bluuebunny/crossref_metadata_2025 huggingface dataset:
LAPAROSCOPIC (L) VERSUS OPEN INGUINAL HERNIA REPAIR (OIHR): HOW ROBUST IS THE DATA? A SYSTEMATIC REVIEW AND FRAGILITY ASSESSMENT OF RANDOMIZED CONTROLLED TRIALS COMPARING LAPAROSCOPIC AND OPEN INGUINAL HERNIA REPAIR
Authors: Holland A , Lorenz W , Hollingsworth R , Scarola G , Augenstein V , Ayuso S , Heniford B T
Published: May 2024

Background

For three decades there has been significant debate over LIHR versus OIHR regarding recurrence, pain, and morbidity. This study assessed the robustness of evidence supporting either approach through a fragility analysis. The fragility index (FI) measures the minimum number of participants whose outcome would have to change to turn a significant result non-significant. The reverse fragility index (RFI) calculates the fewest number of events that would convert a non-significant result.

Methods

A systematic search of PubMed, Wake Forest Library, and Google Scholar was performed for randomized controlled trials (RCTs) comparing OIHR and LIHR with dichotomous outcomes from 1995–2023. FI and RFI were calculated for significant and non-significant outcomes, respectively. FI/RFI ≤ 3 were considered fragile.

Results

Review of 319 studies yielded 28 RCTs with a median of 141.5 (Q1, Q3: 103.0, 283.0) participants and 47 primary or secondary outcomes, including recurrence (n = 24), postoperative complications (n = 16), and chronic pain (n = 7). The median FI of all outcomes was 1.0 (1.0, 4.0), and RFI was 4.0 (3.0, 6.0), exhibiting substantial fragility in the significant results. Individually, recurrence, complications, and pain demonstrated median FIs of 3.0, 1.0, and 4.0, respectively. Sixteen (57.1%) RCTs had more participants lost to follow-up (LTFU) than the FI/RFI.

Conclusions

Of the inguinal hernia RCTs that demonstrate significant outcomes, 64.3% draw fragile conclusions. The overall FI of 1.0 indicates that a change in a single outcome could reverse the significance of the trial. Further, 57.1% of RCTs had more participants LTFU than FI/RFI, further weaking these studies’ conclusions. Inguinal hernia RCTs are remarkably fragile.
A.I. MACHINE LEARNING MODEL RELIABLY PREDICTS SUCCESS OF INGUINAL HERNIA REPAIR TO RESOLVE CHRONIC PELVIC AND GROIN PAIN
Authors: Huynh D , Dale R , Oh C , Towfigh S
Published: May 2024

Background

The differential diagnoses of chronic pelvic pain (CPP) and groin pain are vast and may include inguinal hernia (IH) as well as orthopedic, urologic, and gynecologic disorders.

Methods

A 50-point Hernia Health Questionnaireⓒ (HHQ) was administered prospectively to all patients with CPP or groin pain who underwent inguinal hernia repair. Patients were followed for resolution of preoperative symptoms as the endpoint.

The machine learning model randomly split patients into blinded training and testing sets followed by Random Forest modelling of postoperative symptom resolution. Recursive Feature Elimination identified optimal predictive variables from the HHQ. Bootstrapping determined confidence interval.

Results

Between 2008 and 2022, 494 patients underwent primary IH repair. Mean age was 52 years, mean BMI 26.2 kg/m2, and 202 (41%) were female. Postoperative resolution of preoperative pain was confirmed in 426 (86%).

Random Forest model exhibited strong predictive performance, with high two-sided 95% confidence interval (0.72, 0.91, median 0.83). Significant predictors of IH included female sex (p < 0.001), location/radiation of pain (p < 0.001), painful intercourse (p = 0.02), pain medications preoperatively (p < 0.001), and history of hernia in a female family member (p = 0.02).

Conclusion

We present the first A.I. model to reliably predict whether repairing IH will resolve the patient’s CPP or groin pain. This can be valuable to surgeons and non-surgeons, with the aim of reducing delay in diagnosis and treatment of patients with enigmatic CPP or groin pain.Figure 1:Receiver Operator Characteristic of Random Forest Model on Test Set
A COMPARATIVE ANALYSIS OF FOUR PROMS TO ASSESS MEDIUM TO LONG-TERM PATIENT SATISFACTION FOLLOWING OPEN MIDLINE INCISIONAL HERNIA REPAIR
Authors: Kulkarni G , Attafi W , Nanthakumaran P , Barnes D , Hammond T
Published: May 2024

Purpose

Patient-reported outcome measures (PROMs) are increasingly recognised as the most important metric for evaluating outcomes after hernia repair. The study aim was to evaluate patient satisfaction using 4 different PROMS following open repair of midline incisional hernias.

Methods

72 patients with midline incisional hernias underwent open retrorectus mesh repair, with or without component separation, and concurrent abdominoplasty between 2016–2022. They were invited to complete four PROMs including the Carolinas Comfort Scale (CCS, range 0–115), Brehaut decision regret scale (BDRS, range 5–25), Abdominoplasty questionnaire (Q-PROM, range 7–28) and Patient Scar Assessment Scale (PSAS; range 6–60).

Results

50 out of 72 responses were received and analysed. The mean age of respondents was 60.6 years. The mean post-operative PROMs responses were 1260 days (range 366–2553, SD 894.3 days). Overall, the mean CCS score was 11.36 (range 0–68, SD 16.98), mean BRDS 7.10 (range 5–20, SD 3.24), mean abdominoplasty score 20.51 (range 7–28, SD 6.07) and mean PSAS score 17.36 (range 6–44, SD 11.7).

Conclusion

After open mesh repair of midline incisional hernias nearly all patients had self-reported highly satisfactory outcomes and quality of life in the medium to long term. Embedding PROMs into follow-up regimes improves understanding of post-operative outcomes, enables better decision making and development of management strategies.
THE IMPACT OF SMOKING ON VENTRAL AND INGUINAL HERNIA POSTOPERATIVE OUTCOMES: A SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: Lima D L , Kasmirski J , Balthazar da Silveira C A , Rasador A C , Kasakewitch J P G , Nogueira R , Malcher F , Sreeramoju P
Published: May 2024

Aim

Active smoking is associated with poor outcomes after hernia repair, but a comprehensive consensus or systematic review is lacking in the literature. Hence, we performed a systematic review and meta-analysis to assess the impact of smoking on the outcomes after ventral hernia repair (VHR) and inguinal hernia repair (IHR).

Materials and Methods

A systematic literature review was conducted in Cochrane Central, Scopus, SciELO, and PubMed/MEDLINE databases on studies mentioning smoking and IHR and VHR outcomes.

Results

Out of 3,296 studies, 35 met the inclusion criteria. These comprised 18 studies (123,506 patients) on VHR and 17 studies (204,337 patients) on IHR. The analysis revealed that smokers had significantly higher rates of SSO (13.6% vs. 12.4%; RR 1.5; 95% CI [1.15; 1.95]; P = 0.002) and SSI (6.51% vs. 4.1%; RR 1.8; 95% CI [1.29; 2.5]; P < 0.001) following VHR. No significant differences were observed in recurrence (RR 1.36; 95% CI [0.94; 1.97]; P = 0.102), seroma (RR 2.63; 95% CI [0.88; 7.91]; P = 0.084), and reoperation rates (RR 1.48; 95% CI [0.77; 2.85]; P = 0.236) for VHR. Additionally, smokers undergoing IHR showed higher recurrence (9% vs. 8.7%; RR 1.91; 95% CI [1.21; 3.01]; P < 0.01), SSI (0.6% vs. 0.3%; RR 1.6; 95% CI [1.21; 2.0]; P < 0.001), and chronic pain (9.9% vs. 9.9%; RR 1.24; 95% CI [1.06; 1.45]; P < 0.01) rates.

Conclusions

There is a clear association between smoking and adverse outcomes in both IHR and VHR based on this meta-analysis. It highlights the need for preoperative counseling for smokers undergoing these procedures and clinical awareness of poor outcomes.
INCISIONAL HERNIA AND ITS INFLUENCE ON ABDOMINAL WALL STRENGTH: A CASE-CONTROL STUDY
Authors: López-Huerta A , Martínez-Núñez S , Gil-Delgado J L , Feria-Madueño A , Tallón-Aguilar L , Padillo-Ruiz J
Published: May 2024

Background

Incisional hernia (IH) might lead to a weakened abdominal wall, potentially reducing patients' functionality. This study aims to assess abdominal muscle strength in patients with IH and compare it with that of healthy subjects.

Method

This prospective case-control study included 80 subjects, 40 patients diagnosed with IH (classified as W2-3 by the European Hernia Society Classification) and 40 healthy controls. IH patients were matched with those without abdominal wall disorders, based on gender, BMI, age, and body composition. Patients were assessed using a strain gauge, performing trunk isometric contractions at 90° and 45°, to measure the anterior abdominal wall and lateral abdominal musculature, respectively.

Peak force and the rate of force development at 90° and 45° were compared between groups.

Results

Patients with IH exhibited a substantial 20% reduction in abdominal wall function. Abdominal wall strength significantly decreased in the IH group compared to controls in both the anterior abdominal wall at 90° (mean peak force: 208.61 vs. 169.2, p = 0.001; mean rate force development: 741.73 vs. 366, p = 0.003) and lateral musculature at 45° (mean peak force: 195.49 vs. 151.63, P = 0.001; mean rate force development: 552.27 vs. 302.90, p = 0.001). Regression analysis (p = 0.001, R2 = 0.43) revealed that gender (P = 0.000) and BMI (P = 0.004) significantly affected abdominal strength. For each centimeter increase in maximum hernia diameter, strength decreased by 5 newtons.

Conclusions

Patients with IH experience a significant decline in abdominal wall strength and rapid force production capacity compared to their healthy counterparts.
DEFECT SIZE AND BIOLOGIC MESH OVERLAP: DOES IT INFLUENCE OUTCOMES IN COMPLEX ABDOMINAL WALL (AWR)?
Authors: Lorenz W , Holland A , Mead B , Scarola G , Colavita P , Kercher K , Heniford B , Augenstein V
Published: May 2024

Background

Data does not exist to suggest a mesh to hernia defect area ratio (M:HDR) in AWR. Furthermore, the data are very limited in this respect for biologic mesh. Our aim was to evaluate whether biologic M:HDR or defect size influences outcomes in AWR.

Method

A prospectively maintained hernia database at a tertiary hernia center was queried for all open ventral hernias repaired with a biologic mesh (2003–2023). Patients were stratified by terciles based on defect size, <168 cm2 (HD1), 168–299cm2 (HD2), and ≥300 cm2(HD3). Univariate analysis and multivariable regression were performed.

Results

Overall, 408 patients were evaluated. There were 142, 132, and 134 patients in the HD3,2,1 groups respectively. There were differences in race (Caucasian:86.6% vs. 81.8% vs. 76.1%, P = 0.047), sex (female:43.7% vs. 50.8% vs. 66.4%, P = 0.0005), age (57.9, 61.3, 56.3 years, P = 0.003), ASA score (ASA 3: 54.9% vs. 54.5% vs. 41.8%, P = 0.004) and recurrent hernias (66.2% vs. 59.1% vs. 51.5%, P = 0.045). The rate of diabetes, COPD, overall comorbidities, smoking, and BMI were similar. There was no difference in wound class.

HD3 had more component separations (72.5% vs. 52.3% vs. 39.6%, P <0.0001). Fascial closure was achieved in all patients. HD3 had larger mesh (804.1 vs. 616.9 vs. 416.9 cm2, P <0.0001), longer operative time (246.2 vs. 204.6 vs. 198.3 minutes), and smaller M:HDR (2.0 vs. 2.7 vs. 5.4, P <0.0001).

HD3 patients had longer length-of-stay (11.0 vs. 8.3 vs. 7.6 days, P = 0.0002) and ICU admissions (6.3% vs. 0% vs. 2,2%, P = 0.007). Wound complication and respiratory-failure rates were not different. Hernia recurrence was similar between groups (8.5.vs. 8.2 vs. 3.8, p = 0.227) with 24.5-months follow-up. On logistic regression, the wound complication rate was an independent predictor of recurrence (OR = 3.95,CI [1.82,8.6], P = 0.0005).

Conclusion

HD3 were more complex, had larger hernia defects and mesh size, but smaller M:HDR. Despite this, wound complications and recurrence rate were similar between groups. Fascial closure with biologic mesh reinforcement provides a durable repair across defect sizes despite varying mesh overlap.
LONG-TERM EVALUATION OF THE HERNIA COMPACT COURSE OF THE GERMAN HERNIA SCHOOL
Authors: Lorenz R , Paasch C , Stechemesser B , Reinpold W , Niebuhr H , Fortelny R H , Mayer F , Köckerling F , Mantke R
Published: May 2024

Introduction

Since 2011, the German Hernia Society has developed the German Hernia School (GHS) as a standardized hernia surgery training program for younger surgeons, consisting of the Hernia Compact basic module. It is a standardized three-day training program (cadaver workshop, ultrasound simulation training, and hands-on training). After 12 years of experience, a survey was conducted to evaluate the long-term effect of this training.

Method

Using an anonymous online-questionnaire, we contacted from September 2023 to November 2023 the Hernia Compact course participants via the congress organizer “Weitmeer” and the German Hernia Society. This online questionnaire contains 18 multiple choice questions regarding participants’ age, gender, professional experience, participation in other modules of the German Hernia School, the effect of the course on their daily practice and their specific interest in hernia and abdominal wall surgery.

Results

A total of 146 participants responded to the anonymous online questionnaire. A majority of 132 of 146 participants (90.42%) responded that this course improved the quality of surgical and hernia training (n = 146, no missing data). 141 of 146 individuals (96.58%) recommended the course to surgical colleagues (n = 146, no missing data). There were 89.73% of participants, (n = 146, no missing data) that developed a specific interest in hernia and abdominal wall surgery after the course. For 78.08% (n = 146, no missing data) of participants hernia and abdominal wall surgery was one of the most important activities in their daily surgical practice.

Conclusion

The standardized Hernia Compact basic course of the German Hernia School appears to have a huge impact on the quality of hernia surgery training in Germany and Austria. It might also help generate a specific interest in hernia surgery among participants.
THE FRAGILITY OF RANDOMIZED CONTROLLED TRIALS (RCTS) COMPARING BIOLOGIC VERSUS SYNTHETIC MESH IN ABDOMINAL WALL RECONSTRUCTION (AWR)
Authors: Lorenz W , Holland A , Ayuso S , Mead B , Hollinsworth R , Ku D , Scarola G , Augenstein V , Heniford B
Published: May 2024

Background

The robustness of RCTs in AWR remains underexplored. The fragility index (FI) measures the minimum number of events whose outcome would have to change to reverse the significance of a result. Reverse fragility index (RFI) calculates the minimum number to turn a non-significant result to significant. This study aimed to evaluate the fragility of RCTs comparing biologic versus synthetic mesh.

Method

A comprehensive search of RCTs comparing biologic and synthetic mesh outcomes was conducted. Of 274 studies reviewed, 4 RCTs met the inclusion criteria. Primary outcomes were recurrence (n = 2) and major complications (n = 2). FI, (RFI), fragility quotient (FQ), and reverse FQ (RFQ) were calculated.

Results

Four RCTs, enrolling 87–253 patients, were published in journals with a median impact factor of 13.78. There was heterogeneity in hernia characteristics, mesh choice, mesh placement, and fascial closure among the studies. The follow-up time ranged from 12.4–36 months.

For recurrence, the FI was 1 and 7; FQ was 0.008 and 0.028. For major complications, there was one positive study with an FI of 6 and FQ of 0.024. The one negative study was deemed significant using Bayesian statistics, but on review with the frequentist approach, the P-value = 0.071 and FI = 0, indicating non-significance. Therefore, the RFI was calculated as 1 and RFQ was 0.014.

Conclusion

The fragility analysis underscores the vulnerability of RCTs comparing biologic and synthetic mesh in AWR. Despite RCTs favoring synthetic mesh, the low fragility indices and marked differences in study details should caution translating these findings to clinical practice.
PHASIX™ NON-ST MESH FOR GIANT PARAOESOPHAGEAL HERNIAS – THE WAY OF THE FUTURE?
Authors: Lorenzo A
Published: May 2024

Aim

Mesh reinforcement of the oesophageal hiatus decreases recurrence rates for large paraoesophagal hernias. The use of permanent synthetic mesh is associated with significant risk of erosion which is not observed with absorbable biosynthetic mesh, at the hypothetical cost of long-term hernia recurrence. We aim to assess the safety and effectiveness of Phasix™ non-ST mesh in the repair of giant paraoesophageal hernias.

Material and Methods

Patients presenting for elective laparoscopic mesh repair of giant paraoesophageal hernias with modified Dor fundoplication, between 2019–2021, were included in this cohort study. Phasix™ non-ST mesh was used in all patients and fixed with fibrin glue. Clinical follow-up included yearly non-contrast chest-CT and gastroscopy. Primary endpoint was early endoscopic and/or CT-scan recurrence, secondary endpoints were length-of-hospital stay (LoS), morbidity, mortality and symptom recurrence.

Results

Thirty two patients (mean age 68.1 years) with giant paraoesophageal hernias underwent laparoscopic Phasix™ non-ST mesh repair with modified Dor fundoplication. Dyspnoea (63.6%), dysphagia (51.5%), and epigastric/chest pain (48.5%) were the most common symptoms. Reflux was negligible. There were 62.5% type III and 15.6%% type IV hernias. Thirty five (85%) patients had more than 50% herniation of the stomach. Median LoS was 3 days and 97% were symptom free at mean 24-month follow-up. There was no major complication and no mortality. There was one endoscopic and radiological recurrence found in one patient (3.1%) at 24 months.

Conclusions

Phasix™ non-ST mesh reinforcement of the oesophageal hiatus with fibrin glue fixation shows promise in reducing recurrence rates for repair of giant paraoesophageal hernias.
PATIENT REPORTED OUTCOMES: PILOT ANALYSIS OF 500 PATIENTS
Authors: Mainprize M , Paasch C , Svendrovski A , Netto S
Published: May 2024

Background

Implement patient reported outcome assessments for Shouldice Hospital patients and evaluate these assessments.

Method

A 30–40-day postoperative follow-up of patients at Shouldice Hospital was conducted. Data collection involved chart review and online surveys. The survey included questions like those used in HerniaMed, with additional questions on reasons for surgery, decision making and knowledge, and experience. After preliminary review, it became apparent that some of the questions were not clear and possibly misunderstood by participants. To further verify the participant’s responses (surgical site infection and relapses) follow-up telephone call (conducted by a surgeon) and emails were done.

Results

500 patients underwent primary and recurrent surgery (males: 442; females: 58). The median age and body mass index were 61.1 years and 24.9 kg/m2. Most patients had American Society of Anesthesiologists (ASA) score II (43.0%, ASAI:25.2%; ASAIII:31.8%). There were 432 groin and 65 ventral hernias, and 3 other hernia related surgeries. Hernias were repaired by Shouldice (83.4%), tissue (14%), and mesh (2.6%). When patients were asked about pain, 5% had at rest, 20% on exertion, and 1.8% required treatment. Ten participants responded with a relapse and upon contacting these participants, 9 did not have a relapse but had misinterpreted the question (1 could not be reached). Furthermore, 6 participants responded with a surgical site infection and upon contact 2 were confirmed, 2 remain unconfirmed, and 2 were other complications (hematoma and seroma).

Conclusion

Patient reported outcomes are increasingly important, however, not all assessments may be clear enough for patients, leading to possible insufficient measurements of outcomes.
SEQUENTIAL SURGERIES FOLLOWING TRANSVERSUS ABDOMINIS RELEASE FOR ABDOMINAL WALL RECONSTRUCTION: INSIGHTS FROM A SINGLE-CENTER ANALYSIS
Authors: Messer N , Ellis R C , Maskal S M , Chang J H , Prabhu A S , Miller B T , Beffa L R A , Petro C C , Mazzola Poli de Figueiredo S , Fafaj A , Essani V , Rosen M J
Published: May 2024

Introduction

Abdominal surgery following transversus abdominis release (TAR) procedure commonly involves incisions through the previously implanted mesh, potentially creating vulnerabilities for hernia recurrence. This study aims to reveal the incidence and outcomes of post-TAR non-hernia-related abdominal surgeries of any kind.

Methods

Adult patients who underwent non-hernia-related abdominal surgery following ventral hernia repair with concurrent TAR procedure and permanent synthetic mesh in the Cleveland Clinic Center for Abdominal Core Health between January 2014 and January 2022 were identified. We evaluated 30-day wound morbidity, perioperative complications, and long-term hernia recurrence.

Results

A total of 1137 patients who underwent TAR procedure were identified, with 53 patients (4.7%) undergoing subsequent non-hernia-related abdominal surgery post-TAR. Small bowel obstruction was the primary indication for reoperation (22.6%), and bowel resection was the most frequent procedure (24.5%). 49.1% required urgent or emergent surgery, with the majority (70%) having open procedures. Fascia closure was achieved by absorbable sutures in 50.9%, and of the open cases, fascia closure was achieved by running sutures technique in 35.8%. 20.8% experienced SSO, the SSOPI rate was 11.3%, and 26.4% required more than a single reoperation. A total of 88.7% were available for extended follow-up, spanning 17–30 months, resulting in a 36.1% recurrent hernia diagnosis rate.

Conclusions

Abdominal surgery following TAR surgery is associated with significant comorbidities and significantly impacts hernia recurrence rates. Our study findings underscore the significance of making all efforts to minimize reoperations after TAR procedure and offers suggestions on managing the abdominal wall of these complex cases.
FEASIBILITY OF INTEGRATING PATIENT-REPORTED OUTCOME MEASURES (PROMS) IN A NATIONAL INGUINAL HERNIA REGISTRY – A SINGLE-CENTER PILOT STUDY
Authors: Meuzelaar R R , Smit H V , den Hartog F P J , Schiphorst A H W , Tanis P J , Burgmans J P J
Published: May 2024

Aim

Inguinal hernia (IH) repair is a common surgical procedure. Therefore, minor improvements have the potential to seriously impact quality of life (QoL). Improving healthcare quality and transparency can be accomplished by establishing a national registry, exposing between-hospital variation. Given the absence of the patient’s perspective in clinical data, patient-reported outcome measures (PROMs) are crucial for displaying daily functioning and QoL. This pilot study assessed the feasibility of implementing automated PROMs in a national IH registry, without any healthcare personnel interference to minimize administrative burden.

Methods

A retrospective cohort study of prospectively collected data was conducted in a high-volume IH clinic between January 18, 2023, until February 6, 2024. All adult patients who underwent IH surgery received automated PROMs questionnaires by email pre-operatively, 6 weeks, 3 months, 1 and 2 years postoperatively. The primary outcome was the response rate at different follow-up moments. A rate of 60% was considered sufficient. Secondary outcomes included the questionnaires’ responses about pain, return to work and exercise, patient satisfaction and recurrence.

Results

In total, 1291 patients were included. Response rates were: 81% pre-operatively, 45% at 6 weeks (n = 1221) and 50% at 3 months (n = 837). One and two years of follow-up are pending.

Conclusion

Overall, a declining response rate was observed, which impacts the data’s validity. This decrease can be attributed to the patients unawareness of the recently adopted method. Integration of PROMs into routine patient care may result in improved adherence. Strategies to optimize response rate must be incorporated to ensure successful implementation.
INCREASING THE EFFICIENCY IN THE ROBOTIC ASSISTED PCS (POSTERIOR COMPONENT SEPARATION) SURGERIES BY OPTIMISING THE WORK FLOW
Authors: Misra S
Published: May 2024

Aim

Increasing the efficiency in robotic pcs surgeries by optimising the surgical practice for maximal utilisation of the resource.

Material and Methods

47 PCS were done between Feb 2023 to Jan 2024. Of them 37 surgeries were for r TEP RS (Robotic totally extra-peritoneal Rives Stoppa Repair) with AWR (anterior wall reconstruction) and 10 procedures were r TAR (robotic Transverses abdomens release) procedures. All surgeries were performed on the DA Vinci XI platform.

The need for these measures arose due to the fact that multiple departments were competing for the same resource, i.e., the Robot!

These measures taken to improve the efficiency were as follows:

Pre-Operatively:

All patients were admitted one day in advance.

All patients had an USG marking of the linea semilunaris.

Intra-Operative:

The Port placements were revised.

Only 3 robotic instruments were utilized.

The left retro-rectus plane and the space below the arcuate lines were created before the robot was deployed with the help of the Ligasure.

The midline was reconstructed by using only 15 cm sutures barbed sutures.

Wherever possible, self-fixation meshes were used.

Result

By changing few aspects of our surgical practice, we were able to reduce the operating time of our Robotic PCS from 85 min to 46 minutes.

Conclusion

By optimising the resources, methods and practices, the utilisation of robots can be increased without compromising the safety of the patient.
A META-ANALYSIS OF EMERGENCY INCISIONAL HERNIA REPAIR: DO OUTCOMES DIFFER FROM ELECTIVE SURGERY?
Authors: Quiroga-Centeno A C , Schaaf S , Morante A , Gómez-Ochoa S A , Stabilini C
Published: May 2024

Background

Incisional hernias (IH) have been progressively recognized as independent entities in the hernia field. However, the same indications for deferred treatment of ventral hernias are generally applied to IH, regardless of the potentially different outcomes. This meta-analysis aims to compare the characteristics and outcomes of patients treated urgently for IH with those undergoing elective surgery.

Method

Medline and Scopus were systematically searched from 1990–2023. Original studies comparing patients treated for emergency vs. elective IH were included. Study screening was performed using ASReview®. Data were pooled using random-effects models.

Results

Seventeen studies assessing 88,743 patients were included. Emergency IH patients were significantly older (MD 4.51 years; 95%CI 2.38–6.64. I2: 62%), more frequently women (RR 0.76; 95%CI 0.61–0.94. I2: 73%), and had a higher prevalence of ASA score III-IV (RR 1.38; 95%CI 1.03–1.84. I2: 30%). Furthermore, emergency surgery was associated with a longer hospital stay (MD 4.61 days; 95%CI 3.78–5.45. I2: 0%), higher need for reoperation (RR 2.20; 95%CI 1.73–2.80. I2: 0%), and higher mortality (RR 10.06; 95%CI 3.82–26.52. I2: 45%) compared to elective procedures. No differences in hernia recurrence rates or mesh repair were identified.

Conclusion

Emergent IH repair was associated with worse postoperative outcomes and higher mortality than elective repair. Nevertheless, scarcity of data precluded the inclusion of additional factors (type of repair, hernia size) and stratified/meta-regression analysis by relevant variables (age, sex, surgical risk). Larger studies are needed to determine predictors and outcomes of emergent repair in IH and appropriately identify patients who may benefit from watchful waiting.
ROBOT-ASSISTED REPAIR OF POST-GESTATIONAL RECTUS DIASTASIS WITH THE TARUP APPROACH – A RETROSPECTIVE EVALUATION OF PATIENT SATISFACTION
Authors: Rothman J V , Billustovum B , Henriksen N A
Published: May 2024

Background

To evaluate the TARUP (robotic Transabdominal Retromuscular Umbilical Prosthetic Hernia Repair) technique used for post-gestational rectus abdominis diastasis (RD) in terms of complications and patient satisfaction.

Methods

We retrospectively identified patients with a repair of RD from January 2018 to August 2023. Patients were invited to participate in the study by telephone. Participants completed a questionnaire on physical and cosmetic complaints and patient satisfaction.

Results

Twelve women had a repair of RD during the study period, and 75% (9/12) participated in this study. All patients had a diastasis of at least 3 cm and a concomitant hernia. The mean length of stay was 1,4 days. No patients were readmitted, but two were seen in the emergency room due to pain. Prior to the surgery 67% (6/9) had limitations with strenuous activities, 78% (7/9) with sport activities and 44% (4/9) with daily tasks, this was significantly reduced after surgery to 0%, 22% (2/9), and 0%, respectively. Daily pain or discomfort from the abdominal wall or back was reported in 56% (4/9) at rest and 67% (6/9) while doing activities, and this was reduced to 11% (1/9) and 22% (2/9) after surgery. Cosmetic satisfaction with the shape of the abdomen was improved, but the main complaint was continuous bulging of the skin in the midline and a crooked midline after surgery.

Conclusions

The robot-assisted TARUP repair for RD seems to reduce pain and limitations in daily life, however further studies including more patients are needed.
EVOLUTION OF THE eTEP TECHNIQUE FOR VENTRAL HERNIA REPAIR: SIX-YEAR SINGLE-SURGEON EXPERIENCE WITH TECHNICAL ADVANCEMENTS AND ADAPTATIONS
Authors: Salido S , Guevara-Martínez J , Zapata C , Gutiérrez E , Reinoso F , Abad R , Georgiades A , Monje B , Fondevila C
Published: May 2024

Objective

The aim of this study was to assess the learning curve and the implementation of tools for the correction of ventral hernias using the extended totally extraperitoneal (eTEP) approach.

Materials and Methods

All patients underwent eTEP ventral hernia repair performed by one surgeon. A prospective multicenter study involving patients from General Hospital of Villalba, Jiménez Díaz Foundation, and La Paz Hospital in Madrid was conducted from May 2018 to January 2024.

Results

Over the 6-year period, 216 patients (133 midline and 83 laterals) were operated on. There was an increased percentage of incisional and recurrent hernias compared to primary hernias, along with an observed rise in case complexity and defect size, with no significant increase in surgical time or complications. Over the technical evolution in the last 6 years, a decreasing trend in the utilization of posterior component separation with transversus abdominis release (TAR) for midline defect closure was noted, despite the increased complexity and hernia size. This shift was attributed to the use of peritoneal flap instead of TAR for closing the posterior plane in extensive defects, as well as the use of BOTOX and fascial traction for hernia defect closure.

Conclusions

The results demonstrate a significant evolution in the eTEP technique for treating incisional hernias, addressing larger and more complex hernias over time. Furthermore, the decreasing use of TAR for both posterior and anterior closure, in favor of adjuncts such as BOTOX, peritoneal flap, and fascial traction, facilitated a surgical downstaging and led to low complication rates.
THE INFLUENCE OF ULTRASOUND IN THE CHOICE OF SURGICAL TECHNIQUE TO REPAIR INGUINAL HERNIA: A PROSPECTIVE MULTICENTRIC COHORT STUDY
Authors: Sampaio-Alves M , Alagoa João A , Taveira-Gomes T , Picciochi M
Published: May 2024

Background

Inguinal hernia is diagnosed by physical examination (PE) alone in most patients. Imaging is helpful if there is diagnostic doubt. A previous cohort study identified a high rate of ultrasound (US) use to diagnose inguinal hernias. This study assessed if the use of US influenced the choice of surgical technique to repair inguinal hernias.

Methods

Multicenter prospective cohort study of consecutive patients undergoing elective inguinal hernia repair between October and December 2019. Patients diagnosed with other image exams were excluded. The group of patients diagnosed with PE was compared to the group diagnosed with US. The primary outcome was surgical technique. The association between use of US and choice of surgical technique was tested through a logistic regression model.

Results

A total of 911 patients from 33 Portuguese hospitals were included, 49.2% were diagnosed with PE only and 50.8% had an US. There were no statistically significant differences in the characteristics of the patient, symptoms or hernia between the two groups. Lichtenstein was the most used surgical technique in both groups. There was no association between the use of US and the choice of surgical technique (adjusted odds ratio 1.02, 0.71–1.48, p = 0.901).

Conclusion

The use of US had no impact in the choice of surgical technique to repair inguinal hernias and is not recommended for their diagnosis. Its use can increase costs of care and delay patients' treatment. A plan to decrease the use of the US in this setting is needed.
SURFACE MODIFICATION OF ARTIFICIAL IMPLANTS BY HYBRID NANOLAYERS – ANTIMICROBIAL SURFACE FINISHING TESTS, STRENGTH TESTS, LEACHATES AND SCANNING ELECTRON MICROSCOPE ANALYSIS
Authors: Skach J , Slamborova I , Exnar P
Published: May 2024

Aim

The aim of this study was to evaluate the antibacterial efficacy of surface treated hernia implants modified by a hybrid nanolayer with incorporated Ag, Cu and Zn cations using the sol-gel method and to evaluate minimal influence of these modifications on the mechanical properties of the meshes.

Material and Methods

The materials (polypropylene, polyester and polyvinylidendifluoride) were activated by vacuum plasma treatment or UV C radiation, than modified and tested for bacterial strains of Escherichia coli (Gram-) and Staphylococcus aureus (Gram+).

Maximum strength and ductility of modified samples were measured on a universal Testometric tensile testing machine.

The gradual release of incorporated ions was monitored over time in simulated body fluids using inductively coupled plasma mass spectrometer.

The thickness and the homogeneity of the layers were measured with scanning electron microscope analysis (SEM) and evaluated with an elemental analysis.

Results

Qualitative and quantitative microbiological tests clearly showed the great suitability of surface treatment of all tested implants.

A slight reduction of mechanical properties in modified meshes were not of clinical importance.

The absolute concentration of Ag, Cu and Zn cations in leachates was very low.

SEM showed a high degree of homogeneity of the layer and only very rare nanocracks by all tested materials appeared after mechanical stress.

Conclusions

This study confirms that surface treatment of meshes using the sol-gel method significantly increases the antibacterial properties, does not affect mechanical properties of implants and the nanolayers are sufficiently mechanically resistant, stable and pose no threat to health.
SURGICAL UNIT VOLUME AND REOPERATION FOR RECURRENCE FOLLOWING TOTALLY EXTRA-PERITONEAL GROIN HERNIA REPAIRS
Authors: Widman F , Bergström M , Widhe B , Bringman S , Melkemichel M
Published: May 2024

Background

Quality of totally extra-peritoneal groin hernia repair (TEP-GHR) and recurrence are related to several factors and possibly to the annual volume of repairs carried out by surgical units. The nature of this relationship is still unclear. The aim of this study was to investigate the surgical unit volume influence on reoperation for recurrence.

Material

This observational nationwide population-based study was based on prospectively collected data from the Swedish Hernia Register. All patients ≥15 years old who underwent a TEP-GHR between 2015–2019 were eligible. Follow-up time was minimum 3 years after surgery. Surgical units were grouped into; low-volume (<12 repairs/year), low-medium volume (12–50 repairs/year), medium-high volume (>50–150 repairs/year) and high-volume (>150 repairs/year) units. Primary outcome was reoperation for recurrence. Secondary outcome was postoperative complications within 30 days.

Results

In total, 20,616 elective TEP-GHR within 75 surgical units were included. The reoperation rate was higher in all three lower-volume groups; low-volume (5.3%), low-medium (3.8%) and medium-high (3.5%) compared with the high-volume group (2.9%). Adjusted multivariate cox regression analysis showed a statistically significant increased hazard ratio for reoperation for recurrence in the low-volume group; 1.87 (95% CI 1.31–2.67) and in the low-medium volume group; 1.32 (95% CI 1.07–1.62) compared to the high-volume group. No difference was seen between the groups regarding the risk of postoperative complications.

Conclusion

The reoperation risk for recurrence following TEP-GHR was significantly increased in surgical units with less than 50 TEP-GHR’s per year. This may influence guidelines on required annual surgical unit volume to improve patient outcomes following TEP-GHR.
INTRAOPERATIVE FASCIAL TRACTION FOR THE TREATMENT OF LARGE HERNIAS – RESULTS OF A MULTICENTRE STUDY
Authors: Woeste G , Meier H , Sardoschau N , Kiehle A , Niebuhr H
Published: May 2024

Background

The incidence of incisional hernias after laparotomy ranges between 5 and 20%. Closure of the defect and mesh reinforcement is therapeutic standard. Intraoperative fascial traction (IFT) is a new technique for hernia closure.

Materials and Methods

We analyse data of IFT from five hospitals between 12/2020 and 9/2023. In all cases the Fasciotens®Hernia System was applied. When fascia closure was not possible, transversus abdominis release (TAR) was performed. During follow-up all patients were examined according to a standardized protocol including ultrasound. Quality of life was assessed using the HerQLes questionnaire.

Results

A total of 96 patients were included in the study (HH-62, DA-11, SB-10, D-9, L-4). The age was 59.9 ± 14.1 years, 41% were female, BMI was 31.0 ± 7.3 kg/m², hernia width was 15.7 ± 5.1 cm. 88.5% underwent pretreatment with botulinum toxin (BTX). A TAR was performed in 28.1% cases. Bridging was necessary in 5.2%. Length of stay was 8.3 days.

In the postoperative course, 39/96 (40.6%) patients experienced a complication: 20.8% seroma, 9.4% wound infection, 4.2% haematoma, 2.1% intestinal injury, 1.0% wound dehiscence, 3.1% pneumonia and 2.1% urinary tract infection. No patient died. The incidence of wound infections was higher in patients with additional TAR (11.1% vs. 8.7%).

During the mean follow-up of 15.7 ± 12.6 months 2 hernias at the border of the mesh were recognized. The HerQLes summary score was 64.5.

Conclusion

This multicentre study shows a low incidence of wound infection and recurrences using IFT. The fascia closure rate is high when combining IFT with BTX pretreatment.

Further randomised studies of IFT should follow to support these findings.
APPLICATION OF THREE-DIMENSIONAL VISUALIZATION TECHNOLOGY IN PREOPERATIVE PLANNING OF COMPLEX ABDOMINAL WALL DEFECT REPAIR AND RECONSTRUCTION
Authors: Yang D , Song Z , Song H , Yang J , Gu Y
Published: May 2024

Aim

To prospectively study the role of three-dimensional visualization (3DV) technology in preoperative planning of complex abdominal wall defect repair and reconstruction.

Methods

210 patients with complex abdominal wall defects who underwent reconstruction surgery were enrolled. Preoperative planning was performed by CT imaging (CT group) or 3DV technology (3DV group).

Results

The methods of repair and reconstruction of abdominal wall defects included single or double patch, three-layer bridging (mesh+greater omental flap+mesh), CST+mesh, CST+mesh+omental flap, mesh+tissue flap repair. There was no significant difference in the clinical cure rates of abdominal wall defect observed between the CT group and 3DV group (82.61% vs.91.30%, P > 0.05). The clinical cure rates of abdominal wall defect caused by primary and secondary abdominal wall tumors were 96.23% and 89.66% in the 3DV group, respectively, which were significantly higher than those in the CT imaging group (84.91% and 68.97%, both P < 0.05).

Conclusion

3D visualization technology can accurately evaluate the indicators of complex abdominal wall defects before surgery, helping clinicians to make an improved individualized surgical planning.
FUNCTIONAL CT IN LAPAROENDOSCOPIC ABDOMINAL WALL SURGERY. KEY POINTS AND SURGICAL APPLICATION
Authors: Zárate Gomez J , Cano Alonso R , Peinado Iríbar B , Supelano Eslait G , Álvarez de Sierra P , Gil López J M , Fernández Alfonso A , Merello Godino J
Published: May 2024

Background

At present the abdominal wall hernia treatmen is clearly trending towards less invasive techniques and we believe the functional CT scan offers great value information for patient selection as well as for surgical planning. We descibe de image key points and landmarks we use to design the best surgical.

Method

After 5 years performing eTEP Rives-Stoppa for ventral hernia sugery, we describe the secuential standardized steps we use to evaluate a functional Ctscan to plan the surgical approach. A CT scan, without any oral or intravenous contrast, combining Valsalva maneouver images along with negative pressure will provide the best information of the dynamic behaviour of the abdominal wall. The preoperative study of the volumetric and anatomical landmarks will guide us to tailor surgery.

Defect measures:

Wide

Location

Volumen

Content

Previous mesh, fixation devices placement.

Undiagnosed diseases.

Anatomic key points

Anatomic landmarks

Diastasis

Abdominal rectus wide

Muscular atrophy

Distance to:

Pubis

Xifoid

Subcostal margin

Semilunar line

Quadratus lumborum muscle

Results

Preoperative study of the volumetric and anatomical landmarks will guide us to design our surgical strategy:

Need for surgical prehabilitation.

Patient position.

Number and port placement.

Spaces we need to approach (retrorectal, pretransversalis, preperitoneal) to repair the defect and deploy the mesh with enough overlap.

Need to perform a TAR.

Conclusion

Functional CTscan provides us basic information of the patient’s abdominal wall. Thorough anamnesis and physical examination combined with this image test will help us render the best surgical repair.
LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR IN ELDERLY PATIENTS: ACS NSQIP ANALYSIS OF 35,539 CASES
Authors: Zeng M , Olsen N , Badiani S S , Berney C R
Published: May 2024

Background

There is controversy regarding the adoption of laparoscopic inguinal hernia repair in the elderly population. The aim of this study was to determine whether there is a difference in 30-days postoperative outcome in this group of patients, when compared to open herniorrhaphy, using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database.

Method

Data was accessed from operative years 2015 to 2022. All patients aged ≥75 years undergoing elective inguinal hernia repair were retrieved from the database. SPSS software was used. Propensity scores were calculated and included in the multivariate analysis to adjust for selection biases.

Results

The study population included 35,539 patients. A steady increase in the utilisation of laparoscopic approach was observed, from 23% in 2015, reaching 42% in 2022. The laparoscopic group had a longer mean operative time of 12 minutes (p < 0.001), but a shorter hospital stays of 0.08 days (p < 0.005).

Overall, the proportion of people developing any serious postoperative complication was equivalent at 2.8% between two groups. In the laparoscopic group, there was a lower risk for superficial surgical site infection (SSI) (p < 0.05). However, there was a higher risk for urinary tract infection (P < 0.005) and return to theatres (p < 0.05). There were no statistically significant differences for organ space SSI, pneumonia, readmission and mortality.

Conclusion

Laparoscopic inguinal hernia repair in the elderly population offers comparable outcomes to open approach, with shorter hospital stay and reduced risk of SSI, but increased chance of return to theatre.
APPROACHES TO ATYPICAL HERNIAS
Authors: Borgaonkar V
Published: May 2024

Atypical hernias are those located close to abdominal wall margin. They are located at the periphery of abdominal wall and are adjacent to bony structures like xiphoid, costal margins, and pelvis. Due to their locations they pose challenges for repair These challenges are due to lack of tissue mobility in these areas, sufficient mesh overlap over defect is not possible since they are at periphery, mesh fixation is an issue because use of tacks may not be possible at costal margin, diaphragm and tacks may fail to penetrate bony structures like iliac crest. Vicinity of these hernias to anatomical structure like diaphragm, pleura, pericardium and urinary bladder pose technical problem while fixation.

Atypical hernias M1, M5, L1 L2 by locations can be managed by MIS and also open techniques depending upon the patient/hernia characteristic and experience and resources of surgeon.

Case 1

Large complicated atypical hernia with loss of domain post sternotomy incision M1 M2 was managed by open TAR repair.

Case 2

L3 Hernia post laparoscopic nephrectomy hernia at specimen retrieval site was managed by open Surgery Reverse TAR Technique

Case 3

Rare case of urinary bladder herniation, hernia located at L2 position. Patient typically had history of lump disappearing after urination confirmed on CT Imaging managed by MIS technique TAPP.

Conclusions

Atypical hernias are located close to the abdominal wall margin

Technically pose difficulties for repair in view of proximity to important structures, mesh overlap is not sufficient, fixation of mesh is also challenging in these situations.

Both Open as well as MIS Techniques are feasible.

Every case of Atypical Hernias should be managed by experienced surgeons on individual merits.

Here we present our experience in dealing with these Atypical Hernias.
TWO STAGED LAPAROSCOPIC REPAIR OF INFERIOR LUMBAR HERNIA DUE TO APPENDICULAR ABSCESS
Authors: Agrawal M K , Kumar A , Pal A K , Anand A , Pahwa H S , Sonkar A A
Published: May 2024

Background

Often caused by an abnormality in the abdominal wall, inferior lumbar hernias are rare hernias. They may develop spontaneously following trauma or lumbar incision surgery, or they may arise during infancy (congenital defect. We describe a case of an inferior lumbar hernia that resulted from the appendicular abscess.

Method

A 59-year-old man had been experiencing right lumbar reducible swelling for nine months. The swelling was gradually increasing in size. He had an incision and drainage of an abscess at the same site in 2003 and 2013 for drainage of abscess. Examination revealed soft, smooth, non-tender, reducible swelling of size 5 × 3 cm with an overlying scar of the previous incision. Contrast-enhanced CT scan showed herniation of bowel loops, mesenteric fat and vessels through a defect of size 23.9 × 20 mm in the right lumbar region.

Results

The patient was taken for laparoscopic lumbar hernia repair in the left lateral position. The bowel was reduced from the inferior lumbar triangle. The appendix was inflamed with a tip adhered to the lateral abdominal wall along with loculated pus. Pus was drained and following a thorough lavage & herniorrhaphy was done. The patient was taken up for Laparoscopic TAPE after 3 weeks. The postoperative period and 1-year follow-up were uneventful.

Conclusion

Inferior lumbar hernias are rare due to appendicular abscess tracking to the inferior lumbar region. Two-stage Laparoscopic hernioplasty is feasible in selected cases of inferior lumbar hernia presenting with appendicular abscess.