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??Discussion of laparoscopic transabdominal preperitoneal prosthetics in the treatment of recurrent inguinal hernia WANG Ming-gang. Department of Hernia and Abdominal Wall Surgery, Chaoyang Hospital of Capital Medical University??Beijing 100043, China
Abstract The treatment of recurrent hernia after inguinal operation especially tension-free repair has been a difficult problem that hernia surgeons must face. Laparoscopic technique has been accepted and used gradually by surgeons with the advantages of retroperitoneal approach and direct vision. At present??there has been not yet a normalized operation manual and guideline of laparoscopic technique in the treatment of recurrent hernia because of the complex situation. The preperitoneal space could be gotten with TAPP completely in most cases; some could cut the peritoneum with shuttle or T-type incisions. There is no need to move the previous mesh and could relax restrictions appropriately in fixing mesh. In some particular cases, surgeons could repair defects with local repairing??intraperitoneal onlay mesh (IPOM) or transabdominal partial extraperitoneal ??TAPE??.     

Technique and outcomes of abdominal incisional hernia repair using a synthetic composite mesh: a report of 455 cases

BACKGROUND: Abdominal wall hernias are a frequent and formidable challenge for general surgeons. Several different surgical techniques and types of mesh prosthetics are available for repair. We evaluated outcomes of an open ventral hernia repair using a synthetic composite mesh. STUDY DESIGN: We prospectively collected data on consecutive patients undergoing open ventral hernia repair using a synthetic composite mesh from January 1, 2000 to December 31, 2005 at four large medical centers. Four surgeons used a standardized surgical procedure for all patients. RESULTS: The study consisted of 455 patients with an average age of 56 years; 54% were men. Sixty-nine percent of the patients underwent repairs for recurrent hernias. Mean defect size was 44 cm(2), and mean mesh size was 213 cm(2). Average length of hospital stay was 1.1 days. Thirty-one patients had 33 early complications (7%), and 3 patients (0.7%) required reoperation (one each for seroma, bowel injury, and wound breakdown). Early infection occurred in four patients (0.9%), and one patient required reoperation and graft removal. Late complications occurred in nine patients (2%), with two patients requiring reoperation. Late infections occurred in two patients (0.4%); both required antibiotic treatment. Recurrent hernias were observed in 6 patients (1%; 6 of 450 because of 5 patients with unknown recurrence) at a mean followup of 29.3 months. CONCLUSIONS: In this large multicenter series, open ventral hernia repair using a composite mesh resulted in a short hospital stay, moderate complication rate, low infection rate, and low recurrence rate.     

Classification of prosthetics used in hernia repair based on weight and biomaterial

Purpose  

The aim of this study was to classify the polymeric prosthetics used for hernia repair based on biomaterial composition and weight in an effort to clarify to surgeons what kinds of material they are dealing with and to provide a standardized system of categorization.     

腹腔镜经腹腹膜前补片植入术治疗复发性腹股沟疝技术探讨

复发性腹股沟疝尤其是无张力疝修补术后复发疝的治疗依然是疝外科医师必须面对的难题。腹腔镜疝修补术凭借其“后入路”的手术特点和直视下操作的技术优势逐渐成为处理开放手术后复发疝的优选术式而被外科医师所接受和应用。因为复发疝情况复杂多变,目前尚无规范化的复发疝腹腔镜手术操作规范和指南。应用腹腔镜经腹腹膜前修补术（TAPP）治疗复发疝时绝大多数病人可以完整游离腹膜前间隙,部分病人须选择梭形或“T”形切口切开腹膜。原有补片一般不建议去除,在补片固定方面建议适当放宽指征,在特殊情况下可以选择局部修补法、腹腔内补片植入术（IPOM）或经腹部分腹膜外修补术（TAPE）修补缺损。     

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复习腹股沟区域的基本解剖,针对"腹股沟盒"后壁的无张力修补和针对"耻骨肌孔"的腹膜前无张力修补阐明两类腹股沟疝无张力修补理念及操作方法 ,对上述两类手术操作的要求、关键步骤和难点处理进行描述和讨论。希望外科医生通过自身的不断努力,掌握腹股沟疝无张力修补手术的规范化操作,以达到最佳的治疗效果。     

The argument for lightweight polypropylene mesh in hernia repair

The development of polypropylene prosthetics revolutionized surgery for the repair of abdominal wall hernias. A tension-free mesh technique has drastically reduced recurrence rates for all hernias compared to tissue repairs and has made it possible to reconstruct large ventral defects that were previously irreparable. The repair of abdominal wall defects is one of the most commonly performed general surgical procedures, with over 1 million polypropylene implants inserted each year. Surprisingly, little research has been performed to investigate the interaction of abdominal wall forces on a ventral hernia repair or the required amount or strength of the foreign-body material necessary for an adequate hernia repair. The long-term consequences of implantable polypropylene prosthetics are not without concern. The body generates an intense inflammatory response to the prosthetic that results in scar plate formation, increased stiffness of the abdominal wall, and shrinkage of the biomaterial. Reducing the density of polypropylene and creating a 'light weight' mesh theoretically induces less foreign-body response, results in improved abdominal wall compliance, causes less contraction or shrinkage of the mesh, and allows for better tissue incorporation. A review of the laboratory data and short-term clinical follow-up is reviewed to provide a strong basis or argument for the use of 'light weight' prosthetics in hernia surgery.     

Commercial Mesh versus Nylon Mosquito Net for Hernia Repair. A Randomized Double-blind Study in Burkina Faso

Purpose

The goal of this study was to investigate whether locally available Nylon mosquito net might be a useful alternative to expensive commercial mesh implants for hernia repair, a clinical randomized double-blind study was performed.

Materials and Methods

Over a period of 3 months 35 patients with a total of 40 inguinal hernias were randomized for hernia repair with either a commercial graft (Ultrapro^®) or a piece of sterilized 100% Nylon mesh available as mosquito net in most African village markets. The surgeons’ comfort in handling the meshes, the incidence of complications, and the patients’ quality of life before and 30 days after hernia repair were evaluated. In addition, the costs of the two materials were compared.

Results

There was no significant difference in the clinical short-term outcome of the hernia treatment or the surgeons’ comfort in handling the two different materials. The price of the locally bought Nylon mesh was 0.0043 US$ as compared to 108 US$ for the commercial mesh.

Conclusions

In situations where superior results of hernia repair depend on the use of a mesh prosthesis but where commercial material is not available or affordable, the use of Nylon mosquito net may be an alternative. Further studies with a larger number of patients and longer follow-up are justified and recommended.     

Surgical progress in inguinal and ventral incisional hernia repair

The goals of this article are to describe the history of hernia repair and how innovations in surgical technique, prosthetics, and technology have shaped current practice.     

Retromuscular Mesh Repair of Midline Incisional Hernia with Polyester Standard Mesh: Monocentric Experience of 261 Consecutive Patients with a 5-year Follow-up

Background  

Midline incisional hernia (MIH) repair remains a major challenge for surgeons. Multiple procedures and types of mesh to treat incisional hernia are available. We evaluated outcomes of MIH treated by retromuscular mesh repair (RMR) using a polyester standard prosthesis.     

Allograft dermal matrix hiatoplasty during laparoscopic primary fundoplication, paraesophageal hernia repair, and reoperation for failed hiatal hernia repair

Background

Hiatal repair failure is the nemesis of laparoscopic paraesophageal hernia repair as well as the major cause of failure of primary fundoplication and reoperation on the hiatus. Biologic prosthetics offer the promise of reinforcing the repair without risks associated with permanent prosthetics.

Design

Retrospective evaluation of safety and relative efficacy of laparoscopic hiatal hernia repair using an allograft (acellular dermal matrix) onlay. Patients with symptomatic failures underwent endoscopic or radiographic assessment of hiatal status.

Results

Greater than 6-month follow-up was available for 252 of 450 consecutive patients undergoing laparoscopic allograft-reinforced hiatal hernia repair between January 2007 and March 2011. No erosions, strictures, or persisting dysphagia were encountered. Adhesions were minimal in cases where reoperation was required. Failure of the hiatal repair at median 18 months (6–51 months) was significantly (p < 0.005) different between groups: group A (primary fundoplication with axial hernia ≤ 2 cm), 3.7 %; group B (primary fundoplication with axial hernia 2–5 cm), 7.1 %; group G (giant/paraesophageal), 8.8 %; group R (reoperative), 23.4 %. Additionally, mean time to failure was significantly shorter in group R (247 days) compared with the other groups (462–489 days).

Conclusions

Use of allograft reinforcement to the hiatus is safe at 18 months median follow-up. Reoperations had a significantly higher failure rate and shorter time to failure than the other groups despite allograft, suggesting that primary repairs require utmost attention and that additional techniques may be needed in reoperations. Patients with hiatal hernias >2 cm axially had a recurrence rate equal to that of patients undergoing paraesophageal hiatal hernia repair, and should be treated similarly.     

Meshes in abdominal wall surgery - an overview

Abdominal wall surgery and hernia repair is nowadays not conceivable without the use of mesh prosthetics. There are countless products from various health-care companies available. This article gives an overview of meshes currently in use, describes their characteristics and indicates the relevant differences between the various groups of implants.     

An animal model to train Lichtenstein inguinal hernia repair

Purpose

Inguinal hernia repair is a common surgical procedure, and the majority of operations worldwide are performed ad modum Lichtenstein (open tension-free mesh repair). Until now, no suitable surgical training model has been available for this procedure. We propose an experimental surgical training model for Lichtenstein’s procedure on the male and female pig.

Methods

In the pig, an incision is made 1 cm cranially to the inguinal sulcus where a string of subcutaneous lymph nodes is located and extends toward the pubic tubercle. The spermatic cord is located in a narrow sulcus in the pig, thus complicating the procedure if operation should be done in the inguinal canal. The chain of lymph nodes resembles the human spermatic cord and can be used to perform Lichtenstein’s hernia repair.

Results

This experimental surgical model has been tested on two adult male pigs and three adult female pigs, and a total of 55 surgeons have been educated to perform Lichtenstein’s hernia repair in these animals.

Conclusions

This new experimental surgical model for training Lichtenstein’s hernia repair mimics the human inguinal anatomy enough to make it suitable as a training model. The operation facilitates the training in the positioning and fixation of the mesh and can be performed numerous times on the same pig. It is therefore a useful training method for inexperienced surgeons to obtain experience in aspects of the Lichtenstein procedure.     

Ventral hernia repair by the laparoscopic approach

An analysis of these results indicates that laparoscopic hernia repair can be performed safely by experienced laparoscopic surgeons, and with lower perioperative complication rates than for open hernia repair. Although the follow-up period for the laparoscopic repair is only 2 or 3 years, the recurrence rate is likely lower than with open repair. Most patients with ventral hernias are candidates for this laparoscopic repair if safe access and trocar placement can be obtained. The choice of mesh often provokes a debate among surgeons, but little practical difference in the results seems to exist between the two types of mesh available. Although the ePTFE mesh has a good theoretic basis for promoting tissue ingrowth on the parietal side of the mesh and minimizing adhesions to the bowel side of the mesh, data indicate that no difference in outcome exists related to adhesions or fistula formation (Tables 1 and 2), so surgeon preference and cost of the prosthesis should be the deciding variables. Fistulas are of concern because of the experience with mesh in the trauma patient and in the treatment of severe abdominal wall infections, when abdominal wall reconstruction often is performed in contaminated wounds in the acute phases and leaves the mesh exposed without soft tissue coverage. These conditions do not apply for most cases of elective hernia repair. Laparoscopic ventral hernia repair offers advantages over the conventional open mesh repair and may decrease the hernia recurrence rate to 10% to 15%. When properly performed, the laparoscopic approach does not and should not compromise the principles for successful mesh repair of ventral hernias.     

A systematic review of synthetic and biologic materials for abdominal wall reinforcement in contaminated fields

Background

Guidelines recommend the use of bioprosthetics for abdominal wall reinforcement in contaminated fields, but the evidence supporting the use of biologic over synthetic non-absorbable prosthetics for this indication is poor. Therefore, the objective was to perform a systematic review of outcomes after synthetic non-absorbable and biologic prosthetics for ventral hernia repair or prophylaxis in contaminated fields.

Methods

The systematic literature search identified all articles published up to 2013 that reported outcomes after abdominal wall reinforcement using synthetic non-absorbable or biologic prosthetics in contaminated fields. Studies were included if they included at least 10 cases (excluding inguinal and parastomal hernias). Quality assessment was performed using the MINORS instrument. The main outcomes measures were the incidence of wound infection and hernia at follow-up. Weighted pooled proportions were calculated using a random effects model.

Results

A total of 32 studies met the inclusion criteria and were included for synthesis. Mean sample size was 41.4 (range 10–190), and duration of follow-up was >1 year in 72 % of studies. Overall quality was low (mean 6.2, range 1–12). Pooled wound infection rates were 31.6 % (95 % CI 14.5–48.7) with biologic and 6.4 % (95 % CI 3.4–9.4) with synthetic non-absorbable prosthetics in clean-contaminated cases, with similar hernia rates. In contaminated and/or dirty fields, wound infection rates were similar, but pooled hernia rates were 27.2 % (95 % CI 9.5–44.9) with biologic and 3.2 % (95 % CI 0.0–11.0) with synthetic non-absorbable. Other outcomes were comparable.

Conclusions

The available evidence is limited, but does not support the superiority of biologic over synthetic non-absorbable prosthetics in contaminated fields.     

Combined anterior and posterior inguinal hernia repair: Intermediate recurrence rates with three groups of surgeons

Background Use of a bilayer polypropylene mesh device (BPMD) for inguinal hernia repair began in 1998. Intermediate follow-up is now available for patients undergoing repair by three groups of surgeons.Methods Surgeons whose practice is dedicated to hernia repair trained preceptors who, in turn, assisted in the training of other surgeons in this new technique. All three groups provided information regarding their recurrence rates with this technique.Results Recurrence rates were similar for all three groups. Hernia specialists reported three recurrences out of 4,801 repairs. Preceptors reported one recurrence in 3,780 repairs. Other surgeons reported one failure in 3,369 repairs.Conclusions Use of the BPMD (Prolene Hernia System) provides reliable results in the hands of hernia specialists, as well as general surgeons whose practices are not concentrated on the management of hernias.     

Impact of randomized trials on the application of endoscopic techniques for inguinal hernia repair in the netherlands

BACKGROUND: One year after publication of a Dutch prospective trial randomizing patients with inguinal hernias to either endoscopic or open repair, a questionnaire was sent to all Dutch surgeons to evaluate the impact of this trial on the application of endoscopic inguinal hernia repair in the Netherlands. METHODS: All 780 registered Dutch surgeons were surveyed. The performance of endoscopic inguinal hernia repair, the technique and the indications, the involvement of surgical residents, the motives for use of conventional techniques, and the type of open repair were documented. RESULTS: The response rate was 100%. Endoscopic inguinal hernia repair was performed by 16% of Dutch surgeons. For 81% of the surgeons, the total extraperitoneal approach was the preferred endoscopic technique. Primary inguinal hernias were approached endoscopically by only 54% of these surgeons, and recurrent hernias by 92%. The technique of choice for open repair of primary hernias was the Shouldice repair. The predominant repair for recurrent inguinal hernias was the Lichtenstein technique. CONCLUSIONS: Although randomized clinical trials have provided evidence that the endoscopic approach to inguinal hernias is preferable, only 1 of 6 Dutch surgeons has adopted endoscopic inguinal hernia repair. Improvement in training of both surgical residents and surgeons and increasing awareness among medical doctors and patients about the benefits of endoscopic inguinal hernia repair are necessary to enhance the acceptance of this valuable technique for inguinal hernia repair.     

Quantitative assessment of expert and novice surgeons' thinking processes: an application to hernia repair

Background

The aim of this study was to capture quantitatively surgeons' decision making when faced with a choice of open or laparoscopic inguinal hernia repair.

Methods

Twenty-one general surgeons (10 consultants or attending surgeons, 11 registrars or residents) were presented with 46 clinical vignettes differing in clinical and patient factors. Surgeons' choices of open or laparoscopic repair were submitted to multiple regression. Beta coefficients were computed for each factor and compared across expert and novice participants.

Results

Consultants and attending surgeons considered the nature of the hernia (primary or recurrent; β = .40), the site of the hernia (unilateral or bilateral; β = .27), American Society of Anesthesiologists score (β = −.25), and previous abdominal surgery (β = .20). Trainees weighted most the site of the hernia (β = .30), previous abdominal surgery (β = .23), the nature of the hernia (β = .20), and American Society of Anesthesiologists score (β = −.10).

Conclusions

This study offers an objective assessment of surgeons' decision making, with specific application to hernia repair. Further research into quantitative methods that capture surgeons' thinking processes could distill factors that expert surgeons consider important in a number of key situations and assist in trainees' decision making.     

The use of graft materials in anterior compartment pelvic reconstruction

Since 1996, the number of reports in the urologic and gynecologic literature using synthetic and allograph prosthetics to enhance the durability of anterior compartment repairs have increased significantly. Central to the use of these prosthetics is long-term follow-up to demonstrate that their use actually confers a benefit to patients and surgeons alike. This review attempts to catalog those reports and the outcomes, with an emphasis on the cadaveric prolapse repair with sling, which is used by the authors for repair of anterior compartment prolapse with overt or occult genuine stress urinary incontinence.     

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

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

Ambulatory outpatient hernia surgery. Including a new concept, introducing tension-free repair

In 1985, Medicare started an experimental study in California mandating "Same-day" herniorrhaphy for all patients unless serious medical contraindication existed. Blue Shield and Blue Cross are rapidly following suit. It is little wonder therefore that ambulatory outpatient surgi-centers are now including hernia repair in their armamentarium. Change in environmental milieu must not compromise the quality of the surgery and care of the patient. This paper reviews the author's experience with outpatient hernia surgery and introduces a new surgical concept, tension-free repair. Since the first true herniorrhaphy was performed by Bassini over 100 years ago, all modifications and surgical techniques have shared a common disadvantage-suture line tension. This is the prime etiologic factor behind hernia recurrence. By using modern mesh prosthetics, it is now possible to repair all hernias without distortion of normal anatomy and with no suture line tension. The technique is simple, rapid, less painful, and effective; allowing prompt resumption of unrestricted physical activity.