Mesh repair for lateral inguinal hernias: a non-evidence-based practice.

INTRODUCTION: The EHS clinical guidelines recommend the use of mesh to repair symptomatic primary inguinal hernias (PIH) in adult males but, in spite of this, it begs the question as to why there is still place for tissue techniques. Lack of stratification of patients according to risk of recurrence in RCTs might be a cause of results disparity, since medial and mixed are hernias with higher risk of recurrence (HRRH), whereas lateral hernias present a lower risk (LRRH). OBJECTIVE: To determine whether the lack of stratification may lead to questionable conclusions regarding the protective effect of mesh techniques and to identify other methodological flaws. METHODS: In the RCTs included in the clinical guidelines that addressed recurrences of PIH after mesh and non-mesh techniques, we assessed the type of hernias classification used, the number needed to treat in LRRH and HRRH and the statistical power. RESULTS: Most of trials were underpowered; five studies classified the hernia types; in the three studies that compared the recurrence rates of LRRH and HRRH the effect of mesh techniques was small; only two trials record data needed to calculate the NNT in LRRH (46 y 84 patients, respectively). CONCLUSION: The idea that mesh techniques reduce the recurrence rate in all PIHs is not supported by high level of evidence. The NNT for pure lateral hernias was very high and should be interpreted taking into account chronic pain rates and costs.

Sports hernias: experience in a sports medicine center.

PURPOSE: Chronic pain of the inguino-crural region or "pubalgia" explains the 0.5-6.2% of the consultations by athletes. Recently, areas of weakness in the posterior wall called "sports hernias," have been identified in some of these patients, capable of producing long-standing pain. Several authors use different image methods (CT, MRI, ultrasound) to identify the lesion and various techniques of repair, by open or laparoscopic approaches, have been proposed but there is no evidence about the superiority of one over others due to the difficulty for randomizing these patients. In our experience, diagnosis was based on clinical and ultrasound findings followed by laparoscopic exploration to confirm and repair the injury. The present study aims to assess the performance of our diagnostic and therapeutic management in a series of athletes affected by "pubalgia". METHODS: 1450 athletes coming from the orthopedic office of a sport medicine center were evaluated. In 590 of them (414 amateur and 176 professionals) sports hernias were diagnosed through physical examination and ultrasound. We performed laparoscopic "TAPP" repair and, thirty days after, an assessment was performed to determine the evolution of pain and the degree of physical activity as a sign of the functional outcome. We used the U Mann-Whitney test for continuous scale variables and the chi-square test for dichotomous variables with p < 0.05 as a level of significance. RESULTS: In 573 patients ultrasound examination detected some protrusion of the posterior wall with normal or minimally dilated inguinal rings, which in 498 of them coincided with areas affected by pain. These findings were confirmed by laparoscopic exploration that also diagnosed associated contralateral (30.1%) and ipsilateral defects, resulting in a total of 1006 hernias. We found 84 "sport hernias" in 769 patients with previous diagnosis of adductor muscle strain (10.92%); on the other hand, in 127 (21.52%) of our patients with "sport hernias" US detected concomitant injuries of the adductor longus tendon, 7 of which merited additional surgical maneuvers (partial tenotomy). Compared with the findings of laparoscopy, ultrasound had a sensitivity of 95.42% and a specificity of 100%; the positive and negative predictive values were 100 and 99.4% respectively. No postoperative complications were reported. Only seven patients suffered recurrence of pain (successful rate: 98.81%); the ultrasound ruled out hernia recurrence, but in three cases it diagnosed tendinitis of the rectus abdominis muscle. CONCLUSIONS: Our series reflects the multidisciplinary approach performed in a sports medicine center in which patients are initially evaluated by orthopedic surgeons in order to discard the most common causes of "pubalgia". "Sports hernias" are often associated with adductor muscle strains and other injuries of the groin allowing speculate that these respond to a common mechanism of production. We believe that, considering the difficulty to design randomized trials, only a high coincidence among the diagnostic and therapeutic instances can ensure a rational health care.

Infections associated with prosthetic repairs of abdominal wall hernias: pathology, management and results.

PURPOSE: To analyse clinical and demographic factors of patients who suffered infection of the surgical site requiring mesh removal as a complication of prosthetic repairs, details of the hernioplasties in which meshes were implanted and their management and outcomes. METHODS: Factors related to infection (demographic variables and characteristics of the repairs and mesh utilised) and the management before proceeding to mesh removal were obtained from patient charts. Collected specimens (meshes and tissues) from 32 consecutive patients were cultured and observed microscopically. The outcomes after mesh removal were prospectively evaluated. RESULTS: Twenty-two patients underwent incisional hernioplasties and ten inguinal hernioplasties; most of the procedures took a long time, and 28 patients presented early wound complications (seroma or haematoma). During the "implantation­removal" interval, some conservative treatments, such as drainages or sinus resection, were attempted under local anaesthesia. Twenty-two meshes were totally removed (nine after partial extraction); in the remaining ten cases partially removal was successful. Most of the meshes (24) were made of multi-filament polypropylene; microscopic observation of neighbouring tissues showed leucocyte infiltration, giant cell reaction, disorganisation of the collagen fibres and abscedation. Treatment of 32 patients required 51 operations. Following mesh removal, there were six recurrences and two fistulas of the bowel. The average follow-up was 40 months (30­97). CONCLUSIONS: Most of the infections requiring mesh removal were related to prolonged repair operations that presented untreated early postoperative wound complications. Partial extraction of meshes frequently leads to failures and complications. Surgical exploration should be performed under general anaesthesia to accomplish complete mesh extraction.