Single-Center Experience With Parastomal Hernia Repair Using Retromuscular Mesh Placement

Background

Parastomal hernias (PHs) are frequent complications of enterostomies. We aimed to evaluate our outcomes of open PH repair with retromuscular mesh reinforcement.

Methods

From 2006 to 2013, 48 parastomal hernias were repaired in 46 consecutive patients undergoing open retromuscular repair. Surgical technique included stoma relocation, retromuscular dissection, posterior component separation, and retromuscular mesh placement. All stomas were prophylactically reinforced with cruciate incisions through mesh. Main outcome measures included demographics, perioperative details, wound complications (classified according to the CDC guidelines), and recurrences.

Results

There were 24 male and 22 female patients with a mean age of 61.8 and body mass index (BMI) of 31.7 kg/m². Twenty-four patients had recurrent PH with an average of 3.8 prior repairs. Ostomies included 18 colostomies, 20 ileostomies, and 10 ileal conduits. Thirty-two patients had a concurrent repair of a midline incisional hernia. All patients underwent mesh repair with either biologic (n?=?29), lightweight polypropylene (n?=?15), or absorbable synthetic mesh (n?=?2). There were 15 superficial surgical site infections (SSIs) and 6 deep SSIs. There was one case of an ischemic ostomy requiring surgical revision. No mesh grafts required removal and there were no mesh erosions. At a mean follow-up time of 13 months, five patients (11 %) developed a recurrence; three patients required re-repair.

Conclusion

In this largest series of complex open repairs with retromuscular mesh reinforcement and stoma relocation, we demonstrate that this results in an effective repair. This technique should be considered for complex parastomal hernia repair.     

Spigelian hernia repair as a day-case procedure

Purpose

Only a few series of patients with a spigelian hernia managed on an outpatient basis have been reported in the literature. The aim of this prospective study was to evaluate the results of the elective spigelian hernia repair as an ambulatory procedure.

Methods

From June 2007 to June 2010, 8 patients with 9 spigelian hernias were electively operated on under local anesthesia as a day case. Four patients had unilateral spigelian hernia, 1 had spigelian and inguinal on the same side, 1 had spigelian and epigastric, 1 had spigelian and umbilical, and 1 patient had bilateral spigelian and umbilical hernia. Spigelian hernia was managed by the “open preperitoneal flat mesh technique.” In patients with several ventral hernias at different sites, “the open preperitoneal flat mesh technique” was performed using one separate flat mesh for each of the hernias; for the patient with inguinal hernia, the Lichtenstein procedure was performed in addition.

Results

No complications and recurrences were recorded during a mean follow-up of 23.5 months (range: 11–35).

Conclusion

The elective spigelian hernia can be successfully repaired under local anesthesia as a day-case procedure. The “open preperitoneal flat mesh technique” provides excellent results under these conditions.     

Single center experience with the modified retromuscular Sugarbaker technique for parastomal hernia repair

Purpose

Parastomal hernias are challenging to manage, and an optimal repair has yet to be defined. An open, modified, retromuscular Sugarbaker technique has recently been described in the literature as a technically feasible approach to parastomal hernia repair. This study evaluates our initial institutional experience with parastomal hernia repair with the aforementioned technique with respect to safety and durability.

Methods

All patients who underwent an open, modified retromuscular Sugarbaker parastomal hernia repair from 2014 through 2016 at our institution were identified. Patient characteristics, hernia variables, operative details, and 30-day and medium-term outcomes were abstracted from the Americas Hernia Society Quality Collaborative database. Outcomes of interest included 30-day wound morbidity, mesh-related complications, and hernia recurrence.

Results

Thirty-eight patients met inclusion criteria. 20 (53%) patients presented to our institution for management of a recurrent parastomal hernia. 35 (92%) patients had a concurrent midline incisional hernia with a mean total hernia width of 15.1 cm and mean defect size of 353 cm². Thirty-day wound morbidity rate was 13%. At a mean of follow-up of 13 months (range 4–30), the hernia recurrence rate was 11%. Three patients (8%) experienced mesh erosion into the stoma bowel, leading to stoma necrosis, bowel obstruction, and/or perforation which required reoperation at day 8, 12, and 120 days, respectively.

Conclusions

The outcomes of the retromuscular Sugarbaker technique for the management of parastomal hernias have been disappointing at our institution, with a concerning rate of serious mesh-related complications. This operation, as originally described, needs further study before widespread adoption with a particular focus on the technique of mesh placement, the most appropriate mesh selection, and the long-term rate of mesh erosion.

     

The preperitoneal memory-ring patch for inguinal hernia: a prospective multicentric feasibility study

Purpose

To evaluate the feasibility, the reproducibility, the safety and the efficacy of a recently introduced preperitoneal memory-ring patch (Polysoft^®, Davol Inc., C.R. Bard Inc., Crawley, UK) by a prospective multicentric observational study.

Methods

We performed 235 unilateral groin hernia repairs in 200 consecutive patients during a 12-month period. Patients were operated by three different surgeons in two different centres. Pre- and intraoperative data, as well as postoperative complications, were prospectively recorded.

Results

Two hundred patients, with a mean age of 55.4 years, were operated for primary or recurrent unilateral groin hernias. The mean operation time for unilateral hernia repair was 22 min (range 14–37 min). Seventy-one patients (35.5%) were operated in an ambulatory setting. Considering pain scores, we observed a preoperative visual analogue scale (VAS) score of 1.4 (range 0–3.7). After 24 h, 3 weeks and 6 months, VAS was 4.2 (0.5–6.9), 1.7 (0–2.0) and 0.1 (0–1.5), respectively. The follow-up was more than 18 months in all patients (range 19–31 months). In total, three patients were diagnosed with a recurrence and were reoperated by an anterior Lichtenstein repair with large-pore mesh.

Conclusion

This transinguinal minimally invasive preperitoneal mesh repair is reproducible, easy to perform and safe with acceptable mid-term results. These elements, together with a minimal superficial dissection in the inguinal canal, preperitoneal mesh placement and the absence of fixation, are possible elements to reduce acute and chronic postoperative pain compared to other open and also laparoscopic techniques that have to be proven in larger (randomised) trials.     

Laparoscopic transabdominal preperitoneal inguinal hernia repair using needlescopic instruments: a 15-year, single-center experience in 317 patients

Background

Laparoscopic inguinal hernia repair is associated with a decrease in postoperative pain, shortened hospital stay, earlier return to normal activity, and decrease in chronic pain. Moreover, laparoscopic surgery performed with needlescopic instruments has more advantages than conventional laparoscopic surgery. However, there are few reports of large-scale laparoscopic transabdominal preperitoneal inguinal hernia repair using needlescopic instruments (nTAPP). This report reviews our experiences with 352 nTAPP in 317 patients during the 15-year period from April 1996 to April 2011.

Methods

We performed nTAPP as the method of choice in 88.5% of all patients presenting with inguinal hernia. To perform the nTAPP, 3-mm instruments were used. A 5-mm laparoscope was inserted from the umbilicus, and surgical instruments were inserted through 5- and 3-mm trocars. After reduction of the hernia sac and dissection of the preperitoneal space, we placed polyester mesh or polypropylene soft mesh with staple fixation. The peritoneum was closed with 3–0 silk interrupted sutures.

Results

The mean operative time was 102.9?min for unilateral hernias and 155.8?min for bilateral hernias. There was no conversion to open repair. Forty-three patients (13.6%) used postoperative analgesics, and the mean frequency of use was 0.5 times. Regarding intraoperative complications, we observed one bladder injury, but no bowel injuries or major vessel injuries. Postoperative complications occurred in 32 patients (10.1%). One patient with a retained lipoma required reoperation. There was no incidence of chronic pain or mesh infection. The operative time for experienced surgeons (≥20 repairs) was significantly shorter than that of inexperienced surgeons (<20 repairs; P?Conclusions The nTAPP was a safe and useful technique for inguinal hernia repair. Large prospective, randomized controlled trials will be required to establish the benefit of nTAPP.     

Combined laparoscopic and open extraperitoneal approach to scrotal hernias

Background

Laparoscopic repair of scrotal hernias is often a difficult endeavor to successfully complete. The longstanding nature of these hernias often results in significant adhesions and anatomic distortion of the inguinal floor. These two issues make reduction of the hernia arduous and subsequent reinforcement of the parietal sac difficult. We have previously described techniques to increase the chances of success when attempting laparoscopic repair of scrotal hernias. Here, we describe some of those techniques as well as a combined laparoscopic and open approach to achieve a robust preperitoneal repair of incarcerated scrotal hernias when the usual totally extraperitoneal approach does not work.

Patients and methods

We performed a retrospective review of 1890 TEP hernia repairs we performed from 1990 to 2010. Rate of conversion to an open approach or a combined laparoscopic and open approach was examined. Incidence of complications or recurrences was assessed over a 12-month follow-up period.

Results

Among the 1890 TEP repairs, 94 large scrotal hernias were identified. Of these, nine cases (9.5 %) required conversion to an open procedure due to an incarcerated and indurated omentum. Three were completed with a conventional open preperitoneal whereas six patients (6.4 %) underwent repair with the combined approach. In this group, no recurrences or complications were found over a 12-month period.

Conclusion

In cases where a large scrotal hernia may be difficult or dangerous to reduce laparoscopically, immediate conversion to an open repair may not be necessary. A combined laparoscopic and open approach can greatly assist in the visualization and dissection of the preperitoneal space, thereby facilitating reduction of the hernia and placement of the mesh.     

Inguinal hernia repair with the mesh plug method is safe after radical retropubic prostatectomy

Purpose

We evaluated the safety and efficiency of using the mesh plug method (MP) to repair inguinal hernias in patients with a history of radical retropubic prostatectomy (RRP). We also investigated how RRP influences the development of inguinal hernias and impacts their repair.

Methods

Among 488 adult male patients who underwent inguinal hernia repair during a recent 5-year period, 37 had a history of RRP. We compared the characteristics and surgical outcomes of the patients who had undergone RRP (post-RRP group) with those who had not (non-RRP group).

Results

All post-RRP hernias were treated by MP. The 37 post-RRP patients had a collective 41 hernias, 40 of which were of the indirect type. The side affected by the hernia did not differ significantly between the groups. We compared the short-term surgical outcomes of the indirect post-RRP hernias vs. the indirect non-RPP hernias without recurrence and incarceration. The operation times, postoperative hospital stay, and mobility rates did not differ significantly between the two groups. The blood loss was almost equal in both groups.

Conclusion

Inguinal hernia repair after RRP may be difficult because of inflammatory changes in the preperitoneal cavity, but the surgical outcomes of MP were equivalent in patients with or without a history of RPP in this study. MP is a safe and effective method for post-RPP hernia repair.     

A modified sublay–keyhole technique for in situ parastomal hernia repair

Objective

The surgical treatment of a parastomal hernia is always challenging due to the high incidence of recurrence following primary repair, or stoma relocation and severe morbidities in prosthetic repair with polypropylene materials. We therefore developed a modified sublay–keyhole technique employing a polypropylene material to minimize the associated high risk of the procedure. We herein describe our initial clinical experience with this modified procedure.

Methods

A retrospective review was performed to obtain the clinical data for 11 patients with parastomal hernias who underwent the modified in situ Sublay–keyhole repair from November 2008 to August 2010.

Results

The mean hernia size was 58.7?cm² (range 30–96?cm²), with an average polypropylene mesh size of 376.3?cm² (range 270–464?cm²). The mean length of the operation was 147.9?min (range 120–195.0?min), and the mean postoperative hospital stay was 11?days (range 9–14?days). All patients had an uneventful incisional recovery, with no infections. Two seromas and one hematoma were found and treated with conservative management, such as with aspiration, physical therapy and compression. All patients had been followed up, with a mean length of follow-up of 23.5?months (range 11–39?months). One parastomal hernia recurrence was seen 11?months postoperatively. Breakdown of the sutures and an over-sized aperture cut in the mesh were detected as the causes of the recurrence during the secondary repair procedure. Only re-sutures in both the mesh aperture and myofascial dehiscence were executed for this patient, and no re-recurrence was observed during an additional follow-up of 15?months. No recurrence of the parastomal hernia or presentation of an incisional hernia was detected during the follow-up.

Conclusions

The modified Sublay–keyhole repair appears to be an effective procedure for parastomal hernias, with a low incidence of recurrence and risk of morbidities. Collection of more cases and further follow-up examinations will be needed to confirm our findings.     

How I do it: novel parastomal herniorrhaphy utilizing transversus abdominis release

Introduction

Parastomal hernias are a complex surgical problem affecting a large number of patients. Recurrences continue to occur despite various methods of repair. We present a novel method of open parastomal hernia repair with retromuscular mesh reinforcement in a modified Sugarbaker configuration.

Methods

A full mildline laparotomy is performed and all adhesions are taken down. We then perform an open parastomal hernia repair by utilizing retromuscular dissection, posterior component separation via transversus abdominis release, and lateralization of the bowel utilizing a modified Sugarbaker mesh configuration within the retromuscular space. We demonstrate this technique in a cadaveric model for illustrative purposes.

Discussion

This repair provides the benefits of an open posterior component separation with transversus abdominis release and maintains the biomechanics of a functional abdominal wall, all while simultaneously benefitting from the advantages of mesh reinforcement in a modified Sugarbaker configuration. Our clinical experience with this novel technique to this point has been positive.

     

Female ‘groin’ hernia: totally extraperitoneal (TEP) endoscopic repair seems the most appropriate treatment modality

Background

About 30% of all female ‘groin’ hernias are femoral hernias, although often only diagnosed during surgery. A Lichtenstein repair though, as preferred treatment modality according to guidelines, would not diagnose and treat femoral hernias. Totally extraperitoneal (TEP) hernia repair, however, offers the advantage of being an appropriate modality for the diagnosis and subsequent treatment of both inguinal and femoral hernias. TEP therefore seems an appealing surgical technique for women with groin hernias.

Methods

This study included all female patients ≥18?years operated for a groin hernia between 2005 and 2009.

Results

A total of 183 groin hernias were repaired in 164 women. TEP was performed in 85% of women; the other 24 women underwent an open anterior (mesh) repair. Peroperatively, femoral hernias were observed in 23% of patients with primary hernias and 35% of patients with recurrent hernias. There were 30 cases (18.3%) of an incorrect preoperative diagnosis. Peroperatively, femoral hernias were observed in 17.3% of women who were diagnosed with an inguinal hernia before surgery. In addition, inguinal hernias were found in 24.0% of women who were diagnosed with a femoral hernia preoperatively. After a follow-up of 25?months, moderate to severe (VAS 4-10) postoperative pain was reported by 8 of 125 patients (6.4%) after TEP and 5 of 23 patients (21.7%) after open hernia repair (P?=?0.03). Five patients had a recurrent hernia, two following TEP (1.4%) and three following open anterior repair (12.5%, P?=?0.02). Two of these three patients presented with a femoral recurrence after a previous repair of an inguinal hernia.

Conclusion

Femoral hernias are common in women with groin hernias, but not always detected preoperatively; this argues for the use of a preperitoneal approach. TEP hernia repair combines the advantage of a peroperative diagnosis and subsequent appropriate treatment with the known good clinical outcomes.     

Low recurrence rate and low chronic pain associated with inguinal hernia repair by laparoscopic placement of Parietex ProGrip™ mesh: clinical outcomes of 220 hernias with mean follow-up at 23 months

Introduction

The aim of this study was to demonstrate the safety and the efficacy of the self-gripping Parietex ProGrip? mesh (Sofradim Production, Trévoux, France) used with the laparoscopic approach for inguinal hernia repair. The incidence of chronic pain, post-operative complications, patient satisfaction and hernia recurrence at follow-up after 12 months was evaluated.

Methods

Data were collected retrospectively from patient files and were analyzed for 169 male and female patients with 220 primary inguinal hernias. All patients included had undergone surgical repair for inguinal hernia by the laparoscopic transabdominal preperitoneal approach using Parietex ProGrip? meshes performed in the same clinical center in Germany. Pre-, per- and post-operative data were collected, and a follow-up after 12 months was performed prospectively. Complications, pain scored on a 0–10 numeric rating scale (NRS), patient satisfaction and hernia recurrence were assessed.

Results

The only complications were minor and were post-operative: hematoma/seroma (3 cases), secondary hemorrhage through the trocar’s site (2 cases), hematuria, emphysema in the inguinal regions (both sides) and swelling above the genital organs (1 case for each). At mean follow-up at 22.8 months, there were only 3 reports of hernia recurrence: 1.4 % of the hernias. Most patients (95.9 %) were satisfied or very satisfied with their hernia repair with only 1.2 % reporting severe pain (NRS score 7–10) and 3.6 % reported mild pain.

Conclusion

This study demonstrates that in experienced hands, inguinal hernia repair surgery performed by laparoscopic transabdominal preperitoneal hernioplasty using Parietex ProGrip? self-gripping meshes is rapid, efficient and safe with low pain and low hernia recurrence rate.     

Unsuspected femoral hernia in patients with a preoperative diagnosis of recurrent inguinal hernia

Purpose

Small femoral hernias may be difficult to diagnose by physical examination and are sometimes identified unexpectedly by laparoscopy. The aim of this study was to examine the incidence of unsuspected femoral hernia discovered during laparoscopic inguinal hernia repair in two well-defined patient groups.

Methods

Patients undergoing laparoscopic transabdominal preperitoneal inguinal hernia repair from April 2000 until December 2009 (n?=?561) were prospectively registered including data on previous hernia operations and identified type of hernia during surgery. We included patients whose preoperative diagnosis was either bilateral primary inguinal hernia (Primary Group) or recurrent inguinal hernia (Recurrent Group).

Results

Four hundred and sixty-one (82.2?%) patients were included in the study, of whom 211 (45.8?%) was in the Primary Group and 250 (54.2?%) in the Recurrent Group. The incidence of unsuspected femoral hernia in the Recurrent Group [23/250, 9.2?% (95?% CI 5.9–13.5?%)] was significantly higher than in the Primary Group [8/211, 3.8?% (95?% CI 1.7–7.3?%)], p?=?0.02. Furthermore, 38.1?% of women operated on for a recurrent inguinal hernia, presented with an unsuspected femoral hernia at surgery as opposed to 6.6?% of the men, p?=?0.003.

Conclusion

Unsuspected femoral hernias are more prevalent in patients with recurrent hernia than in patients with primary hernia in the inguinal region. Femoral hernias may be unrecognized at the primary inguinal hernia operation, or the previous inguinal hernia operation may facilitate the formation of a femoral hernia. Unsuspected femoral hernias are especially frequent in women with recurrent inguinal hernia. In women with a groin hernia, a femoral hernia should always be excluded by laparoscopy or by open exploration of the preperitoneal space.     

Two-stage laparoscopic treatment for strangulated inguinal,femoral and obturator hernias: totally extraperitoneal repair followed by intestinal resection assisted by intraperitoneal laparoscopic exploration

Purpose

Total extraperitoneal preperitoneal (TEP) repair is widely used for inguinal, femoral, or obturator hernia treatment. However, mesh repair is not often used for strangulated hernia treatment if intestinal resection is required because of the risk of postoperative mesh infection. Complete mesh repair is required for hernia treatment to prevent postoperative recurrence, particularly in patients with femoral or obturator hernia.

Cases

We treated four patients with inguinocrural and obturator hernias (a 72-year-old male with a right indirect inguinal hernia; an 83-year-old female with a right obturator hernia; and 86- and 82-year-old females with femoral hernias) via a two-stage laparoscopic surgery. All patients were diagnosed with intestinal obstruction due to strangulated hernia. First, the incarcerated small intestine was released and then laparoscopically resected. Further, 8–24 days after the first surgery, bilateral TEP repairs were performed in all patients; the postoperative course was uneventful in all patients, and they were discharged 5–10 days after TEP repair. At present, no hernia recurrence has been reported in any patient.

Conclusion

The two-stage laparoscopic treatment is safe for treatment of strangulated inguinal, femoral, and obturator hernias, and complete mesh repair via the TEP method can be performed in elderly patients to minimize the occurrence of mesh infection.

     

Long-term results after laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair under spinal anesthesia

Background

Laparoscopic transabdominal preperitoneal (TAPP) repair is indicated for recurrent and bilateral inguinal hernias and traditionally is performed under general anesthesia. However, the feasibility of performing TAPP under spinal anesthesia has been recently reported by our team.

Aim

To assess the long-term results of TAPP repair under spinal anesthesia for primary inguinal hernia.

Materials and methods

Between January 2006 and October 2009, 94 consecutive patients with primary unilateral inguinal hernia were submitted to laparoscopic transabdominal preperitoneal repair under spinal anesthesia. We looked at the immediate postoperative outcome as well as the long-term outcome, mainly recurrences and incidence of chronic pain.

Results

One patient experienced a scrotal hematoma, one patient a trocar site infection, two patients were diagnosed with an operation-related orchitis, while 31 patients (33?%) developed symptoms of urinary retention. At a median follow-up of 35?months (range 14-59), four patients (4.3?%) were diagnosed with a recurrence, while 89?% of patients reported satisfied from the procedure in the long-term. Chronic pain was not encountered in any of the patients studied. Four patients (4.3?%) reported an intermitted foreign body sensation and/or rigidity and two patients (2.1?%) numbness in the operated inguinal area.

Conclusion

Laparoscopic TAPP hernia repair under spinal anesthesia is associated with satisfactory short- and long-term results. Use of regional anesthesia instead of the traditional general anesthesia does not seem to adversely affect the quality of repair, and moreover, it offers the patient an attractive anesthetic alternative.     

Infected large pore meshes may be salvaged by topical negative pressure therapy

Purpose

To evaluate the efficacy of negative pressure therapy for superficial and deep mesh infections after ventral and incisional hernia repair by a prospective monocentric observational study.

Methods

During a 6-year period, 724 consecutive open ventral and incisional hernia repairs were performed. Pre- and intraoperative data as well as postoperative complications were prospectively recorded. In case of wound infection, negative pressure therapy (NPT) was our primary treatment.

Results

Sixty-three patients (8.7 %) were treated using negative pressure therapy after primary ventral and incisional hernia repair. Infectious complications needing NPT occurred in 54 patients in the retromuscular group (54/523; 10.3 %), none when laparoscopically treated and in 9 patients (9/143; 6.3 %) treated by an open intraperitoneal mesh technique. Considering outcome, all meshes were completely salvaged in the retromuscular mesh group after a median of 5 dressing changes (range, 2–9), while in the intraperitoneal mesh, group 3 meshes needed complete (n = 2) or partial (n = 1) excision. Mean duration to complete wound closure was 44 days (range, 26–63 days).

Conclusion

NPT is a useful adjunct for salvage of deep infected meshes, particularly when large pore monofilament mesh is used.     

A randomized prospective trial comparing clinical outcomes 3 years after surgery by Marcy repair and Prolene Hernia System® repair for adult indirect inguinal hernia

Purpose

The use of mesh in the surgical repair of adult indirect inguinal hernias is widely recommended in Western countries, but no randomized controlled trials have so far been reported in Japan. The purpose of the present randomized prospective trial was to compare a mesh method with non-mesh method for surgical repair of primary adult indirect inguinal hernias in which the diameter of the internal inguinal ring was up to 3.0 cm (I-1 or I-2 of Japanese Hernia Society Classification).

Methods

Patients with a primary unilateral inguinal hernia and I-1 or I-2 surgical findings were randomized to undergo either Marcy repair or Prolene Hernia System^® repair. Primary endpoints were recurrence, infection, and pain, with follow-up continued for 3 years postoperatively.

Results

Ninety-one of 479 patients with an inguinal hernia during the study period did not meet the exclusion criteria, and 46 were allocated to Marcy repair and 45 were allocated to Prolene Hernia System^® repair. No recurrence was observed in either group, and no significant differences were identified between the groups in any of the primary endpoints.

Conclusion

This randomized prospective trial of I-1 and I-2 inguinal hernias suggests that Marcy repair is not inferior to PHS repair. A large-scale randomized controlled trial appears warranted to confirm whether to use mesh for Japanese adult I-1 and I-2 hernias.     

Lightweight versus heavyweight mesh in laparoscopic inguinal hernia repair: a meta-analysis

Background

Reinforcement of inguinal hernia repair with prosthetic mesh is standard practice but can cause considerable pain and stiffness around the groin and affect physical functioning. This has led to various types of mesh being engineered, with a growing interest in lighter-weight mesh. Minimally invasive approaches have also significantly reduced postoperative recovery from inguinal hernia repair. The aim of this systematic review was to compare the outcomes after laparoscopic inguinal repair using new lightweight or traditional heavyweight mesh in published randomised controlled trials.

Methods

Medline, Embase, trial registries, conference proceedings, and reference lists were searched for controlled trials of heavyweight versus lightweight mesh for laparoscopic repair of inguinal hernias. The primary outcomes were recurrence and chronic pain. Secondary outcomes were visual analogue pain score at 7?days postoperatively, seroma formation, and time to return to work. Risk differences were calculated for categorical outcomes and standardised mean differences for continuous outcomes.

Results

Eight trials were included in the analysis of 1,667 hernias in 1,592 patients. Mean study follow-up was between 2 and 60?months. There was no effect on recurrence [pooled analysis risk difference 0.00 (95% CI ?0.01 to 0.01), p?=?0.86] or chronic pain [pooled analysis risk difference ?0.02 (95% CI ?0.04 to 0.00); p?=?0.1]. Lightweight and heavyweight mesh repair had similar outcomes with regard to postoperative pain, seroma development, and time to return to work.

Conclusion

Both mesh options appear to result in similar long- and short-term postoperative outcomes. Further long-term analysis may guide surgeon selection of mesh weight for laparoscopic inguinal hernia repair.     

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

Background

Mesh repair of large ventral or incisional hernias is problematic when primary fascial closure cannot be achieved, as this leaves mesh exposed, bridging the gap. We describe a modified retromuscular sublay repair which overcomes this problem and report a retrospective review of cases to assess outcome.

Methods

Mesh is positioned between transposed flaps of preserved hernial sac and rectus sheath. Patients undergoing this repair by one author (BT) from 1 January 2004 to 31 December 2010 were identified, and clinical outcome was assessed by a combination of case-note review, outpatient consultation and telephone interview.

Results

Twenty-one ventral and incisional hernias were treated by this method. Eighteen were incisional (13 midline, three transverse and two oblique incisions), and three were primary paraumbilical hernias. Defect sizes ranged from 25 to 500 cm² and mesh sizes from 300 to 900 cm². Patients were reviewed at 6 weeks, 6 months and at a median of 37 months post-operatively. Three cases of superficial skin edge necrosis, two superficial wound infections and two sizeable seromas developed, but all had resolved within 6 months. One patient developed abdominal wall necrosis requiring mesh removal and eventual abdominal wall reconstruction without mesh, resulting in late recurrence. All other cases achieved excellent long-term outcomes with a high degree of patient satisfaction.

Conclusion

This is a useful method for repairing large ventral and incisional hernias when primary fascial closure is not achievable, combining a sublay mesh repair with autologous tissue transposition across the fascial gap.     

The incidence and natural course of occult inguinal hernias during TAPP repair

Background

One of the proposed advantages of laparoscopic inguinal hernia repair is complimentary inspection of the contralateral side and possible detection of occult hernias. Incidence of occult contralateral hernias is as high as 50 %. The natural course of such occult defects is unknown and therefore operative rationale is lacking. This study was designed to analyze the incidence of occult contralateral inguinal hernias and its natural course.

Methods

A total of 1,681 patients were diagnosed preoperatively with unilateral inguinal hernia. None of these patients had complaints of the contralateral side preoperatively. All patients underwent laparoscopic inguinal hernia transabdominal preperitoneal (TAPP) repair. Operative details were analyzed retrospectively. Patients with occult contralateral defects were identified and tracked. Patients with an evident occult hernia received immediate repair. Patients with a smaller beginning or incipient hernia were followed.

Results

In 218 (13 %) patients, an occult hernia was found at the contralateral side during preoperative exploration. In 129 (8 %) patients, an occult true hernia was found. In 89 (5 %) patients, an occult incipient hernia was found. An incipient hernia was defined as a beginning hernia. All patients with an incipient hernia were followed. The mean follow-up was 112 (range 16–218) months. Twenty-eight (32 %) patients were lost to follow-up. In the 61 remaining patients, 13 (21 %) occult incipient hernias became symptomatic requiring repair. The mean time between primary repair and development of a symptomatic hernia on the contralateral side was 88 (range 24–210) months.

Conclusions

This study shows that the incidence of occult contralateral hernias is 13 % during TAPP repair of unilateral diagnosed inguinal hernias. In 5 % of the cases, the occult hernia consisted of a beginning hernia. Eventually, one of five will become symptomatic and require repair. These outcomes support immediate repair of occult defects, no matter its size.