Open inguinal hernia repair with the use of polyglycolic acid/trimethylene carbonate mesh: gross and pathologic assessment of the inguinal area at reoperation for recurrence

Purpose

Our group tried to test the hypothesis of using a totally absorbable material for open inguinal hernia repair. However, the increased incidence of recurrences alleviated our initial enthusiasm regarding the technique. The purpose of the present study was to attain both gross and microscopic data that could at least in part justify the hernia repair failure from a patient included in our initial pilot study and was re-operated for recurrence.

Methods

A 65-year-old male patient was diagnosed clinically with a recurrence 24 months after open inguinal hernia repair with the use of polyglycolic acid/trimethylene carbonate mesh. The patient was operated for the recurrence upon our group on July 2012. The gross appearance of the inguinal area as well as the degree of chronic inflammation provoked by the used mesh as depicted by the pathologic analysis of specimens obtained intraoperatively were assessed.

Results

An open tension-free repair with the use of a non-absorbable mesh under spinal anesthetic was undertaken. Intraoperatively, after the division of the external oblique aponeurosis, only minor fibrotic reaction was observed a finding that was additionally confirmed pathologically.

Conclusion

Polyglycolic acid/trimethylene carbonate mesh used for inguinal hernia repair was associated with a minimal inflammatory host reaction in the inguinal area at 3 years verified both grossly and microscopically.     

Preliminary study of hiatal hernia repair using polyglycolic acid: trimethylene carbonate mesh

Background:

Repairing large hiatal hernias using mesh has been shown to reduce recurrence. Drawbacks to mesh include added time to place and secure the prosthesis as well as complications such as esophageal erosion. We used a laparoscopic technique for repair of hiatal hernias (HH) >5cm, incorporating primary crural repair with onlay fixation of a synthetic polyglycolicacid:trimethylene carbonate (PGA:TMC) absorbable tissue reinforcement. The purpose of this report is to present short-term follow-up data.

Methods:

Patients with hiatal hernia types I-III and defects >5cm were included. Primary closure of the hernia defect was performed using interrupted nonpledgeted sutures, followed by PGA:TMC mesh onlay fixed with absorbable tacks. A fundoplication was then performed. Evaluation of patients was carried out at routine follow-up visits. Outcomes measured were symptoms of gastroesophageal reflux disease (GERD), or other symptoms suspicious for recurrence. Patients exhibiting these complaints underwent further evaluation including radiographic imaging and endoscopy.

Results:

Follow-up data were analyzed on 11 patients. Two patients were male; 9 were female. The mean age was 60 years. The mean length of follow-up was 13 months. There were no complications related to the mesh. One patient suffered from respiratory failure, one from gas bloat syndrome, and another had a superficial port-site infection. One patient developed a recurrent hiatal hernia.

Conclusions:

In this small series, laparoscopic repair of hiatal hernias >5cm with onlay fixation of PGA:TMC tissue reinforcement has short-term outcomes with a reasonably low recurrence rate. However, due to the preliminary and nonrandomized nature of the data, no strong comparison can be made with other types of mesh repairs. Additional data collection is warranted.     

Open preperitoneal mesh repair of recurrent inguinal hernia

Purpose  

To determine the outcome of open preperitoneal mesh repair of recurrent inguinal hernia.     

Open inguinal hernia repair in women: is mesh necessary?

Background There is little information available on recurrence rates following primary open inguinal hernia repair in women. Women are less prone to inguinal hernias than men; for the same reason, recurrences after hernia repair may also be lower so that the well-known advantage of using mesh could be lost on them. Method Women having primary open inguinal hernia repair under the care of one surgical team were identified from the unit database. Recurrences in those who had non-mesh repair were sought by a combination of a written questionnaire and clinical examination. Results Fifty-two women had a non-mesh inguinal hernia repair over a 12-year interval; 37 responded to a questionnaire. There were no major perioperative complications; one recurrence was diagnosed, giving an overall recurrence rate of 2.8% (95% confidence interval 8.2%). During the study interval 37 women had open mesh repair of an inguinal hernia. There were three major complications. Conclusions The routine use of mesh for open indirect inguinal hernia repair in women may not be necessary.     

Evaluation of absorbable polyglycolic acid mesh as a wound support

The ideal wound-support material would reinforce a wound early in the healing process when intrinsic wound strength is the weakest, yet disappear over time, preventing many of the untoward late effects seen with currently utilized nonabsorbable materials. This study was designed to evaluate the effectiveness of a newly designed absorbable material, polyglycolic acid mesh (Dexon), as a buttress for abdominal wounds closed under moderate tension. Young male rats (n = 211) were divided into three experimental groups. Animals in groups 1 (n = 96) and 2 (n = 95) had a 1.2 cm2 midline abdominal wall defect created and closely primarily. Animals in group 2 had a 2 X 5 cm piece of polyglycolic acid mesh sutured to the anterior abdominal wall overlying the closed abdominal defect. Animals in group 3 (n = 20) were unoperated controls. The animals in groups 1 and 2 were killed 1, 2, 3, 4, and 5 weeks after surgery. The entire anterior abdominal wall was removed and placed upon a bursting strength testing device. Bursting strength determinations of the supported and unsupported abdominal closures revealed that the strength of the wounds reinforced with polyglycolic acid mesh was significantly greater than unsupported wounds at 1, 2, and 3 weeks after surgery. Wounds supported with mesh had bursting strengths similar to unoperated abdomens by the first postoperative week. This study demonstrates that abdominal wall defects in rats closed primarily develop increased wound strength when the closure is supported by absorbable polyglycolic acid mesh. The use of an absorbable material may alleviate potential late complications associated with implantation of nonabsorbable materials. The clinical application of such a material remains to be determined.     

Laparoscopic slit mesh repair of parastomal hernia using a designated mesh: long-term results

Background  

Parastomal hernia (PH) is a frequent complication of colorectal surgery, which incidence reaches 55% of all stoma formation. Currently, there is no definitive strategy for its repair. This study was designed to assess the outcome in patients who underwent laparoscopic PH repair using a slit mesh/keyhole technique.     

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.     

Open tension-free Lichtenstein repair of inguinal hernia: use of fibrin glue versus sutures for mesh fixation

Purpose

To investigate pain and other complications following inguinal hernioplasty performed by the Lichtenstein technique with mesh fixation by fibrin glue or sutures.

Methods

Five hundred and twenty patients were enrolled in this 12-month observational multicenter study and received either sutures or fibrin glue (Tissucol^?/Tisseel^?) based on the preference of the surgeon. Pain, numbness, discomfort, recurrence, and other complications were assessed postoperatively and at 1, 3, 6, and 12?months. Pain intensity was assessed by a visual analog scale (VAS; 0 [no pain] to 10 [worst pain]).

Results

One hundred and seventy-one patients received sutures and 349 received fibrin glue. During the early postoperative phase, 87.4% of patients in the fibrin glue group and 76.6% of patients in the sutures group were complication-free (P?=?0.001). Patients who received fibrin glue were also less likely to experience hematoma/ecchymosis than those in the suture group (both P?=?0.001). The mean pain score was significantly lower in the fibrin group than the sutures group (2.5 vs. 3.2, P?<?0.001). At 1?month, significantly fewer patients in the fibrin glue group reported pain, numbness, and discomfort compared with patients in the sutures group (all P?<?0.05). Fibrin glue patients also experienced less intense pain (0.6 vs. 1.2; P?=?0.001). By 3?months, the between-group differences had disappeared, except for numbness, which was more prevalent in the sutures group. By 12?months, very few patients reported complications.

Conclusions

Tissucol fibrin glue for mesh fixation in the Lichtenstein repair of inguinal hernia shows advantages over sutures, including lower incidence of complications such as pain, numbness, and discomfort, and should be considered as a first-line option for mesh fixation in hernioplasty.     

Lightweight partially absorbable monofilament mesh (polypropylene/poliglecaprone 25) for TAPP inguinal hernia repair: initial experience

OBJECTIVE: An ideal mesh should produce slight foreign-body reactions and be compatible with the human organisms. Studies focusing on these aspects indicate that the use of mesh with less nonabsorbable material may reduce postoperative complications, insofar the web structure and its rigidity play an important role in compatibility. We evaluated retrospectively the patients of the past 1 year, who underwent laparoscopic transabdominal preperitoneal (TAPP) hernioplasty (without the use any trocar and/or instrument of 10 mm in diameter) focusing attention on the feasibility of the technique and on the incidence of complications, especially those possibly related to the new type of mesh implanted. METHODS: Between June 2004 and September 2005, 76 patients have been operated on by using TAPP hernioplasty (bilateral or unilateral) without any 10 mm instrument/optic/trocar, and by applying a lightweight composite mesh fixed by "glues" (fibrin sealant and N-butyl 2-cyanoacrylate). RESULTS: The mean overall operative time was 55.57 (+/-15.2) minutes. All the procedures have been performed on a day surgery basis. We have registered any kind of major or minor morbidity (early or late), relapse, prosthesis rejection, and/or infection. We have registered no severe pain at 10 days; whereas a mild pain is still reported in 10.5% of our cases at a 3-month follow-up. The mean follow-up is 12.4 (+/-5.1; range 4 to 19) months. CONCLUSIONS: On the basis of this our initial experience, TAPP hernioplasty with a lightweight composite mesh is feasible, effective, and easy to perform by experienced hands, with good results. The well-known characteristics of a mini-invasive and gentle approach, together with the type of mesh implanted and its fixation of related glues, might explain the encouraging results of our experience.     

A self-adhering mesh for inguinal hernia repair: preliminary results of a prospective,multicenter study

Background  

Prosthetic reinforcement is the gold standard treatment for inguinal hernia and reduces the risk of recurrence. Yet up to one-third of patients complain of post-surgical pain due to irritation and inflammation caused by the mesh and the fixation materials. Of these patients, 3–4% will experience severe and disabling chronic pain. We performed a prospective multicenter clinical study of a self-adhering prosthesis, consisting of a lightweight polypropylene mesh (40 g/m2) coated on each side with synthetic glue, to evaluate early postoperative complications and patient outcomes.     

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.     

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目的总结1997年11月至2011年12月复旦大学附属华东医院开展开放式腹股沟疝无张力修补术4438例的临床经验。方法根据各种不同类型的开放式腹股沟疝无张力修补术,对4438例腹股沟疝采用相对应的不同补片进行手术治疗,对不同术式的手术时间、术后疼痛、疝复发、血肿、血清肿、慢性疼痛、生殖系统并发症等及其他相关并发症进行观察、总结及数据分析。结果无手术死亡病例。术后平均随访33.7个月,术后血肿18例(0.40%),血清肿45例(1.01%),切口感染或愈合不良16例(0.40%),缺血性睾丸炎3例(0.07%)。复发14例(0.32%),慢性疼痛7例(0.60%),异常勃起1例(0.02%);3例睾丸疼痛(0.07%)。结论开放式无张力疝修补术治疗腹股沟疝安全有效,不同术式的疗效及并发症发生率情况接近,开展技术早期需特别注意预防手术并发症,对不同的病例宜采用个体化治疗方案,以期达到最佳的治疗效果。     

Onlay parastomal hernia repair with cross-linked porcine dermal collagen biologic mesh: long-term results

Purpose

The optimal technique and mesh type for parastomal hernia repair have yet to be ascertained. Biologic meshes have been advocated in parastomal hernia repair due to purported resistance to infection in contaminated fields. The aim of this study was to evaluate the effectiveness of additionally cross-linked acellular porcine dermal collagen mesh (Permacol?) for onlay parastomal hernia repair.

Methods

A retrospective review of case notes, and abdominal CT scans when available, was performed for consecutive patients who had a parastomal hernia repaired between January 2007 and May 2010. All hernias were repaired with onlay placement of the biologic mesh. Hernias were classified according to the Moreno-Matias classification where CT scans were available.

Results

Over a 34-month period, 30 consecutive patients, median age 74 years, 17 female, underwent parastomal hernia repair using onlay biologic mesh. There were 23 paracolostomy and seven paraileostomy hernias. The hernia was primary in 26 patients. Pre-operative CT scans were available in 18 patients (Moreno-Matias Type 1 = 1, Type 2 = 4, Type 3 = 13). There was one perioperative death, and 29 patients were available for follow-up, and median duration of follow-up (either CT or clinical) was 36 months (range 3–79). Twenty-six patients developed recurrence of the parastomal hernia (89.6 %), and median time to recurrence was 10 months (range 3–72),with Moreno-Matias Type 1 = 0, Type 2 = 4, Type 3 = 14, unknown = 8. Fifteen out of 26 patients have had repairs of the recurrence using a variety of techniques. Of these, 10 patients have had further recurrence.

Conclusion

Onlay repair of parastomal hernia with cross-linked porcine dermal collagen biologic mesh reinforcement has poor long-term outcomes with unacceptably high recurrence rates and should not be performed.

     

Open preperitoneal mesh repair of inguinal hernias using a mesh with nitinol memory frame

Purpose

To prospectively evaluate the use of a continuous Nitinol containing memory frame patch during a TIPP-technique in the open repair of inguinal and femoral hernias.

Methods

Over a 3-year period all consecutive adult patients that needed treatment for an inguinal or femoral hernia were treated by the TIPP repair using the Rebound Shield mesh. Intra-operatively the type and size of the hernia were evaluated according to the EHS classification, as well as the size of the mesh used. Baseline characteristics for all patients were evaluated considering age, gender, BMI and American society of Anesthesiologists score. Standard X-ray was performed to evaluate mesh position. All patients were evaluated for post-operative pain using the visual analogue scale (VAS 0–10 scale).

Results

In total 289 groin hernias were operated using a nitinol containing patch in 235 patients. The mean operating time was 38 min for unilateral hernias and 59 min for bilateral hernias. The median follow-up is 21.2 months (14–33 months) during which three patients died, unrelated to the groin hernia repair. At the time of re-evaluation 12 patients (5.0 %) complained of chronic pain, with a VAS score higher than 3 after 3 months (range 3–10). Two of these patients already had severe pain pre-operatively. A total of 3 recurrences (2.9 %) were noted with strong correlation with X-ray findings.

Conclusion

A nitinol memory frame containing mesh is a valuable tool to achieve complete deployment of a large pore mesh in a TIPP repair for inguinal hernias with acceptable morbidity and a low recurrence rate.     

应用Kugel补片进行腹膜前修补腹股沟复发疝

目的 探讨Kugel补片开放式腹膜前修补腹股沟复发疝的临床疗效.方法 回顾性分析2005年1月～2009年6月福建医科大学附属协和医院应用Kugel补片开放式腹膜前置入治疗65例77侧腹股沟复发疝的临床资料.结果 单侧手术时间40～150 min,平均(76.5±20.4)min.术后切口疼痛轻,无切口感染.并发尿潴留4例、腹股沟区浆液肿6例、皮下血肿2例、阴囊积液3例,随访3～54个月,未发现明显异物感或腹股沟区慢性疼痛,无再复发疝.结论 开放式腹膜前放置Kugel补片治疗成人腹股沟复发疝具是合理性和可行性.