Fate of the inguinal hernia following removal of infected prosthetic mesh

Open tension-free hernioplasty using a prosthetic mesh is a common operation for inguinal hernia repair because of the relative ease of the operation and low recurrence rate. Wound infection is a potential complication of all hernia repairs and deep-seated infection involving an inserted mesh may result in chronic groin sepsis which usually necessitates complete removal of mesh to produce resolution. Removal of mesh would potentially result in a weakness of the repair and subsequent hernia recurrence. We reviewed the outcome of all our patients who had mesh removal for sepsis over an 8-year period, particularly examining for hernia recurrence and chronic groin pain. This was a retrospective review of the database of patients who had mesh repair of inguinal hernias over an 8-year period. There were 2,139 inguinal hernias repaired using prosthetic mesh. All patients who had mesh removal for infection were identified and followed up. Fourteen patients had deep-seated wound infection which required mesh removal for resolution of sepsis. No peri-operative complications occurred during mesh removal. After a median follow-up of 44 months (range 5–91 months), there were two asymptomatic recurrences and none of the patients had chronic groin pain. Hernia recurrence is uncommon following mesh removal for chronic groin sepsis, suggesting that the strength of a mesh repair lies in the fibrous reaction evoked within the transversalis fascia by the prosthetic material rather than in the physical presence of the mesh itself. When there is established deep infection, there should be no unnecessary delay in removing an infected mesh in order to allow resolution of chronic groin sepsis.     

Open tension-free mesh repair for adult inguinal hernia: eight years of experience in a community hospital

OBJECTIVE: The aim of this study was to determine the feasibility of using open tension-free mesh repair for adult inguinal hernias performed by resident surgeons under the supervision of a chief surgeon in a community hospital. METHODS: From May, 1992 through April, 2000, we performed 314 open tension-free mesh repairs on 289 patients (234 men, 55 women) with a mean age of 65.7 years. There were 173 right and 141 left hernias, and 25 were bilateral; while 220 were indirect, 77 were direct and 17 were of the femoral type. There were 281 primary and 33 recurrent lesions. Resident surgeons under the supervision of the first author (SY) performed all hernioplasties. Three types of open tension-free mesh repairs were performed; the Lichtenstein repair (n = 72), the mesh-plug repair (n = 134), and the Hernia System repair (n = 108). RESULTS: The duration of surgery averaged 73.0 minutes. There was no perioperative mortality. Five patients developed subcutaneous wound infections; no case required mesh removal. Hematoma occurred in eight patients, and seroma developed in 25. All haematomas and seromas subsided with repeated aspiration. The average duration of hospitalization was 6.5 days. The length of follow-up rose from 1 to 8 years, with a mean of 3.7 years. No patients in any group had a recurrence during the follow-up period. CONCLUSIONS: Under the close supervision of the staff surgeon, tension-free hernioplasties can be performed on adult inguinal hernias by surgeons-in-training in non-specialist centres with excellent outcomes, low postoperative complications and no recurrence.     

Late-onset deep mesh infection after inguinal hernia repair

Background Groin sepsis requiring mesh removal is said to be a rare complication of tension-free inguinal hernioplasty. Furthermore, late-onset deep-seated prosthetic infection seems to be an unexpected complication. The aim of this study was to report our experience on late mesh infection occurring years after open hernia repair. Methods Between 1998 and 2005, 1,452 patients (954 men), median age 64 years (range 19–89) underwent groin hernioplasty using a tension-free polypropylene mesh technique. Five patients (0.35%) appeared with late mesh infection (between 2 and 4.5 years postoperatively). The patients’ records were retrospectively reviewed for the purpose of this study. Antibiotic prophylaxis had been given in the five patients, while none of them had a prior history of wound infection. Results The patients were re-operated and the meshes were removed. Pus was found in three patients and Staphylococcus aureus was isolated in one. There was no hernia recurrence and none of the patients had chronic groin pain for a period of 6–44 months postoperatively. Conclusion From the results of this study, it appears that late-onset deep-seated prosthetic mesh infection is an important complication which has been rarely reported upon. Its true incidence is yet to be established. Late graft infection does not seem to correlate to neither the administration or not of antibiotic prophylaxis, nor to the presence or not of previous superficial wound infection. Furthermore, graft infection does not seem to correlate to neither the type of mesh inserted, nor to the fixation material. With the increasing use of synthetic materials for primary and recurrent hernia repair, the number of patients presenting with late mesh infections is likely to increase.     

Crucial anatomy and technical cues for laparoscopic transabdominal preperitoneal repair: Advanced manipulation for groin hernias in adults

Groin hernias include indirect inguinal, direct inguinal, and femoral hernias. Obturator and supravesical hernias appear very close to the groin. High-quality repairs are required for groin hernias. The concept of "tension-free repair" is generally accepted, and surgical repairs with mesh are categorized as "hernioplasties". Surgeons should have good knowledge of the relevant anatomy. Physicians generally focus on the preperitoneal space, myopectineal orifice, topographic nerves, and regional vessels. Currently, laparoscopic surgery has therapeutic potential in the surgical setting for hernioplasty, with laparoscopic transabdominal preperitoneal(TAPP) repair appearing to be a powerful tool for use in adult hernia patients. TAPP offers the advantages of accurate diagnoses, repair of bilateral and recurrent hernias, less postoperative pain, early recovery allowing work and activities, tension-free repair of the preperitoneal(posterior) space, ability to cover obturator hernias, and avoidance of potential injury to the spermatic cord. The disadvantages of TAPP are the need for general anesthesia, adhering to a learning curve, higher cost, unexpected complications related to abdominal organs, adhesion to the mesh, unexpected injuries to vessels, prolonged operative time, and as-yet-unknown long-term outcomes. Both technical skill and anatomical familiarity are important for safe, reliable surgery. With increasing awareness of the importance of anatomy during TAPP repair, we address the skills and pitfalls during laparoscopic TAPP repair in adult patients using illustrations and schemas. We also address debatable points on this subject.     

Tension-free mesh hernia repair: review of 1098 cases using local anaesthesia in a day unit.

The technical problems, early complications and short-term results of a tension-free method of 1098 inguinal hernia repairs in 1017 patients have been assessed. The operation was conducted under local anaesthesia, and the inguinal canal floor was reinforced by a polypropylene mesh. Patients were discharged home the same day. There was no mortality, no urinary complications and one case of venous thrombosis. There was one recurrence after a primary hernia repair and two patients have developed recurrences after repair of a recurrent hernia. The overall sepsis rate was 0.9% and 1% of patients had persistent neuralgia. No prosthesis required removal. In all, 49.6% of office workers returned to work in 1 week or less and 61% of manual workers in 2 weeks or less. The major advantages of the tension-free mesh repair under local anaesthesia are simplicity, substantial cost savings and very low rates of complications.     

Current Practices in Adult Groin Hernias: A Survey of Japanese General Surgeons

The tendency to perform abdominal wall reinforcement using various types of mesh (tension-free repair) is increasing. A questionnaire to poll Japanese surgeons on their current surgical modalities for groin hernias was sent to 105 hospitals and was returned by 83 hospitals. The majority (83%) of responders to this survey supported the tension-free repair as a standard operation for adult groin hernias. Of these 69 tension-free repairs, the mesh-plug repair was the most frequent standard operation (n = 53, 64%) and was performed by all responders. Ten (12%) opted for the prolene hernia system (PHS) repair as a standard operation and 52% of responders had experience of the PHS repair. Laparoscopic repair was performed as a standard operation by only one responder and was performed by only 34% of responders. Received: January 18, 2002 / Accepted: July 2, 2002 Reprint requests to: A. Onitsuka     

Combined open and laparoscopic approach to chronic pain following open inguinal hernia repair

Introduction: Chronic groin pain is the most common long-term complication after open inguinal hernia repair. Traditional surgical management of the associated neuralgia consists of injection therapy followed by groin exploration, mesh removal, and nerve transection. The resultant hernia defect may be difficult to repair from an anterior approach. We evaluate the outcomes of a combined laparoscopic and open approach for the treatment of chronic groin pain following open inguinal herniorrhaphy. Methods: All patients who underwent groin exploration for chronic neuralgia after a prior open inguinal hernia repair were prospectively analyzed. Patient demographics, type of prior hernia repair, and prior nonoperative therapies were recorded. The operation consisted of a standard three trocar laparoscopic transabdominal preperitoneal hernia repair, followed by groin exploration, mesh removal, and nerve transection. Outcome measures included recurrent groin pain, numbness, hernia recurrence, and complications. Results: Twelve patients (11 male and 1 female) with a mean age of 41 years (range 29–51) underwent combined laparoscopic and open treatment for chronic groin pain. Ten patients complained of unilateral neuralgia, one patient had bilateral complaints, and one patient complained of orchalgia. All patients failed at least two attempted percutaneous nerve blocks. Prior repairs included Lichtenstein (n=9), McVay (n=1), plug and patch (n=1), and Shouldice (n=1). There were no intraoperative complications or wound infections. With a minimum of 6 weeks follow up, all patients were significantly improved. One patient complained of intermittent minor discomfort that required no further therapy. Two patients had persistent numbness in the ilioinguinal nerve distribution but remained satisfied with the procedure. Conclusions: A combined laparoscopic and open approach for postherniorrhaphy groin pain results in good to excellent patient satisfaction with no perioperative morbidity. It may be the preferred technique for the definitive management of chronic neuralgia after prior open hernia repair.     

181例腹股沟疝普理灵网片前路修补经验

目的：对成人腹股沟疝人工网片修补的技术问题进行总结和探讨。方法：1997年1月－2002年8月间对181例腹股沟疝病人采用普理灵（Prolene,聚丙稀纺织纤维）网片进行无张力修补,手术方法包括Rutkow手术,Lichtenstein Lichtenstein手术平片修补10例次,“三明治”式修补11例次,Gilbert手术17例次。其中有双侧同期修补19例。1例术后2d后死于脑血管意外;阴囊血肿5例。150例病人随访8个月以上,1例术后3个月出现阴囊鞘膜积液,2例术后残留腹股沟区疼痛超过2个月,无一例复发。结论：人工网片修补是治疗腹股沟疝的有效方法,熟练的操作技术,腹横筋膜的有效修复,人工材料和手术方法的合理选择是获得较好疗效的关键性因素。     

无张力疝修补术后慢性疼痛的临床研究

目的探讨无张力疝修补术后慢性疼痛的原因及防治方法。方法对2007-01—2011-06实施无张力疝修补术142例患者的临床资料进行回顾性地分析。结果均行无张力疝修补术,按补片类型分为2组:聚丙烯类组(n=70)和聚四氟乙烯组(n=72)。术后疼痛发生率,聚丙烯类组为10.0%(7/70),聚四氟乙烯组为4.2%(3/72),差异有统计学意义(P<0.05)。结论聚四氟乙烯平片无张力疝修补术可减少腹股沟疝修补术后慢性疼痛的发生,疝修补材料应采用更符合生理、柔软舒适、并发症少的材质。     

Hernioplasty and simultaneous laparoscopic cholecystectomy: a prospective randomized study of open tension-free versus laparoscopic inguinal hernia repair

BACKGROUND: The laparoscopic repair of unilateral primary groin hernia remains controversial. This randomized study evaluates the outcome of the laparoscopic technique in hernia repair in patients undergoing simultaneous laparoscopic cholecystectomy (LC) and compares laparoscopic repair with tension-free open groin hernia repair. METHODS: Sixty-four low-risk patients with symptomatic chronic calculous cholecystitis and synchronous unilateral primary inguinal hernia were randomized to undergo either laparoscopic transabdominal preperitoneal mesh hernia repair (TAPP) and LC or LC and open tension-free hernia repair. RESULTS: The operating time was longer in the TAPP and LC group (mean +/- SD = 121 +/- 32 minutes) than in the LC and open group (95 +/- 27 minutes) (P <.01). The mean operating costs were higher in the TAPP and LC group ($1235 versus $1080) (P <.03). The intensity of postoperative pain at rest was greater in the LC and open group at 24 hours (P <.01) and 48 hours (P <.05), with a greater consumption of pain medication (P <.01). No differences between the 2 groups were found in terms of postoperative complications, disability period before return to work, or hernia recurrences. CONCLUSIONS: The totally laparoscopic procedure does not result in a significant benefit other than improved comfort in the first 2 postoperative days. However, laparoscopic hernia repair is considerably more difficult to perform than open tension-free hernioplasty. Thus, the totally laparoscopic approach should be performed only by experienced laparoscopic surgeons with special expertise in hernia surgery.     

无张力疝修补术后慢性疼痛的原因分析及防治

目的 探讨无张力疝修补术后慢性疼痛的原因及防治方法.方法 对142例实施无张力疝修补术患者的临床资料进行回顾性地分析.结果 均行无张力疝修补术,按补片类型分为2组:聚丙烯类组(n=70)和聚四氟乙烯组(n=72).术后疼痛发生率:聚丙烯类组为10.0%(7/70),聚四氟乙烯组为4.2%(3/72),2者差异有统计学意...     

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.     

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??Appropriate selection of tension-free inguinal hernia repair procedures LI Jian-wen??YUE Fei. Department of General Surgery??Ruijin Hospital??Shanghai Jiao Tong University School of Medicine??Shanghai Clinical Minimally Invasive Surgery Center??Shanghai 200025??China
Corresponding author: LI Jian-wen??E-mail??ljw5@yeah.net
Abstract The tension-free hernioplasty for inguinal hernia consists of anterior and posterior repair. Anterior repair includes plain mesh repair as well as plug and patch repair. Plain mesh reinforces the posterior wall of inguinal box, while plug could reinforce local defect. Posterior repair includes various preperitoneal repairs based on the principle of myopectineal orifice reinforcement. Laparoscopic hernia repair applies laparoscopic instruments via posterior approach to accomplish posterior repair under direct vision. Both TAPP and TEP are major procedures for inguinal hernia repair. The selection of appropriate procedure depends on surgeons’ experiences and patients’ situation.     

腹股沟疝无张力修补术后慢性疼痛的原因及治疗

目的 探讨无张力疝修补术后慢性疼痛的原因、预防对策及治疗.方法 回顾性分析我院2009年4月至20lO年5月106例腹股沟疝无张力修补术后患者的临床资料进行随访.结果 本组患者均行无张力疝修补术,随访时间3～13个月,术后出现3个月以上慢性疼痛不能缓解并需要进一步治疗的患者6例,发生率为5.66%.结论 局麻下熟练的手术操作、部分可吸收修补材料应用、腹膜外修补方式以及改良的补片固定方式可以减少腹股沟疝无张力修补术后慢性疼痛的发生.     

Five-year outcome of laparoscopic and Lichtenstein hernioplasties

Background: Laparoscopic hernia repair has been proved superior to open repairs in terms of short-term results, but long-term results of laparoscopic and open mesh repairs have been lacking until recently. Methods: A total of 123 patients were randomly allocated to two treatment groups comparing laparoscopic and Lichtenstein hernioplasties in three separate trials. The first and second trials compared small and large mesh used in transabdominal preperitoneal repairs, and the third study compared totally extraperitoneal hernioplasty with the Lichtenstein operation. A 5-year follow-up visit was scheduled to assess recurrencies, symptoms, and patient satisfaction. Results: For the follow up evaluation, 121 (98.4%) of the patients were reached. There were five hernia recurrences in the laparoscopic group (small mesh) and two in the Lichtenstein group (difference, 5%; 95% confidence interval, –4–13%; p = 0.3). One patient who underwent the transabdominal preperitoneal polypropylene procedure underwent reoperation 3 years later because of dense small bowel adhesions at the inguinal surgical site. Chronic groin pain was more common after open operation (0 vs 4) patients (difference 7%; confidence interval, –0.4–16%; p = 0.04). Ten patients (16%) in the laparoscopic group and 12 (20%) in the open group reported discomfort or pain at the surgical site. Conclusions: Both laparoscopic and Lichtenstein hernioplasties have a low risk for hernia recurrence if proper mesh size is used. The patients who undergo hernioplasty with open mesh hernioplasty seem to experience chronic symptoms and pain more often than those managed with the laparoscopic procedure.     

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??Management of infection and chronic pain post inguinal hernioplasty CHEN Si-meng??LIU Li-jia. Department of General Surgery??the First Affiliated Hospital of Nanjing Medical University??Nanjing 210029??China
Corresponding author??CHEN Si-meng??E-mail??chensim@sohu.com
Abstract Surgical site infection and incision pain are constant subjects in field of surgery. Once the infection involves the implanted prosthesis??the standard surgical practice is removal of the infected prosthesis. Mesh infection rate after tension-free hernia repair remains low??which still causes uncertainty about the removal of the infected mesh among surgeons. There is evidence to support that prognosis of infection is related to time and mesh. Therefore??relevant treatment standard has been established to shorten the healing process of infected incision. Due to higher incidence rate??difficulty in management as well as unpredictable prognosis??chronic pain has been the complication of the utmost importance after tension-free hernia repair??which remains highly controversial in term of management. “Prevention is better than treatment” reflects the dilemma that hernia surgeons have to face chronic pain.     

腹股沟疝无张力修补术中并发症的预防501例分析

目的目的探讨腹膜前修复对防止疝复发等并发症的作用。方法从2007年1月至2009年12月,共501例腹股沟疝患者行无张力修补术,其中232例采用疝环充填法术式,269例采用腹膜前修补术式。观察随访患者术中、术后并发症及复发率。结果 501例患者的术后随访资料显示,两种术式在手术时间、术中并发症（出血、血管神经损伤、膀胱损伤）及术后并发症（阴囊积液、切口感染）上无明显差异（P〉0.05）。但在术后异物感和慢性疼痛、复发方面,腹膜前组比疝环充填组明显减少,有显著性差异（P〈0.01）。结论腹膜前耻骨肌孔的修复,构成完整腹股沟管后壁,能有效预防疝复发,可减轻术后局部异物感和慢性疼痛。     

Groin Hernia Repair: Open Techniques

Since the introduction of the Bassini method in 1887, more than 70 types of pure tissue repair have been reported in the surgical literature. An unacceptable recurrence rate and prolonged postoperative pain and recovery time after tissue repair along with our understanding of the metabolic origin of inguinal hernias led to the concept of tension-free hernioplasty with mesh. Currently, the main categories of inguinal hernia repair are the open repairs and the laparoscopic repairs. In the open category, repair of the hernia is achieved by pure tissue approximation or by tension-free mesh repair. The most commonly performed tissue repairs are those of Bassini, Shouldice, and to a lesser extent McVay. In the tension-free mesh repair category, the mesh is placed in front of the transversalis fascia, such as with the Lichtenstein tension-free hernioplasty, or behind the transversalis fascia in the preperitoneal space, such as during the Nyhus, Rives, Read, Stoppa, Wantz, and Kugel procedures. Numerous comparative randomized trials have clearly demonstrated the superiority of the tension-free mesh repair over the traditional tissue approximation method. Placing mesh behind the transversalis fascia, although a sound concept, requires extensive dissection in the highly complex preperitoneal space and can lead to injury of the pelvic structures, major hematoma formation, or both. In addition, according to the prospective randomized comparative study of mesh placement in front of versus behind the transversalis fascia, the latter offers no advantage over the former, and it is more difficult to perform, learn, and teach. More importantly, preperitoneal mesh implantation (via open and laparoscopic procedure) leads to obliteration of the spaces of Retzius and Bogros, making certain vascular and urologic procedures, in particular radical prostatectomy and lymph node dissection, extremely difficult if not impossible. In conclusion, according to level A evidence from randomized comparative studies, (1) mesh repair is superior to pure tissue approximation repairs, and (2) mesh implantation in front of the transversalis fascia is superior, safer, and easier than open or laparoscopic mesh implantation behind the transversalis fascia.     

Is the Lichtenstein Operation of Strangulated Groin Hernia a Safe Procedure?

Background In spite of many published articles describing the hernia repairs, there are only a few original reports concerning the polymer mesh application during emergency procedures for strangulated inguinal hernias. The aim of our study was to evaluate the results of the Lichtenstein and Bassini operations for strangulated groin hernias and to show the changing number of the tension-free repairs. Methods From 1997 to 2004, the Bassini procedure was performed in 21 patients, 6 of whom underwent small intestine resection and 2 others required resection of the necrotic omentum. The strangulated intestinal loop or omentum were released in 13 cases. After the repair 1 patient died of shock caused by intestinal necrosis. Of 56 patients who underwent an emergency Lichtenstein procedure, 55 were followed-up. A small intestine resection was performed in 2 cases to correct segmental necrosis. The gangrenous omental appendix of the sigmoid colon was excised in 1 patient, and necrotic omental fragments were resected in 2 cases. The strangulated intestinal loop or omentum was released in 51 patients. All patients were given wide-spectrum antibiotics intravenously. Results Between 1997 and 2000 tension-free procedures were performed in half of the patients undergoing emergency operation for strangulated hernia; between 2001 and 2004 such procedures were employed in more than 90% of the cases. In 2 patients we observed a small inflammatory infiltration of the wound that resolved within several days after Lichtenstein repair. A serous fluid collection was present in 2 cases. The treatment consisted of puncture and was successful in both cases. Conclusions The use of monofilament polypropylene mesh for strangulated inguinal hernia repair is safe, and the risk of the local infectious complications is low.     

Re-operation due to severe late-onset persisting groin pain following anterior inguinal hernia repair with mesh

Objectives  Mild pain lasting for a few days is common following mesh inguinal hernia repair. In some patients however, severe groin pain may appear months or even years postoperatively. The aim of this study was to report our experience of late-onset persisting severe postoperative groin pain occurring years after mesh hernioplasty. Methods  In a 9-year period, 1,633 patients (1,073 men), median age 63 years (range 19–88), underwent mesh groin hernia repair. Between 1.5 and 4 years postoperatively, six patients (0.35%) presented with severe chronic groin pain unrelieved by conservative measures and surgical exploration was essential. The patients’ records were retrospectively reviewed for the purpose of this study. Results  Ilioinguinal nerve entrapment was detected in four patients. The meshes appeared to be indistinguishable from the nerve and were removed along with the stuck nerve. New meshes were properly inserted. Mesh fixation on the periostium of the pubic tubercle by a staple was found in the other two patients. The staples were removed from the periostium in both patients. Neither hernia recurrence nor chronic groin pain was persisting in all six patients during a follow-up of 6–44 months postoperatively. Conclusion  From the results of this study, it appears that ilioinguinal nerve entrapment and/or mesh fixation on the periostium of the pubic tubercle are the causes of late-onset severe chronic pain after inguinal mesh hernioplasty. Mesh removal, along with the stuck ilioinguinal nerve and staple detachment from the periostium, are the gold-standard techniques if conservative measures fail to reduce pain.