Prevalence of rectus diastasis is higher in patients with inguinal hernia.

PURPOSE: To determine the prevalence of rectus diastasis (RD) in patients with inguinal hernia. MATERIAL AND METHODS: Multicenter, cross-sectional study. Patients with inguinal hernia were included in the study group (IH) and those with benign proctologic complaints created the control group (CG). Age, gender, BMI, family history for inguinal hernias, comorbid diseases, alcohol use, smoking, constipation, malignancy, chemotherapy, number of births, multiple pregnancies and prostate hypertrophy history of all patients in both groups were recorded. All patients were evaluated for RD and umbilical hernias by physical examination. RESULTS: A total of 528 consecutive patients were included in the study (292 IH / 236 CG). Overall prevalence of RD was 35.6% and it was significantly higher in IH than in CG (46.9% vs 21.6%, p < 0.001). Also, umbilical hernia was more frequently detected in the patients with inguinal hernia. Other risk factors for RD were age, BMI, DM, BPH and smoking. The mean inter-rectus distance for 528 patients was 18.1 mm; it was 20.71 ± 10.68 mm in IH and 14.88 ± 8.82 in CG (p < 0.001). It was determined that the increase in age and BMI caused an increase in the inter-rectus distance, and that the presence of DM, inguinal hernia and umbilical hernia increased the inter-rectus distance quantitatively. CONCLUSIONS: The prevalence of RD seems to be higher in patients with inguinal hernia comparing to that in general population. Increased age, high BMI and DM were found to be independent risk factors for RD development.

Internet search by the patients undergoing hernia surgery about the disease and surgeon selection.

AIM: To find out the current status of the internet use of patients who undergo surgery for repair of their hernias. MATERIALS AND METHODS: The patients who were diagnosed with abdominal wall hernia and scheduled for elective hernia repair were requested to answer a questionnaire. The questions were directed face-to-face by the surgeons themselves. The age, gender, education status, American Society of Anesthesiologists (ASA) physical status, place of living, health insurance, access to the Internet, surgical method, the person who did the search, previous hernia surgery, recurrence of previous hernia surgery, surgery other than hernia, and the hernia type were the recorded parameters at the first stage. Then, the answers for three main questions were taken: "Did you make a search about your hernia?", "Did you make a search about your surgeon?", "Would you prefer another surgeon if you could?" RESULTS: A total of 200 patients were included in the study (146 male/54 female). 55.5% of the patients made an Internet search about their hernias. 58.5% of the patients made a search to find a proper surgeon. 12.5% of the patients stated that they would like to go to another surgeon for the hernia repair if it was possible. Internet search rate was significantly higher in younger patients in comparison with older patients. The higher the education level of the patients, the higher the rate of making Internet searches about the hernias and surgeons. Patients who live in the cities more frequently made Internet searches in comparison with those living in towns or villages. Internet searches about the hernias were similar in patients who had a history of hernia surgery (n = 23, 52%), and were even operated for recurrence of the same hernia (n = 30, 60%), compared to other patients (p = 0.569). Similarly, the rates of conducting surgeon research of the patients in these two groups (66.7%, 56.5%, respectively) were statistically similar (p = 0.450). The effect of ASA classification of patients on the Internet researches conducted about the disease and about the surgeons was not statistically significant (p = 0.799, p = 0.388, respectively). It was found that the rates of researching about the disease and about the surgeon on the Internet were significantly higher in patients who had undergone a minimally invasive surgery (p < 0.001, p < 0.001, respectively). CONCLUSIONS: Less than two-thirds of the hernia patients make Internet search about their disease. Higher education level, younger age, patient's preference for minimally invasive surgery and living in a city positively affect Internet search rates.

Crossing mesh tails in the Lichtenstein repair method for medial (direct) inguinal hernia: recurrence and chronic pain rates after five years.

PURPOSE: This study aimed to determine whether crossing of the mesh's lateral tails is beneficial in Lichtenstein repairs for medial (direct) inguinal hernias. METHODS: We allocated 116 patients with unilateral medial (direct) inguinal hernias into two groups: mesh tail crossing (group C) or no mesh tail crossing (group N). In group C, the lateral tails were sutured together at the inguinal ligament, whereas the lateral tails were sutured in a parallel position in group N. Visual analog scale (VAS) scores were postoperatively recorded in person at the 1st, 7th, 30th, and 90th days and at the 1st year. The Short-Form Health Survey (SF-36) scores were calculated postoperatively at one month and one year. Examinations to detect hernia recurrence were performed at the end of the 1st year. Follow-ups at the 5th year were performed via phone calls to obtain the Sheffield pain scale and VAS values and to determine the possibility of hernia recurrence. RESULTS: VAS and SF-36 scores at the 1st, 7th, 30th, and 90th days and 1st year were all higher in group C than in group N. In group C, one patient experienced moderate pain, and one experienced severe pain. In the 5th year, VAS and Sheffield pain scores were significantly higher in group C than in group N. CONCLUSIONS: During Lichtenstein repair for medial (direct) inguinal hernias, crossing of the mesh tails may increase the frequency of postoperative chronic inguinal pain.

Return to outdoor walking, car driving, and sexual activity following elective inguinal hernia repair: surgeons' perspective versus patients' reality.

PURPOSE: To determine the time to resumption of outdoor walking, car driving, sports, and sexual activity following elective inguinal hernia repair, and to reveal if there are differences between surgeons' recommendations and patients' real return times. METHODS: A questionnaire including questions about recommendations to hernia patients for times to resume outdoor walking ability without assistance, driving and sexual intercourse after an elective inguinal hernia repair was sent to surgeons. Also, a short questionnaire was sent to patients who had undergone elective inguinal hernia repair to search the exact times for resuming these physical activities. RESULTS: Surgeons' thoughts and recommendations to their patients varied significantly. The range of recommendations were same day to 20 days for outdoor walking, and same day to 3 months both for driving and sexual intercourse. Patients' actual resumption of postoperative activities were 1-14 days for outdoor walking, 1 day to 3 months for driving, and 1 day to 2 months for sexual intercourse. When the answers from the two questionnaires were compared, it was observed that the mean times for resumption of outdoor walking and sexual intercourse were significantly longer in the patients' lives than recommended by the surgeons. Patients ≥ 60 years were able to walk outside, drive, and participate in sexual activity earlier than the younger patients. Bilateral and recurrent hernia repairs caused slower resumption of different activities in comparison to primary hernias. CONCLUSIONS: Patients reported that times for resumption of outdoor walking, driving, and sexual activity were significantly longer than those recommended by surgeons. Age, BMI, bilateral repair, and recurrent hernias were found to be factors affecting return time to different activities.

Individual mesh size for open anterior inguinal hernia repair: an anthropometric study in Turkish male patients.

PURPOSE: To conduct a study to determine the measurements of the inguinal region in male patients with inguinal hernias to reveal the proper mesh size for each patient. METHODS: In this prospective study, the anthropometric measurements were obtained from 100 consecutive adult male patients with unilateral primary inguinal hernias. First, the distance between the pubic tubercle and the medial border of the deep inguinal ring was measured (x). Second, the distance between the inner edge of the inguinal ligament and the uppermost level of the internal oblique aponeurosis at the midpoint of the inguinal ligament corresponding to the Hesselbach triangle was measured (y). Individual mesh sizes were calculated according to the original recommendations for mesh overlap. RESULTS: The mean x value was 41.6 mm (22-55 mm), the mean y value was 45.2 mm (30-68 mm). The mean dimensions of the mesh were 126.6 mm × 65.2 mm. The largest mesh was 140 mm × 88 mm, and the smallest one was 107 mm × 62 mm. The mean mesh area was 8320 mm2. It was larger than the index mesh area recommended by the Lichtenstein Hernia Institute in 45 patients and smaller in 55 patients. CONCLUSIONS: The intraoperative measurements for ideal mesh size in Lichtenstein repair of inguinal hernias may present somewhat different mesh dimensions in many patients. Individualization of mesh size may be of importance in surgical outcomes.

Is hemithyroidectomy a rational management for benign nodular goitre? A Multicentre Retrospective Single Group Study.

BACKGROUND: The incidence and potential risk factors for the recurrence of benign nodular goitre after unilateral thyroidectomy are not clearly defined. The aim of this study was to assess the rate of progression of nodular goitre in the contralateral thyroid lobe and of hypothyroidism requiring replacement therapy after unilateral thyroid lobectomy for benign nodular goitre. PATIENTS AND METHODS: Patients who underwent hemithyroidectomy for benign nodular goitre between 2000 and 2009 were included in the study. The primary outcome of this study was the reoperation rate for recurrent goitre, the rate of progression of nodular goitre and the rate of hypothyroidism requiring L-T4 replacement therapy. Clinical factors that have an effect on progression were further analysed. RESULTS: 259 patients were included for study. Progression of the nodular goitre in the remnant lobe was observed in 32% (n = 83) of the patients. However, over time, only 2% of these 83 patients underwent contralateral hemithyroidectomy due to this progression. Fifty-six (22%) patients required L-thyroxin replacement due to persistent hypothyroidism after hemithyroidectomy. The factors shown to affect progression of nodular goitre were advanced age, preoperative hyperthyroidism, preoperative diagnosis of toxic nodular goitre and the presence of surgical indication for a toxic goitre causing hyperthyroidism and a definitive pathological diagnosis of nodular hyperplasia. CONCLUSION: There was a progression of the nodular goitre in the remnant lobe in about one-third of the patients who underwent hemithyroidectomy. However, only 2% of these patients underwent complementary contralateral hemithyroidectomy due to clinical progression in 31 months of follow-up.

Hemithyroidectomy for unilateral thyroid disease.

AIM: To identify rates of recurrence and hypothyroidism after hemithyroidectomy for unilateral nodular thyroid diseases and its advantages over bilateral radical resections. METHODS: Fifty patients who underwent thyroid lobectomy with unilateral thyroid disease were included. Follow-up with thyroid function tests on the first month and then once every three months, as well as ultrasonography controls once a year were performed postoperatively. Recurrence, which was accepted asat least one nodule with a diameter of 5 mm on the remnant lobe, and the need for postoperative thyroxin therapy were analysed, along with the relation of both with preoperative medical therapy, histological results, numbers and diameters of thyroid nodules, follow-up duration. RESULTS: The incidence of recurrent disease after hemithyroidectomy was 12% after a mean follow-up time of 25.2 months (range, 10-43) while the incidence of clinical hypothyroidism which needs thyroxin therapy was 8%. Gender, age,substitutive and suppressive therapy before operation,histological evaluation, the presence of multiple nodules and diameter of nodules were predictive of neither recurrence nor post operative thyroxin therapy. CONCLUSION: Hemithyroidectomy for unilateral thyroid disease has a moderate rate of recurrence, low rates of hypothyroidism and rare postoperative complications, with short hospital stay.

A safety-based comparison of pure LigaSure use and LigaSure-tie technique in total thyroidectomy.

BACKGROUND AND AIM: Sutureless total thyroidectomy by using vessel sealing devices has been shown to be safe in some recent clinical studies. However, some surgeons are still concerned about the use of these energy devices in the vicinity of there current laryngeal nerve and parathyroid glands. The objective of this study was to investigate the effects of the use of pure LigaSure on postoperative complications and to discuss the pertinent literature. METHODS: A total of 456 patients having undergone a total thyroidectomy operation between June 2009 and March 2011 were included in the study. Data were prospectively collected and retrospectively evaluated. Patients were separated into 2 groups. Group L comprised of 182 patients where onlyLigaSure was used, and group LT consisted of 274 patients where ligation was used in the vicinity of the recurrent laryngeal nerve and parathyroid glands, and LigaSure was used in all other parts of the surgery. Patient's blood calcium values were checked preoperatively and at postoperative 24, 48, and 72 hours. Groups were assessed in terms of demographic properties, thyroid pathology, duration of operation, and postoperative complications. RESULTS: Groups were similar in respect of demographic properties, operation duration, thyroid gland pathology. No mortality rate was recorded. Laboratory hypocalcemia rate was higher in group L (P 0.003), but no significant difference was identified between groups in terms of symptomatic hypocalcemia.No permanent hypocalcemia or recurrent laryngeal nerve injury developed in any of the patients in the two groups. CONCLUSIONS: Pure LigaSure for total thyroidectomy may increase laboratory hypocalcemia rate, but not symptomatic hypocalcemia. Hemorrhage related complications were similar and low in the two groups. Ligations in the places close to delicate anatomic structures did not cause longer operative times and may be a safer option in total thyroidectomy.

Effects of ethylene oxide resterilization and in-vitro degradation on mechanical properties of partially absorbable composite hernia meshes.

BACKGROUND AND AIM: Prosthetic mesh repair for abdominal wall hernias is widely used because of its technical simplicity and low hernia recurrence rates. The most commonly used material is pure polypropylene mesh, although newer composite materials are recommended by some centers due to their advantages.However, these meshes are more expensive than pure polypropylene meshes. Resterilization of a pure polypropylene mesh has been shown to be quite safe, and many centers prefer slicing a large mesh into smaller pieces, suitable for any hernia type or defect size. Nevertheless there is no data about the safety after resterilization of the composite meshes. The present study was carried out to investigate the effects of resterilization and in vitro degradation in phosphate buffered saline solution on the physical structure and the mechanical properties of partially absorbable lightweight meshes. METHODS: Two composite meshes were used in the study: One mesh consists of monofilament polypropylene and monofilament polyglecaprone -a copolymer of glycolide and epsilon(ε)- caprolactone - (Ultrapro®, 28 g m2, Ethicon, Hamburg,Germany), and the other one consisted of multifilament polypropylene and multifilament polyglactine (Vypro II®, 30g m2, Ethicon, Hamburg, Germany). Two large meshes were cut into rectangular specimens sized 50 x 20 mm for mechanical testing and 20 x 20 mm for in vitro degradation experiments.Meshes were divided into control group with no resterilization and gas resterilization. Ethylene oxide gas sterilization was performed at 55°C for 4.5 hours. In vitro degradation in 0.01M phosphate buffered saline (PBS, pH 7.4) solution at 37 ± 1°C for 8 weeks was applied to one subgroup in each mesh group. Tensiometric measurements and scanning electronmicroscopic evaluations were completed for control and resterilization specimens. RESULTS: Regardless of resterilization, when the meshes were exposed to in vitro degradation, all mechanical parameters decreased significantly. Highest reduction in mechanical properties was observed for Ultrapro due to the degradation of absorbable polyglecaprone and polyglactin parts of these meshes. It was observed that resterilization by ethylene oxide did not determine significant difference on the degradation characteristics and almost similar physical structures were observed for resterilized and non-resterilized meshes. For VyproII meshes, no significant mechanical difference was observed between resterilized and non-resterilized meshes after degradation while resterilized Ultrapro meshes exhibited stronger characteristics than non-resterilized counterparts, after degradation. CONCLUSION: Resterilization with ethylene oxide did not affect the mechanical properties of partially absorbable compositemeshes. No important surface changes were observed inscanning electron microscopy after resterilization.

In which cases surgical gastrostomy and jejunostomy techniques are inevitable?

PURPOSE: This study investigated the surgical gastrostomy and jejunostomy procedures in cancer patients who needed nutritional support and endoscopy was unattainable. METHODS: Operation time and procedure, anesthesia and tube types, procedure-specific and surgical complications, and tube replacement at the follow up period were retrospectively analyzed. RESULTS: 109 patients (44 female, 65 male, mean age 50.9 years, range 14-87) were subjected to surgical gastrostomy/ jejunostomy. Ninety-three (85.4%) patients had head-neck and gastrointestinal cancers. In 94 (86.2%) patients endoscopy was impossible due to obstruction of the esophagus and stomach. Gastrostomy/jejunostomy was combined with other surgical procedures in 12 (11 %) patients. Procedure- related complications occurred in 22 (20.7%) patients. Early 30-day mortality occurred in 12 (11 %) cases. The median follow up period was 3.6 months (range 0-18). CONCLUSION: Obstructing cancer, obesity or previous laparotomy make the use of endoscopic techniques impossible. For these patients, surgical gastrostomy/jejunostomy is safe with acceptable complication rates and improves the treatment outcomes with nutritional support.

EFFECTS OF ETHYLENE OXIDE RESTERILISATION AND IN-VITRO DEGRADATION ON MECHANICAL PROPERTIES OF PARTIALLY ABSORBABLE COMPOSITE HERNIA MESHES.

BACKGROUND: Prosthetic mesh repair for abdominal wall hernias is widely used because of its technical simplicity and low hernia recurrence rates. The most commonly used material is pure polypropylene mesh, however newer composite materials are recommended by some centers because of their advantages. However, these meshes are more expensive than pure polypropylene meshes. Resterilisation of a pure polypropylene mesh has been shown to be quite safe, and many centers prefer slicing a large mesh into smaller pieces that suitable for hernia type or defect size. Nevertheless there is no data about the safety after resterilisation of the composite meshes. OBJECTIVE: To search the effects of resterilisation and In vitro degradation in phosphate buffered saline solution on the physical structure and the mechanical properties of partially absorbable lightweigth meshes. DESIGN: Laboratory-based research. SUBJECTS: Two composite meshes were used in the study: One mesh is consisted of monofilament polypropylene and monofilament polyglecaprone--a copolymer of glycolide and epsilon (ε)-caprolactone--(Ultrapro®, 28 g/m2, Ethicon, Hamburg, Germany),andthe otherone consisted of multifilamentpolypropyleneandmultifilament polyglactine (Vypro II®, 30 g/m2,Ethicon, Hamburg, Germany). Two large meshes were cut into rectangular specimens sized 50x20 mm for mechanical testing and 20x20 mm for In vitro degradation experiments. Meshes were divided into control group with no resterilisation and gas resterilisation. Ethylene oxide gas sterilisation was performed at 55°C for 4.5 hours. In vitro degradation in 0.01 M phosphate buffered saline (PBS, pH 7.4) solution at 37 ± 1°C for 8 weeks was applied to one subgroup in each mesh group. Tensiometric measurements and scanning electron microscopyic evaluations were completed for control and resterilisation specimens. RESULTS: Regardless of resterilisation, when meshes were exposed to In vitro degradation, all mechanical parameters decreased significantly. Highest reduction in mechanical properties was observed for Ultrapro due to the degradation of absorbable polyglecaprone and polyglactin parts of these meshes. It was observed that resterilisation by ethylene oxide did not have significant difference on the degradation characteristics and almost similar physical structures were observed for resterilised and non-resterilised meshes. For Vypro II meshes, no significant mechanical difference was observedbetweenresterilised andnon-resterilised meshes after degradationwhile resterilised Ultrapro meshes exhibited stronger characteristics than non-resterilised counterparts, after degradation. CONCLUSION: Resterilisation with ethylene oxide did not affect the mechanical properties of partially absorbable composite meshes. No important surface changeswere observed in scanning electron microscopy after resterilisation.

Mesh size in Lichtenstein repair: a systematic review and meta-analysis to determine the importance of mesh size.

PURPOSE: Small mesh size has been recognized as one of the factors responsible for recurrence after Lichtenstein hernia repair due to insufficient coverage or mesh shrinkage. The Lichtenstein Hernia Institute recommends a 7 × 15 cm mesh that can be trimmed up to 2 cm from the lateral side. We performed a systematic review to determine surgeons' mesh size preference for the Lichtenstein hernia repair and made a meta-analysis to determine the effect of mesh size, mesh type, and length of follow-up time on recurrence. METHODS: Two medical databases, PubMed and ISI Web of Science, were systematically searched using the key word "Lichtenstein repair." All full text papers were selected. Publications mentioning mesh size were brought for further analysis. A mesh surface area of 90 cm(2) was accepted as the threshold for defining the mesh as small or large. Also, a subgroup analysis for recurrence pooled proportion according to the mesh size, mesh type, and follow-up period was done. RESULTS: In total, 514 papers were obtained. There were no prospective or retrospective clinical studies comparing mesh size and clinical outcome. A total of 141 papers were duplicated in both databases. As a result, 373 papers were obtained. The full text was available in over 95 % of papers. Only 41 (11.2 %) papers discussed mesh size. In 29 studies, a mesh larger than 90 cm(2) was used. The most frequently preferred commercial mesh size was 7.5 × 15 cm. No papers mentioned the size of the mesh after trimming. There was no information about the relationship between mesh size and patient BMI. The pooled proportion in recurrence for small meshes was 0.0019 (95 % confidence interval: 0.007-0.0036), favoring large meshes to decrease the chance of recurrence. Recurrence becomes more marked when follow-up period is longer than 1 year (p < 0.001). Heavy meshes also decreased recurrence (p = 0.015). CONCLUSION: This systematic review demonstrates that the size of the mesh used in Lichtenstein hernia repair is rarely discussed in clinical studies. Papers that discuss mesh size appear to reflect a trend to comply with the latest recommendations to use larger mesh. Standard heavy meshes decrease the recurrence in hernia repair. Even though there is no evidence, it seems that large meshes decrease recurrence rates.

Modified patch repair of femoral hernia after inguinal herniorrhaphy.

BACKGROUND AND AIM: It has been reported that femoral hernias are rather common after a previous repair of inguinal hernia. We herein present a modified patch repair technique for large femoral hernias that develop after a Lichtenstein operation for ipsilateral inguinal hernia. PATIENTS AND METHODS: The modified technique for femoral hernia was applied to three patients who had a Lichtenstein repair for inguinal hernia. All patients were male. Hernia sac is dissected completely and sent back into to the preperitoneal space. Special attention should be given to the prevascular component of the sac. It is dissected as deep as possible into the preperitoneal space over the femoral vein. The defect is quite wide in this particular type of femoral hernia following Lichtenstein repair. A prosthetic patch that matches the defect is prepared. The medial edge of the mesh is configured to correspond to the pubic corner and lacunar ligament. The lateral margin of the patch is cut to create several petals for inverting the mesh above and medial to the femoral vein to prevent prevascular herniation. The mesh is secured to inguinal ligament, ilioinguinal tract, lacunar ligament, and Cooper ligament. Few sutures are put on the pubic corner and lacunar ligament. RESULTS: One patient was discharged after two hours, other two stayed overnight. Readmission because of seroma development was recorded in two cases where standard polypropylene meshes were used. No complication was observed in the other patient who received lightweight meshes. No early recurrences were recorded after 4, 9, and 30 months. CONCLUSION: Femoral recurrence after previous inguinal hernia repair seems to be a specific entity. It has a prevascular component and the hernia defect can be much larger than that of a primary femoral hernia. A patch repair with infra-inguinal approach can be a valuable alternative with low complication rate.

Predictors for duration of hospital stay after abdominal wall hernia repairs.

BACKGROUND: To identify variables those predict length of hospital stay separately after groin, primary ventral and incisional hernias. METHODS: A total of 1170 groin, primary ventral, and incisional hernia repairs (n = 959, 132, 79 respectively) and their perioperative variables were analyzed. For each subgroup of hernia type, univariate analysis was performed. Multivariate logistic regression model was used to determine independent variables that predict length of hospital stay in each group of hernia. RESULTS: Out of 1170 repairs; 959 were inguinal, 132 were primary ventral repairs and 79 were incisional hernia repairs. Strangulation (p = 0.021), ASA III-IV class (p < 0.001), longer duration of surgery (p < 0.001), systemic postoperative complications (p < 0.001), and local postoperative complications (p < 0.001) were associated with longer length of hospital stay in inguinal hernia repairs; type of repair procedure (p = 0.028), longer duration of surgery (p < 0.001), and systemic postoperative complications (p = 0.006) were associated with longer length of hospital stay in ventral primary hernias repairs; ASA III-IV class (p = 0.027) and longer duration of surgery (p = 0.003) were associated with longer length of hospital stay in incisional hernia repairs. CONCLUSIONS: Postoperative hospital stay can be predicted before the operation by evaluating certain factors related to the patient or procedure. Longer duration of surgery predict longer hospital stay in all types of ventral hernias where as strangulation, high ASA class, systemic-local postoperative complications, and type of repair procedures may predict longer length of hospital stay in different ventral hernia types.

Prosthetic repair of umbilical hernias in adults with local anesthesia in a day-case setting: a comprehensive report from a specialized hernia center.

BACKGROUND: Umbilical hernia is a common surgical problem. However, there seems to be a certain discrepancy between its importance and the attention it has received in the literature to date. This prospective study aimed to report a detailed analysis of prosthetic umbilical hernia repairs with local anesthesia in a day-case setting. METHODS: It was planned to enroll 100 consecutive patients who underwent an elective umbilical hernia repair with local anesthesia. Patients who required general anesthesia and simultaneous hernia repairs were excluded. The procedure including local anesthesia and intravenous sedation was explained to the patients in detail by the operating surgeons and the anesthesiologist. The following parameters were strictly recorded: gender, age, body mass index (BMI), concomitant diseases, history of hernia (primary/recurrent), size of fascial defect, duration of operation, level of intravenous sedation (light/moderate), discharge time, and complications. RESULTS: There were 54 male and 46 female patients. The mean age was 48.6 years (24-78 years). Four patients were older than 70 years of age. Forty-one patients had 84 concomitant diseases. Eleven patients had a recurrent hernia. Female patients more frequently presented with a recurrent hernia than male patients (19.6 vs. 3.7%, P = 0.009). A standard polypropylene mesh was used in the onlay position in 91 cases. In nine cases, a light mesh was placed in the preperitoneal space. A closed vacuum drain was left in situ in 37 cases. Light sedation was set in 86 cases, whereas 12 patients received a moderate sedation. Monitored anesthesia care was used in two cases. When moderate sedation was needed, a concurrent increase in lidocaine dose and total volume was recorded. There was a positive correlation between increased lidocaine use and high midazolam dose and additional propofol requirement. The mean total local anesthetic volume was 33 ml (10-63 ml). Lidocaine doses displayed a large range between the cases (70-600 mg). The mean lidocaine dose was 263.3 mg (standard deviation [SD]: 103.4). No bupivacaine was given in 19 cases, whereas the mean bupivacaine dose was 35.1 mg (0-100 mg) in 81 cases. The mean duration in the operation room was 69 min (25-150 min). It was significantly longer for recurrent hernias than primary ones (95 vs. 65 min; P = 0.0001). Higher total volume and higher lidocaine doses were required for the repair of recurrent hernias. In addition, it was observed that the longer the operation time, then the longer the lidocaine dose and the higher the total volume of local anesthetic agents. The patient satisfaction rate was 97%. The mean discharge time was 122 ± 58 min (45-420 min). Sixty-seven patients were sent home within 2 h. Early wound problems were observed in 11 patients. Small seromas and hematomas developed in six cases, and dissolved without drainage. Three superficial surgical site infections diagnosed by erythema and enduration were recorded without obvious suppuration. No recurrence was recorded after a mean follow-up of 17 months (5-41 months). One patient complained of pain at the lower edge of a standard polypropylene mesh at the third postoperative month. CONCLUSIONS: The repair of umbilical hernias with local anesthesia in a day-case setting is a good option, with low infection and recurrence rates. Most patients can be discharged early as planned. Separate doses and total volume of local anesthetic agents needed for umbilical hernia repair are clearly higher than those used in inguinal hernia repair. Patients with higher BMI, recurrent hernia, and defects larger than 3 cm may require higher local analgesic doses. The patient satisfaction is very good when the patients are provided with detailed information about day-surgery and local anesthesia.

Prophylactic antibiotic use in elective inguinal hernioplasty in a trauma center.

PURPOSE: In this double-blind prospective randomized trial, our objective was to investigate the effect of antibiotic prophylaxis in patients undergoing elective inguinal hernia surgery with mesh repair in a large-volume tertiary referral trauma center. METHODS: Eligible patients were assigned randomly to either an antibiotic prophylaxis group or a control group. Patients in the prophylaxis group were given 1 g cefazolin by IV bolus injection whereas the placebo control group received an equal volume of sterile saline preoperatively. A Lichtenstein repair was done in all cases. The patients were examined for surgical site infection (SSI) and other postoperative local complications before discharge, and reexamined 3, 5, 7, and 30 days after discharge. RESULTS: Groups were well matched for age, sex, coexisting diseases, ASA scores, type of hernia, type of anesthesia, duration of surgery. Incidence of infection was 7% in the control group (7/100) and 5% in the prophylaxis group (5/100) (P = 0.38). All the infections were superficial and responded well to drainage and proper antibiotic therapy. All other postoperative complications were similar in the two groups. CONCLUSIONS: In our settings antibiotic prophylaxis has no significant effect on the incidence of SSI in elective repair of inguinal hernias with mesh. The most effective way to reduce the incidence of infection in prosthetic repair may be a specific center for treatment of abdominal wall hernias.

Growth and trends in publications about abdominal wall hernias and the impact of a specific journal on herniology: a bibliometric analysis.

PURPOSE: The aim of this systematic review was to determine the exact volume and growth pattern of articles on abdominal wall hernias, in particular the effect of the journal Hernia on publications about hernias. METHODS: A PubMed search was performed for every year between 1965 and 2010, using the title words "inguinal hernia," "incisional hernia," and "umbilical hernia." Then, two consecutive 10-year periods were chosen for a systematic PubMed search, before and after 2001--the year in which Hernia began to be indexed in PubMed. The main keywords used were as follows: "inguinal hernia" "incisional hernia" "umbilical hernia" "mesh" "laparoscopic" and "experimental." RESULTS: The number of all articles indexed in PubMed increased 1.6-fold between the periods 1991-2000 and 2001-2010. The number of articles with the title word "inguinal hernia" increased 1.7-fold, whereas the rises for incisional and umbilical hernias were more prominent: 3.9- and 2.6-fold. Article titles with the combined keywords "hernia and mesh" and "hernia and laparoscopic" increased 2.8- and 2.4-fold. The most striking combined search was for "umbilical hernia and mesh" with a 20.5-fold rise. The percentage of articles published in the journal Hernia among all articles in all 25 selected journals, including Hernia was 30% on average. Hernia, Surgical Endoscopy and the British Journal of Surgery were the leading journals for publications for inguinal hernia in the last decade. CONCLUSIONS: Growth in hernia papers is greater than the overall growth in PubMed. Articles on incisional hernia increased faster than did those on inguinal and umbilical hernias. The establishment and indexing of Hernia decreased the proportion of hernia publications in other journals. The core journals for herniology are Hernia, Surgical Endoscopy, and the British Journal of Surgery.

Current options in inguinal hernia repair in adult patients.

Inguinal hernia is a very common problem. Surgical repair is the current approach, whereas asymptomatic or minimally symptomatic hernias may be good candidate for watchful waiting. Prophylactic antibiotics can be used in centers with high rate of wound infection. Local anesthesia is a suitable and economic option for open repairs, and should be popularized in day-case setting. Numerous repair methods have been described to date. Mesh repairs are superior to "nonmesh" tissue-suture repairs. Lichtenstein repair and endoscopic/laparoscopic techniques have similar efficacy. Standard polypropylene mesh is still the choice, whereas use of partially absorbable lightweight meshes seems to have some advantages.