Screening for abdominal aortic aneurysms in men: a Canadian perspective using Monte Carlo–based estimates

Objective

Recently generated randomized screening trial data have provided good evidence in favour of routine screening for abdominal aortic aneurysm (AAA) to reduce AAA-related deaths in men aged 65 years and older. We developed an economic model that assessed the incremental cost–utility of AAA screening to help decision makers judge the relevance of a national screening program in Canada.

Methods

We constructed a 14 health state Markov model comparing 2 cohorts of 65-year-old men, where the first cohort was invited to attend screening for AAA using ultrasonography (US) and the second cohort followed the current practice of opportunistic detection. Lifetime outcomes included the life-years gained, AAA rupture avoided, AAA-related mortality, quality-adjusted life years (QALYs) and costs. Transition probabilities were derived from a systematic review of the literature, and a probabilistic sensitivity analysis was carried out to examine the effect of joint uncertainty in the variables of our analysis. The perspective adopted was that of the health care provider.

Results

Invitations to attend screening produced an undiscounted gain in life expectancy of 0.049 years and a gain in discounted QALY of 0.019 for an estimated incremental lifetime cost of CAN$118. The estimated incremental cost–utility ratio was CAN$6194 per QALY gained (95% confidence interval [CI] 1892–10 837). The numbers needed to invite to attend screening, and the numbers needed to screen to prevent 1 AAA-related death were 187 (95% CI 130–292) and 137 (95% CI 85–213), respectively. The acceptability curve showed a greater than 95% probability of the program''s being cost-effective, and the model was robust to changes in the values of key parameters within plausible ranges.

Conclusion

Our results support the economic viability of a national screening program for men reaching 65 years of age in Canada. More clinical studies are needed to define the role of screening in subgroups at high risk, especially in the female population.     

Direct inguinal hernia containing bladder carcinoma: A case report and review of the literature

INTRODUCTION

Inguinal hernia containing bladder carcinoma is a very rare occurrence.

PRESENTATION OF CASE

We report a case of a male patient who presented with a left groin hernia containing an irregular mass. The hernia was repaired without the use of mesh and a partial cystectomy was done.

DISCUSSION

Only 1–3% of all inguinal hernias involve the bladder, with very few reports containing a carcinoma.

CONCLUSION

Treatment consists of removing the tumor and repairing the hernia.     

A Comparison of Patient Recovery Following Unilateral and Bilateral Endoscopic Preperitoneal Herniorrhaphy

Introduction:

The advantage of using minimally invasive techniques over open techniques in the repair of inguinal hernias remains unclear. One of the more established indications for the performance of minimally invasive (e.g. endoscopic preperitoneal) herniorrhaphy is the presence of bilateral hernias. However, no prior study has compared the recovery following unilateral and bilateral endoscopic preperitoneal hernia repairs.

Patients and Methods:

From July 15, 1994 through August 16, 1996 one primary surgeon performed 373 hernia repairs on 250 patients. Unilateral herniorrhaphy (UH) was performed on 114 males and 13 females with an average age of 58 (range 18–89). Bilateral herniorrhaphy (BH) was performed on 121 males and 2 females with an average age of 53 (range 18 – 86) (p>0.05). Within the UH group there were 105 virgin hernias and 22 recurrent hernias. The BH group included 212 virgin hernias and 34 recurrent (p>0.05).Bilateral repairs took longer to perform than unilateral repairs (65 minutes vs. 45 minutes) (p<0.05). At the time of discharge, all patients were given a postoperative survey and asked to record their level of pain, narcotic use and level of activity on the day of surgery and postoperative days 1, 2, 3, 7, 14, and 28.

Results:

No differences were found in pain perception, narcotic use or level of activity on any of the days measured between the two groups (p>0.05). In addition, both groups returned to work at a similar time (UH: 6.32 +/−3.29 days, BH: 6.68 +/− 4.13 days) (p>0.05).

Conclusion:

Bilateral endoscopic preperitoneal herniorrhaphy can be performed with the same expected patient recovery as unilateral repairs.     

Swelling of the right thigh for over 30 years—The rare finding of a De Garengeot hernia

INTRODUCTION

Femoral hernias may – in some rare cases – contain the appendix, a phenomenon called de Garengeot hernia. It is usually an incidental finding in hernia repair. We found our case to be of interest because of the long standing femoral swelling before peracute appendicitis led to its removal.

PRESENTATION OF CASE

We present the case of a 71-year-old woman with a swelling of the right medial thigh for over more than 30 years. When the swelling suddenly grew in size and became tender, she was referred to our emergency department. Sonographically as well as clinically a femoral hernia was diagnosed. Intraoperatively, the appendix was found and open appendectomy as well as a hernioplasty was performed.

DISCUSSION

Open appendectomy is an elegant and safe procedure to repair a long standing de Garengeot hernia. Most case reports call for extensive diagnostics such as CT scan etc. We found a sonography of the femoral region to be conclusive.

CONCLUSION

Apart from the inherent risk of sudden incarceration in hernias, De Garengeot hernias can also develop peracute appendicitis years after their formation. This differential diagnosis needs to be taken into consideration in patients presenting with the clinical signs of a femoral hernia.     

An irreducible left scrotal hernia containing a sigmoid colon tumor (adenocarcinoma) – Case report

INTRODUCTION

In relation to all inguinal hernias, large irreducible scrotal hernias are quite rare, while such hernias containing colon tumors in the sac have so far been described in fewer than 30 cases.

PRESENTATION OF CASE

A 61-year-old patient was admitted for a planned surgery because of a large irreducible left-sided scrotal hernia. Intraoperatively, a large tumor of the sigmoid colon was found in the hernial sac. In a histopathological examination it was diagnosed as adenocarcinoma. A palliative operation was performed and he was referred to further systemic and palliative treatment (because of numerous coexisting liver metastases).

DISCUSSION

Until now, only about 30 cases of colon tumor in inguinal hernia sac have been reported.

CONCLUSION

It should be remembered that even the most obvious preoperative diagnosis may be verified intraoperatively.     

Incidental Non-Inguinals Hernias in Totally Extra-Peritoneal Hernia Repair

Introduction

Totally extra-peritoneal (TEP) inguinal hernia repair allows identification and repair of incidental non-inguinal groin hernias. We assessed the prevalence of incidental hernias during TEP inguinal hernia repair and identified the risk factors for incidental hernias.

Materials and Methods

Consecutive patients undergoing TEP repair from May 2005 to November 2012 were the study cohort. Inspection for ipsilateral femoral, obturator and rarer varieties of hernia was undertaken during TEP repair. Patient characteristics and operative findings were recorded on a prospectively collected database.

Results

A total of 1,532 TEP repairs were undertaken in 1,196 patients. Ninety-three patients were excluded due to incomplete data, leaving 1,103 patients and 1,404 hernias for analyses (1,380 male; 802 unilateral and 301 bilateral repairs; median age, 59 years). Among the 37 incidental hernias identified (2.6% of cases), the most common type of incidental hernia was femoral (n=32, 2.3%) followed by obturator (n=2, 0.1%). Increasing age was associated with an increased risk of incidental hernia, with a significant linear trend (p<0.01). The risk for patients >60 years of age was 4.0% vs 1.4% for those aged <60 years (p<0.01). Incidental hernias were found in 29.2% of females vs 2.2% of males, (p<0.0001). Risk of incidental hernia in those with a recurrent inguinal hernia was 3.0% vs 2.6% for primary repair (p=0.79).

Conclusions

Incidental hernias during TEP inguinal hernia repair were found in 2.6% of cases and, though infrequent, could cause complications if left untreated. The risk of incidental hernia increased with age and was significantly higher in patients aged >60 years and in females.     

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.     

Aspiration pneumonia as a complication of a rare type of hernia

INTRODUCTION

Inguinal hernias are a common pathology and can contain unusual abdominal contents; the stomach is only infrequently involved due to its position in the abdominal cavity.

PRESENTATION OF CASE

An 85-year old male patient presented with symptoms of bowel obstruction and was subsequently found to have an incarcerated stomach within his chronic left-sided inguinal hernia. The patient had also developed aspiration pneumonia.

DISCUSSION

Aspiration pneumonia is a yet unreported complication of this unusual type of hernia. Our aim is to describe the presentation and management of this complication.

CONCLUSION

Development of aspiration pneumonia in a patient with an incarcerated stomach within an inguinal hernia.     

Conversion to Stoppa Procedure in Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair

Background and Objectives:

Conversion to open surgery is an important problem, especially during the learning curve of laparoscopic totally extraperitoneal (TEP) inguinal hernia repair.

Methods:

Here, we discuss conversion to the Stoppa procedure during laparoscopic TEP inguinal hernia repair. Outcomes of patients who underwent conversion to an open approach during laparoscopic TEP inguinal hernia repair between September 2004 and May 2010 were evaluated.

Results:

In total, 259 consecutive patients with 281 inguinal hernias underwent laparoscopic TEP inguinal hernia repair. Thirty-one hernia repairs (11%) were converted to open conventional surgical procedures. Twenty-eight of 31 laparoscopic TEP hernia repairs were converted to modified Stoppa procedures, because of technical difficulties. Three of these patients underwent Lichtenstein hernia repairs, because they had undergone previous surgeries.

Conclusion:

Stoppa is an easy and successful procedure used to solve problems during TEP hernia repair. The Lichtenstein procedure may be a suitable option in patients who have undergone previous operations, such as a radical prostatectomy.     

Learning curve for laparoscopic totally extraperitoneal repair of inguinal hernia

Background

Laparoscopic totally extraperitoneal (TEP) repair has been accepted as a popular procedure for inguinal hernia repair, but surgeons still encounter technical difficulties owing to unfamiliar pelvic anatomy and limited working space. We sought to estimate the learning curve for laparoscopic TEP repair without supervision.

Methods

We retrospectively analyzed the medical records of patients scheduled for laparoscopic TEP repair of an inguinal hernia from December 2000 to October 2007.

Results

We reviewed medical records for 700 patients. The cases were divided into 8 groups: 20 patients each in groups I–V and 200 patients each in groups VI–VIII. No significant difference in demographic characteristics was identified among the groups. The mean duration of surgery significantly decreased (p < 0.001) in relation to experience; it reached a plateau of less than 30 minutes (mean 28 min) after 60 cases. The mean length of stay in hospital was 0.97 days, reaching a plateau after 20 cases. Six patients were converted to other techniques: 1 patient each in groups III and VIII and 4 patients in group VII. Three recurrences were detected; however, 2 were excluded because the patient had bilateral inguinal hernias.

Conclusion

We estimate the learning curve for laparoscopic TEP repair is 60 cases for a beginner surgeon. The presence of an experienced supervisor during the first 60 cases can help prevent unnecessary complications and shorten the duration of surgery.     

New minimally invasive technique for repairing femoral hernias: 3-D patch device through a femoris approach

Background

Femoral hernias are less common than inguinal hernias. The use of preformed mesh to repair femoral hernias without tension has become increasingly common. We sought to investigate the safety and feasibility of repairing femoral hernias with a Prolene 3-dimentional (3-D) patch using a femoris approach.

Methods

We identified all consecutive patients with femoral hernias treated at our centre with a Prolene 3-D patch using a femoris approach in our institution over a 5-year period (2004–2009). We assessed duration of surgery, length of stay in hospital, recurrence, postoperative pain and complications.

Results

We repaired 73 hernias with this technique during the study period. The mean duration of surgery was 13.1 minutes, most patients were discharged in less than 24 hours, no recurrence was noted, and only minor complications occurred.

Conclusion

This technique has not only the same advantage of other tension-free repairs, but also the advantages of convenience and shorter duration of surgery.     

Laparoscopic Hernia: Umbilical-Pubis Length Versus Technical Difficulty

Laparoscopic hernia repair is more difficult than open hernia repair. The totally extraperitoneal procedure with 3 trocars on the midline is more comfortable for the surgeon. We studied the impact of the length between the umbilicus and the pubis on the totally extraperitoneal procedure (95 hernias operated on in 70 patients). This length did not influence the totally extraperitoneal procedure in this study.

Background:

The laparoscopic repair of hernias is considered to be difficult especially for the totally extra-peritoneal technique (TEP) due to a limited working space and different appreciation of the usual anatomical landmarks seen through an anterior approach. The aim of our study has been to answer a question: does the umbilical-pubic distance, which influences the size of the mesh, affect the TEP technique used in the treatment of inguinal hernias?

Methods:

From January 2001 to May 2011, the umbilical-pubic (UP) distance was measured with a sterile ruler graduated in centimeters in all patients who underwent a symptomatic inguinal hernia by the TEP technique in two hernia surgery centers. The sex, age, BMI, hernia type, UP distance, operation time, hospital stay and complications were prospectively examined based on the medical records.

Results:

Seventy patients underwent 95 inguinal hernia repairs by the TEP technique. The umbilical-pubic distance average was 14 cm (10 to 22) and a 25 kg/m2 (16–30) average concerning the body mass index (BMI). Seventy percent of patients were treated on an outpatient basis. The postoperative course was very simple. There was no recurrence of hernia within this early postoperative period.

Conclusion:

The umbilical-pubic distance had no influence on the production of TEP with 3 trocars on the midline in this study.     

Unintended consequences of policy change to watchful waiting for asymptomatic inguinal hernias

Introduction

In 2009 the Department of Health instructed McKinsey & Company to provide advice on how commissioners might achieve world class National Health Service productivity. Asymptomatic inguinal hernia repair was identified as a potentially cosmetic procedure, with limited clinical benefit. The Birmingham and Solihull primary care trust cluster introduced a policy of watchful waiting for asymptomatic inguinal hernia, which was implemented across the health economy in December 2010. This retrospective cohort study aimed to examine the effect of a change in clinical commissioning policy concerning elective surgical repair of asymptomatic inguinal hernias.

Methods

A total of 1,032 patients undergoing inguinal hernia repair in the 16 months after the policy change were compared with 978 patients in the 16 months before. The main outcome measure was relative proportion of emergency repair in groups before and after the policy change. Multivariate binary logistic regression was used to adjust the main outcome for age, sex and hernia type.

Results

The period after the policy change was associated with 59% higher odds of emergency repair (3.6% vs 5.5%, adjusted odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.03–2.47). In turn, emergency repair was associated with higher odds of adverse events (4.7% vs 18.5%, adjusted OR: 3.68, 95% CI: 2.04–6.63) and mortality (0.1% vs 5.4%, p<0.001, Fisher’s exact test).

Conclusions

Introduction of a watchful waiting policy for asymptomatic inguinal hernias was associated with a significant increase in need for emergency repair, which was in turn associated with an increased risk of adverse events. Current policies may be placing patients at risk.     

Intrasaccular caecal adenocarcinoma presenting as enlarging right inguinoscrotal hernia

INTRODUCTION

Colorectal cancer and inguinal hernias are both common surgical pathologies in the elderly but rarely co-exist. Where the conditions overlap, there can be difficulties in both diagnosis and treatment.

PRESENTATION OF CASE

A 78 year old man with unexplained iron deficiency anaemia was investigated for gastrointestinal cancer. He was found to have enlarging bilateral inguinoscrotal hernias. CT colonoscopy revealed a herniated caecal carcinoma contained within the scrotum. An open excision was performed.

DISCUSSION

Iron deficiency anaemia without obvious bleeding is associated with colorectal cancer and should be thoroughly investigated. Asymptomatic inguinal hernias are often ignored by patients. However, a change in an existing hernia may be associated with neoplasia.

CONCLUSION

Dual pathology raises new difficulties in assessment, investigation and management of colorectal cancer.     

Inguinal herniae: Valuable clues to concurrent abdominal pathology: A series of case studies describing unusual findings in 'routine' hernia operations which demonstrate the need for thorough surgical training

Introduction

The case series presented here demonstrates that the pathology encountered during inguinal hernia repair can often provide clues to concurrent pathology; the well trained surgeon''s broader medical knowledge can lead to earlier diagnosis.

Presentation of cases

The case series examines four cases of men presenting with inguinal hernias, who were found to have concurrent abdominal pathology after further investigation of the intraoperative findings of the surgeon.

Discussion

Operating surgeons not only require the necessary surgical skills to deal with the unexpected, but must also rely on their ability to think laterally when interpreting atypical incidental findings during ‘routine’ procedures.

Conclusion

Experience and knowledge gained through a surgeon''s career is essential to enable them to correctly interpret their intraoperative findings and potentially diagnose concurrent pathology. The authors believe that surgical care practitioners, trained in just 2 years, would lack these essential skills.     

Vesical calculus formation on non-absorbable sutures used for open inguinal hernia repair

INTRODUCTION

Iatrogenic injuries to the urogenital tract are rare, with the bladder being the organ most affected. We describe a case of a vesical calculus that formed on non-absorbable sutures that were used to repair an inguinal hernia.

PRESENTATION OF CASE

A 45-year-old male presented with frank haematuria and dysuria 2 years following an open left inguinal hernia repair. A CT urography showed a vesical calculus adherent to the left anterio-lateral wall of the bladder. Cystoscopy revealed that the calculus formed on non-absorbable sutures. Cystolapaxy was performed followed by cystoscopic excision of the sutures. The patient''s post-operative course was uneventful.

DISCUSSION

Foreign bodies in the urinary bladder always act as a nidus for formation of a calculus. Iatrogenic bladder injuries are common during hernia repair. It is however rare for sutures used to repair an inguinal hernia to involve the urinary bladder wall. The patient most likely had a full bladder at the time of hernia repair or the bladder was part of the contents of the hernia sac.

CONCLUSION

This case illustrates the need to ensure that the bladder is empty prior to pelvic surgery and for surgeons to have a good understanding of inguinal anatomy to avoid injuring the contents of the hernia sac.     

A combined Richter's and de Garengeot's hernia

INTRODUCTION

de Garengeot''s hernia is very rare. Richter''s hernia is responsible for 10% of acute strangulated hernias.

PRESENTATION OF CASE

A 91-year-old woman with three days of abdominal distention was found on computed tomogram to have an incarcerated femoral hernia. Operation revealed a de Garengeot''s hernia combined with a Richter''s hernia of small bowel. Primary repair was performed along with appendectomy.

DISCUSSION

We discuss these rare hernias, not previously reported in combination, and options for management.

CONCLUSION

Combined de Garengeot''s and Richter''s hernias are rare, represent a significant diagnostic challenge, and should be repaired urgently to prevent ischemic bowel, or limit contamination if ischemia is already present. Use of computed tomography will likely lead to increased pre-operative diagnosis of this rare entity.     

Duplication of vas deferens-A rare anomaly with review of literature

INTRODUCTION

Isolated duplication of vas deferens is a rare anomaly with only eleven cases reported in medical literature. Unawareness regarding this rare anomaly can lead to inadvertent injury to the vas during inguinal hernia surgery or failure of vasectomy procedure.

PRESENTATION OF CASE

A 27-year-old gentleman was diagnosed with isolated duplication of vas during left sided open inguinal hernia surgery. He had no other genito-urinary anomaly. Patient had an uneventful recovery from surgery.

CONCLUSION

It is a rare anomaly and unawareness regarding this condition can lead to catastrophic consequences during inguinal hernia and vasectomy surgeries.     

Paraduodenal herniation: An internal herniation in a virgin abdomen

INTRODUCTION

A paraduodenal hernia is an uncommon hernia that results from an abnormal rotation of the midgut. Commonly, these hernias are congenital in nature, and are reported to cause 1.5–5.8% of intestinal obstructions. These hernias occur when a part of the jejunum herniates through the posterior portion of the ligament of Treitz. Diagnosing these hernias preoperatively has been shown to be difficult, despite the studies that are available. Early diagnosis is imperative to the patient in order to avoid strangulation of the bowel, which is associated with a high mortality.

PRESENTATION OF CASE

In this case, we present a case of a left-sided paraduodenal hernia in a virgin abdomen in a 38-year-old African American male with a herniation of a loop of jejunum through a defect of the posterior portion of the ligament of Treitz. The patient also had a volvulized segment of the proximal jejunum, and part of this bowel was found to be ischemic.

DISCUSSION

Acute intestinal obstruction caused by a left paraduodenal hernia is a rare cause of intestinal obstruction. A literary search of PubMed between 1980 and 2012 indicated only 44 cases of intestinal obstruction secondary to a left paraduodenal hernia.

CONCLUSION

The patient underwent exploratory laparotomy, and the herniated bowel was found to be ischemic. The hernia was reduced, and the ischemic bowel resected. The defect was closed, and the patient had a non-complicated recovery.     

Safety and Efficacy of Laparoendoscopic Single-Site Surgery for Abdominal Wall Hernias

Background:

Laparoendoscopic single-site surgery has rapidly progressed from the animal laboratory to clinical use since mass production of multichannel ports began in 2007. Indeed, it has now been shown to be feasible and safe for many commonly performed operations.

Methods:

This study cohort comprised 22 unselected patients with abdominal wall hernias of varying types: multiply recurrent inguinal (n=2), suprapubic (n=1), ventral/incisional (n=17), and parastomal hernias (n=2), who underwent laparoendoscopic single-site ventral hernia repair between December 2009 and February 2011. Standard dissecting instruments and a 52cm/5.5mm/30^°angle laparoscope were used.

Results:

Patients included 14 men and 8 women, with a median age of 56 (range, 32 to 78) years and a mean body mass index of 31.5±4.7kg/m². The mean mesh size was 460cm² (range, 225 to 884cm²). Mean operation time was 125 minutes for ventral/incisional hernias and 270 minutes for parastomal hernias. No conversions to multiport or open surgeries were necessary. There was no mortality or morbidity, and no recurrence at 6- to 18-month follow-up. The mean satisfaction score was 2.7 (range, 2 to 3) with no patients reporting dissatisfaction with the procedure.

Conclusion:

This series, though relatively small, represents a diverse group of patients with varying abdominal wall hernias, including parastomal hernias. These successful laparoendoscopic single-site surgeries, with no complications, demonstrate safety and efficacy, albeit in a specialized hernia center. This study is a prelude to the eventual validation of laparoendoscopic single-site hernia surgery with prospective randomized controlled trials.