. For laparosocpic repair, 98.4% of cases were carried out under general anaesthesia, and all patients had mesh repair using the totally extraperitoneal approach. A significantly higher proportion of bilateral repair and recurrent hernia repair was performed with the laparoscopic approach (P = 0.000). For primary unilateral repair, there was no significant difference in the postoperative length of stay (LOS) and the total LOS between the laparoscopic and the open surgery groups. No difference in LOS was found in recurrent hernia repair between the two groups. With respect to bilateral repair, both the preoperative LOS (P = 0.036) and total LOS (P = 0.039) were shorter in the laparoscopic group. Furthermore, a significantly higher proportion of day‐surgery patients was observed in the laparoscopic group than the open surgery group (21.3%vs 16.9%, P = 0.001). Nevertheless, when only the results of 2003 were analyzed, the postoperative LOS (P = 0.000) and total LOS (P = 0.000) were significantly shorter in the laparoscopic group than the open surgery group. The LOS parameters were significantly shorter in the open surgery LA subgroup compared with the non‐LA subgroup (P = 0.000), and they were not different from those in the laparoscopic group. Conclusions: The open mesh repair is the predominant approach for inguinal hernia repair in HA hospitals. The originally described local anaesthetic approach was under utilized, although it resulted in good outcome. The use of laparoscopic hernia repair is increasing and a learning curve was recently observed with improved outcome.     

Use of porcine small intestinal submucosa as a prosthetic device for laparoscopic repair of hernias in contaminated fields: 2-year follow-up

Background: Surgisis is a new four- or eight-ply bioactive, prosthetic mesh for hernia repair derived from porcine small intestinal submucosa (SIS). It is a naturally occurring extracellular matrix, which is easily absorbed, supports early and abundant new vessel growth, and serves as a template for the constructive remodeling of many tissues. As such, we believe that Surgisis mesh is ideal for use in contaminated or potentially contaminated fields in which ventral, incisional, or inguinal hernia repairs are required.Methods: From November 2000–May 2003, 53 patients (23 male, 30 female) underwent placement of Surgisis mesh for a variety of different hernia repairs. A total of 58 hernia repairs were performed in our patient population. Twenty procedures (34%) were performed in a potentially contaminated setting (i.e., with incarcerated/strangulated bowel within the hernia or coincident with a laparocopic cholecystectomy/colectomy). Thirteen repairs (22%) were performed in a grossly contaminated field, including one in which an infected polypropylene mesh from a previous inguinal hernia repair was replaced with Surgisis mesh and one in which dead bowel was discovered within the hernia sac. Median follow-up is 19 months with a range of 1–30 months.Results: Of the 58 total repairs, there was one wound infection complicated by enterocutaneous fistula in a patient originally operated on for ischemic bowel. The fistula was in a location independent of the Surgisis mesh. There have been no mesh-related complications or recurrent hernias in our early postoperative follow-up period.Conclusions: Surgisis mesh appears to be a promising new prosthetic material for hernia repair and appears to function well, especially in contaminated or potentially contaminated fields. Obviously, long-term follow-up is still required.     

Management of primary and recurrent inguinal hernia by surgeons from the South West of England

BACKGROUND: The National Institute of Clinical Excellence (NICE) has advocated open mesh repair for primary hernia but suggested laparoscopic repair may be considered for recurrent hernias. AIM: To establish current surgical practice by surgeons from the South West of England. METHODS: A postal survey was distributed to 121 consultant surgeons and a response rate of 75% was achieved. RESULTS: The majority (86%) of the surgeons surveyed performed hernia repairs, and most (95%) of these used open mesh repair as standard for primary inguinal hernia. Only 8% used laparoscopic repair routinely for primary hernias. Few consultants (only 28%) were able to quote formally audited hernia recurrence rates. A total of 90% of respondents still employed open mesh repair routinely for recurrent hernias; however, if mesh had been used for the primary repair, this figure fell to 55%. Some 7% of respondents recommended laparoscopic repair for recurrent hernia, but this increased to 17% if the primary repair was done with mesh. All laparoscopic surgeons in the South West employed the totally extraperitoneal approach (TEP). There was a range of opinion on the technical demands of repair of a recurrent hernia previously mended with mesh; the commonest cause of mesh failure was thought to be a medial direct recurrence (insufficient mesh medially). CONCLUSIONS: Current surgical practice for primary hernias in the South West England reflects NICE guidelines although many surgeons continue to manage recurrent hernias by further open repair. In this survey, there was anecdotal evidence to suggest that hernia recurrence can be managed effectively by open repair.     

Improved outcomes with the Prolene Hernia System mesh compared with the time-honored Lichtenstein onlay mesh repair for inguinal hernia repair

BACKGROUND: Inguinal hernia repairs are commonly performed operations. Recently, Neumayer et al examined the gold standard Lichtenstein onlay mesh repair (LMR) against laparoscopic inguinal hernia repair and showed that the recurrence rates are higher for laparoscopic mesh repairs when compared with the open onlay mesh repair (laparoscopic = 10.1% versus open = 4.9%). In 1998, the Prolene Hernia System (PHS) mesh, consisting of an onlay and an underlay patch attached with a connector, was introduced as an option for tension-free open repair of inguinal hernias combining the benefits of a posterior and anterior repair from an open approach. Our objective was to evaluate the PHS mesh repair versus the LMR for inguinal hernias. We hypothesized that the recurrence rate of PHS mesh would be lower compared with the LMR with overall similar complication rates. METHODS: PHS mesh hernia repairs performed from January 2003 to July 2005 and LMR repairs from January 2000 to July 2002 were included. Demographic data such as age, race, and gender as well as comorbid conditions such as chronic obstructive pulmonary disease, congestive heart failure, previous myocardial infarction, diabetes, hypertension, prostatism, and chronic cough were collected. Complications such as cord injury, seroma, hematoma, urinary retention, urinary tract infection, orchitis, and wound infection were recorded. Recurrences in each group were also recorded. A student t test and chi-square analysis were used for statistical analysis. RESULTS: Six hundred twenty-two charts were reviewed during the 2 time periods (PHS mesh = 321, LMR = 302). The median follow-up for the study was 17 months. There was no significant difference with regards to age, race, gender, or comorbidities between the 2 groups. Overall, there was a trend toward decreased complications in the PHS mesh group compared with the LMR group (PHS mesh = 17%, LMR = 23%, P = .07), with a significant difference in the hematoma/seroma rates (PHS mesh = 6.9%, LMR = 12.6%, P = .015). Finally, there was a significant decrease in the recurrence rate for the PHS mesh group when compared with the LMR group (PHS mesh = 0.6%, LMR = 2.7%, P = .04). CONCLUSION: Our study shows, during a median follow-up of 17 months, improved outcomes by using the PHS mesh compared with the gold standard Lichtenstein onlay mesh for inguinal hernias with significantly lower recurrence rates. Additionally, in the PHS mesh group, there was a trend toward decreased overall complication rates with significantly less seroma/hematoma rates. Therefore, the PHS mesh repair may represent a superior alternative for the repair of inguinal hernias.     

Management of groin hernias in patients with ascites.

The records of 18 cirrhotic patients with ascites and groin hernias (20 inguinal and one femoral) were retrospectively reviewed. Eleven patients underwent repair of their groin hernias (total of 13 repairs). Ten herniorrhaphies were performed electively, two were performed urgently because of recent difficult reduction, and one was performed emergently for incarceration without strangulation. No major and four minor postoperative complications occurred. There were no perioperative deaths or ascites leaks. Of the 13 hernias in 11 patients undergoing repair, 12 (92%) were available for follow-up. In this group, the 12 groin hernia repairs were followed for a mean of 25 months. One recurrence (8%) occurred 11 months after repair. In this same group of patients, five umbilical hernias were repaired, with three recurrences (60%). From this retrospective study, it appears that serious complications from groin hernias in cirrhotics are not common, and elective repair can usually await control of ascites. Additionally, for appropriately selected patients with ascites, elective inguinal hernia repair can be performed safely, with an acceptable rate of recurrence.     

Minimal postoperative pain using properitoneal nontension sutured repair of direct inguinal hernias

BACKGROUND: Numerous repairs exist for direct inguinal hernias. These repairs are limited by the shortcomings of their respective technique. Reported recurrence rates for all currently employed hernia repairs for direct inguinal hernias range from 1% to 10%. With recurrence rates for nontension mesh repairs <2%, the evaluation of postoperative outcomes has shifted instead to that of pain and return to normal activities. METHODS: We describe a novel inexpensive technique that employs the placement of conventional properitoneal tension-free mesh for repair of direct inguinal hernia. This technique, performed as day surgery with the patient under local anaesthetic, offers the beneficial aspects of contemporary mesh repair while avoiding its limitations. RESULTS: Three-year independent follow-up of 52 patients undergoing this repair demonstrated 1 (1.9%) early failure. Postoperative pain was measured using a visual analog pain scale (0 to 10) at 2 months (mean +/- SD; 1.39 +/- .58), 1 year (.37 +/- .27), 3 years (.58 +/- .40), at work (.59 +/- .33), and with recreational activity (.73 +/- .40). More than one third of patients had returned to work 1 week after surgery (37.8%) with 62.2% returning by 2 weeks and 100% by 6 weeks. Most significantly, 90.9% of patients had resumed full recreational activities by 8 weeks. CONCLUSIONS: In addition to providing minimal recurrence, these results of our technique demonstrate that this it provides less postoperative pain than has been reported in other nontension types of repair. Furthermore, use of this procedure results in earlier return to work and full recreational activities, thus it has significant social and economic implications.     

Laparoscopic transabdominal preperitoneal (TAPP) hernia repair. A 7-year two-center experience in 3017patients

BACKGROUND: This report reviews our experience with 3530 transabdominal preperitoneal (TAPP) hernia repairs in 3017 patients (513 bilateral) over the 7-year period from May 1992 to July 1999. We have continually audited our practice and modified the techniques in response. METHODS: Unless contraindicated, laparoscopic TAPP repair is considered the procedure of choice at our institution for all reducible inguinal hernias. We initially stapled an 11 x 6 cm polypropylene mesh in the preperitoneal space but now place a 15 x 10 cm mesh in the preperitoneal space with sutured peritoneal closure. RESULTS: There have been a total of 22 recurrences, of which 17 were identified in the first 325 repairs (5%) using the 11 x 6 cm mesh. Five recurrences occurred in the later 3205 repairs (0.16%) (median follow up of 45 months). There was one 30-day death unrelated to the procedure. There have been seven conversions (four due to irreducibility, two due to extensive adhesions, one due to bleeding). Bladder perforations have occurred in seven cases, of which six were recognized immediately and treated laparoscopically without sequelae. There have been seven cases of small bowel obstruction from herniation through the peritoneal closure. Sutured repair of the peritoneum has reduced the incidence of this complication. Four patients had mesh infections, of whom three were treated conservatively. The incidence of postoperative seroma and hematoma was 8%. Median operation time remains at 40 min with a mean hospitalization of 0.9 nights. Sixty percent of TAPP hernia repairs are now performed on the Day Surgical Unit with a 3% admission rate. Median return to normal activities is 7 days. Forty percent of patients require no postoperative analgesia. These figures remain the same whether the hernia is primary, recurrent, unilateral, or bilateral. Consultants performed most operations early in the series, but latterly surgical trainees have performed the majority of these procedures under supervision. CONCLUSIONS: Laparoscopic TAPP hernia repair is technically difficult, but in the hands of a well-trained surgeon, it is safe and effective with a high degree of patient satisfaction. The low recurrence rate compares favorably to other tension-free mesh hernia repairs.     

Recurrent groin hernia: a cognitive survey in Piedmont

The aim of this study was to analyze, using a cognitive survey, how recurrent groin hernia are treated in our region by surgical centres. A form was sent to 49 surgical centres in our region, considering the period 2002 -first six months of 2004, asking the number of primitive hernias treated, surgical technique, number of recurrent hernias treated, surgical technique, kind of anaesthesia and types of complications. We sent 49 forms, 41 (83.7%) were given back. During the considered period, 18 580 primitive hernias and 1102 recurrent (5.6% of all repair) were treated. The greatest part of it was performed with an open mesh technique tension free (77% of primitive hernias, and 62% of recurrent ones). Laparoscopic repair was performed in 0.2% of primitive hernias and 3.2% of recurrent ones. The operations were carried out mainly in spinal anaesthesia (722, 65.5%). Recurrence occurred in 34 cases (3.1%). In our region inguinal hernia repair both for primitive and recurrent groin hernia has been performed mainly by an open mesh technique, tension free and sutureless and, in greatest part, in spinal anaesthesia. Laparoscopic repair has not been used very much.     

Assessing the impact of short-term surgical education on practice: a retrospective study of the introduction of mesh for inguinal hernia repair in sub-Saharan Africa

Purpose

Inguinal hernia repair is the most common general surgery operation performed globally. However, the adoption of tension-free hernia repair with mesh has been limited in low-income settings, largely due to a lack of technical training and resources. The present study evaluates the impact of a 2-day training course instructing use of polypropylene mesh for inguinal hernia repair on the practice patterns of sub-Saharan African physicians.

Methods

A surgical training course on tension-free mesh repair of hernias was provided to 16 physicians working in rural Ghanaian and Liberian hospitals. Three physicians were requested to prospectively record all their inguinal hernia surgeries, performed with or without mesh, during the 14-month period following the training. Demographic variables, diagnoses, and complications were collected by an independent data collector for mesh and non-mesh procedures.

Results

Surgery with mesh increased significantly following intervention, from near negligible levels prior to the training to 8.1 % of all inguinal hernia repairs afterwards. Mesh repair accounted for 90.8 % of recurrent hernia repairs and 2.9 % of primary hernia repairs after training. Overall complication rates between mesh and non-mesh procedures were not significantly different (p = 0.20).

Conclusions

Three physicians who participated in an intensive education course were routinely using mesh for inguinal hernia repair 14 months after the training. This represents a significant change in practice pattern. Complication rates between patients who underwent inguinal hernia repairs with and without mesh were comparable. The present study provides evidence that short-term surgical training initiatives can have a substantial impact on local healthcare practice in resource-limited settings.     

Ubiquitous use of prosthetic mesh in inguinal hernia repair: the dilemma

Summary The omnipresence of prosthetic materials (mesh) used in hernia repairs throughout the world deserves careful review. The propensity to develop operative techniques wherein prosthetic mesh is used routinely, regardless of type hernia, has reached an unacceptable level of practice. Being foreign bodies, postoperative complications occur which directly can be traced to the implanted meshes. Recent interest in mesh complications, i.e., infection, mesh shrinkage, migration and fistula formation, has escalated. Although mesh foreign body tumorigenesis has not been seen in humans following hernia repair, there is sufficient animal data to cause concern. Similarly, neural complications following use of mesh, particularly after the open anterior notension repair methods, are being reported at alarming rates. Many types of inguinal hernias do not need mesh repairs. It is our premise that these hernias must be identified preoperatively. Certainly, type I, II and III C inguinal hernias of our classification, should not receive a prosthetic mesh repair. If prosthetic mesh is to be used, it should be placed to buttress the inguinal wall posteriorly so that advantage of Pascal's law may be assured.     

'One-stop' inguinal hernia surgery--day-case referral, diagnosis and treatment

BACKGROUND: Patients with unilateral inguinal hernias are conventionally seen at an out-patient appointment before being placed on a waiting list for surgery. Many patients are also required to attend a pre-assessment clinic prior to admission. AIM: To establish whether patients fit for day surgery inguinal hernia repair could be assessed and treated at a single hospital appointment. PATIENTS AND METHODS: Patients referred with unilateral inguinal hernias were sent an information sheet and health questionnaire by post. General practitioners were asked to help patients complete the medical details. Patients suitable for day surgery were sent a single appointment for assessment and treatment by an open, tension-free Lichtenstein mesh repair. RESULTS: Ninety-eight patients were sent an appointment for 'one-stop' inguinal hernia treatment. Ninety-two patients (93.5%) underwent inguinal hernia repair and were discharged on the same day without complication. CONCLUSIONS: Patients with unilateral primary inguinal hernias who are under 70 years old and ASA grade I or II can been seen, assessed and treated on the same day. 'One-stop' inguinal hernia surgery reduces the number of patient visits to the hospital and could be expanded to incorporate many more hernia repairs and other day case procedures.     

Umbilical hernia, Mayo or mesh?

Summary Unlike inguinal herniorraphy, the results of surgery for umbilical hernia have been poorly audited. The extent to which the popular sutured repair of Mayo has given way to mesh-based repairs in recent years is also unknown. To investigate these deficiencies, a review was undertaken of 651 umbilical hernia repairs performed between April 1994 and March 1999 at a single institution by 10 general surgeons.Excluding children and umbilical hernias repaired at laparotomy, a total of 473 primary adult hernias and 18 recurrent hernias were repaired. The proportion repaired for recurrence was 3.8%. Follow up ranges between 12 and 60 months (mean 27 months, median 25 months).Of the 18 recurrences, there were 16 sutured repairs and 11 of the patients had predisposing factors for recurrence such as wound infection, obesity, chronic renal failure or ascites.Sutured repair of primary umbilical hernias in this large series was successful in 96% of cases; in the remainder underlying co-morbidity was an important predisposing factor for recurrence.This study does not support the routine use of mesh in primary adult umbilical hernia repair.     

Inguinal Hernia Repair: Local or General Anaesthesia?

INTRODUCTION

Specialist hernia centres and public hospitals with a dedicated hernia service (Plymouth Hernia Service) have achieved remarkable results for inguinal hernia repair with the use of local anaesthesia and set the standards for groin hernia surgery. There is minimal data in the literature as to whether such results are reproducible in the National Health Service in the UK.

PATIENTS AND METHODS

A retrospective analysis of all inguinal hernia repairs performed in one district general hospital over a 9-year period was performed. The outcome measures were type of anaesthesia used, early and late postoperative complications and recurrence. A postal questionnaire survey was conducted to obtain satisfaction rates. In addition, a postal questionnaire survey of consultant surgeons in Wales was performed to determine the use of local anaesthesia and day-case rates for inguinal hernia repair.

RESULTS

A total of 577 hernia repairs were performed during the study period. Of these, 369 (64%) repairs were performed under local anaesthesia (LA) and 208 (36%) under general anaesthesia (GA). Day-case repair was achieved in 70% (400) of cases. The day-case rates were significantly higher under LA compared to GA (82.6% versus 42.6%; P < 0.05). Patients operated under LA had lower postoperative analgesic requirements and lower incidence of urinary retention compared with the GA group (P < 0.05). There were 7 (1.2%) recurrences at a median follow-up of 5.1 years (range, 10.3–2.5 years). Postal questionnaire revealed higher satisfaction rates with LA compared to GA repair. Only 15% of surgeons in Wales offer the majority of their patients local anaesthetic repair.

CONCLUSIONS

The use of LA results in increased day-case rates, lesser postoperative analgesic requirements and fewer micturition problems. The excellent results obtained by specialist hernia centres can be reproduced by district general hospitals by increasing the use of LA to repair inguinal hernias.