Current Concepts of Inguinal Hernia Repair.

With more than 20 million patients annually, inguinal hernia repair is one of the most often performed surgical procedures worldwide. The lifetime risk to develop an inguinal hernia is 27-43% for men and 3-6% for women. In spite of all advances, 11% of all patients suffer from a recurrence and 10-12% from chronic pain following primary inguinal hernia repair. By developing evidence-based guidelines and recommendations, the international hernia societies aim to improve the outcome of inguinal hernia repair due to standardization of care. From a total of more than 100 different repair techniques for inguinal and femoral hernias, classified as tissue repair, open mesh repair, and laparo-endoscopic mesh repair, the new International Guidelines of the Hernia-Surge Group only recommend the totally extraperitoneal patch plasty (TEP), transabdominal preperitoneal patch plasty (TAPP), and Lichtenstein techniques. Since a generally accepted technique suitable for all inguinal hernias does not exist, surgeons should provide both an anterior open (Lichtenstein) and a posterior laparo-endoscopic (TEP or TAPP) approach option. The guidelines strongly recommend that surgeons tailor the treatment of inguinal hernias based on expertise, local/national resources, and patient- and hernia-related factors. A tailored approach in inguinal hernia repair should pay heed to the patient- and hernia-related factors, unilateral hernia in men and women, bilateral hernia, recurrent hernia, scrotal hernia, previous pelvic and lower abdominal surgery, severe cardiac or pulmonary comorbidities, and incarcerated hernia.

Mesh versus suture repair of umbilical hernia in adults: a randomised, double-blind, controlled, multicentre trial.

BACKGROUND: Both mesh and suture repair are used for the treatment of umbilical hernias, but for smaller umbilical hernias (diameter 1-4 cm) there is little evidence whether mesh repair would be beneficial. In this study we aimed to investigate whether use of a mesh was better in reducing recurrence compared with suture repair for smaller umbilical hernias. METHODS: We did a randomised, double-blind, controlled multicentre trial in 12 hospitals (nine in the Netherlands, two in Germany, and one in Italy). Eligible participants were adults aged at least 18 years with a primary umbilical hernia of diameter 1-4 cm, and were randomly assigned (1:1) intraoperatively to either suture repair or mesh repair. In the first 3 years of the inclusion period, blocked randomisation (of non-specified size) was achieved by an envelope randomisation system; after this time computer-generated randomisation was introduced. Patients, investigators, and analysts were masked to the allocated treatment, and participants were stratified by hernia size (1-2 cm and >2-4 cm). At study initiation, all surgeons were invited to training sessions to ensure they used the same standardised techniques for suture repair or mesh repair. Patients underwent physical examinations at 2 weeks, and 3, 12, and 24-30 months after the operation. The primary outcome was the rate of recurrences of the umbilical hernia after 24 months assessed in the modified intention-to-treat population by physical examination and, in case of any doubt, abdominal ultrasound. This trial is registered with ClinicalTrials.gov, number NCT00789230. FINDINGS: Between June 21, 2006, and April 16, 2014, we randomly assigned 300 patients, 150 to mesh repair and 150 to suture repair. The median follow-up was 25·1 months (IQR 15·5-33·4). After a maximum follow-up of 30 months, there were fewer recurrences in the mesh group than in the suture group (six [4%] in 146 patients vs 17 [12%] in 138 patients; 2-year actuarial estimates of recurrence 3·6% [95% CI 1·4-9·4] vs 11·4% (6·8-18·9); p=0·01, hazard ratio 0·31, 95% CI 0·12-0·80, corresponding to a number needed to treat of 12·8). The most common postoperative complications were seroma (one [<1%] in the suture group vs five [3%] in the mesh group), haematoma (two [1%] vs three [2%]), and wound infection (one [<1%] vs three [2%]). There were no anaesthetic complications or postoperative deaths. INTERPRETATION: This is the first study showing high level evidence for mesh repair in patients with small hernias of diameter 1-4 cm. Hence we suggest mesh repair should be used for operations on all patients with an umbilical hernia of this size. FUNDING: Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands.

Watchful Waiting Versus Surgery of Mildly Symptomatic or Asymptomatic Inguinal Hernia in Men Aged 50 Years and Older: A Randomized Controlled Trial.

OBJECTIVE: To compare if watchful waiting is noninferior to elective repair in men aged 50 years and older with mildly symptomatic or asymptomatic inguinal hernia. BACKGROUND: The role of watchful waiting in older male patients with mildly symptomatic or asymptomatic inguinal hernia is still not well-established. METHODS: In this noninferiority trial, we randomly assigned men aged 50 years and older with mildly symptomatic or asymptomatic inguinal hernia to either elective inguinal hernia repair or watchful waiting. Primary endpoint was the mean difference in a 4-point pain/discomfort score at 24 months of follow-up. Using a 0.20-point difference as a clinically relevant margin, it was hypothesized that watchful waiting was noninferior to elective repair. Secondary endpoints included quality of life, event-free survival, and crossover rates. RESULTS: Between January 2006 and August 2012, 528 patients were enrolled, of whom 496 met the inclusion criteria: 234 were assigned to elective repair and 262 to watchful waiting. The mean pain/discomfort score at 24 months was 0.35 [95% confidence interval (CI) 0.28-0.41)] in the elective repair group and 0.58 (95% CI 0.52-0.64) in the watchful waiting group. The difference of these means (MD) was -0.23 (95% CI -0.32 to -0.14). In the watchful waiting group, 93 patients (35·4%) eventually underwent elective surgery and 6 patients (2·3%) received emergent surgery for strangulation/incarceration. Postoperative complication rates and recurrence rates in these 99 operated individuals were comparable with individuals originally assigned to the elective repair group (8.1% vs 15.0%; P = 0.106, 7.1% vs 8.9%; P = 0.668, respectively). CONCLUSIONS: Our data could not rule out a relevant difference in favor of elective repair with regard to the primary endpoint. Nevertheless, in view of all other findings, we feel that our results justify watchful waiting as a reasonable alternative compared with surgery in men aged 50 years and older.

Classification systems for distal radius fractures.

Background and purpose - The reliability of conventional radiography when classifying distal radius fractures (DRF) is fair to moderate. We investigated whether reliability increases when additional computed tomography scans (CT) are used. Patients and methods - In this prospective study, we performed pre- and postreduction posterior-anterior and lateral radiographs of 51 patients presenting with a displaced DRF. The case was included when there was a (questionable) indication for surgical treatment and an additional CT was conducted within 5 days. 4 observers assessed the cases using the Frykman, Fernández, Universal, and AO classification systems. The first 2 assessments were performed using conventional radiography alone; the following 2 assessments were performed with an additional CT. We used the intraclass correlation coefficient (ICC) to evaluate reliability. The CT was used as a reference standard to determine the accuracy. Results - The intraobserver ICC for conventional radiography alone versus radiography and an additional CT was: Frykman 0.57 vs. 0.51; Fernández 0.53 vs. 0.66; Universal 0.57 vs. 0.64; AO 0.59 vs. 0.71. The interobserver ICC was: Frykman: 0.45 vs. 0.28; Fernández: 0.38 vs. 0.44; Universal: 0.32 vs. 0.43; AO: 0.46 vs. 0.40. Interpretation - The intraobserver reliability of the classification systems was fair but improved when an additional CT was used, except for the Frykman classification. The interobserver reliability ranged from poor to fair and did not improve when using an additional CT. Additional CT scanning has implications for the accuracy of scoring the fracture types, especially for simple fracture types.

Single Fascia Iliaca Compartment Block is Safe and Effective for Emergency Pain Relief in Hip-fracture Patients.

INTRODUCTION: Currently, it is common practice in the emergency department (ED) for pain relief in hip-fracture patients to administer pain medication, commonly systemic opioids. However, with these pain medications come a high risk of side effects, especially in elderly patients. This study investigated the safety profile and success rate of fascia iliaca compartment block (FICB) in a busy ED. This ED was staffed with emergency physicians (EPs) and residents of varying levels of experience. This study followed patients' pain levels at various hourly intervals up to eight hours post procedure. METHODS: Between September 2012 and July 2013, we performed a prospective pilot study on hip-fracture patients who were admitted to the ED of a teaching hospital in the Netherlands. These patients were followed and evaluated post FICB for pain relief. Secondary outcome was the use of opioids as rescue medication. RESULTS: Of the 43 patients in this study, patients overall experienced less pain after the FICB (p=0.04). This reduction in pain was studied in conjunction with the use and non-use of opioids. A clinically meaningful decrease in pain was achieved after 30 minutes in 62% of patients (54% with the use of opioids, 8% without opioids); after 240 minutes in 82% of patients (18% with opioids, 64% without opioids); after 480 minutes in 88% of patients (16% with opioids, 72% without opioids). No adverse events were reported. CONCLUSION: In a busy Dutch ED with rotating residents of varying levels of experience, FICB seems to be an efficient, safe and practical method for pain reduction in patients with a hip fracture. Even without the use of opioids, pain reduction was achieved in 64% of patients after four hours and in 72% of patients after eight hours.

[European practice guidelines for the treatment of inguinal hernia: a summary]. / Europese richtlijn voor behandeling van liesbreuken: een samenvatting.

The European best practice guidelines on the treatment of inguinal hernia were published in 2009. Publications on this subject in international journals were updated in 2012. In patients with asymptomatic inguinal hernia or with minimal symptoms, conservative treatment is safe, but they do need to be informed that the risk for undergoing surgery increases by nearly 10% a year. Conservative treatment is less useful in younger patients. All adult men with symptomatic inguinal hernia need to undergo surgery. They should be treated with a technique in which a synthetic prosthesis (mesh) is used. The Lichtenstein technique is advised for the open treatment of inguinal hernia, since this is the most thoroughly evaluated technique. For endoscopic treatment, the European best practice guidelines advise the total extra-peritoneal technique. Nowadays the focus in complications is on the prevention of postoperative chronic pain.

[Which surgical technique for inguinal hernia is best?]. / Wat is de beste techniek voor liesbreukchirurgie?

There is an ongoing discussion about the best technique for repairing an inguinal hernia. In a study with a long follow-up period in which the endoscopic Total Extra Peritoneal (TEP)-approach and open-Lichtenstein repair procedures were compared, it was concluded that inguinal hernia should be repaired by experienced surgeons by means of TEP. The results of the study are consistent with the content of the European guidelines for inguinal hernia repair, but the above recommendation is not. The differences in postoperative pain and chronic pain in favour of TEP are small, and appear to diminish over time. There were more complications with TEP, the learning curve was longer and hospital costs were higher. The Lichtenstein repair procedure, on the other hand, was probably not performed well with its high pain scores. Both techniques had comparably high recurrence rates.

Safety and efficacy of procedural sedation with propofol in a country with a young emergency medicine training program.

OBJECTIVES: To evaluate the safety and effectiveness of procedural sedation with propofol by newly trained Dutch emergency physicians. METHODS: A prospective observational cohort study of patients in emergency department undergoing procedural sedation at two teaching hospitals. Primary outcomes were serious adverse events, sedation events, and efficacy. A standardized protocol and data collection form was used at both sites. RESULTS: Three hundred and eighty-six patients were enrolled over 18 months. The median age was 57 years (range 6-94, interquartile range 38-70), 55% were male patients. All had an American Society of Anesthesiologists class score of 3 or less. Indications for procedural sedation were reduction of dislocations (51%), electrocardioversion (32%), fracture reduction (8%), and abscess/wound treatment (6%). The median propofol dose was 1.0 mg/kg (0.70-1.5) and 45% received fentanyl in addition; median dose was 1 mcg/kg (0.6-1.3). Most had a Ramsay sedation score of 4 or 5. The procedural success rate was 99.5%. No serious adverse events were reported. Sedation events included; hypoventilation (11%), desaturation (5%), hypotension (3%), and bradycardia (1%), all of which resolved with simple supportive interventions. One patient vomited without aspirating. Increased age (>60 years) (P=0.001) and high Ramsay score (>3) (P=0.024) were the only significant predictors of events. Sex, weight, total dose of propofol, use of fentanyl, and type of procedure were not independent risk factors for any event. CONCLUSION: Newly trained Dutch emergency physicians can perform procedural sedation with propofol safely and effectively. Increased age and high Ramsay scores were the only risk factors for sedation events. All events were minor and responded to simple interventions.

Validation of the Emergency Severity Index (ESI) in self-referred patients in a European emergency department.

OBJECTIVE: To validate the Emergency Severity Index (ESI) triage algorithm in predicting resource consumption and disposition by self-referred patients in a European emergency department. METHODS: This was a prospective, observational cohort study using a convenience sample of self-referred emergency department patients >14 years of age presenting to a busy urban teaching hospital during a 39-day period (27 May-4 July 2001). Observed resource use was compared with resource utilisation predicted by the ESI. Outpatient referrals after discharge and hospitalisations were also recorded. RESULTS: ESI levels were obtained in 1832/3703 (50%) self-referred patients, most of whom were in the less severe ESI-4 (n = 685, 37%) and ESI-5 (n = 983, 54%) categories. Use of resources was strongly associated with the triage level, rising from 15% in ESI-5 to 97% in ESI-2 patients. Specialty consultations and admissions also rose with increasing ESI severity. Only 5% of ESI-5 patients required consultation and <1% were admitted, whereas 85% of ESI-2 patients received a consultation and 56% were admitted, 26% to a critical care bed. Only 2% of the ESI-5 patients underwent blood tests, compared with 76% of the sicker ESI-2 patients. X rays were the most commonly used resource in patients triaged to ESI-4 and ESI-5. CONCLUSION: The ESI triage category reliably predicts the severity of a patient's condition, as reflected by resource utilisation, consultations and admissions in a population of self-referred patients in a European emergency department. It clearly identifies patients who require minimal resources, or at most an x ray, and those unlikely to require admission.

Antegrade locked nailing of open humeral shaft fractures.

This retrospective study of 21 patients evaluates the effectiveness of primary antegrade locked intramedullary nailing for open humeral shaft fractures. Study participants were culled from the patient database of Harborview Medical Center, an urban level-1 trauma center in Seattle, Wash. Patients were evaluated for infection, nerve injury, shoulder function, range of motion, union, and healing. All 21 fractures united. Nineteen united in an average of 9.5 weeks. Two complications united in an average of 42 weeks. Seven patients had preoperative nerve palsies with complete recovery in 4 and incomplete recovery in 2 weeks. At final follow-up, 4 patients had clinically significant shoulder pain.

Emergency department patient characteristics: Potential impact on emergency medicine residency programs in the Netherlands.

OBJECTIVES: We set out to study emergency department patient characteristics at a busy level-2 trauma center, to gain insight into the practise of emergency medicine, which is not yet recognized as a specialty in the Netherlands. METHODS: From May 27 to July 4 2001, the following data were recorded from the charts of all patients presenting to the emergency department: age, time and form of presentation, diagnostics, treatment, disposition and the single best diagnosis (International Classification of Disease-10 classification). RESULTS: The majority (84%) of the 5234 patients (134/day) patients seen were self-referred and treated by the emergency department physician. The remaining 16% were referred, usually by their general practitioner, directly to a specialty service, which saw them in the emergency department. Self-referred patients tended to be younger (average 33 years), with minor trauma, and infrequently required diagnostics (37%), treatment (49%) or admission (4%). The referred patients were older (average 50 years), with 41% needing admission. Only 16% of all patients were under 16 years of age. In all, there were five deaths (referred patients), 12 resuscitations, seven intubations, seven chest tube insertions and no lumbar punctures performed during the study period. CONCLUSION: The acuity of self-referred patients seen by the emergency physicians is low, with little diagnostic testing and few interventions and resuscitations, even in a busy center. This has both training and practise implications and it may be inappropriate to take an emergency medicine practise model or curriculum from another country based on its emergency department population.

The role of antibiotic prophylaxis in prevention of wound infection after Lichtenstein open mesh repair of primary inguinal hernia: a multicenter double-blind randomized controlled trial.

OBJECTIVE: To determine whether the use of prophylactic antibiotics is effective in the prevention of postoperative wound infection after Lichtenstein open mesh inguinal hernia repair. SUMMARY BACKGROUND DATA: A recent Cochrane meta-analysis (2003) concluded that "antibiotic prophylaxis for elective inguinal hernia repair cannot be firmly recommended or discarded." METHODS: Patients with a primary inguinal hernia scheduled for Lichtenstein repair were randomized to a preoperative single dose of 1.5 g intravenous cephalosporin or a placebo. Patients with recurrent hernias, immunosuppressive diseases, or allergies for the given antibiotic were excluded. Infection was defined using the Centers for Disease Control and Prevention criteria. RESULTS: We included 1040 patients in the study between November 1998 and May 2003. According to the intention-to-treat principle, 1008 patients were analyzed. There were 8 infections (1.6%) in the antibiotic prophylaxis group and 9 (1.8%) in the placebo group (P = 0.82). There was 1 deep infection in the antibiotic prophylaxis group and 2 in the placebo group (P = 0.57). Statistical analysis showed an absolute risk reduction of 0.19% (95% confidence interval, -1.78%-1.40%) and a number needed to treat of 520 for the total number of infections. For deep infection, the absolute risk reduction is 0.20% (95% confidence interval, -0.87%-0.48%) with a number needed to treat of 508. CONCLUSIONS: A low percentage (1.7%) of wound infection after Lichtenstein open mesh inguinal (primary) hernia repair was found, and there was no difference between the antibiotic prophylaxis or placebo group. The results show that, in Lichtenstein inguinal primary hernia repair, antibiotic prophylaxis is not indicated in low-risk patients.

Emergency medicine in the Netherlands, the necessity for changing the system: results from two questionnaires.

OBJECTIVE: To obtain information about patient, staff and organization characteristics of Emergency Departments in the Netherlands, and evaluate the changes between 1996 and 1999. METHODS: The heads of the Emergency Departments of all hospitals in the Netherlands were sent a questionnaire concerning patient, staff, and organization characteristics, as well as questions about intended future developments. The results were compared with data obtained from a comparable questionnaire in 1996. RESULTS: In the Netherlands, 113 hospitals (113/126) have an Emergency Department; 105/113 returned the questionnaire (93%). Ninety-two percent of the hospitals reported an increase in annual Emergency Department census and in the number of self-referred patients. The number of Emergency Departments staffed by only surgical residents decreased (52% in 1996 versus 41% in 1999), whereas the number of hospitals employing emergency physicians increased (24% in 1996 versus 45% in 1999). In 92% of the hospitals, nurses who work in the Emergency Department receive specific training. For emergency physicians, a specific training programme is not available, and in fact 30% of the physicians did not have any specific emergency medicine training. Therefore, none of the emergency physicians were fully trained in emergency medicine. According to 88% of all responders, there is a future for emergency medicine as an independent speciality in the Netherlands, and 35% of all hospitals intend to initiate a training programme for emergency physicians in the future. CONCLUSION: Almost all hospitals in the Netherlands reported an increase in the number of patients visiting the Emergency Department, especially in the number of self-referred patients. A majority of the Emergency Departments are now staffed by emergency physicians instead of surgical residents. Developing specific training programmes for emergency physicians should be a priority for the Netherlands in the future.