Sex-based differences in inguinal hernia factors.

BACKGROUND: Much of our knowledge about inguinal hernias is based on males. Meanwhile, it is established that women have worse outcomes after inguinal hernia repair, with more chronic pain and higher recurrences. Pediatric literature shows inguinal hernias in females are more likely to be bilateral, incarcerated, and carry a stronger genetic predisposition than males. We aimed to evaluate sex-based differences in inguinal hernia factors in adults, to help supplement the paucity of literature in the adult population. METHODS: An institutional database of patients undergoing repair of primary inguinal hernias was queried with focus on preoperative risk factors and operative characteristics. Multivariate analysis was performed looking for independent variables associated with a greater number of hernia defects found intraoperatively. RESULTS: Among 494 patients, 202 (40.9%) were female. Number of risk factors among females was significantly higher than males (1.53 vs 1.2, p = 0.003). Females had significantly more constipation, GERD, and asthma and lower BMI than males. Family history of hernias was similar between both sexes. As expected, females had significantly less direct hernias (12.9% vs 32.9%, p < 0.001) and more femoral hernias (38.5% vs 12.2%, p < 0.001) than males. Bilaterality was similar. Females undergoing inguinal hernia repair averaged 1.23 prior deliveries. Regression analysis showed age, sex, BMI, and number of deliveries were not correlated with the number of defects. CONCLUSIONS: Females undergoing primary inguinal hernia repair had more preoperative risk factors for inguinal hernia than males. In our population, there was no higher incidence of bilaterality or significant genetic predisposition in females as noted by family history of hernias. Age, sex, BMI and number of deliveries did not correlate with the number of hernia defects found. Our study promotes awareness of inguinal hernias in females and presents new data to quantify sex-based differences and predispositions to inguinal hernias.

Mesh overlap for ventral hernia repair in current practice.

INTRODUCTION: Sufficient overlap of mesh beyond the borders of a ventral hernia helps prevent hernia recurrence. Guidelines from the European Hernia Society and American Hernia Society recommend ≥ 2 cm overlap for open repair of < 1-cm hernias, ≥ 3-cm overlap for open repair of 1-4-cm hernias, ≥ 5-cm overlap for open repair of > 4-cm hernias, and ≥ 5-cm overlap for all laparoscopic ventral hernia repairs. We evaluated whether current practice reflects this guidance. METHODS: We used the Michigan Surgical Quality Collaborative Hernia Registry to evaluate patients who underwent elective ventral and umbilical hernia repair between 2020 and 2022. Mesh overlap was calculated as [(width of mesh - width of hernia)/2]. The main outcome was "sufficient overlap," defined based on published EHS and AHS guidelines. Explanatory variables included patient, operative, and hernia characteristics. The main analysis was a multivariable logistic regression to evaluate the association between explanatory variables and sufficient mesh overlap. RESULTS: 4178 patients underwent ventral hernia repair with a mean age of 55.2 (13.9) years, 1739 (41.6%) females, mean body mass index (BMI) of 33.1 (7.2) kg/m2, and mean hernia width of 3.7 (3.4) cm. Mean mesh overlap was 3.7 (2.5) cm and ranged from - 5.5 to 21.4 cm. Only 1074 (25.7%) ventral hernia repairs had sufficient mesh overlap according to published guidelines. Operative factors associated with increased odds of sufficient overlap included myofascial release (adjusted odds ratio [aOR] 5.35 [95% CI 4.07-7.03]), minimally invasive approach (aOR 1.86 [95% CI 1.60-2.17]), and onlay mesh location (aOR 1.31 [95% CI 1.07-1.59]). Patient factors associated with increased odds of sufficient overlap included prior hernia repair (aOR 1.59 [95% CI 1.32-1.92]). CONCLUSION: Although sufficient mesh overlap is recommended to prevent ventral hernia recurrence, only a quarter of ventral hernia repairs in a state-wide cohort of patients had sufficient overlap according to evidence-based guidelines. Factors strongly associated with sufficient overlap included myofascial release, mesh type, and laparoscopic repair.

Risks of therapeutic versus prophylactic neurectomies.

INTRODUCTION: Neuralgia due to a peripheral nerve injury may result in chronic pain, requiring a therapeutic surgical neurectomy. Meanwhile, some neurectomies are performed prophylactically, such as during inguinal mesh removal. Outcomes and risks associated with neurectomies are largely unknown despite consensus panels recommending them. METHODS: All patients who underwent neurectomy 2013-2020 were analyzed. Data collection included demographics, preoperative symptoms, and postoperative outcomes. Indications for neurectomy were categorized as "therapeutic" if the patient had preoperative neuralgia or "prophylactic" if neurectomy was deemed necessary intra-operatively. RESULTS: 66 patients underwent 80 operations and a total of 122 neurectomies. On average, 1.5 neurectomies were performed per operation. Therapeutic neurectomies were performed in 42 (64%) patients and prophylactic in 34 (52%). The most commonly transected nerve was the ilioinguinal nerve. Average preoperative pain score was 5.8/10. On paired analysis, there was a significant reduction in pain after prophylactic neurectomy (2.5 points, p = 0.002) but not after therapeutic neurectomy. None of the nerves transected prophylactically had postoperative neuralgia, whereas 35% of the nerves transected therapeutically resulted in persistent or recurrent neuralgia (p < 0.001). To treat this, 21% required only nerve blocks and 9% required ablation or reoperative neurectomy. Three patients had complex regional pain syndrome (CRPS), a severe complication; all three were diagnosed with chronic pain syndrome pre-operatively. DISCUSSION: We demonstrate that prophylactic neurectomy is largely safe. In contrast, a therapeutic neurectomy had a 35% risk of persistent or recurrent neuralgia, 9% required additional ablative or reoperative neurectomy. Three patients advanced from chronic pain syndrome to CRPS. We recommend the decision to perform a neurectomy be judicious and selective, especially in patients with known chronic pain syndrome. Prior to planning surgical neurectomy, other less invasive modalities should be exhausted and patients should be aware of its risks.

Outcomes from laparoscopic versus robotic mesh removal after inguinal hernia repair.

INTRODUCTION: Preperitoneally placed mesh for inguinal hernia repair may require removal to address hernia recurrence, mesh reaction, meshoma, or other chronic pain. These are best approached either laparoscopically or robotically, but there is no consensus on which is the best approach for mesh removal nor are there any studies to evaluate and compare their outcomes. METHODS: All patients who underwent inguinal mesh removal via laparoscopic and robotic approaches from 2011 to 2020 were analyzed. Data regarding demographics, preoperative, intraoperative, and postoperative outcomes were collected. RESULTS: Over 9 years, 62 patients underwent 24 laparoscopic and 50 robotic operations. Laparoscopic cases had a shorter operative time by a mean of 55 min (p = 0.02). There were no differences in intraoperative complications or postoperative outcomes between the two groups. Patients in both groups showed significant improvement after mesh removal (p = 0.02, p < 0.01) within 2 weeks postoperatively and at long-term follow up (p < 0.01, p < 0.01). CONCLUSION: It is our experience that both laparoscopic and robotic approaches are viable options for removal of retroperitoneally placed inguinal mesh. Operative time with the laparoscopic approach was significantly shorter than the robotic approach. Patients on average had significant reduction in their preoperative pain, regardless of the approach. Minimally invasive mesh removal is a technically challenging operation, with risk of vascular and nerve injuries regardless of the approach. These findings demonstrate that both modalities are safe and effective with experienced surgeons.

Thou shalt not trust online videos for inguinal hernia repair techniques.

BACKGROUND: Videos are used by surgeons when learning new techniques; however, online videos are often not vetted. Our aim is to review online videos of laparoscopic inguinal hernia repairs based on a benchmark for critical view of the myopectineal orifice (MPO) and safe inguinal hernia repair as defined by Daes and Felix and commonly referred to as "the 9 Commandments." METHODS AND MATERIALS: YouTubeⓇ was queried for "laparoscopic inguinal hernia repair." The top 50 videos were ranked based on number of views. Those endorsed and/or vetted by surgical societies were excluded (n = 4). Three expert hernia surgeons scored the videos based on adherence to the 9 Commandments. RESULTS: The 50 videos originated from 11 countries. They had 72,825 mean views and a mean runtime of 14 min. Videos obeyed a median of 77.8% of commandments shown. Eight videos (16%) obeyed all 9 (100%) commandments. Three videos (6%) failed to obey any commandments. Operations employed TEP (18, 36%), TAPP (28, 56%), and rTAPP (4, 8%) approach. Stratification by approach showed significant variance in commandments obeyed (Kurskal-Wallis, p = 0.016) with significant difference between TEP and rTAPP scores (p = 0.008) and no significant difference between TEP and TAPP or rTAPP and TAPP scores. Twenty-three videos (46%) displayed unsafe techniques including: threatened critical structures (16, 32%), rough tissue handling (15, 30%), and dangerous placement of fixation (9, 18%). CONCLUSION: Online surgical videos on YouTube are not reliable in demonstrating best practices for minimally invasive inguinal hernia repairs. In our study, only 16% of the most viewed videos followed all 9 Commandments for critical view of the MPO. Many showed suboptimal repairs with significant safety concerns. While a significant number of online videos are a free and readily available resource for surgeons around the world, we recommend caution in relying on non-vetted videos as a form of surgical education.

Closed Facebook™ groups and CME credit: a new format for continuing medical education.

BACKGROUND: The International Hernia Collaboration (IHC) is a closed Facebook™ group that allows international surgeons to post clinical questions and exchange transparent feedback with the intent to optimize patient outcomes. Despite the educational value of closed FB groups, CME credits have not been available to members. To determine feasibility of and user interest in earning CME credit through social media, the IHC piloted a series of expert lectures followed by an interactive Facebook Live session as a novel pathway offering CME credit. METHODS: Nine monthly lectures and Facebook Live sessions were presented. CME credit was offered for the final seven lectures. Participation in the form of views, comments, and likes was quantified by a Facebook analytics service and an engagement score, defined as [(the number of comments × 2) + (the number of reactions)], was calculated for each lecture and Facebook Live session. CME credit was obtained through a two-question quiz. RESULTS: Of 5400 + Facebook members of the IHC, an average of 1116 (20.4 ± 4.0%) viewed the live session event following each lecture (n = 9 events). The average Facebook engagement score for Facebook Live was 259 ± 75, a significant difference with the average Facebook engagement score on the IHC (40.8) over the same time period (p < 0.001). On average, 16 users [range 8-35, (n = 7 events)] claimed CME credit for each educational series. CONCLUSIONS: Closed Facebook groups can be a useful media to offer educational content and CME credit. The pilot IHC Lecture and Facebook Live series offering CME credit resulted in significantly more engagement amongst its members compared to other posts during the same time period. A small portion of participants qualified for CME credit. Future social media educational series may increase participants qualifying for CME by streamlining the interface to obtain CME credit.

Outcomes of robot-assisted versus laparoscopic repair of small-sized ventral hernias.

INTRODUCTION: The aim of the study is to investigate the outcomes of the da Vinci robot-assisted laparoscopic hernia repair of small-sized ventral hernias with circumferential suturing of the mesh compared to the traditional laparoscopic repair with trans-fascial suturing. METHODS: A retrospective review was conducted of all robot-assisted umbilical, epigastric and incisional hernia repairs performed at our institution between 2013 and 2015 compared to laparoscopic umbilical or epigastric hernia repairs. Patient characteristics, operative details and postoperative complications were collected and analyzed using univariate analysis. Three primary minimally invasive fellowship trained surgeons performed all of the procedures included in the analysis. RESULTS: 72 patients were identified during the study period. 39 patients underwent robot- assisted repair (21 umbilical, 14 epigastric, 4 incisional), and 33 patients laparoscopic repair (27 umbilical, 6 epigastric). Seven had recurrent hernias (robot: 4, laparoscopic: 3). There were no significant differences in preoperative characteristics between the two groups. Average operative time was 156 min for robot-assisted repair and 65 min for laparoscopic repair (p < 0.0001). The average defect size was significantly larger for the robot group [3.07 cm (1-9 cm)] than that for the laparoscopic group [2.02 cm (0.5-5 cm)] (p < 0.0001), although there was no significant difference in the average size of mesh used (13 vs. 13 cm). There was no difference in patients requiring postoperative admission or length of stay between the two groups. The mean duration of follow-up was 47 days. There was no difference in complication rate during this time, and no recurrences were reported. CONCLUSION: There are no significant differences in terms of safety and early efficacy when comparing small-sized ventral hernias repaired using the robot-assisted technique versus the standard laparoscopic repair.

An anti-inflammatory bundle may help avoid opioids for low-risk outpatient procedures.

BACKGROUND: Currently, over half of drug overdose deaths are due to opioids. Opioid alternatives may be prescribed to help curb the opioid epidemic. However, little is known about their efficacy for acute postoperative pain. METHODS: We studied patients who underwent low-risk outpatient surgery. Perioperatively, all patients were started on an anti-inflammatory bundle consisting of multimodal pain remedies. Opioids were available to the patients postoperatively. Pain scores and opioid use were recorded. RESULTS: Over 18 months, 120 patients underwent low-risk outpatient surgery and all used the anti-inflammatory bundle. All patients had a significant decrease in postoperative pain scores (p = 0.001). There was no significant difference in postoperative pain scores between those who followed the anti-inflammatory bundle alone and those who also used opioids (mean 2.2 vs 3.1/10). Twenty-five (21%) patients were using opioids preoperatively and 50 (42%) postoperatively. Of those using opioids preoperatively, six (24%) patients used the anti-inflammatory bundle alone and avoided opioids postoperatively. CONCLUSIONS: For 58% of our patients, an anti-inflammatory bundle alone provided adequate pain control after a low-risk outpatient operation, such as hernia repair. Our practice uses the anti-inflammatory bundle for all patients. Our goal is to reduce both the need for opioids and the surgeon's contribution to the opioid epidemic.

Patients With Systemic Reaction to Their Hernia Mesh: An Introduction to Mesh Implant Illness.

In our practice, we have noticed an increased number of patients requiring mesh removal due to a systemic reaction to their implant. We present our experience in diagnosing and treating a subpopulation of patients who require mesh removal due to a possible mesh implant illness (MII). All patients who underwent mesh removal for indication of mesh reaction were captured from a hernia database. Data extraction focused on the patients' predisposing medical conditions, presenting symptoms suggestive of mesh implant illness, types of implants to which reaction occurred, and postoperative outcome after mesh removal. Over almost 7 years, 165 patients had mesh removed. Indication for mesh removal was probable MII in 28 (17%). Most were in females (60%), average age was 46 years, with average pre-operative pain score 5.4/10. All patients underwent complete mesh removal. Sixteen (57%) required tissue repair of their hernia; 4 (14%) had hybrid mesh implanted. Nineteen (68%) had improvement and/or resolution of their MII symptoms within the first month after removal. We present insight into a unique but rising incidence of patients who suffer from systemic reaction following mesh implantation. Predisposing factors include female sex, history of autoimmune disorder, and multiple medical and environmental allergies and sensitivities. Presenting symptoms included spontaneous rashes, erythema and edema over the area of implant, arthralgia, headaches, and chronic fatigue. Long-term follow up after mesh removal confirmed resolution of symptoms after mesh removal. We hope this provides greater attention to patients who present with vague, non-specific but debilitating symptoms after mesh implantation.

New Traditional Chinese Medicine Supplement Reduces Pain Faster than Conventional Pain Pills Alone: A Phase I/II Prospective, Double-Blinded Placebo-Controlled Randomized Trial.

BACKGROUND: The opioid crisis demands novel solutions for postoperative pain control. Traditional Chinese medicine (TCM) has used herbs for the treatment of pain for thousands of years. We studied whether a synergistic multimodal TCM supplement could reduce the need for conventional pain pills for low risk surgical procedures. METHODS: In a Phase I/II, prospective, double-blind, placebo-controlled, randomized clinical trial (PRCT), 93 patients were randomized to either TCM supplement or placebo oral medication for low-risk outpatient surgical procedures. Study medications began 3 days preoperatively and continued for 5 days postoperatively. Conventional pain pill use was not restricted. Patients were monitored postoperatively for all forms of pain pill use (Pain Pill Scoring Sheet) and subjective pain ratings (Brief Pain Inventory Short Form). Primary outcomes included type and number of pain pills used and subjective pain ratings. Secondary outcomes included an assessment of mood, general activity, sleep, and enjoyment of life. RESULTS: TCM use well tolerated. Conventional pain pill use was similar between groups. Linear regression analysis revealed that TCM reduced postoperative pain 3 times faster than placebo (P < .0001) with a 4-fold greater magnitude of relief by postoperative day 5 (P = .008). TCM also significantly improved sleep habits (P = .049) during the postoperative period. TCM effect was independent of type of surgery or amount of preoperative pain. DISCUSSION: This PRCT is the first to show that a multimodal, synergistic TCM supplement is safe and can effectively reduce acute postoperative pain more rapidly, and to a lower level, than conventional pain pills alone.

Conversion of laparoscopic sleeve gastrectomy to Roux-en-Y gastric bypass: patterns predicting persistent symptoms after revision.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric operation performed. However, it is not without its drawbacks and patients may develop gastroesophageal reflux (GERD) after LSG. There are limited data available to guide treatment choice for patients suffering these sequelae. OBJECTIVE: This study was undertaken to evaluate the success of conversion to Roux-en-Y gastric bypass (RYGB) in treating GERD symptoms after LSG. SETTING: Single bariatric center, United States. METHODS: Analysis of a prospectively maintained clinical database was performed. Outcomes studied included heartburn-related quality of life score (GERD-HRQL), anti-secretory usage, and body mass index (BMI). RESULTS: A total of 54 patients met inclusion criteria during the review period. Of these, 41 patients (76%) underwent conversion for indication including GERD. Mean BMI at conversion was 33.8 ± 5.61 and was found to be significantly reduced at 12 months after conversion (n = 26; 63%; P < .001) and at long-term follow-up (n = 37; 90%) (P ≤ .001; mean follow-up period: 33.3 mo). Mean GERD-HRQL at time of conversion was 31.5 ± 11.4. Conversion to RYGB produced a significant reduction of HRQL at 6 months after conversion (n = 30; 73%) (mean: 5.6, P < .001) and long-term follow-up (n = 38; 93%) (mean: 7.3, P < .001. mean follow-up period: 15.1 mo). Prior to conversion, 32 patients (78%) required antisecretory therapy for GERD and after conversion, 12 of these patients (38%) required antisecretory therapy (P < .001). These 12 patients were found to exhibit a significantly (P = .005) smaller decrease in GERD-HRQL after revision compared with their peers who were liberated from antisecretory therapy. Preoperative symptoms were compared between these 2 groups. Delayed onset of GERD symptoms after LSG (>3 mo) was found to be a significant risk factor for continued antisecretory dependence after conversion to RYGB. CONCLUSION: Conversion of LSG to RYGB quantitatively reduces GERD symptoms, and results in a modest but significant amount of weight loss. While there was a significant improvement in HRQL after revision, a subgroup of patients continued to be antisecretory-dependent and showed a limited improvement in HRQL. This limited response was predicted by a gradual onset of GERD symptoms prior to revision. An interval of 3 months or greater between LSG and onset of symptoms was found to be a significant risk factor for limited response to conversion.

#Mesh: Social Media and Its Influence on Perceptions in Hernia Repair.

Social media can influence public perception in health care. By 2016, social media discussion against the use of transvaginal mesh influenced changes in Food and Drug Administration (FDA) regulations. We propose that the fate of hernia mesh will follow that of transvaginal mesh. Thus, we compare the trend of social media discussion of hernia and transvaginal mesh. Posts on Twitter and public Facebook groups were tracked for keywords "hernia," "hernia mesh," and "pelvic/vaginal mesh." Posts were categorized based on sentiment. On Facebook, 16 public groups with 14 526 members expressed negative sentiments in 95% of their 750 daily posts. Meanwhile, of the 1.1 million tweets on Twitter, those about hernia mesh were more negative (36.5%) than those about pelvic/vaginal mesh (29.2%). Three of the 5 top tweeters about hernia mesh and pelvic/vaginal mesh were linked to law firms involved in mesh-based lawsuits. The negative sentiments and steering of social media discussion by lawyers may directly affect surgical care. As surgeons, we may adapt our informed consent to acknowledge our patients' apprehensions about mesh. We may also be more involved in social media discussions ourselves. Meanwhile, we await FDA decisions in the regulation and availability of hernia mesh.

Median Arcuate Ligament Syndrome and Its Associated Conditions.

The risk factors and associated conditions of median arcuate ligament syndrome (MALS) have not been well characterized in the literature. In this study, we aim to investigate the presentation and outcomes of MALS patients with an emphasis on the prevalence of other uncommon disorders. To this end, data of patients with MALS who underwent surgery between 2013 and 2018 were collected and compiled into a retrospective database and analyzed. Eleven patients were identified. Seven of these eleven patients underwent diagnostics to evaluate gastric emptying. Five of these seven patients (71.4%) had radiographic evidence of delayed gastric emptying. Four of the eleven patients (36.4%) were found to have anatomic abnormalities of their visceral vasculature. Two of the eleven patients (18.2%) were found to have connective tissue disorders, both with Ehlers-Danlos syndrome. Three of the eleven (27.3%) had a diagnosis of postural orthostatic tachycardia syndrome. This is the first case series reporting on an association between MALS and delayed gastric emptying. We also explored the relationship between MALS and visceral vascular abnormalities, Ehlers-Danlos syndrome, and postural orthostatic tachycardia syndrome. It is notable that these conditions are more prevalent in the MALS population than in the general population, suggesting a possible pathophysiologic relationship.

A rapid and economical method for profiling feature heights during microfabrication.

Quality control is an important and integral part to any microfabrication process. While the widths of features often can be easily assessed by light microscopy, the heights of the fabricated structures are more difficult to determine. Here, we present a rapid, accurate, and low-cost method to measure the heights of microfabricated structures during and after the fabrication process. This technique is based on white-light interferometry, which offers accuracy on the submicrometre scale.