Are immunosuppressive conditions and preoperative corticosteroid treatment risk factors in inguinal hernia repair?

INTRODUCTION: Immunosuppressive conditions and/or preoperative corticosteroid treatment have a negative influence on wound healing and can, therefore, lead to higher rates of surgical site infections (SSIs) and seromas. For inguinal hernia, no such studies have been carried out to date. METHODS: In an analysis of data from the Herniamed Registry, 2312 of 142,488 (1.6%) patients with primary unilateral inguinal hernia repair had an anamnestic history of an immunosuppressive condition and/or preoperative corticosteroid treatment. Using propensity score matching, 2297 (99.4%) pairs with comparative patient characteristics were formed. These were then compared using the following primary outcome criteria: intra- and postoperative complications, complication-related reoperations, recurrence at one-year follow-up, pain on exertion, pain at rest, and chronic pain requiring treatment at one-year follow-up. Of the 2297 matched pairs with primary unilateral inguinal hernia repair, 82.76% were male patients. 1010 (44.0%) were operated in laparo-endoscopic techniques (TEP, TAPP), 1225 (53.3%) in open techniques (Bassini, Shouldice, Lichtenstein, Plug, TIP, Gilbert, Desarda), and 62 (2.7%) in other techniques. RESULTS: The matched pair analysis results did not identify any disadvantage in terms of the outcome criteria for patients with an anamnestic history of immunosuppressive condition and/or preoperative corticosteroid treatment (yes vs no). In particular, no disadvantage was noted in the rate of surgical site infections (0.65% vs 0.70%; ns) or seromas (1.22% vs 1.57%; ns). The overall rates of postoperative complications were 3.40% vs 4.31% (p = ns) (plus 0.22% concordant events in five matched pairs). CONCLUSION: In primary unilateral inguinal hernia surgery, an immunosuppressive condition and/or preoperative corticosteroid treatment does not appear to have a negative influence on wound complications.

Is round ligament varicosity in pregnancy a common precursor for the later development of inguinal hernias? The prospective analysis of 28 patients over 9 years.

PURPOSE: Short-term effects of round ligament varicosity (RLV) in pregnancy have been investigated in small-scale studies. The long-term effects are unknown. This study aims to evaluate the risk of groin hernia manifestation after RLV in pregnancy, to delineate possible risk factors and to analyze the natural course of pregnancy and post-partum period with regard to RLV. METHODS: In a prospective analysis 28 pregnant women with RLV presented to the hernia clinic over 9 years. After clinical and ultrasound examination during pregnancy and publication of early results in 2013 a second structured follow-up was conducted. Demographic data, hernia-specific risk factors, comorbidities, pregnancy and birth-related data as well as post-partum period were documented without loss of follow-up. In these women, all pregnancies that occurred, including the ones without RLV, were analyzed. RESULTS: Median follow-up was 68 months (11.4-104.9). Only one groin hernia was found. No risk factors could be identified. After uncomplicated childbirth complaints subsided spontaneously in all but one patient within 4 weeks. Recurrence rates in subsequent pregnancies are up to 89%. CONCLUSION: Temporary RLV-induced dilation of the deep inguinal ring in pregnancy is not a common precursor for the development of inguinal hernias later in life. All findings support the theory that the hindrance of venous blood flow caused by the gravid uterus is an important contributing factor for RLV in pregnancy, which is self-limited but has a high risk of recurrence and is not an indication for surgery before or after delivery or for cesarean section.

Surgical and radiological behavior of MRI-depictable mesh implants after TAPP repair: the IRONMAN study.

PURPOSE: Knowledge of postoperative behavior of mesh implants used for hernia repair is generally limited to cases of recurrence, local complications or return to the previous operative field in other pathological conditions. Previous studies with MRI-visible mesh implants in different parts of the abdominal wall have led to variable findings with regard to mesh properties and mostly described a reduction in size over time with subsequently limited mesh overlap over hernia defects which could contribute to recurrence. We aimed to evaluate implant properties in a mechanically stable anatomical region after TAPP repair of primary unilateral inguinal hernias in men with clinical and MRI examinations 4 weeks and 1 year after surgery. METHODS: From 11/2015 to 01/2019, 23 men with primary, unilateral, inguinal hernias underwent TAPP repair with iron particle-loaded, MRI-visible mesh implants in a prospective cohort study. In 16 patients the operative outcome could be evaluated 4 weeks and 12 months after surgery by clinical examination and MRI evaluation with regard to postoperative course, possible adverse outcomes and radiological findings related to implant behavior-namely MRI-identifiability, mesh dislocation or reduction in surface area. RESULTS: All included patients had an uneventful postoperative clinical course. MRI after 4 weeks revealed one postoperative seroma, which resolved spontaneously. No recurrence was detected. Mesh implants could be accurately delineated in DIXON-IN studies and showed neither clinically nor statistically significant changes in size or position. CONCLUSION: 4 weeks and 1 year after a standardized TAPP procedure the mesh implant used in this study showed no tendency towards dislocation or reduction in size in this anatomical position. Its MRI visibility allows accurate delineation during the postoperative course by experienced radiologists in appropriate MRI protocols. Larger patient series are desirable to further support these findings. Shrinkage of implants in the groin as a reason for early recurrence may be overestimated.

Retroperitoneal Liposarcoma: A Concern in Inguinal Hernia Repair.

BACKGROUND AND OBJECTIVES: The goal of the study was to evaluate retroperitoneal sarcomas with continuous growth into the scrotum through the inguinal canal with regard to diagnostic approach, surgical treatment, and outcome. The analysis is based on a comprehensively documented case and a complete systematic review of published literature. Potential pitfalls are highlighted. METHODS: We describe the case of a 57-year-old male Caucasian who presented with a swelling in the right groin. Suspecting a scrotal hernia, transabdominal preperitoneal plasty surgery was planned but intraoperatively a large retroperitoneal mass was revealed. After computed tomography scan and magnetic resonance imaging, a complete resection of the tumor was performed. Ten previously published cases describing the same pathology were retrieved from the PubMed database and analyzed systematically in a complete literature review. RESULTS: Histology showed a well-differentiated liposarcoma with tumor-free resection margins. Twenty-two months postoperatively, the patient is in complete clinical remission. CONCLUSION: Preoperative clinical suspicion of retroperitoneal involvement is paramount for developing of a surgical strategy and in unclear cases demands extended preoperative diagnostic workup. Following the appropriate patient management is crucial to prognosis.

A model for the regulation of brain adenylate cyclase by ionic equilibria.

Multiple-equilibrium equations were solved to investigate the individual and separate effects of Mg2+, Mn2+, Ca2+, ATP4-, and their complexes on the kinetics of brain adenylate cyclase. The effects of divalent metals and/or ATP4- (in excess of their participation in complex formation) were determined and, from the corresponding apparent affinity values, the following kinetic constants were obtained: Km(MgATP) = 1.0 mM, Ki(ATP4-) = 0.27 mM, Km(MnATP) = 0.07 mM, and Ki(CaATP) = 0.015 mM. MgATP, MnATP, ATP4-, and CaATP were shown to compete for the active site of the enzyme. Hence, it is proposed that endogenous metabolites with a strong ligand activity for divalent metals, such as citrate and some amino acids, become integrated into a metabolite feedback control of the enzyme through the release of ATP4- from MgATP. Ca2+ fluxes may participate in the endogenous regulation of adenylate cyclase by modifying the level of CaATP. The free divalent metals show an order of affinity K0.5(Ca2+) = 0.02 mM, K0.5(Mn2+) = 3.8 mM, K0.5(Mg2+) - 4.7 mM, and an order of activity Mn2+ greater than Mg2+ greater than Ca2+. The data indicate that Mn2+ and Mg2+ ions may compete for a regulatory site distinct from the active site and increase Vm without changing Km(MgATP), Km(MnATP), or Ki(ATP4-). The interactions of ATP4- and CaATP, which act as competitive inhibitors of the reaction of the enzyme with the substrates MgATP and MnATP, and Mg2+ and Mn2+, which act as activators of the enzyme in the absence of hormones, are shown to follow the random rapid equilibrium BiBi group-transfer mechanism of Cleland with the stipulation that neither Mg2+ nor Mn2+, in excess of their respective participation in substrate formation, are obligatorily required for basal activity. ATP4- and CaATP are involved in dead-end inhibition. For MgCl2 saturation curves at constant total ATP concentration, the computer-generated curves based on the RARE BiBi model predict a change in the Hill cooperativity h from a basal value of 2.6, when Mg2+ is not obligatorily required, to 4.0 when the addition of hormones or neurotransmitters induces an obligatory requirement for Mg2+.