Worldwide hernia repair: variations in the treatment of primary unilateral inguinal hernias in adults in the United Kingdom and in low- and middle-income countries.

INTRODUCTION: In this invited commentary, we aim to quantify and explain the variation between, and also within, developed healthcare systems (using the UK as an example) and low- to middle-income countries (LMICs). Rather than including complex cases, we have looked only at 'uncomplicated' primary unilateral inguinal hernias, an area where limited variation may be identified. METHODS: Data were obtained from Hospital Episode Statistics and structured surveys in the United Kingdom and in low- and middle-income countries. CONCLUSION: There is widespread variation in the repair of 'uncomplicated' primary inguinal hernias worldwide and within developed healthcare systems.

Is there a role for hernia subspecialists? Or is this a step too far?

Specialization influences the way that we deliver surgical care and has a direct impact on surgeons, healthcare systems and patients. Abdominal wall hernia repairs are among the most commonly performed surgical procedures worldwide, and over 20 million prosthetic meshes are inserted annually. Worldwide outcomes from groin hernia repair, as reflected by 5-year recurrence rates, range from 1 to 4 %. However, the results for incisional hernia repair are at least ten times worse, with worldwide recurrence rates of about 25 % and upwards. This editorial aims to debate the argument for and against hernia subspecialists and provide a framework for implementing specialist hernia services.

Mechanical failure of a lightweight polypropylene mesh.

We report the case of a 41-year-old male who underwent repair of a recurrent midline abdominal incisional hernia with components separation. The hernia defect was repaired with a 30 cm × 30 cm underlay biological (Strattice) mesh used to partially bridge a small residual gap between the rectus muscles and reinforced with a 30 cm × 30 cm lightweight polypropylene onlay mesh (BARD™ soft mesh). The patient later developed a large persistent seroma that was excised 18 weeks later. On exploration of the previous hernia repair, it was noted that the onlay polypropylene mesh had fractured leaving a 3 cm by 2 cm defect, but the underlying biological mesh was intact preventing a recurrence of the hernia (see Fig. 1). The fractured mesh was repaired with an additional onlay 10 cm × 10 cm polypropylene mesh, the seroma was de-roofed, and the patient was later discharged. This case highlights the early mechanical failure of a lightweight polypropylene mesh; the precise mechanism of failure in this case is unclear and, however, may be related to high intra-abdominal pressures postoperatively. Fig. 1 Photograph showing onlay polypropylene (BARD™ soft mesh) mesh superficial to a biological (Strattice) sublay mesh bridging the recti (on the left and right wound edges). Arrow indicates the 2 cm by 3 cm fracture.

Medical talc increases the incidence of seroma formation following onlay repair of major abdominal wall hernias.

PURPOSE: Seroma is a well established complication of the repair of major abdominal wall hernias, occasionally requiring aspiration and reoperation. Medical talc seromadesis (MTS) has been described in the literature. The aim of this study was to determine the effect of MTS on seroma formation after onlay repair of incisional hernia. METHODS: A retrospective review of a prospective database was conducted for 5 months from April 2011, when 21 consecutive patients received MTS. Outcomes were compared with a published and validated series from the same unit. RESULTS: There were no differences in basic demographics and co-morbidities between the two groups. The mean BMI was 34 for the MTS group. The incidence of recurrent incisional hernia prior to surgery was greater in MTS (9/21 vs. 36/116, p = 0.39). The mean area of fascial defect measured intra-operatively and mesh used to cover the incisional hernia defect was 170 and 309 cm(2) for the MTS group. The mean operating time was 152 min and a mean of 10 g of medical talc was used for seromadesis. The seroma rate increased from 11/116 (9.5 %) to 16/21 (76 %) (p = 0.001) as did the rate of superficial wound infection 10/116 (8.6 %) to 9/21 (43 %) (p = 0.03) in the MTS group. There was no difference in the length of in-hospital stay between the two groups. CONCLUSIONS: The application of medical talc increased the rate of seroma formation and superficial wound infection in patients undergoing open 'onlay' repair of major abdominal wall hernia.

From ancient to contemporary times: a concise history of incisional hernia repair.

PURPOSE: This historical review explores the origins of incisional hernia surgery. METHODS: Resources from each significant historical time period were reviewed, namely ancient times, the Greco-Roman period, the Middle Ages and the dawn of the surgeon anatomist, and the modern era. RESULTS: Although incisional hernias only started to be widely reported in the literature in the early twentieth century, an awareness of the risk of incisional hernia formation dates back to ancient times. CONCLUSIONS: Sometimes, it is important to look back at the history and evolution of a topic to continue making positive advances in that field.

A two-centre blinded randomised control study comparing the Lichtenstein patch, Perfix plug and ProLoop plug in the repair of primary inguinal hernia.

INTRODUCTION: Mesh plug is an established and effective method for repair of inguinal hernia. The ProLoop plug (Atrium) is a recently developed mesh plug with a novel configuration, which may offer advantages over the standard Prefix plug (Bard) or the Lichtenstein repair. This two-centre double-blinded randomised control trial assessed the short- and medium-term outcomes, comparing the above three methods. PATIENTS AND METHODS: Consecutive patients over the age of 18 years with primary unilateral inguinal hernia were randomised to receive a Lichtenstein tension free mesh repair (LTFM), Perfix plug (Bard) (PF) or ProLoop plug (Atrium) (PL) repair. Follow-up was at 2 weeks, 6 months and 12 months. Endpoints were operative time, hospital stay, bodily pain scores, return to daily activity and complications. RESULTS: A total of 295 consecutive patients were recruited to the study. Ninety-three patients were randomised to receive PL plug repairs, 101 PF plug repairs and 101 LTFM repairs. There was no significant difference among the three groups in terms of age, sex or BMI. There was no significant difference among the groups in terms of operative time (PL vs PF P = 0.92; PL vs LTFM P = 0.52), hospital stay (PL vs PF P = 0.74; PL vs LTFM P = 0.44), bodily pain scores (at 12 months PL vs PF P = 0.84, PL vs LTFM P = 0.85, PF vs LTFM P = 0.16), complication rates or return to daily activity. CONCLUSIONS: The ProLoop plug (Atrium) is a safe and effective method of repairing primary inguinal hernias. Its novel lightweight configuration does not increase the risk of recurrence when compared to thicker mesh plugs, and it may offer benefit in terms of long-term patient comfort. The ProLoop plug (Atrium) represents a new effective alternative to the established mesh repairs.

The use of sterilised polyester mosquito net mesh for inguinal hernia repair in Ghana.

BACKGROUND: The use of alloplastic mesh is now commonplace in hernia repair. However, in developing countries, cheaper alternatives to commercial mesh are required due to the high associated cost. Whilst nylon mosquito net mesh has been trialled previously, this study aimed to assess the use of polyester mosquito net mesh in tension-free inguinal hernia repair in Ghana. METHODS: All patients undergoing inguinal hernia repair during the 5-day 'Operation Hernia' mission in 2007 were eligible for the study. A piece of sterilised 10 x 15-cm 100% polyester mosquito net mesh, manufactured and donated by Scotmas Limited, was implanted for all tension-free hernia repairs. The surgeons' ease of handling and incidence of complications at 6 weeks and 6 months were assessed. RESULTS: Ninety-five patients underwent inguinal hernia repair using a total of 106 polyester mosquito net meshes. The mean (range) age of patients was 44.3 (15-78) years. Seventy-two (76%) were repaired using local anaesthesia. At 6 weeks and 6 months, a total of seven (7%) patients suffered wound complications (five haematomas, two wound infections). Ease of practical handling improved after the first 2-5 cases. The cost of an individual 10 x 15-cm mesh was estimated at US$0.0072-0.014, and the cost of sterilisation and packaging was US$1.46 per mesh. CONCLUSIONS: Polyester mosquito net mesh represents a cost-effective alternative to commercial meshes in developing countries, with a relatively low rate of early complications and similar short-term recurrence rates. The use of local anaesthesia may enhance this further.

Inguinal hernia repair in the anticoagulated patient: a retrospective analysis.

INTRODUCTION: Guidelines and local hospital protocols dealing with anticoagulation at the time of surgery vary, but most suggest stopping Warfarin at least three days preoperatively with or without interim low-molecular-weight heparin or intravenous heparin infusion. This study addresses whether it is safe to perform inguinal hernia surgery on the patient who is fully anticoagulated with Warfarin. METHODS: We performed a retrospective case note analysis of consecutive patients who underwent elective inguinal hernia repair at the Plymouth Hernia Service between 1999 and 2007. All patients on therapeutic oral anticoagulation with Warfarin were selected. Data analysis was of complications and patient-related, hernia-related, and surgery-related variables. International normalising ratio (INR) was measured on the day preceding surgery. RESULTS: A total of 49 patients had been operated on whilst anticoagulated with Warfarin. The mean age of the patients was 75 years (range 44-96 years). Thirty patients were on Warfarin for atrial fibrillation, seven for previous PE, three for previous DVT, and nine for mechanical heart valves. Forty patients had a desired INR range of 2-3, and nine a desired range of 3-4. Forty-five (91.8%) patients had no complications or mild bruising requiring no further management. Three (6.1%) patients developed haematomas requiring surgical management and there was one death of unrelated cause. An INR of greater than 3 increased the risk of postoperative haematoma (P = 0.03). None of the other measured patient-related, hernia-related, or surgery-related variables predicted complications (P > 0.05). CONCLUSIONS: Patients can safely undergo inguinal hernia repair whilst on Warfarin as long as the INR is less than 3.

A prospective cohort study comparing the African and European hernia.

INTRODUCTION: The prevalence of inguinal hernia in Ghana, western Africa, is as high as 7.7% of the population. The elective operation rate is significantly lower because many of the hernias are repaired as emergencies. This discrepancy results in a pool of longstanding large hernias. PATIENTS AND METHODS: This prospective cohort study compared consecutive patients having day case local anaesthetic inguinal hernia repairs under the Plymouth Hernia Service, UK, and in Ghana, Africa. Assessment was made of hernia size and subscapular skin-fold thickness. In the Ghanaian group, data were collected on patient age, type of inguinal hernia, duration of the hernia, and disability caused. RESULTS: A total of 241 patients were included in the study (UK: n = 106, Ghana: n = 135). The mean age of the UK group was 62 years (range 28-91 years) and of the Ghanaian group 34 years (range 2 months-80 years). One hundred and twelve (82.9%) of the Ghanaian hernias were indirect. Ninety (67%) of the Ghanaian hernias extended into the scrotum compared with 7 (6.0%) in the UK group. The Ghanaian hernias were significantly larger (P = 0.01) and the patients significantly thinner (P = 0.02). In the Ghanaian group, 22 (16%) of the patients were unable to work due to their hernia, and in a further 87 (64%) patients, the hernia limited daily activity. One hundred and fifteen (85%) of the Ghanaian hernias were present for more than 1 year, and of those, 50 (37%) had been present for more than 5 years. CONCLUSION: In Ghana (a developing country), the hernia is larger than the UK hernia. The majority of Ghanaian hernias are indirect and occur in a young population. This places an economic burden on the country. Appropriate management is needed to reduce the pool of these hernias.

A pragmatic approach to cutaneous nerve division during open inguinal hernia repair.

AIMS: Chronic pain following inguinal hernia repair may be related to the handling of cutaneous nerves. This study aims to investigate the frequency of cutaneous nerve division in routine practice and the effect that nerve division has on long-term pain outcomes. METHODS: The outcomes of 172 patients who underwent open inguinal hernia repair over a two-year period during the course of a clinical trial were recorded prospectively for 1 year. Pain scores for patients in whom one of the nerves was divided were compared with those of patients in whom all three were preserved. RESULT: All nerves were preserved in 95 cases (55.2%). The ilioinguinal, genital and iliohypogastric nerves were divided in 33 (19.2%), 12 (7.0%) and 14 (8.1%) cases, respectively. There was no significant difference in pain scores between any of the nerve division groups compared to the group in which all three were preserved. There were three (1.7%) cases of significant chronic pain, two in which no nerves were divided. CONCLUSION: The division of cutaneous nerves during inguinal hernia repair has no significant effect on postoperative pain. However, there are very few adverse outcomes, and so, a pragmatic approach of dividing nerves when they would otherwise be damaged may be appropriate.

Operation hernia: humanitarian hernia repairs in Ghana.

Ghana has a high incidence of inguinal hernias and the healthcare system is unable to deliver an adequate repair rate. This results in morbidity and mortality and has a knock-on effect on the local economy. A project has been set up to try and reduce the burden of these hernias by establishing Africa's first Hernia Centre. This is supported by structured visits by European surgeons to the centre. In October 2006, a team of four surgeons, two specialist registrars, one hernia nurse specialist, and three nurses was assembled in order to open the Hernia Centre, which will provide a base for the delivery of hernia services in the West of Ghana. A 2-year teaching programme has been formulated, tailored to the needs of local surgeons and nurses, with the aim of developing an integrated team that will initially deliver up to 50 hernia repairs each month. It is planned that the centre will be supported by structured periodic visits from surgeons and nurses based in Plymouth, the European Hernia Society, and any other volunteers wishing to support the link.

The European hernia society groin hernia classification: simple and easy to remember.

After reviewing the available classifications for groin hernias, the European Hernia Society (EHS) proposes an easy and simple classification based on the Aachen classification. The EHS will promote the general and systematic use of this classification for intraoperative description of the type of hernia and to increase the comparison of results in the literature.

Operation Hernia to Ghana.

Inguinal hernia repair and Caesarian section are the two most commonly occurring operations in Africa. Trained surgeons are few, distances between hospitals are large and strangulated hernia is the most common cause of intestinal obstruction. Numerous deaths and cases of permanent disability occur because patients with inguinal hernias requiring elective or urgent surgery are not properly cared for, or they do not actually reach hospital. Operation Hernia was a humanitarian mission between the European Hernia Society and the Plymouth-Takoradi (Ghana) Link conceived specifically to treat and teach groin hernia surgery in the Western region of Ghana.

Randomized clinical trial comparing lightweight composite mesh with polyester or polypropylene mesh for incisional hernia repair.

BACKGROUND: Polymer mesh has been used to repair incisional hernias with lower recurrence rates than suture repair. A new generation of mesh has been developed with reduced polypropylene mass and increased pore size. The aim of this study was to compare standard mesh with new lightweight mesh in patients undergoing incisional hernia repair. METHODS: Patients were randomized to receive lightweight composite mesh, or standard polyester or polypropylene mesh. Outcomes were evaluated at 21 days, 4, 12 and 24 months from patient responses to the Short Form 36 (SF-36) and daily activity questionnaires. Complications and recurrence rates were recorded. RESULTS: A total of 165 patients were included in an intention-to-treat analysis (83 lightweight mesh, 82 standard mesh). Postoperative complication rates were similar. The overall hernia recurrence rate was 17 per cent with the lightweight mesh versus 7 per cent with the standard mesh (P = 0.052). There were no differences in SF-36 physical function scores or daily activities between 21 days and 24 months after surgery. CONCLUSION: The use of the lightweight composite mesh for incisional hernia repair had similar outcomes to polypropylene or polyester mesh with the exception of a non-significant trend towards increased hernia recurrence. The latter may be related to technical factors with regard to the specific placement and fixation requirements of lightweight composite mesh.