Is mesh fixation necessary in laparoendoscopic techniques for M3 inguinal defects? An experimental study.

BACKGROUND: Although international guidelines recommend not fixing the mesh in almost all cases of laparoendoscopic repairs, in case of large direct hernias (M3) mesh fixation is recommended to reduce recurrence risk. Despite lack of high-quality evidence, the recommendation was upgraded to strong by expert panel. The authors conducted a research experiment to verify the hypothesis that it is possible to preserve the mesh in the operating field in large direct hernias (M3) without the need to use fixing materials. METHOD: The authors conducted an experiment with scientists from Universities of Technology in a model that reflects the conditions in the groin area. By simulating conditions of the highest possible intra-abdominal pressure, they examined the mesh behavior within the groin and its ability to dislocate under the forces generated by this pressure. The experiment involved six spatial implants and one flat macroporous mesh. RESULTS: Heavyweight spatial meshes and lightweight spatial-individualized meshes showed no tendency to dislocate or move directly to the orifice, which was considered a rapid hernia recurrence. Lightweight meshes, both spatial and flat, underwent significant migration and shifting toward the hernial orifices. CONCLUSION: Based on the results, we believe that mesh fixation is not the only alternative to preventing recurrence in complex defects. Similar effects can be achieved using a larger, more rigid, and anatomically fitted implant. The type of implant (rather than its fixation) seems to be a key factor from the point of view of mechanics and biophysics. Clinical trials confirming the results in vivo will allow to supplement or amend the guidelines for the treatment of large inguinal hernias.

Development and Implantation of 3D Anatomically Tailored Polypropylene Mesh for Laparoscopic Inguinal Hernia Repair Designed on the Basis of CT Images (the ILAM Study).

OBJECTIVE: The aim of the ILAM (Individualized Laparoscopic Anatomical Mesh) study was to create and implant a fully individualized mesh based on CT scans, taking into account the published body of knowledge about the material and mechanical behavior of the implant for laparoscopic inguinal hernia repair. SUMMARY BACKGROUND DATA: The team creating and conducting this study consisted of surgeons and engineers. A specific project was made and divided into 4 phases. METHODS: The process of development and implantation was divided into 4 milestones: CT scans and modeling based on predefined subgroups, mesh manufacture, certification and clinical evaluation. RESULTS: The result of the study was the first individually designed hernia mesh to have been implanted in a human subject. After 12 months of follow-up, no recurrences or other complications were reported. CONCLUSIONS: The new mesh provides a better anatomic fit to the patients' inguinal region geometry. Mechanical stability is ensured by the multiple contact points between the implant and the tissues, which generate friction forces. Together with the possibility of shape design (proper overlap), the authors believe that there is no need for mesh fixation. If so, the use of such design meshes can change the guidelines in laparoendoscopic hernia repair in the future.

Post-partum abdominal wall insufficiency syndrome (PPAWIS): lessons learned from a single surgeon's experience based on 200 cases.

BACKGROUND: Post-partum abdominal wall insufficiency (PPAWI) with rectus diastasis is present in over 30% of women after pregnancy. Little is known about how PPAWI affects the social, sexual life and self-esteem of patients. This study was designed to evaluate the safety of onlay mesh combined with abdominoplasty and its impact on the well-being of the patients. METHOD: Two hundred patients with PPAWI underwent surgery with onlay mesh and abdominoplasty. The safety of the procedure was assessed by postoperative complications, time of hospitalization and time of drainage. Before the operation and 6 months later, a questionnaire asking about the patient's sexual and social life and the presence of back pain was completed. The final cosmetic effect was assessed separately. RESULTS: The onlay procedure with abdominoplasty was found to be safe and fast. The mean operation time was 82 min, and the drainage time was 2.1 days. In this group < 2% postoperative complications were noted. There were no recurrences within the 6 month. Significant improvements in social and sexual life and the level of self-esteem were noted. Back pain was relieved or minimalized in all patients. The final cosmetic effect was insufficient for 2 patients (1%). CONCLUSION: PPAWI can be treated safely with onlay mesh and abdominoplasty. The patients' symptoms were strongly correlated with the morphological status of the front abdominal wall and improved after the procedure. Describing the psychological and social consequences of PPAWI should lead the surgical societies to propose a definition of a new disease called PPAWIS (post-partum abdominal wall insufficiency syndrome).

MEsh FIxation in Laparoendsocopic Repair of Large M3 inguinal hernias: multicenter, double-blinded, randomized controlled trial-study protocol for a MEFI Trial.

BACKGROUND: International guidelines of groin hernia treatment strongly recommend to fixate the mesh in large M3 medial defects during TAPP/TEP procedures. The main purpose of fixation is to decrease the recurrence rate which is alarmingly high in case of those defects. In 2022, a team consisting of hernia surgeons and scientists from universities of technology conducted an experimental study with the use of 3D groin model to verify the hypothesis that fixation is not necessary in above cases. Experiment showed that rigid and anatomically shaped meshes are able to maintain its position in the groin without fixation. Similar conclusions were recently published in Swedish database registry analysis. To confirm above results, we decided to conduct a multicenter randomized controlled trial. METHODS: Main objective of MEFI Trial is to verify the hypothesis that non-fixation of spatial, standard polypropylene meshes is non-inferior to fixation of flat, polypropylene lightweight meshes in M3 hernias by laparoendoscopic approach. Eleven large surgery centers in Poland having proficiency in laparoendoscopic groin hernia repairs were recruited for this study. Recurrence in 12-month follow-up was set as a primary endpoint. Pain sensation (Visual Analog Scale) and incidence of other complications (hematoma, seroma, SSI) were also noted. Based on the statistical analysis, minimal sample size in both arms was established at 83-102. The first arm (control) consists of patients undergoing a repair with the use of a flat, macroporous mesh with fixation using histoacryl glue. In the second arm, patients will be operated with the use of anatomically shaped, standard-weight mesh without fixation. Study will be double-blinded (patient/surgeon). After the dissection of preperitoneal space, surgeon will open a sealed envelope and find out which technique he will have to perform. Follow-up will be performed by Study Secretary (also blinded to the method used) via phone call 3 and 12 months after surgery. DISCUSSION: Based on experimental study and recent registry analysis, we believe that the recurrence rate in both groups would be on the same level, giving hernia societies a strong argument for amending the guidelines. TRIAL REGISTRATION: ClinicalTrials.gov NCT05678465. Registered on 10 January 2023.

Efficacy of intraoperative hypertonic saline irrigation in seroma prevention after abdominal wall reconstruction procedures - a pilot cohort study.

INTRODUCTION: Seromas refer to collections of fluid secreted into the so-called dead spaces when extensive dissection takes place. Various methods of preventing seroma have been reported in the literature but their outcomes are far from spectacular. AIM: To verify the expected benefit on usage of IHSI (intra-operative hypertonic saline irrigation) in aspect of decreasing subcutaneous fluid secretion and decreased hospital stay in patients undergoing various abdominal wall reconstruction procedures. MATERIAL AND METHODS: We conducted a cohort study of total 64 patients treated by two techniques and divided into 2 groups. In the first group (SUBLAY), we assessed patients undergoing abdominal wall reconstruction with the positioning mesh underneath the rectus muscles. Group was divided into two subgroups: control and experimental. In second group (ONLAY), we analysed patients who had undergone reconstruction procedure combined with abdominoplasty and placement of a mesh between the subcutaneous tissue and the fascia. Intervention consisted in administration of 20 mL of 10% hypertonic saline into subcutaneous tissue 10 min before definitive wound closure. RESULTS: Mean drain output, starting from day 2 post-op, was significantly lower in the experimental subgroups of the ONLAY and SUBLAY compared to the respective control subgroups. This had a beneficial effect on shortening the time to drainage removal. CONCLUSIONS: In the short-term results, we demonstrated that intraoperative hypertonic saline irrigation significantly decreased the amount of the drained fluid and shortened the hospital stay. Further multicentre studies in larger groups of patients are needed.

Biomechanical causes for failure of the Physiomesh/Securestrap system.

This study investigates the mechanical behavior of the Physiomesh/Securestrap system, a hernia repair system used for IPOM procedures associated with high failure rates. The study involved conducting mechanical experiments and numerical simulations to investigate the mechanical behavior of the Physiomesh/Securestrap system under pressure load. Uniaxial tension tests were conducted to determine the elasticity modulus of the Physiomesh in various directions and the strength of the mesh-tissue-staple junction. Ex-vivo experiments on porcine abdominal wall models were performed to observe the system's behavior under simulated intra-abdominal pressure load. Numerical simulations using finite element analysis were employed to support the experimental findings. The results reveal nonlinearity, anisotropy, and non-homogeneity in the mechanical properties of the Physiomesh, with stress concentration observed in the polydioxanone (PDO) stripe. The mesh-tissue junction exhibited inadequate fixation strength, leading to staple pull-out or breakage. The ex-vivo models demonstrated failure under higher pressure loads. Numerical simulations supported these findings, revealing the reaction forces exceeding the experimentally determined strength of the mesh-tissue-staple junction. The implications of this study extend beyond the specific case of the Physiomesh/Securestrap system, providing insights into the mechanics of implant-tissue systems. By considering biomechanical factors, researchers and clinicians can make informed decisions to develop improved implants that mimic the mechanics of a healthy abdominal wall. This knowledge can contribute to better surgical outcomes and reduce complications in abdominal hernia repair and to avoid similar failures in future.

Randomised controlled trial: standard lightweight mesh vs self-gripping mesh in Lichtenstein procedure.

<b> Introduction:</b> Lichtenstein hernioplasty has been a gold standard of hernioplasty for 30 years now. However, the procedure may be followed by an unacceptably high rate of chronic pain, numbness and discomfort. </br></br> <b>Aim:</b> To compare outcomes of Lichtenstein repair using a Parietene ProGrip self-fixing mesh versus the standard lightweight macroporous mesh. </br></br> <b>Material and methods:</b> As many as 141 patients with unilateral primary inguinal hernia participated in this single-centre, randomised, prospective, single-blind (patient-blinded) study. Randomisation yielded two treatment groups: control group of 88 patients treated with Lichtenstein method using lightweight standard mesh (LS) and study group of 53 patients receiving treatment with self-fixing mesh (PG). Patients were followed up for 6 months. Primary outcome was the presence and severity of postoperative pain at discharge, at 30 days and 6 months post-procedure. Other study parameters were: duration of the procedure, duration of hospitalisation, presence of early and late complications, time needed to return to full activity and patient satisfaction. </br></br> <b>Results:</b> No statistically significant differences in pain severity were demonstrated at discharge or at long-term follow-up. In the first 30 days post-procedure the patients in the PG group complained of pain of greater severity on the NRS (2.0 vs 1.4) (P = 0.0466). The duration of the procedure in the PG group was 9.4 minutes shorter than in the LS group (P = 0.0027). No statistically significant differences between the groups were found in other studied parameters. </br></br><b>Conclusions:</b> Self-fixing mesh can be safely used in inguinal canal repair procedures. It significantly shortened the duration of the procedure but at the same time did not reduce the severity of pain, including the rate of chronic postoperative inguinal pain.

Patient with metastatic breast cancer presenting as acute cholecystitis with one-year survival on hormonotherapy.

Breast cancer has high metastatic potential with distant metastases involving mainly lungs, liver and bones. Less frequently it gives distant spread to other organs. Herein we would like to present a very rare case of an acute cholecystitis which turned out to be a metastatic breast cancer in previously healthy woman. A female patient, 64-years old, presented to the emergency department with symptoms of biliary colic and acute abdomen. During the emergency cholecystectomy, we diagnosed the gallbladder empyema with thickened wall. There were also multiple metastatic nodules in the peritoneal cavity and an excessive amount of free fluid. The emergency physicians diagnosing female patient with the acute abdominal symptoms and a breast cancer history might suspect malignant spread into abdominal organs including gallbladder. On the other hand, acute cholecystitis symptoms might be the first symptoms of metastatic process in the gallbladder from the unknown primary source, which may be breast.

Antibiotic prophylaxis in open inguinal hernia repair: a literature review and summary of current knowledge.

More than 1 million inguinal hernia repairs are performed in Europe and the US annually. Although antibiotic prophylaxis is not required in clean, elective procedures, the routine use of implants (90% of inguinal hernia repairs are performed with mesh) makes the topic controversial. The European Hernia Society does not recommend routine antibiotic prophylaxis for elective inguinal hernia repairs. However, the latest randomized controlled trial, published by Mazaki et al., indicates that the use of prophylaxis is effective for the prevention of surgical site infection. Unnecessary prophylaxis contributes to the development of bacterial resistance and significantly increases healthcare costs. This review documents clinical trials on inguinal hernia repairs with mesh and summarizes the current knowledge. It also tries to solve certain problems, namely: what constitutes a real risk factor, late-onset infection, and how the "surgical environment" impacts on the need to use antibiotic prophylaxis.

High Pressure Injection Injury of the Thumb. Case Study.

High-pressure injection injury (HPII) is a rare severe hand trauma associated with high rates of complications and amputations of the peripheral parts of the fingers and permanent hand dysfunction. Early detection and treatment are crucial as any delay may result in a considerable functional deficit of the affected limb or amputation. The rate of amputation following HPII is 48%. This case report aims mainly to present the problem of HPII and general standards of management of such injuries. The routine use of supportive treatment in hyperbaric chambers, in the absence of contraindications, is also encouraged.