Worldwide hernia repair: variations in the treatment of primary unilateral inguinal hernias in adults in the United Kingdom and in low- and middle-income countries.

INTRODUCTION: In this invited commentary, we aim to quantify and explain the variation between, and also within, developed healthcare systems (using the UK as an example) and low- to middle-income countries (LMICs). Rather than including complex cases, we have looked only at 'uncomplicated' primary unilateral inguinal hernias, an area where limited variation may be identified. METHODS: Data were obtained from Hospital Episode Statistics and structured surveys in the United Kingdom and in low- and middle-income countries. CONCLUSION: There is widespread variation in the repair of 'uncomplicated' primary inguinal hernias worldwide and within developed healthcare systems.

Is there a role for hernia subspecialists? Or is this a step too far?

Specialization influences the way that we deliver surgical care and has a direct impact on surgeons, healthcare systems and patients. Abdominal wall hernia repairs are among the most commonly performed surgical procedures worldwide, and over 20 million prosthetic meshes are inserted annually. Worldwide outcomes from groin hernia repair, as reflected by 5-year recurrence rates, range from 1 to 4 %. However, the results for incisional hernia repair are at least ten times worse, with worldwide recurrence rates of about 25 % and upwards. This editorial aims to debate the argument for and against hernia subspecialists and provide a framework for implementing specialist hernia services.

An international surgical collaboration: humanitarian surgery in Brazil.

PURPOSE: Brazil is the fifth most populous country in the world with widespread regional and social inequalities. Regional disparities in healthcare are unacceptably large, with the remote and poor regions of the north and northeast having reduced life expectancy compared to the south region, where life expectancy approaches that of rich countries. We report our experience of a humanitarian surgery mission to the Amazonas state, in the northwest part of Brazil. METHODS: In August 2014, a team of seven consultant surgeons, and two trainees with the charity 'International Hernia', visited three hospitals in the Amazonas state to provide hernia surgery and training. RESULTS: Eighty-nine hernias were repaired in 74 patients (female = 22, male = 52) with a median age of 44 years (range 2-83 years). Nine patients underwent more than one type of hernia repair, and there were 9 laparoscopic inguinal and ventral incisional hernia repairs. Local doctors were trained in hernia repair techniques, and an International Hernia Symposium was held at the University of the State of Amazonas, Manaus. CONCLUSION: The humanitarian mission provided hernia surgery to an underserved population in Brazil and training to local doctors, building local sustainability. Continued cooperation between host and international surgeons for future missions to Brazil will ensure continuing surgical training and technical assistance.

Identification and management of the ilio-inguinal and ilio-hypogastric nerves in open inguinal hernia repair: benefits of self-gripping mesh.

PURPOSE: A large randomized, multicenter European study recently reported a reduction in early pain after open inguinal surgery when self-gripping mesh was used compared with sutured Lichtenstein repair. This secondary exploratory study is focused on the influence of nerve identification and handling on post-operative pain. METHODS: Post-operative VAS pain data and Surgical Pain Scores (SPS) from 507 patients included in this study were analyzed according to whether inguinal nerves were preserved or resected during surgery to investigate whether identification and peri-operative nerve handling impact post-operative pain. RESULTS: Preservation of the ilio-hypogastric nerve during Lichtenstein mesh repair with suture fixation was associated with significantly more post-operative pain compared with resection at each follow-up (p ≤ 0.003). This difference was not significant with self-gripping mesh repair. The decrease from baseline in post-operative VAS and SPS scores were significantly greater after self-gripping mesh repair compared to Lichtenstein repair at 1 year, but only when the ilio-hypogastric nerve was preserved (VAS scores, p = 0.009; SPS scores, p = 0.015). No such difference was observed with the ilio-inguinal nerve. When self-gripping mesh was used, preservation of the ilio-hypogastric nerve was associated with significantly greater decreases in post-operative pain (change in VAS score from baseline) compared with Lichtenstein repair at each follow-up (p ≤ 0.018). CONCLUSIONS: The ilio-hypogastric nerve is in danger of being traumatized during Lichtenstein mesh repair with suture fixation. The use of self-gripping mesh was shown to reduce the level of post-operative pain when the ilio-hypogastric nerve was preserved. Resection of the ilio-hypogastric nerve during Lichtenstein repair eliminates this difference.

Post-operative benefits of Tisseel(®)/Tissucol (®) for mesh fixation in patients undergoing Lichtenstein inguinal hernia repair: secondary results from the TIMELI trial.

PURPOSE: The Tisseel/Tissucol for mesh fixation in Lichtenstein hernia repair (TIMELI) study showed that mesh fixation with human fibrin sealant during inguinal hernia repair significantly reduced moderate-severe complications of pain 12 months post-operatively compared with sutures. Further analyses may assist surgeons by investigating predictors of post-surgical complications and identifying patients that may benefit from Tisseel/Tissucol intervention. METHODS: Univariate and multivariate analyses identified risk factors for combined pain, numbness and groin discomfort (PND) visual analogue scale (VAS) score 12 months post-operatively. Variables tested were: fixation method, age, employment status, physical activity, nerve handling, PND VAS score at pre-operative visit and 1 week post-operatively. The effect of fixation technique on separate PND outcomes 12 months post-surgery was also assessed. Analyses included the intention-to-treat (ITT) population and a subpopulation with pre-operative PND VAS > 30 mm. RESULTS: 316 patients were included in the ITT, with 130 patients in the subpopulation with pre-operative PND VAS > 30. Multivariate analysis identified mesh fixation with sutures, worsening pre-operative PND and worsening PND 1 week post-surgery as significant predictors of 12-month PND in the ITT population; mesh fixation with sutures was a significant predictor of 12-month PND in the pre-operative PND VAS > 30 subpopulation (p < 0.05). Mesh fixation with Tisseel/Tissucol resulted in significantly less numbness and a lower intensity of groin discomfort compared with sutures at 12 months; there was no difference in pain between the treatment groups. CONCLUSIONS: Pre-operative discomfort may be an important predictor of post-operative pain, numbness and discomfort. Tisseel/Tissucol may improve long-term morbidity over conventional sutures in these patients.

Mechanical failure of a lightweight polypropylene mesh.

We report the case of a 41-year-old male who underwent repair of a recurrent midline abdominal incisional hernia with components separation. The hernia defect was repaired with a 30 cm × 30 cm underlay biological (Strattice) mesh used to partially bridge a small residual gap between the rectus muscles and reinforced with a 30 cm × 30 cm lightweight polypropylene onlay mesh (BARD™ soft mesh). The patient later developed a large persistent seroma that was excised 18 weeks later. On exploration of the previous hernia repair, it was noted that the onlay polypropylene mesh had fractured leaving a 3 cm by 2 cm defect, but the underlying biological mesh was intact preventing a recurrence of the hernia (see Fig. 1). The fractured mesh was repaired with an additional onlay 10 cm × 10 cm polypropylene mesh, the seroma was de-roofed, and the patient was later discharged. This case highlights the early mechanical failure of a lightweight polypropylene mesh; the precise mechanism of failure in this case is unclear and, however, may be related to high intra-abdominal pressures postoperatively. Fig. 1 Photograph showing onlay polypropylene (BARD™ soft mesh) mesh superficial to a biological (Strattice) sublay mesh bridging the recti (on the left and right wound edges). Arrow indicates the 2 cm by 3 cm fracture.

'Treatment of the sportsman's groin': British Hernia Society's 2014 position statement based on the Manchester Consensus Conference.

INTRODUCTION: The aim was to produce a multidisciplinary consensus to determine the current position on the nomenclature, definition, diagnosis, imaging modalities and management of Sportsman's groin (SG). METHODS: Experts in the diagnosis and management of SG were invited to participate in a consensus conference held by the British Hernia Society in Manchester, U.K. on 11-12 October 2012. Experts included a physiotherapist, a musculoskeletal radiologist and surgeons with a proven track record of expertise in this field. Presentations detailing scientific as well as outcome data from their own experiences were given. Records were made of the presentations with specific areas debated openly. RESULTS: The term 'inguinal disruption' (ID) was agreed as the preferred nomenclature with the term 'Sportsman's hernia' or 'groin' rejected, as no true hernia exists. There was an overwhelming agreement of opinion that there was abnormal tension in the groin, particularly around the inguinal ligament attachment. Other common findings included the possibility of external oblique disruption with consequent small tears noted as well as some oedema of the tissues. A multidisciplinary approach with tailored physiotherapy as the initial treatment was recommended with any surgery involving releasing the tension in the inguinal canal by various techniques and reinforcing it with a mesh or suture repair. A national registry should be developed for all athletes undergoing surgery. CONCLUSIONS: ID is a common condition where no true hernia exists. It should be managed through a multidisciplinary approach to ensure consistent standards and outcomes are achieved.

Medical talc increases the incidence of seroma formation following onlay repair of major abdominal wall hernias.

PURPOSE: Seroma is a well established complication of the repair of major abdominal wall hernias, occasionally requiring aspiration and reoperation. Medical talc seromadesis (MTS) has been described in the literature. The aim of this study was to determine the effect of MTS on seroma formation after onlay repair of incisional hernia. METHODS: A retrospective review of a prospective database was conducted for 5 months from April 2011, when 21 consecutive patients received MTS. Outcomes were compared with a published and validated series from the same unit. RESULTS: There were no differences in basic demographics and co-morbidities between the two groups. The mean BMI was 34 for the MTS group. The incidence of recurrent incisional hernia prior to surgery was greater in MTS (9/21 vs. 36/116, p = 0.39). The mean area of fascial defect measured intra-operatively and mesh used to cover the incisional hernia defect was 170 and 309 cm(2) for the MTS group. The mean operating time was 152 min and a mean of 10 g of medical talc was used for seromadesis. The seroma rate increased from 11/116 (9.5 %) to 16/21 (76 %) (p = 0.001) as did the rate of superficial wound infection 10/116 (8.6 %) to 9/21 (43 %) (p = 0.03) in the MTS group. There was no difference in the length of in-hospital stay between the two groups. CONCLUSIONS: The application of medical talc increased the rate of seroma formation and superficial wound infection in patients undergoing open 'onlay' repair of major abdominal wall hernia.

Randomized controlled multicenter international clinical trial of self-gripping Parietex™ ProGrip™ polyester mesh versus lightweight polypropylene mesh in open inguinal hernia repair: interim results at 3 months.

PURPOSE: To compare clinical outcomes following sutureless Parietex™ ProGrip™ mesh repair to traditional Lichtenstein repair with lightweight polypropylene mesh secured with sutures. METHODS: This is a 3-month interim report of a 1-year multicenter international study. Three hundred and two patients were randomized; 153 were treated with Lichtenstein repair (L group) and 149 with Parietex™ ProGrip™ precut mesh (P group) with or without fixation. The primary outcome measure was postoperative pain using the visual analog scale (VAS, 0-150 mm); other outcomes were assessed prior to surgery and up to 3 months postoperatively. RESULTS: Compared to baseline, pain score was lower in the P group at discharge (-10%) and at 7 days (-13%), while pain increased in the L group at discharge (+39%) and at 7 days (+21%). The difference between groups was significant at both time points (P = 0.007 and P = 0.039, respectively). In the P group, patients without fixation suffered less pain compared to those with single-suture fixation (1 month: -20.9 vs. -6.15%, P = 0.02; 3 months: -24.3 vs. -7.7%, P = 0.01). The infection rate was significantly lower in the P group during the 3-month follow-up (2.0 vs. 7.2%, P = 0.032). Surgery duration was significantly shorter in the P group (32.4 vs. 39.1 min; P < 0.001). No recurrence was observed at 3 months in both groups. CONCLUSIONS: Surgery duration, early postoperative, pain and infection rates were significantly reduced with self-gripping polyester mesh compared to Lichtenstein repair with polypropylene mesh. The use of fixation increased postoperative pain in the P group. The absence of early recurrence highlights the gripping efficiency effect.

From ancient to contemporary times: a concise history of incisional hernia repair.

PURPOSE: This historical review explores the origins of incisional hernia surgery. METHODS: Resources from each significant historical time period were reviewed, namely ancient times, the Greco-Roman period, the Middle Ages and the dawn of the surgeon anatomist, and the modern era. RESULTS: Although incisional hernias only started to be widely reported in the literature in the early twentieth century, an awareness of the risk of incisional hernia formation dates back to ancient times. CONCLUSIONS: Sometimes, it is important to look back at the history and evolution of a topic to continue making positive advances in that field.

A two-centre blinded randomised control study comparing the Lichtenstein patch, Perfix plug and ProLoop plug in the repair of primary inguinal hernia.

INTRODUCTION: Mesh plug is an established and effective method for repair of inguinal hernia. The ProLoop plug (Atrium) is a recently developed mesh plug with a novel configuration, which may offer advantages over the standard Prefix plug (Bard) or the Lichtenstein repair. This two-centre double-blinded randomised control trial assessed the short- and medium-term outcomes, comparing the above three methods. PATIENTS AND METHODS: Consecutive patients over the age of 18 years with primary unilateral inguinal hernia were randomised to receive a Lichtenstein tension free mesh repair (LTFM), Perfix plug (Bard) (PF) or ProLoop plug (Atrium) (PL) repair. Follow-up was at 2 weeks, 6 months and 12 months. Endpoints were operative time, hospital stay, bodily pain scores, return to daily activity and complications. RESULTS: A total of 295 consecutive patients were recruited to the study. Ninety-three patients were randomised to receive PL plug repairs, 101 PF plug repairs and 101 LTFM repairs. There was no significant difference among the three groups in terms of age, sex or BMI. There was no significant difference among the groups in terms of operative time (PL vs PF P = 0.92; PL vs LTFM P = 0.52), hospital stay (PL vs PF P = 0.74; PL vs LTFM P = 0.44), bodily pain scores (at 12 months PL vs PF P = 0.84, PL vs LTFM P = 0.85, PF vs LTFM P = 0.16), complication rates or return to daily activity. CONCLUSIONS: The ProLoop plug (Atrium) is a safe and effective method of repairing primary inguinal hernias. Its novel lightweight configuration does not increase the risk of recurrence when compared to thicker mesh plugs, and it may offer benefit in terms of long-term patient comfort. The ProLoop plug (Atrium) represents a new effective alternative to the established mesh repairs.

European Hernia Society guidelines on the treatment of inguinal hernia in adult patients.

The European Hernia Society (EHS) is proud to present the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. They have been developed by a Working Group consisting of expert surgeons with representatives of 14 country members of the EHS. They are evidence-based and, when necessary, a consensus was reached among all members. The Guidelines have been reviewed by a Steering Committee. Before finalisation, feedback from different national hernia societies was obtained. The Appraisal of Guidelines for REsearch and Evaluation (AGREE) instrument was used by the Cochrane Association to validate the Guidelines. The Guidelines can be used to adjust local protocols, for training purposes and quality control. They will be revised in 2012 in order to keep them updated. In between revisions, it is the intention of the Working Group to provide every year, during the EHS annual congress, a short update of new high-level evidence (randomised controlled trials [RCTs] and meta-analyses). Developing guidelines leads to questions that remain to be answered by specific research. Therefore, we provide recommendations for further research that can be performed to raise the level of evidence concerning certain aspects of inguinal hernia treatment. In addition, a short summary, specifically for the general practitioner, is given. In order to increase the practical use of the Guidelines by consultants and residents, more details on the most important surgical techniques, local infiltration anaesthesia and a patient information sheet is provided. The most important challenge now will be the implementation of the Guidelines in daily surgical practice. This remains an important task for the EHS. The establishment of an EHS school for teaching inguinal hernia repair surgical techniques, including tips and tricks from experts to overcome the learning curve (especially in endoscopic repair), will be the next step. Working together on this project was a great learning experience, and it was worthwhile and fun. Cultural differences between members were easily overcome by educating each other, respecting different views and always coming back to the principles of evidence-based medicine. The members of the Working Group would like to thank the EHS board for their support and especially Ethicon for sponsoring the many meetings that were needed to finalise such an ambitious project.

Classification of primary and incisional abdominal wall hernias.

PURPOSE: A classification for primary and incisional abdominal wall hernias is needed to allow comparison of publications and future studies on these hernias. It is important to know whether the populations described in different studies are comparable. METHODS: Several members of the EHS board and some invitees gathered for 2 days to discuss the development of an EHS classification for primary and incisional abdominal wall hernias. RESULTS: To distinguish primary and incisional abdominal wall hernias, a separate classification based on localisation and size as the major risk factors was proposed. Further data are needed to define the optimal size variable for classification of incisional hernias in order to distinguish subgroups with differences in outcome. CONCLUSIONS: A classification for primary abdominal wall hernias and a division into subgroups for incisional abdominal wall hernias, concerning the localisation of the hernia, was formulated.