Elective incisional hernia repair: lower risk of postoperative wound infection with laparoscopic versus open repair

INTRODUCTION@#The superiority of laparoscopic repair over open repair of incisional hernias (IHs) in the elective setting is still controversial. Our study aimed to compare the postoperative outcomes of laparoscopic and open elective IH repair in an Asian population.@*METHODS@#This retrospective study was conducted in an acute general hospital in Singapore between 2010 and 2015. Inclusion criteria were IH repair in an elective setting, IHs with diameter of 3-15 cm, and location at the ventral abdominal wall. We excluded patients who underwent emergency repair, had recurrent hernias or had loss of abdominal wall domain (i.e. hernia sac containing more than 30% of abdominal contents or any solid organs). Postoperative outcomes within a year such as recurrence, pain, infection, haematoma and seroma formation were compared between the two groups.@*RESULTS@#There were 174 eligible patients. The majority were elderly Chinese women who were overweight. Open repair was performed in 49.4% of patients, while 50.6% underwent laparoscopic repair. The mean operation time for open repair was 116 minutes (116 ± 60.6 minutes) and 139 minutes (136 ± 64.1 minutes) for laparoscopic repair (P = 0.079). Within a year after open repair, postoperative wound infection occurred in 15.1% of the patients in the open repair group compared to 1.1% in the laparoscopic group (P = 0.0007). Postoperative pain, recurrence and haematoma/seroma formation were comparable.@*CONCLUSION@#Elective laparoscopic IH repair has comparable outcomes with open repair and may offer the advantage of reduced postoperative wound infection rates.

Influencing factors of small intestinal ischemia in elderly patients with incarcerated hernia / 中华外科杂志

Objective: To investigate the factors influencing small intestinal ischemia in elderly patients with incarcerated hernia. Methods: The clinical data of 105 elderly patients admitted for surgical procedures of incarcerated hernia at Department of General Surgery, Huadong Hospital between January 2014 and December 2021 were retrospectively analyzed. There were 60 males and 45 females, aged (86.1±4.3) years (range: 80 to 96 years). They were divided into normal group (n=55) and ischemic group (n=50) according to intraoperative intestinal canal condition. The t test, χ2 test and Fisher's exact probability method were used for the univariate analysis of the factors that influence intestinal ischemia in patients, and Logistic regression was used for multifactorial analysis. Results: In all patients, 18 patients (17.1%) had irreversible intestinal ischemia with bowel resection. Six patients died within 30 days, 3 cases from severe abdominal infection, 2 cases from postoperative exacerbation of underlying cardiac disease, and 1 case from respiratory failure due to severe pulmonary infection. The results of the univariate analysis showed that there were differences in gender, history of intussusception, duration of previous hernia, white blood cell count, neutrophil percentage, C-reactive protein, type of incarcerated hernia, and preoperative intestinal obstruction between the two groups (all P<0.05). The Logistic regression results showed that the short time to the previous hernia (OR=0.892, 95%CI 0.872 to 0.962, P=0.003), high C-reactive protein (OR=1.022, 95%CI 1.007 to 1.037, P=0.003), non-indirect incarcerated hernia (OR=10.571, 95%CI 3.711 to 30.114, P<0.01) and preoperative intestinal obstruction (OR=6.438, 95%CI 1.762 to 23.522, P=0.005) were independent risk factors for the development of intestinal ischemia in elderly patients with incarcerated hernia. Conclusions: The short duration of the previous hernia, the high values of C-reactive proteins, the non-indirect incarcerated hernia, and the preoperative bowel obstruction are influencing factors for bowel ischemia in elderly patients with incarcerated hernia. A timely operation is necessary to reduce the incidence of intestinal necrosis and improve the prognosis.

Femoral hernia: uncommon, but associated with potentially severe complications / Hérnia femoral: incomum, mas associada a complicações potencialmente graves

ABSTRACT Background: Although the laparoscopic access is becoming the preferable treatment for femoral hernia, there are only few studies on this important subject. Aim: To assess the outcomes of the totally extraperitoneal laparoscopic (TEP) access in the treatment of femoral hernia. Methods: Data of 62 patients with femoral hernia who underwent herniorrhaphy were retrospectively reviewed. The diagnosis of femoral hernia was established by clinical and/or imaging exams in 55 patients and by laparoscopic findings in seven. Results: There were 55 (88.7%) females and 7 (11.3%) males, with female to male ratio of 8:1. The mean age was of 58.9±15.9 years, ranging from 22 to 92 years. Most patients (n=53; 85.5%) had single hernia and the remaining (n=9; 14.5%) bilateral, making a total of 71 hernias operated. Prior lower abdominal operations were recorded in 21 (33.9%) patients. Conversion to laparoscopic transabdominal preperitoneal procedure was performed in four (6.5%). Open herniorrhaphy was needed in two (3.2%), one with spontaneous enterocutaneous fistula in the groin region (Richter's hernia) and the another with incidental perforation of the adjacent small bowel that occurred during dissection of hernia sac. There was no mortality. Conclusion: Femoral hernia is uncommon, and it may be associated with potentially severe complications. Most femoral hernias may be successfully treated with totally extraperitoneal laparoscopic access, with low conversion and complication rates.

RESUMO Racional: Embora o acesso laparoscópico esteja se tornando o tratamento preferencial para a hérnia femoral, poucos são os estudos sobre esse importante assunto. Objetivo: Avaliar os resultados do acesso laparoscópico totalmente extraperitoneal no tratamento da hérnia femoral. Métodos: Os dados de 62 pacientes com hérnia femoral que foram submetidos a herniorrafia foram revisados ​​retrospectivamente. O diagnóstico foi estabelecido por exames clínicos e/ou de imagem em 55 pacientes e por achados laparoscópicos em sete. Resultados: Havia 55 (88,7%) mulheres e 7 (11,3%) homens, com proporção feminino/masculino de 8: 1. A média de idade foi de 58,9±15,9 anos (22-92). A maioria (n=53, 85,5%) apresentava hérnia única e o restante (n=9, 14,5%) bilaterais, perfazendo um total de 71 hérnias femorais operadas. Operações prévias no abdome inferior foram registradas em 21 (33,9%) pacientes. A conversão para procedimento pré-peritoneal transabdominal laparoscópico foi realizada em quatro (6,5%). Herniorrafia aberta foi necessária em dois pacientes (3,2%), um com fístula enterocutânea espontânea na região da virilha (hérnia de Richter) e o outro com perfuração incidental do intestino delgado adjacente que ocorreu durante a dissecção do saco herniário. Não houve mortalidade. Conclusão: A hérnia femoral é incomum e pode estar associada a complicações potencialmente graves. A maioria das hérnias femorais pode ser tratada com sucesso através do acesso laparoscópico totalmente extraperitoneal, com baixas taxas de conversão e complicações.

Simultaneous laparoscopic inguinal hernia repair and cholecystectomy: does it cause mesh infection? / Colecistectomia e herniorrafia inguinal laparoscópica simultâneas: causa infecção de tela?

ABSTRACT Background: Repair of inguinal hernia concomitant with cholecystectomy was rarely performed until more recently when laparoscopic herniorrhaphy gained more adepts. Although it is generally an attractive option for patients, simultaneous performance of both procedures has been questioned by the potential risk of complications related to mesh, mainly infection. Aim: To evaluate a series of patients who underwent simultaneous laparoscopic inguinal hernia repair and cholecystectomy, with emphasis on the risk of complications related to the mesh, especially infection. Methods: Fifty patients underwent simultaneous inguinal repair and cholecystectomy, both by laparoscopy, of which 46 met the inclusion criteria of this study. Results: In all, hernia repair was the first procedure performed. Forty-five (97,9%) were discharged within 24 h after surgery. Total mean cost of the two procedures performed separately ($2,562.45) was 43% higher than the mean cost of both operations done simultaneously ($1,785.11). Up to 30-day postoperative follow-up, seven (15.2%) presented minor complications. No patient required hospital re-admission, percutaneous drainage, antibiotic therapy or presented any other signs of mesh infection after three months. In long-term follow-up, mean of 47,1 months, 38 patients (82,6%) were revaluated. Three (7,8%) reported complications: hernia recurrence; chronic discomfort; reoperation due a non-reabsorbed seroma, one in each. However, none showed any mesh-related complication. Satisfaction questionnaire revealed that 36 (94,7%) were satisfied with the results of surgery. All of them stated that they would opt for simultaneous surgery again if necessary. Conclusion: Combined laparoscopic inguinal hernia repair and cholecystectomy is a safe procedure, with no increase in mesh infection. In addition, it has important advantage of reducing hospital costs and increase patient' satisfaction.

RESUMO Racional: Reparo da hérnia inguinal concomitante à colecistectomia era raramente realizado até mais recentemente, quando a herniorrafia laparoscópica ganhou mais adeptos. Embora geralmente seja opção atraente para pacientes, a realização simultânea tem sido questionada pelo risco potencial de complicações relacionadas à tela, principalmente infecção. Objetivo: Avaliar uma série de pacientes submetidos a colecistectomia e herniorrafia inguinal laparoscópica simultâneas, com ênfase no risco de complicações relacionadas a tela, em especial infecção. Métodos: Cinquenta pacientes foram submetidos a herniorrafia e colecistectomia simultâneas por videolaparoscopia, dos quais 46 atenderam aos critérios de inclusão. Resultados: Em todos, a herniorrafia foi realizada inicialmente. Quarenta e cinco (97,9%) tiveram alta em 24 h. O custo médio total dos dois procedimentos realizados separadamente ($2.562,45) foi 43% maior do que o custo médio das duas operações feitas simultaneamente ($1.785,11). Após 30 dias de acompanhamento pós-operatório, sete (15,2%) apresentaram complicações menores. Após três meses, nenhum necessitou de readmissão hospitalar, drenagem, antibioticoterapia ou sinal de infecção de tela. No seguimento em longo prazo, média de 47,1 meses, 38 (82,6%) foram reavaliados. Três (7,8%) relataram complicações: recorrência de hérnia; desconforto crônico; reoperação por seroma não reabsorvido. No entanto, nenhum apresentou qualquer complicação relacionada à tela. Questionário de satisfação revelou que 36 (94,7%) ficaram satisfeitos com o resultado da operação. Todos afirmaram que optariam pela ela simultânea novamente se necessário. Conclusão: O reparo da hérnia inguinal concomitante com colecistectomia por laparoscopia é procedimento seguro, sem aumento de infecção da tela. Além disso, tem a vantagem importante de reduzir custos hospitalares e aumentar a satisfação do paciente.

Abordaje multidisciplinario del dolor inguinal crónico luego de hernioplastia inguinal / Multidisciplinary approach to chronic postoperative inguinal pain

RESUMEN Antecedentes: el dolor inguinal crónico posoperatorio representa una complicación que altera la ca lidad de vida después de la hernioplastia inguinal. Su incidencia es variable con informes de hasta el 16%. Objetivo: describir el tratamiento y los resultados en pacientes con dolor inguinal crónico luego de una hernioplastia inguinal con malla. Material y métodos: estudio descriptivo, observacional y retrospectivo. Se definió como dolor ingui nal crónico posoperatorio la presencia de dolor inguinal por daño nervioso o afectación del sistema somatosensorial tisular que persiste por más de 6 meses luego de la cirugía inicial. Se revisaron las historias clínicas de los pacientes que cursaban el posoperatorio de hernioplastia inguinal convencio nal y laparoscópica en el período 2010-2018. Se realizó la encuesta EuraHS Quality of life score antes y después del abordaje terapéutico multidisciplinario para evaluar cambios en el dolor y restricción de la actividad física. Los resultados fueron analizados y comparados. Resultados: se identificaron 8 pacientes con dolor inguinal crónico posoperatorio grave. El 100% fue evaluado por el Servicio de tratamiento del dolor y requirieron 3 o más fármacos para manejo del do lor. Posteriormente requirieron bloqueo guiado por tomografía computarizada a causa de la persisten cia de los síntomas. Se realizaron 3 (50%) exploraciones quirúrgicas con retiro de material protésico y 2 triples neurectomías. Se observó una disminución estadísticamente significativa (p < 0,05) en el dolor en reposo, dolor durante la actividad y dolor que experimentaron en la última semana. Conclusión: el abordaje multidisciplinario y escalonado permitiría seleccionar a los pacientes que se beneficiarán con el tratamiento quirúrgico.

ABSTRACT Background: Chronic postoperative inguinal pain represents a complication that alters the quality of life after inguinal hernioplasty. Its incidence is variable with reports of up to 16%. Objective: To describe the treatment and results in patients with chronic inguinal pain after an inguinal hernioplasty with mesh. Material and methods: Descriptive, observational and retrospective study. The postoperative chronic inguinal pain was defined as the presence of inguinal pain due to nerve damage or involvement of the somatosensory tissue system that persists for more than 6 months after the initial surgery. The medical records of patients in the postoperative period of conventional and laparoscopic inguinal hernioplasty in the period 2010-2018 were reviewed. The EuraHS Quality of life score pre and post multidisciplinary therapeutic approach was used to evaluate changes in pain and restriction of physical activity. The results were analyzed and compared. Results: 8 patients with severe chronic postoperative inguinal pain were identified. 100% were eva luated by the pain management service and required 3 or more drugs for pain management. Sub sequently, they required block guided by computed tomography due to persistence of symptoms. 3 (50%) surgical examinations were performed with removal of prosthetic material and 2 triple neurec tomies. A statistically significant decrease (p <0.05) was observed in pain at rest, pain during activity and pain experienced in the last week. Conclusion: The multidisciplinary and step up approach would allow selecting the patients who will benefit from the surgical treatment.

Hiatal hernia repair: prevention of mesh erosion and migration into the esophagogastric junction / Correção de hérnia hiatal: prevenção de erosão e migração de tela na junção esofagogástrica

ABSTRACT Background: Erosion and migration into the esophagogastric lumen after laparoscopic hiatal hernia repair with mesh placement has been published. Aim: To present surgical maneuvers that seek to diminish the risk of this complication. Method: We suggest mobilizing the hernia sac from the mediastinum and taking it down to the abdominal position with its blood supply intact in order to rotate it behind and around the abdominal esophagus. The purpose is to cover the on-lay mesh placed in "U" fashion to reinforce the crus suture. Results: We have performed laparoscopic hiatal hernia repair in 173 patients (total group). Early postoperative complications were observed in 35 patients (27.1%) and one patient died (0.7%) due to a massive lung thromboembolism. One hundred twenty-nine patients were followed-up for a mean of 41+28months. Mesh placement was performed in 79 of these patients. The remnant sac was rotated behind the esophagus in order to cover the mesh surface. In this group, late complications were observed in five patients (2.9%). We have not observed mesh erosion or migration to the esophagogastric lumen. Conclusion: The proposed technique should be useful for preventing erosion and migration into the esophagus.

RESUMO Racional: Com a colocação de tela foi têm sido publicadas erosões e migrações para o lúmen esofagogástrico após correção de hérnia hiatal laparoscópica. Objetivo: Apresentar manobras cirúrgicas que buscam diminuir o risco dessa complicação. Método: Sugerimos mobilizar o saco de hérnia do mediastino e levá-lo à posição abdominal com o suprimento sanguíneo intacto, a fim de girá-lo para trás e ao redor do esôfago abdominal. O objetivo é cobrir a malha colocada sobre a forma "U" para reforçar a sutura da crura haital. Resultados: Realizamos reparo laparoscópico de hérnia hiatal em 173 pacientes (grupo total). Complicações pós-operatórias precoces foram observadas em 35 pacientes (27,1%) e um morreu (0,7%) devido a tromboembolismo pulmonar maciço. Cento e vinte e nove pacientes foram acompanhados por média de 41+28 meses. A colocação da tela foi realizada em 79 desses pacientes. O saco remanescente foi girado atrás do esôfago para cobrir a superfície da tela. Nesse grupo, complicações tardias foram observadas em cinco pacientes (2,9%). Não observamos erosão da tela ou migração dela para o lúmen esofagogástrico. Conclusão: A técnica proposta pode ser útil para prevenir a erosão e a migração para o esôfago de telas na correção de hérnias hiatais.

Inguinodynia: review of predisposing factors and management / Inguinodinia: revisão sobre fatores predisponentes e manejo

ABSTRACT Herniorrhaphy is one of the most common surgical procedures, with an estimated 20 million operations performed annually worldwide. One of the common complications associated with this procedure is inguinodynia, defined as pain beyond three months after inguinal hernia surgery. In this review, we have addressed the main aspects of this complication with current articles, published in the last five years. Inguinodynia has a multifactorial nature and studies have shown that its development is related to the surgical technique and intrinsic factors of the patient that imply greater predisposition to this phenomenon. In this regard, it has been discussed which surgical techniques imply a lower incidence of this complication. Many studies have focused on understanding intrinsic features of each patient, both in physical and cognitive aspects, and how the approach of these factors can favor a better post-surgical recovery. The treatment of this condition is still challenging, and there are no established universal guidelines. We believe that due to its multifactorial nature, the treatment is hampered due to the individuality inguinodynia presentations.

RESUMO A herniorrafia é um dos procedimentos cirúrgicos mais realizados, com estimativa de 20 milhões de operações feitas anualmente em todo o mundo. Uma das complicações comuns associadas a esse procedimento é a inguinodinia, definida como dor inguinal crônica, com duração superior a três meses após herniorrafia inguinal. Nesta revisão, abordamos os principais aspectos dessa complicação com base em artigos sobre o tema, publicados nos últimos cinco anos. A inguinodinia tem natureza multifatorial e estudos mostram que está relacionada à técnica cirúrgica e aos fatores intrínsecos do paciente, que implicam maior predisposição a esse fenômeno. Nesse sentido, têm sido discutidas quais técnicas cirúrgicas implicam menor incidência dessa complicação. Muitos estudos têm se concentrado em compreender características inerentes a cada paciente, tanto no aspecto físico, quanto cognitivo, e como a abordagem desses fatores pode favorecer a melhor recuperação pós-cirúrgica. O tratamento dessa condição ainda é desafiador e não há diretrizes universais estabelecidas. Acreditamos que, devido à natureza multifatorial, o tratamento é dificultado em razão da individualidade das apresentações da inguinodinia.

Cirugía herniaria electiva en pacientes portadores de tratamiento anticoagulante / Elective hernia surgery in patients with anticoagulant treatment

Resumen Introducción: Diversas patologías requieren de tratamiento anticoagulante oral (TACO). Algunos de estos pacientes requieren resolución quirúrgica. El manejo perioperatorio de estos pacientes es variable dependiendo del centro. Objetivos: Evaluar la morbilidad y mortalidad del protocolo de manejo de patología herniaria en TACO, atendidos en nuestro hospital. Material y Métodos: Estudio descriptivo prospectivo de 37 pacientes sometidos a cirugía herniaria en TACO entre 2008-2016. Los datos fueron obtenidos de la base de datos computacional del Equipo de Hernias, con un seguimiento mínimo de 1 mes. Se evaluaron las características clínicas, quirúrgicas y la morbimortalidad postoperatoria. El traslape consistió en hospitalizar al paciente tres días previos a la cirugía, suspendiéndose el TACO e iniciando heparina de bajo peso molecular (HBPM) en dosis terapéuticas, que se suspende 24 h previas a la cirugía. Se reinicia la HPBM a las 12 a 24 h postoperatorias, y se inicia el traslape a TACO a las 24-48 h. Los datos fueron analizados con Stata v14. Resultados: De los 37 pacientes estudiados, veintiséis pacientes fueron hombres (70,2%), la media de edad fue de 67,3 años. El 48,7% tenían fibrilación auricular. El 100% consumía acenocumarol como TACO. La media en el inicio del traslape a la anticoagulación oral fue de 1,4 días. El promedio de INR al momento del alta fue de 2,04. Dos pacientes fueron dados de alta con dalteparina. Un paciente (2,7%), presentó dolor en el postoperatorio inmediato y uno (2,7%), equimosis del sitio quirúrgico. Conclusiones: El protocolo de trabajo utilizado, demostró ser seguro, con una mínima morbilidad postoperatoria.

Introduction: Various pathologies require oral anticoagulant treatment (TACO). Some of these patients present pathologies of surgical resolution. The perioperative management of these patients is variable depending on the center. Aim: To evaluate the morbidity and mortality of patients attended with hernia pathology and TACO, assisted in our hospital. Materials and Method: Prospective, descriptive study of 37 patients submmited to hernia surgery in TACO between 2008-2016. The data was obtained from the computer database of the Hernia Team, with a minimum follow-up of 1 month. Clinical, surgical characteristics and postoperative morbidity and mortality were evaluated. The treatment overlap from TACO to Low Molecular Weight Heparin (LMWH) in therapeutic doses, was initiated three days before surgery. LMWH was suspended 24 hours prior to surgery, and reinitiated 12 to 24 hours post operation. 48 to 72 hours TACO was resumed. The data was analyzed with Stata v14. Results: Twenty-six patients were men, the mean age was 67.3 years. 48.7% had atrial fibrillation. 100% consumed acenocoumarol as TACO. The mean time for resuming TACO after surgery was 1.4 days. The average INR at the time of discharge was 2.04. Two patients were discharged with dalteparin. One patient (2.7%) presented pain in the immediate postoperative period and one showed ecchymosis of the surgical site (2.7%). Conclusions: The work protocol used, proved to be safe, with minimal postoperative morbidity.

TEP versus Lichtenstein, which one to choose? A retrospective cohort study

SUMMARY OBJECTIVES Inguinal hernioplasty techniques have been improved since the first hernioplasty. Tension-free techniques that apply synthetic mesh materials, as in the Lichtenstein approach, are the gold standard. Laparoscopic hernioplasty is the strongest alternative to Lichtenstein. The superiority of laparoscopic hernioplasty over Lichtenstein is a major topic of debate. In this study, we aimed to find a conclusion to this debate by comparing our totally extraperitoneal (TEP) experiences with Lichtenstein experiences. METHODS Patients who underwent inguinal hernioplasty at the Gulhane Training and Research Hospital from 2013 to 2018 were included in this retrospective cohort study. The sample included 96 TEP and 90 Lichtenstein patients for a total of 186 patients. The variables assessed were hospitalization duration, postoperative early visual analog scale score, chronic pain, paresthesia, recurrence, and early postoperative complications. Data were collected from patient records and via telephone questionnaire if needed. Data analysis was done by SPSS v20, using chi-square, Fisher's exact, and Mann-Whitney U tests. RESULTS Male/female ratios were similar between the TEP and Lichtenstein groups. There was no difference in mean age between groups (p=0.1). The hospital stay was shorter (p=0.0001), and early postoperative visual analog scale score was lower in the TEP group (p=0.003). Chronic pain, paresthesia, recurrence, and early postoperative complications (hematoma, seroma, wound infection) were similar. CONCLUSIONS TEP is superior to Lichtenstein with shorter hospitalization duration and lower rates of early postoperative pain. No difference between the two techniques was found for chronic pain. We believe that laparoscopic hernioplasty approach may be the best alternative technique for inguinal hernia repair.

RESUMO OBJETIVOS As técnicas de hernioplastia inguinal foram melhoradas desde a primeira hernioplastia. Técnicas livres de tensão que aplicam materiais de malha sintética, como na abordagem de Lichtenstein, são o padrão ouro. A hernioplastia laparoscópica é a alternativa mais forte ao Lichtenstein. A superioridade da hernioplastia laparoscópica sobre o Lichtenstein é um dos principais temas debatidos. Neste estudo, procuramos encontrar uma conclusão para esse debate comparando nossas experiências totalmente extraperitoneais (TEP) com as experiências de Lichtenstein. MÉTODOS Pacientes submetidos à hernioplastia inguinal no Gulhane Training and Research Hospital de 2013 a 2018 foram incluídos neste estudo de coorte retrospectivo. A amostra incluiu 96 pacientes TEP e 90 pacientes Lichtenstein para um total de 186 pacientes. As variáveis avaliadas foram tempo de internação, escore da escala analógica visual precoce no pós-operatório, dor crônica, parestesia, recidiva e complicações pós-operatórias precoces. Os dados foram coletados dos prontuários e do questionário por telefone, se necessário. A análise dos dados foi realizada pelo SPSS v20, utilizando os testes qui-quadrado, exato de Fisher e U de Mann-Whitney. RESULTADOS As razões homem/mulher foram semelhantes entre os grupos TEP e Lichtenstein. Não houve diferença na média de idade entre os grupos (p=0,1). A permanência hospitalar foi menor (p=0,1) e a escala visual analógica precoce foi menor no grupo TEP (p=0,003). Dor crônica, parestesia, recorrência e complicações pós-operatórias imediatas (hematoma, seroma, infecção da ferida) foram semelhantes. CONCLUSÕES O TEP é superior ao Lichtenstein, com menor tempo de internação e menores taxas de dor pós-operatória precoce. Nenhuma diferença entre as duas técnicas foi encontrada para dor crônica. Acreditamos que a abordagem de hernioplastia laparoscópica pode ser a melhor técnica alternativa para correção de hérnia inguinal.

Transabdominal preperitoneal (TAPP) versus open Lichtenstein hernia repair. Comparison of the systemic inflammatory response and the postoperative pain

Abstract Purpose: To compare open Lichtenstein repair and laparoscopic transabdominal preperitoneal (TAPP) repair to treat primary unilateral hernia, regarding systemic inflammatory response, postoperative pain, and complications. Methods: A non-randomized prospective cohort study, with the preoperative and postoperative (24 hours) collection of blood samples for C reactive protein (CRP), interleukin 6 (IL-6), leukocyte and neutrophil analysis. Visual Analog Scale (VAS) was used to quantify the level of pain, and the operative time was correlated with the inflammatory response. VAS and CRP were also obtained on the 8th postoperative day. Results: Groups were homogeneous regarding preoperative characteristics. There were no differences between groups in 24h values of CRP, IL-6, leukocytes, neutrophils or VAS. Similarly, CRP and VAS did not differ between groups on the 8th postoperative day. However, the operative time for laparoscopic hernia repair was longer than the time for the open procedure. There was a weak correlation (r coefficient 0.31) between the duration of the surgical procedure and the VAS score at the eighth day. Conclusions: There were no statistically significant differences in the inflammatory response, pain scores, or complications between groups. We conclude that there is no advantage performing a primary unilateral hernia repair by laparoscopy.

Incidencia de infección del sitio quirúrgico y cumplimiento de prácticas de prevención en apendicectomía y cirugía herniaria / Incidence of the surgical infection site and fulfillment of preventive practices in appendicectomy and hernial surgery

Introducción: La vigilancia de infección del sitio quirúrgico en procederes quirúrgicos frecuentes es esencial para su prevención. Objetivo: Determinar la incidencia de infección del sitio quirúrgico y el cumplimiento de las prácticas de prevención en apendicectomía y cirugía de hernia. Método: Estudio descriptivo de pacientes intervenidos de estos procederes desde enero 2017 hasta marzo 2018 en Hospital Clínico Quirúrgico Universitario Joaquín Albarrán. La Habana, Cuba. Se recolectó información de las características demográficas de los pacientes, los procederes y el CPP (profilaxis antibiótica, normoglicemia, normotermia y eliminación del pelo). Se utilizaron técnicas de vigilancia durante el ingreso y posterior al egreso para identificar los pacientes con infección del sitio quirúrgico. Se calculó la tasa total de infección del sitio quirúrgico y según índice de riesgo (por cada100 procederes quirúrgicos), para cada proceder y el CPP por cada 100 procederes quirúrgicos. Resultados: Se evaluaron 174 pacientes con apendicectomía y 389 de cirugía de hernia, con tasas de infección de 13,8 por ciento y 5,7 por ciento, respectivamente. El cumplimiento del tiempo de administración del antibiótico profiláctico, la selección y dosis, y la discontinuación fueron respectivamente de 53,3 por ciento, 83,3 por ciento y 80,0 por ciento, en apendicectomía, y de 46,3 por ciento, 72,9 por ciento y 63 por ciento, en cirugía de hernia. La normotermia fue alcanzada en 32,4 por ciento y 27,1 por ciento de los casos. La mayoría de los pacientes con infección del sitio quirúrgico fueron diagnosticados utilizando métodos de vigilancia posterior al egreso. Conclusión: Se ha identificado la incidencia de infección del sitio quirúrgico y brechas en el cumplimiento de las prácticas de prevención que requieren acciones correctivas, que incluyan fortalecimiento del sistema de vigilancia y capacitación de los profesionales(AU)

Introduction: Surveillance of the surgical site infection in frequent surgical procedures is essential for its prevention. Objective: To determine the incidence of surgical site infection and the fulfillment of prevention practices in appendicectomy and hernial surgery. Method: Descriptive study of patients operated on by these procedures from January 2017 to March 2018 in "Joaquin Albarran" clinical, surgical and university hospital in Havana, Cuba. Data on demographic characteristics of patients, the types of procedures and the CPP (antibiotic prophylaxis, normoglycemia, normothermia and hair removal) were collected. The use of surveillance techniques during hospitalization and after discharge allowed identifying the patients with surgical site infection. The total surgical site infection rate and the risk index (per 100 surgical procedures) for each procedure and the CPP per 100 surgical procedures were all estimated. Results: One hundred and seventy-four patients with appendicectomy and 389 with hernial surgery were evaluated and their infection rates were 13.8 percent and 5.7 percent, respectively. The compliance with the time of administration of prophylactic antibiotic, selection and dosage, and discontinuation of treatment were 53.3 percent, 83.3 percent and 80 percent, respectively in appendicectomy where those of hernial surgery were 46.3 percent,72.9 and 63 percent, respectively. Normothermia was reached in 32.4 percent and 27.1 percent of cases. Most of the patients with surgical site infection were diagnosed by using the surveillance methods after discharge from hospital. Conclusions: The incidence of the surgical site infection and gaps in the fulfillment of prevention practices has been identified, which require corrective actions including strengthening of the surveillance system and professional training(AU)

Pseudoquiste hemorrágico crónico posterior a hernioplastia crural / Chronic hemorrhagic pseudocyst following crural hernioplasty

Entre las complicaciones alejadas de las hernioplastias inguino-crurales, el pseudoquiste hemorrágico crónico, no ha sido referido en nuestro país. Se describen los métodos complementarios de imagenología para el diagnóstico y se destaca la resección quirúrgica como el tratamiento definitivo. Se concluye que esta complicación al igual que la inguinodinia y la recidiva herniaria influyen en el grado de satisfacción posoperatoria.

Among the long term complications of hernioplasty, chronic hemorrhagic pseudocyst has not been reported so far in our country. Complementary imaging methods for diagnosis are described and surgical resection is highlighted as the definitive treatment. It is concluded that this complication as well as inguinodynia and hernia recurrence influence the degree of postoperative satisfaction.

Evaluation of polyamide surgical mesh as an abdominal ventral implant in rabbits

Abstract Purpose: To evaluate abdominal ventral wound healing by using a specific biomaterial, a handmade polyamide surgical mesh. Methods: A surgical incisional defect was made in ten rabbits to simulate a hernia in the ventral abdominal musculature. A polyamide surgical mesh was used in hernioplasty. They were monitored for surgical wound healing, and macroscopically and histologically evaluated at the end of the experiment. The polyamide surgical mesh did not cause foreign body reaction, pain, edema, or infection in the surgical site. The manure production was not affected by intestinal tissue adherences to the mesh, consistent with the ultrasonography result where adherences were not observed and organized scarring tissue formed in the incisional defect. The polyamide mesh was fixed over the abdominal wall, and its external and internal sides were surrounded by a vascularized connective tissue. Results: None of the experimental animals developed adherences from internal organs to the polyamide mesh, except two rabbits where the omentum formed adherence to the internal scarring tissue without present herniation or compromise of the rabbit's health. Conclusion: Polyamide surgical mesh for hernioplasty presents, in rabbits, excellent biocompatibility, with minimal body adverse reactions and low cost.

Inguinal repair via robotic assisted technique: literature review / Reparo inguinal via técnica robótico-assistida: revisão da literatura

ABSTRACT Introduction: Inguinal hernia is one of the most frequent surgical diseases. Currently, with the advantages of minimally invasive surgery, new questions arise: what will be the best approach for correction of inguinal hernia? Is there real benefit to the robotic approach? Objective: To compile results of the published studies that used the robot-assisted technique in the repair of inguinal hernia, analyzing its limitations, complications and comparing it with those of the pre-existing techniques. Method: The review was performed from the Medline database with the following descriptors: (inguinal hernia repair OR hernioplasty OR hernia) AND (robot OR robotic OR robotic assisted) being retrieved 391 articles. After verification of the titles and abstracts, we identified eight series of cases congruent with the objectives of this review. Three reviewers participated in the extraction and selection of results. Results: Comparative studies showed an increase in surgical time in relation to the open and videolaparoscopic approach. The complications present similar rates with the other repair routes. Conclusion: This technique has been shown to be effective for the correction of inguinal hernia, but the benefits of using robotic surgery are unclear. So, there is a need for randomized studies comparing laparoscopic to robotic repair

RESUMO Introdução: A hérnia inguinal é uma das doenças cirúrgicas mais frequentes. Atualmente, com as vantagens da cirurgia minimamente invasiva, novas questões surgem: qual será a melhor abordagem para correção de hérnia inguinal? Existe benefício real com a abordagem robótica? Objetivo: Compilar resultados dos estudos publicados que utilizaram a técnica robô-assistida no reparo da hérnia inguinal analisando suas limitações, complicações e comparando-a com as das técnicas pré-existentes. Método: A revisão foi realizada a partir da base de dados do Medline com os seguintes descritores: (inguinal hernia repair OR hernioplasty OR hernia) AND (robot OR robotic OR robotic assisted) sendo recuperados 391 artigos. Após verificação dos títulos e resumos, identificou-se oito séries de casos congruentes com os objetivos desta revisão. Três revisores participaram do processo de extração e seleção de resultados. Resultados: Nos estudos comparativos demonstrou-se aumento no tempo cirúrgico em relação à via aberta e videolaparoscópica. As complicações apresentam taxas similares com as outras vias de reparo. Conclusão: Esta técnica demonstrou-se efetiva para correção da hérnia inguinal, mas os benefícios da utilização da cirurgia robótica não estão claros. Para isso, há a necessidade de trabalhos randomizados que comparem o reparo laparoscópico ao robotizado.

Comparision of post operative chronic pain after excision of ilioinguinal nerve in lichtenstein's hernioplasty

Objective: To provide a comparative analysis of mean post-operative pain score after preservation and elective excision of ilioinguinal nerve [UN] using standard Lichtenstein hernia repair [LHR] technique

Study Design: Randomized controlled trial

Place and Duration of Study: Department of Surgery Combined Military Hospital [CMH] Rawalpindi/ Peshawar, from 15 May 2013 to 15 May 2014

Materials and Methods: One hundred and fifty patients with diagnosis of inguinal hernia satisfying inclusion/exclusion criteria were included. Patients were divided into two groups randomly. In group A, UN was carefully protected while excision were done in group B. Demographic as well as data concerning groin pain at 03 months post operatively were collected and analyzed using SPSS

Results: A total of 150 patients were included. Mean age in group A was 37.32 +/- 10.45 years while in group B was 36.56 +/- 10.26 years [p=0.653]. Majority of the patients in both groups were male [group A 89.33% [67], 92% [69] in group-B], while female constituted only minority [8 [10.67%] in group A and 6 [8%] group-B], the difference being statistically insignificant [p=0.571]. Majority of the patients had indirect hernia and mean operation time was similar in both groups. Mean postoperative pain score was 3.76 +/- 1.11 and 2.82 +/- 0.677 in group A and B respectively, the difference being statistically significant [p<0.001]

Conclusion: Mean post-operative pain score is higher in preservation techniques compared to elective excision of UN for the treatment of inguinal hernia

Two cases about mesh adhesion to intra-abdominal cavity tissue after using mesh to repair an incisional hernia

Abdominal incisional hernia is a common postoperative complication. With the development of a new type of surgical anti-adhesion mesh, mesh repair has become a widely-adopted procedure, particularly in the laparoscopic era. However, there were few reports about use of these new meshes to repair incisional hernia in the abdominal cavity. In this report, we present two cases: one a 72-year-old male and the other a 62-year-old female. Both of those patients suffered incisional hernias during abdominal operations, and therefore underwent open incisional hernia anti-adhesion mesh repair operations. Both of them had recurrent incisional hernias after the first repair operation. During the second hernia repair operation via laparoscopy, tissue from the intestine and omentum were found to have adhered seriously to the old meshes, which could cause many serious problems. We need to pay more attention to the issue of adhesion, try to determine possible reasons and improve in our future work

Swing mesh versus Modified Kugel mesh for primary inguinal hernia repair. A prospective randomized clinical trial

ABSTRACT PURPOSE To evaluate the safety and efficacy of a new mesh in the pre-peritoneal repair of inguinal hernia. METHODS We randomly divided 120 patients undergoing pre-peritoneal repair into 2 groups between March 2012 and December 2013. The patients were randomized to receive the Swing mesh (n=60; study group) or the Modified Kugel mesh (n=60; control group). The primary end point of this study was to compare postoperative groin pain of the two groups. Complications, recurrence and analgesic use were also recorded. RESULTS There were no recurrent cases in either group throughout the study period. There was no significant difference between the groups with respect to postoperative complications. The VAS of early postoperative pain was 1.32±1.69 in study group and 1.52±1.93 in control group, with the difference being not statistically significant (p = 0.547). Concerning chronic pain, no remarkable statistically significant difference was observed between the two groups at 3-month, 6-month, 12- and 18-month follow-up period. CONCLUSION Swing mesh can be safely and effectively used in inguinal hernia repair with the same advantage compared to the Modified Kugel mesh.

HERNIOPLASTY WITH AND WITHOUT MESH: ANALYSIS OF THE IMMEDIATE COMPLICATIONS IN A RANDOMIZED CONTROLLED CLINICAL TRIAL / HERNIOPLASTIA COM E SEM TELA: ANÁLISE DAS COMPLICAÇÕES IMEDIATAS EM UM ENSAIO CLÍNICO RANDOMIZADO CONTROLADO

Background:Inguinal hernia repair is the most common procedure in general surgery and 80,000 operations are performed annually in Great Britain, 100,000 in France and 700,000 in the US. Given its high frequency has a major impact, both in the medical and economic aspects.Aim:Analyze the immediate postoperative complications comparing mesh versus non mesh hernioplasty.Method:Randomized control trial, with the enrollment of 263 patients underwent surgery for inguinal hernia randomized by randomization table. Treatment (mesh, Lichtenstein or without mesh, Bassini technique) was assigned using sequentially numbered opaque envelopes having fulfilled the inclusion criteria. The variables analyzed were: postoperative pain, seroma, hematoma, infection, return to normal activities and recurrence.Results:The mean age was 55.5 years, 88% patients were male and 12% female. The pain was higher in patients operated with mesh.Conclusions:The inguinal hernia repair mesh group had less immediate postoperative complications and significantly earlier return to work than hernioplasty without mesh, this being one of the most important conclusions.

Racional:Correção de hérnia inguinal é o procedimento mais comum em cirurgia geral, sendo que 80.000 operações são realizadas anualmente na Grã-Bretanha, 100.000 na França e 700.000 nos EUA. Dada à sua alta frequência tem grande impacto, tanto nos aspectos médicos como nos econômicos.Objetivo:Analisar as complicações pós-operatórias imediatas comparando hernioplastia com e sem tela.Método:Ensaio clínico randomizado, com a inclusão de 263 pacientes que foram submetidos à operação de hérnia inguinal, randomizados por tabela de randomização. Os tratamentos foram para o grupo com tela Lichtenstein e ao sem malha técnica de Bassini. Usaram-se envelopes sequencialmente numeradas opacos após terem sido cumpridos os critérios de inclusão. As variáveis ​​analisadas foram: dor pós-operatória, seroma, hematoma, infecção, retorno às atividades normais e recorrência.Resultados:A idade média foi de 55,5 anos; 88% dos pacientes eram mulheres e 12% homens. A dor foi maior nos pacientes operados com tela.Conclusões:O grupo com tela teve menos complicações pós-operatórias imediatas e significativamente mais rápido retorno ao trabalho do que hernioplastia sem tela, sendo esta uma das conclusões mais importantes.

Polypropylene and polypropylene/polyglecaprone (Ultrapro(r)) meshes in the repair of incisional hernia in rats

PURPOSE: To compare the inflammatory response of three different meshes on abdominal hernia repair in an experimental model of incisional hernia. METHODS: Median fascial incision and skin synthesis was performed on 30 Wistar rats. After 21 days, abdominal hernia developed was corrected as follows: 1) No mesh; 2) Polypropylene mesh; and, 3) Ultrapro(r) mesh. After 21 days, the mesh and surrounding tissue were submitted to macroscopic (presence of adhesions, mesh retraction), microscopic analysis to identify and quantify the inflammatory and fibrotic response using a score based on a predefined scale of 0-3 degrees, evaluating infiltration of macrophages, giant cells, neutrophils and lymphocytes. RESULTS: No significant difference was seen among groups in adherences, fibrosis, giant cells, macrophages, neutrophils or lymphocytes (p>0.05). Mesh shrinkage was observed in all groups, but also no difference was observed between polypropylene and Ultrapro mesh (7.0±9.9 vs. 7.4±10.1, respectively, p=0.967). Post-operatory complications included fistula, abscess, dehiscence, serohematic collection and reherniation, but with no difference among groups (p=0.363). CONCLUSION: There is no difference between polypropylene (high-density) and Ultrapro(r) (low-density) meshes at 21 days after surgery in extraperitoneal use in rats, comparing inflammatory response, mesh shortening, adhesions or complications. .

Surgical management of Necrotizing Enterocolitis following Congenital Diaphragmatic Hernia Repair

Necrotizing Enterocolitis [NEC] is a significant cause of in-hospital mortality. The pathogenesis remains unclear, but may be associated with Staphylococcus epidermidis related sepsis, hypertonic feeds or other stress. It is also associated with Abdominal Compartment Syndrome [ACS] as documented after complete closure of gastroschisis. While the incidence of NEC is rare, the associated mortality is significant. We report a case of NEC following the repair of a congenital diaphragmatic hernia [CDH]; an unusual yet serious complication. A literature search revealed only one similar case which resulted in mortality. The possibility of serious postoperative complications following the repair of CDH must be considered in any neonate who exhibits deterioration in their general condition