Outcomes of primary and recurrent inguinal hernia repair with prosthetic mesh in a single region over 15 years.

BACKGROUND: Sutured inguinal hernia repairs are now uncommon, with evidence suggesting that those augmented with mesh are associated with a lower recurrence rate. We aimed to explore the suggestion that the established use of mesh does indeed lower the rate of operation for recurrence in a single National Health Service region. METHOD: We collected retrospective Office of Population Censuses and Surveys coded data across one region of all primary and recurrent inguinal hernia repairs over 15 years (2004-2019). Electronic records of recurrent repairs were scrutinised to identify year and type of previous primary repair. RESULTS: In total, 7,234 repairs were performed during this time, of which 289 (4%) were for symptomatic recurrence. Operations for primary repair increased year on year (111 in 2004 to 402 in 2019). Frequency of operation for recurrent herniation declined with increasing use of mesh (8.8% in 2004 to 3.5% in 2019). The majority of repairs (73%) for recurrence were by an open approach. As opposed to an open mesh repair, a primary laparoscopic repair was associated with an earlier recurrence. CONCLUSIONS: Inguinal hernia repairs are increasing in frequency but operations for later symptomatic recurrence following an open primary prosthetic mesh repair are not.

The lateral rectus abdominis positioned stoma (LRAPS) in the construction of end colostomies, loop ileostomies and ileal conduits.

BACKGROUND: Stomas are traditionally constructed through the belly of the rectus muscle. Parastomal herniation is common with the use of mesh prophylaxis still deliberated. METHODS: A novel trephine, the lateral rectus abdominis positioned stoma or LRAPS, that minimises damage to the musculature of the anterior abdominal wall, has been used in the construction of end colostomies, loop ileostomies and ileal conduits. RESULTS: In a cohort of 106 patients with end colostomy, the cumulative rate of parastomal herniation at 1, 2 and 3 years were 6, 10 and 17%, respectively. In 56 patients in whom an ileal conduit was performed, there was no clinical or radiological evidence of parastomal herniation at 1 year. CONCLUSION: In contrast to a traditional trephine through the belly of the muscle, this technique avoids damage to the rectus abdominis muscle. Early symptomatic parastomal herniation is unusual after LRAPS.

Ipsilateral Spigelian hernia: just an infrequent variant?

Spigelian hernias are generally considered to occur through solitary defects in the fascial layers of the anterior abdominal wall in the 'Spigelian hernia belt' but can be found anywhere along the line of the linea semilunaris. They are uncommon in children and in adults thought to be acquired and associated with obesity. We describe an unusual case of Spigelian herniation previously unreported and possibly previously unrecognised.

Management of the uncomplicated primary inguinal hernia in 2019: the practice amongst members of the British Hernia Society.

INTRODUCTION: The aim of this study was to survey the current practice of UK-based hernia surgeons in elective inguinal hernia repair. MATERIALS AND METHODS: A questionnaire was created using SurveyMonkey™ and sent electronically to registered members of the British Hernia Society. RESULTS: A total of 368 responses were obtained (a response rate of 55%); 83% were consultant surgeons, 91% were male and 91% stated that they had an interest in laparoscopic surgery. For an uncomplicated inguinal hernia in a male patient, 60% would perform an open Lichtenstein repair, 20% trans-abdominal pre-peritoneal repair and 20% totally extra-peritoneal repair. In a female patient, 54% would perform an open Lichtenstein repair, 25% trans-abdominal pre-peritoneal repair and 21% totally extra-peritoneal repair. 90% always use mesh in inguinal hernia repair. 93% of surgeons rarely or never perform a tissue repair. CONCLUSIONS: Despite recent controversy, UK surgeons support the use of mesh in the repair of inguinal hernias with an open Lichtenstein repair being the most common choice. There has only been a modest increase in the use of laparoscopic surgery over the past 20 years.

Benefits of pre-emptive analgesia by local infiltration at day-case general anaesthetic open inguinal hernioplasty.

Introduction The open prosthetic repair of inguinal hernias under local anaesthesia (LA) is well established, with the concept of intraoperative 'pre-emptive analgesia' evolving so that patients are as comfortable as possible. We used a peri-incisional LA solution in patients undergoing day-case inguinal hernioplasty under general anaesthesia (GA) and recorded use of analgesia in the immediate postoperative period. Methods In this observational cohort study, 100 consecutive unselected men underwent open inguinal hernia repair as a day case. Of these, 75 underwent repair under GA and 25 with peri-incisional LA solution (equal mixture of 0.5% bupivacaine and 1% lignocaine with 1:200,000 adrenaline). Analgesia prescribed at induction, for maintenance and after cessation of anaesthesia was scored in accordance with the World Health Organization (WHO) analgesic ladder. Results The median age in the GA group was 59 years (range: 25-89 years) and in the GA+LA group, it was 62 years (range: 27-88 years). Of the 100 patients, 82 underwent a mesh plug repair by seven surgeons whereas 18 underwent a flat (Lichtenstein) mesh repair by two surgeons. WHO analgesic induction and postoperative scores were significantly lower in the GA+LA group (p=0.034 and p<0.001 respectively). There was also a significant difference in use of postoperative antiemetics (23% vs 0% in the GA only and GA+LA cohorts respectively, p=0.020). Six patients (8%) in the GA group failed day-case discharge criteria. Conclusions Patients undergoing contemporary day-case GA inguinal hernioplasty with pre-emptive LA solution infiltration require lower levels of postoperative opioid analgesia and antiemetics. These cases are less likely to fail discharge criteria for planned day surgery.

Perineal Richter's herniation following proctectomy.

In a Richter's hernia, only part of the anti-mesenteric border of the bowel is incarcerated within the underlying defect. We report three cases presenting between 18 days and 11 years following proctectomy. As all patients had functioning stomas a high index of suspicion is necessary to avoid a delay in diagnosis.

Gallstone ileus in an 'asymptomatic' parastomal hernia.

Parastomal hernias are common and often asymptomatic. We report the first known case in which later, acute symptoms developed owing to gallstone ileus in a sac containing both omentum and small bowel. Urgent computed tomography established the diagnosis.