Exploring the link between poor oral hygiene and mesh infection after hernia repair: a systematic review and proposed best practices.

BACKGROUND: There is a reasonable body of evidence around oral/dental health and implant infection in orthopaedic and cardiovascular surgery. Another large area of surgical practice associated with a permanent implant is mesh hernia repair. This study aimed to review the evidence around oral/dental health and mesh infection. METHODS: The research protocol was registered in PROSPERO (CRD42022334530). A systematic review of the literature was undertaken according to the PRISMA 2020 statement. The initial search identified 582 publications. A further four papers were identified from references. After a review by title and abstract, 40 papers were read in full text. Fourteen publications were included in the final review, and a total of 47,486 patients were included. RESULTS: There is no published evidence investigating the state of oral hygiene/health and the risk of mesh infection or other infections in hernia surgery. Improvement in oral hygiene/health can reduce surgical site infection and implant infection in colorectal, gastric, liver, orthopaedic and cardiovascular surgery. Poor oral hygiene/health is associated with a large increase in oral bacteria and bacteraemia in everyday activities such as when chewing or brushing teeth. Antibiotic prophylaxis does not appear to be necessary before invasive dental care in patients with an implant. CONCLUSION: Good oral hygiene and oral health is a strong public health message. The effect of poor oral hygiene on mesh infection and other complications of mesh hernia repair is unknown. While research is clearly needed in this area, extrapolating from evidence in other areas of surgery where implants are used, good oral hygiene/health should be encouraged amongst hernia patients both prior to and after their surgery.

Thoughts on Trocar Site Hernia Prevention. A Narrative Review.

Background: Laparoscopic and robot-assisted surgery is now common place, and each trocar site is a potential incisional hernia site. A number of factors increase the risk of trocar site hernia (TSH) at any given trocar site. The aim of this paper is to explore the literature and identify the patients and the trocar sites at risk, which may allow target prevention strategies to minimise TSH. Methods: A pub med literature review was undertaken using the MeSH terms of "trocar" OR "port-site" AND "hernia." No qualifying criteria were applied to this initial search. All abstracts were reviewed by the two authors to identify papers for full text review to inform this narrative review. Results: 961 abstracts were identified by the search. A reasonable quality systematic review was published in 2012, and 44 additional more recent publications were identified as informative. A number of patient factors, pre-operative, intra-operative and post-operative factors were identified as possibly or likely increasing the risk of TSH. Their careful management alone and more likely in combination may help reduce the incidence of TSH. Conclusion: Clinically symptomatic TSH is uncommon, in relation to the many trocars inserted every day for "keyhole" surgery, although it is a not uncommon hernia to repair in general surgical practice. There are patients inherently at risk of TSH, especially at the umbilical location. It is likely, that a multi-factored approach to surgery, will have a cumulative effect at reducing the overall risk of TSH at any trocar site, including choice of trocar type and size, method of insertion, events during the operation, and decisions around the need for fascial closure and how this is performed following trocar removal.

Reporting guideline for interventional trials of primary and incisional ventral hernia repair.

BACKGROUND: Primary and incisional ventral hernia trials collect unstandardized inconsistent data, limiting data interpretation and comparison. This study aimed to create two minimum data sets for primary and incisional ventral hernia interventional trials to standardize data collection and improve trial comparison. To support these data sets, standardized patient-reported outcome measures and trial methodology criteria were created. METHODS: To construct these data sets, nominal group technique methodology was employed, involving 15 internationally recognized abdominal wall surgeons and two patient representatives. Initially a maximum data set was created from previous systematic and panellist reviews. Thereafter, three stages of voting took place: stage 1, selection of the number of variables for data set inclusion; stage 2, selection of variables to be included; and stage 3, selection of variable definitions and detection methods. A steering committee interpreted and analysed the data. RESULTS: The maximum data set contained 245 variables. The three stages of voting commenced in October 2019 and had been completed by July 2020. The final primary ventral hernia data set included 32 variables, the incisional ventral hernia data set included 40 variables, the patient-reported outcome measures tool contained 25 questions, and 40 methodological criteria were chosen. The best known variable definitions were selected for accurate variable description. CT was selected as the optimal preoperative descriptor of hernia morphology. Standardized follow-up at 30 days, 1 year, and 5 years was selected. CONCLUSION: These minimum data sets, patient-reported outcome measures, and methodological criteria have allowed creation of a manual for investigators aiming to undertake primary ventral hernia or incisional ventral hernia interventional trials. Adopting these data sets will improve trial methods and comparisons.

Algorithm for management of an incarcerated inguinal hernia in the emergency settings with manual reduction. Taxis, the technique and its safety.

BACKGROUND: An acute inguinal hernia remains a common emergency surgical condition worldwide. While emergency surgery has a major role to play in treatment of acute hernias, not all patients are fit for emergency surgery, nor are facilities for such surgery always available. Taxis is the manual reduction of incarcerated tissues from the hernia sack to its natural compartment, and can help delay the need for surgery from days to months. The aim of this study was to prepare a safe algorithm for performing manual reduction of incarcerated inguinal hernias in adults. METHODS: Medline, Scopus, Ovid and Embase were searched for papers related to emergency inguinal hernias and manual reduction. In addition, the British National Formulary and Safe Sedation Practice for Healthcare Procedures: Standards and Guidance were reviewed. RESULTS: A safe technique of manual reduction of an acute inguinal hernia, called GPS (Gentle, Prepared and Safe) Taxis, is described. It should be performed within 24 h from the onset of a painful irreducible lump in groin, and when concomitant symptoms and signs of bowel strangulation are absent. Conscious sedation guidelines should be followed. The most popular drug combination is of intravenous morphine and short-acting benzodiazepine, both titrated carefully for optimal and safe effect. The dose of drugs must be individualised, and the smallest effective dosage should be used to avoid oversedation. Following successful taxis, the patient should undergo a short period of observation. Urgent surgery can be undertaken during the same admission or up to several weeks later. CONCLUSIONS: Taxis is a benign/non-invasive method for patients with an acute, non-strangulated inguinal hernias. It likely reduces the risk and complications of anaesthesia and surgery in the emergency settings. GPS Taxis should be considered as first line treatment in the majority of patients presenting with an acute inguinal hernia when existing bowel infarction is unlikely.

The darn technique for small (< 2 cm diameter) midline hernias.

PURPOSE: Primary midline hernias arising in the linea alba are common. While mesh repair has been shown to reduce recurrence rates even in small hernias, many surgeons still use a suture repair for defects of less than 2 cm. The recent European and Americas Hernia Societies Guidelines recommended suture repair only for hernias smaller than 1 cm. A suture repair implies edge-to-edge or overlapping fascial margins, which necessarily involves tension on the repair. A darn is a tension-free repair where, in effect, a "mesh" is hand-woven across the defect in situ. METHODS: The darn repair is a modification of the darn techniques for inguinal hernia repair. Eligible patients undergoing this repair at the Royal Infirmary of Edinburgh between 1 January 2008 and 31 December 2017 were identified from a prospective computer-based medical record system and their case notes reviewed. Inclusion criteria were adult patients with a primary midline abdominal wall defect smaller than 2 cm in the widest diameter of the hernia defect measured intra-operatively. Patients were followed up by telephone in 2019. Those who reported possible recurrence or other symptoms in the region of their hernia repair were reviewed in the outpatient clinic. RESULTS: 47 suture-darn repairs were undertaken over the 10-year period. Fifteen of the darn repair operations (32%) were performed under local anaesthesia. Forty-one patients were followed up with a mean of 80 ± 35 and median of 87 months after surgery. Six patients (13%) were lost to follow-up. Recurrence was found in two cases (5%) and one patient has since been diagnosed with a new epigastric hernia some 5 cm cranial to the previous repair. CONCLUSIONS: The darn repair for small primary midline hernias is quick and inexpensive with promising long-term results. It can be performed under local anaesthesia. It can serve as an alternative to mesh repair for defects less than 2 cm in maximum dimension.

Correction to: European Hernia Society (EHS) guidance for the management of adult patients with a hernia during the COVID­19 pandemic.

The originally published article: The surname and given name of authors, M. Pawlak and A.C. de Beaux has been incorrectly published.

A manual reduction of hernia under analgesia/sedation (Taxis) in the acute inguinal hernia: a useful technique in COVID-19 times to reduce the need for emergency surgery-a literature review.

BACKGROUND: Acute IH is a common surgical presentation. Despite new guidelines being published recently, a number of important questions remained unanswered including the role of taxis, as initial non-operative management. This is particularly relevant now due to the possibility of a lack of immediate surgical care as a result of COVID-19. The aim of this review is to assess the role of taxis in the management of emergency inguinal hernias. METHODS: A review of the literature was undertaken. Available literature published until March 2019 was obtained and reviewed. 32,021 papers were identified, only 9 were of sufficient value to be used. RESULTS: There was a large discrepancy in the terminology of incarcerated/strangulated used. Taxis can be safely attempted early after the onset of symptoms and is effective in about 70% of patients. The possibility of reduction en-mass should be kept in mind. Definitive surgery to repair the hernia can be delayed by weeks until such time as surgery can be safely arranged. CONCLUSIONS: The use of taxis in emergency inguinal hernia is a useful first line of treatment in areas or situations where surgical care is not immediately available, including the COVID-19 pandemic. Emergency surgery remains the mainstay of management in the strangulated hernia setting.

International classification of abdominal wall planes (ICAP) to describe mesh insertion for ventral hernia repair.

BACKGROUND: Nomenclature for mesh insertion during ventral hernia repair is inconsistent and confusing. Several terms, including 'inlay', 'sublay' and 'underlay', can refer to the same anatomical planes in the indexed literature. This frustrates comparisons of surgical practice and may invalidate meta-analyses comparing surgical outcomes. The aim of this study was to establish an international classification of abdominal wall planes. METHODS: A Delphi study was conducted involving 20 internationally recognized abdominal wall surgeons. Different terms describing anterior abdominal wall planes were identified via literature review and expert consensus. The initial list comprised 59 possible terms. Panellists completed a questionnaire that suggested a list of options for individual abdominal wall planes. Consensus on a term was predefined as occurring if selected by at least 80 per cent of panellists. Terms scoring less than 20 per cent were removed. RESULTS: Voting started August 2018 and was completed by January 2019. In round 1, 43 terms (73 per cent) were selected by less than 20 per cent of panellists and 37 new terms were suggested, leaving 53 terms for round 2. Four planes reached consensus in round 2, with the terms 'onlay', 'inlay', 'preperitoneal' and 'intraperitoneal'. Thirty-five terms (66 per cent) were selected by less than 20 per cent of panellists and were removed. After round 3, consensus was achieved for 'anterectus', 'interoblique', 'retro-oblique' and 'retromuscular'. Default consensus was achieved for the 'retrorectus' and 'transversalis fascial' planes. CONCLUSION: Consensus concerning abdominal wall planes was agreed by 20 internationally recognized surgeons. Adoption should improve communication and comparison among surgeons and research studies.

ANTECEDENTES: La nomenclatura de la inserción de una malla para la reparación de una hernia incisional ventral (ventral hernia, VH) es inconsistente y confusa. En la literatura indexada se usan varios términos, tales como 'inlay', 'sublay', y 'underlay' que pueden referirse a los mismos planos anatómicos. Este hecho frustra las comparaciones de técnicas quirúrgicas e invalida los metaanálisis que comparan resultados quirúrgicos en función del plano de inserción de la malla. En consecuencia, el objetivo de este estudio fue establecer una clasificación internacional de los planos de la pared abdominal (International Classification of Abdominal Wall Planes, ICAP). MÉTODOS: Se realizó un estudio Delphi, en el que participaron 20 cirujanos de pared abdominal reconocidos internacionalmente. Se identificaron diferentes términos que describían los planos de la pared abdominal anterior mediante la revisión de la literatura y el consenso de expertos. La lista inicial incluía 59 términos posibles. Los panelistas completaron un cuestionario que sugería una lista de opciones para los planos individuales de la pared abdominal. El consenso sobre un término fue predefinido cuando dicho término había sido seleccionado por ≥ 80% de panelistas. Se eliminaron los términos con una puntuación < 20%. RESULTADOS: La votación comenzó en agosto de 2018 y se completó en enero de 2019. Durante la Ronda 1, 43 (73%) términos fueron seleccionados por < 20% de los panelistas y se sugirieron 37 términos nuevos, dejando 53 términos para la Ronda 2. Cuatro planos alcanzaron un consenso en la Ronda 2 con los términos 'onlay', 'inlay', 'pre-peritoneal' e 'intra-peritoneal'. Treinta y cinco (66%) términos fueron seleccionados por < 20% de los panelistas y fueron eliminados. Después de la Ronda 3, se logró un consenso para 'anterectus' (ante-recto), 'interoblique' (inter-oblicuo), 'retrooblique' (retro-oblicuo) y 'retromuscular'. Se alcanzó un consenso por defecto para los planos 'retrorectus' (retro-recto) y 'transversalis fascial' (fascial transverso). CONCLUSIÓN: La ICAP ha sido desarrollada por el consenso de 20 cirujanos reconocidos internacionalmente. Su implementación debería mejorar la comunicación y la comparación entre cirujanos y estudios de investigación.

Dynamic creep properties of a novel nanofiber hernia mesh in abdominal wall repair.

PURPOSE: Incisional hernia is the most common complication following abdominal surgery. While mesh repair is common, none of the current meshes mimic the physiology of the abdominal wall. This study compares suture only repair with polypropylene mesh and a prototype of a novel implant (poly-epsilon-caprolactone nanofibers) and their influence on the physiology of an abdominal wall in an animal model. METHODS: 27 Chinchilla rabbits were divided into six groups based on the type of the implant. Midline abdominal incision was repaired using one of the compared materials with suture alone serving as the control. 6 weeks post-surgery animals were killed and their explanted abdominal wall subjected to biomechanical testing. RESULTS: Both-hysteresis and maximum strength curves showed high elasticity and strength in groups where the novel implant was used. Polypropylene mesh proved as stiff and fragile compared to other groups. CONCLUSION: Poly-epsilon-caprolactone nanofiber scaffold is able to improve the dynamic properties of healing fascia with no loss of maximum tensile strength when compared to polypropylene mesh in an animal model.

Protracted diagnosis of ACNES: a costly exercise.

This case report summarizes the course of events leading to diagnosis and eventual repair of anterior cutaneous nerve entrapment syndrome (ACNES) in a 58-year-old female. The time period elapsing from initial symptoms to final operative repair was 9 months. The diagnosis was missed by both medical and surgical specialists despite multiple outpatient appointments, investigative procedures and a battery of laboratory tests. The diagnosis of ACNES was first considered when reviewed by a hernia surgeon and subsequently confirmed following open exploration of the anterior abdominal wall. The nerve was released and pain symptoms resolved. Access to the NHS Scotland ISD register permitted an economic analysis of the diagnostic services utilized for this patient and these totalled nearly £11 500. At a time when the NHS is focused on cost effectiveness, this particular sequence of investigations illustrates a protracted and costly diagnostic pathway.

Contemporary thoughts on the management of Spigelian hernia.

BACKGROUND: Spigelian hernias are said to be a rare condition of the elderly population, usually arising below the arcuate line. Local experience has led us to challenge these commonly held beliefs. METHODS: Operations for Spigelian hernia from 2006-2016 were identified from the Edinburgh Lothian Surgical Audit computerised database and case notes were reviewed. RESULTS: One hundred and one patients underwent surgery for 107 Spigelian hernias in the 10-year period. The female-to-male ratio was 2:1. Ages ranged from 32 to 88 with a median of 64 years. Sixty-five operations were done open and 42 were laparoscopic. Twelve of the 27 for which the precise anatomic location was recorded were situated above the arcuate line. Twenty-nine hernias had small defects and comprised interstitial fat only with no peritoneal sac. Ages in this group ranged from 32 to 80 (median = 48 years). All presented with intermittent local pain and/or swelling, although in three patients the hernias were impalpable. Those three also underwent ultrasound, CT and/or laparoscopy, but the hernias were only identified after open surgical exploration. The remaining 78 cases had peritoneal sacs of varying size with defects up to 9 cm across, and all were identified on imaging and/or laparoscopy. Ages ranged from 38 to 88 (median = 67 years; p < 0.01). Eighteen patients presented as emergencies and all were in this group. CONCLUSION: Spigelian hernias may be more common than we think and are probably under-diagnosed. They commonly arise above the arcuate line. We describe three clinical stages: Stage 1 hernias are those without peritoneal sacs and tend to arise in younger patients, can be difficult to diagnose and may not seen at laparoscopy. Stages 2 and 3 hernias arise in older patients, do have peritoneal sacs, are visible at laparoscopy and are more likely to present as emergencies. Stage three hernias are too large for laparoscopic repair. The differences between stages likely reflect the natural history of the condition, which begins as extraperitoneal fat protrusion and progresses over many years to develop a peritoneal sac.

European Hernia Society guidelines on the closure of abdominal wall incisions.

BACKGROUND: The material and the surgical technique used to close an abdominal wall incision are important determinants of the risk of developing an incisional hernia. Optimising closure of abdominal wall incisions holds a potential to prevent patients suffering from incisional hernias and for important costs savings in health care. METHODS: The European Hernia Society formed a Guidelines Development Group to provide guidelines for all surgical specialists who perform abdominal incisions in adult patients on the materials and methods used to close the abdominal wall. The guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach and methodological guidance was taken from Scottish Intercollegiate Guidelines Network (SIGN). The literature search included publications up to April 2014. The guidelines were written using the AGREE II instrument. An update of these guidelines is planned for 2017. RESULTS: For many of the Key Questions that were studied no high quality data was detected. Therefore, some strong recommendations could be made but, for many Key Questions only weak recommendations or no recommendation could be made due to lack of sufficient evidence. RECOMMENDATIONS: To decrease the incidence of incisional hernias it is strongly recommended to utilise a non-midline approach to a laparotomy whenever possible. For elective midline incisions, it is strongly recommended to perform a continuous suturing technique and to avoid the use of rapidly absorbable sutures. It is suggested using a slowly absorbable monofilament suture in a single layer aponeurotic closure technique without separate closure of the peritoneum. A small bites technique with a suture to wound length (SL/WL) ratio at least 4/1 is the current recommended method of fascial closure. Currently, no recommendations can be given on the optimal technique to close emergency laparotomy incisions. Prophylactic mesh augmentation appears effective and safe and can be suggested in high-risk patients, like aortic aneurysm surgery and obese patients. For laparoscopic surgery, it is suggested using the smallest trocar size adequate for the procedure and closure of the fascial defect if trocars larger or equal to 10 mm are used. For single incision laparoscopic surgery, we suggest meticulous closure of the fascial incision to avoid an increased risk of incisional hernias.

The peritoneal flap hernioplasty for repair of large ventral and incisional hernias.

BACKGROUND: Mesh repair of large ventral or incisional hernias is problematic when primary fascial closure cannot be achieved, as this leaves mesh exposed, bridging the gap. We describe a modified retromuscular sublay repair which overcomes this problem and report a retrospective review of cases to assess outcome. METHODS: Mesh is positioned between transposed flaps of preserved hernial sac and rectus sheath. Patients undergoing this repair by one author (BT) from 1 January 2004 to 31 December 2010 were identified, and clinical outcome was assessed by a combination of case-note review, outpatient consultation and telephone interview. RESULTS: Twenty-one ventral and incisional hernias were treated by this method. Eighteen were incisional (13 midline, three transverse and two oblique incisions), and three were primary paraumbilical hernias. Defect sizes ranged from 25 to 500 cm(2) and mesh sizes from 300 to 900 cm(2). Patients were reviewed at 6 weeks, 6 months and at a median of 37 months post-operatively. Three cases of superficial skin edge necrosis, two superficial wound infections and two sizeable seromas developed, but all had resolved within 6 months. One patient developed abdominal wall necrosis requiring mesh removal and eventual abdominal wall reconstruction without mesh, resulting in late recurrence. All other cases achieved excellent long-term outcomes with a high degree of patient satisfaction. CONCLUSION: This is a useful method for repairing large ventral and incisional hernias when primary fascial closure is not achievable, combining a sublay mesh repair with autologous tissue transposition across the fascial gap.