Technical aspects of inguino scrotal hernia surgery in developing countries.

PURPOSE: Technical aspects of inguinoscrotal herniorrhaphy performed in low to middle income countries (LMICs) are described here to help surgeons who will operate on these challenging hernias in austere settings. METHODS: Technical considerations related to operative repair were delineated with the consensus of 7 surgeons with extensive experience in inguinoscrotal hernia repair in LMICs. Important steps and illustrations were prepared accordingly. The anatomical and pathologic differences and technical implications of operating in limited resource settings are emphasized with suggestions to approach anticipated challenges. Pre-operative evaluation, anesthetic considerations, and technical guidelines are offered in context. RESULTS: The authors have cumulatively performed over 1775 inguinoscrotal Lichtenstein operations in LMICs. While dedicated, reliable, long-term follow-up is unavailable from LMICs, one author reports outcomes with 5 year follow-up from the HerniaMed registry using the identical technique in similarly classed hernias. In 90 inguinoscrotal Lichtenstein repair patients (78.3% follow-up), there was one recurrence, low rates of chronic pain (2.2% at rest, 4.4% with activity), and low rates of reintervention (1.1%). CONCLUSION: There is a difference between inguinal hernias found in LMICs and those seen in high-income countries with larger, chronic, and more technically challenging pathology. The consequences of intra-operative complications can be catastrophic in a LMIC. Technical measures are offered to improve outcomes, avoid and manage complications, and provide optimal care to this important population.

Staged complex abdominal wall hernia repair in morbidly obese patients.

PURPOSE: The repair of complex abdominal wall hernias in morbidly obese patients is often associated with a higher risk of complications and hernia recurrences. Improvement in obesity and its associated metabolic complications are hypothesized to improve hernia repair outcomes. This study analyzes outcomes from morbidly obese patients who underwent bariatric surgery with staged complex abdominal wall reconstruction at Creighton University Medical Center (CUMC). METHODS: This retrospective study included morbidly obese patients with complex abdominal wall hernia, who underwent bariatric surgery with staged abdominal wall reconstruction. Data points collected included patient demographics, obesity-related co-morbidities, pre-operative BMI, EBMIL at 12 months, hernia characteristics, postoperative complications, BMI at time of hernia repair, and hernia recurrence. RESULTS: Twelve patients with an average BMI of 48 and complex abdominal wall hernias (mean width 14.0 cm) met inclusion criteria. Seven patients (58%) had significant loss of domain. Bariatric procedures included six laparoscopic sleeve gastrectomies (LSG), three laparoscopic Roux-en-Y gastric bypasses (LRNYGB), and three revisional procedures (2 vertical band gastroplasties to LRNYGB and 1 LRNYGB revision). At 12-month follow-up, the mean excess BMI loss (EBMIL) was 64.6%. The average time to staged complex abdominal wall reconstruction was 22.3 months. Two non-elective hernia repairs were performed due to one incarceration and one strangulation. There were no recurrences after an average follow-up of 21.9 months. CONCLUSIONS: In this study, staged mesh repair of complex abdominal wall hernias after bariatric surgery in morbidly obese patients was associated with acceptable morbidity and no hernia recurrences at approximately 1.5 year follow-up.

Surgical site infection: the "Achilles Heel" of all types of abdominal wall hernia reconstruction.

PURPOSE: Surgical site infection is the most common hospital-acquired infection in surgical patients. Recently, public health organizations have updated prevention guidelines. This review discusses surgical site infections as a complication of abdominal wall reconstruction. METHODS: The authors reviewed guidelines on prevention of surgical site infections from the Center for Disease Control and Prevention, World Health Organization, and National Institute for Health and Care Excellence and put them into context with the relevant abdominal wall reconstruction literature. This was the subject of the Nyhus-Wantz lecture given at The International Hernia Congress on March 14, 2018 in Miami, FL and is summarized here. RESULTS: Routine use of preoperative antibiotics in prosthetic groin hernia repair is not supported by the available literature. High-quality data on antibiotic prophylaxis in ventral (both primary and incisional) hernia repair is lacking, but it is widely utilized and may reduce SSIs. Recommended preventative strategies discussed in this manuscript include: treatment of remote site infections, perioperative normothermia and normoglycemia, avoidance of hypoxemia, antiseptic preparation of surgical team hands and patient skin, treatment of obesity, smoking cessation, correction of malnutrition, and physical conditioning. CONCLUSION: Surgical site infections lead to significant morbidity and mortality, hernia recurrences, prolonged hospital stay, and increased hospital costs. This makes surgical site infections the "Achilles Heel" of abdominal wall reconstruction. Strict adherence to standardized guidelines and preoperative optimization of patients' risk profiles are crucial to decrease the incidence of surgical site infections.

Humanitarianism in surgery.

PURPOSE: Humanitarianism is by definition a moral of kindness, benevolence and sympathy extended to all human beings. In our view as surgeons working in underserved countries, humanitarianism means performing the best operation in the best possible circumstances with high income country (HIC) results and training in-country surgeons to do the same. Hernia Repair for the Underserved (HRFU), a not for profit organization, is developing a long term public health initiative for hernia surgery in Western Hemisphere countries. We report the progress of HRFUs methods to render humanitarian care. METHODS: In a collaborative effort, Creighton University and the Institute for Latin American Concern developed an outpatient surgery site for hernia surgery in Santiago, Dominican Republic. Based on this experience, we developed a sustainable care model by recruiting American and European Hernia Society expert surgeons, staff members they recommended, building relationships with local and industry partners, and selecting local surgeons to be trained in mesh hernioplasty. HRFU then extended the care model to other Western Hemisphere countries. RESULTS: Between 2004 and 2015, the HRFU elective hernia morbidity and mortality rates for 2052 hernia operations were 0.7 and 0%, respectively. This is consistent with outcomes from HICs and confirms the feasibility of a public health initiative based on the principles of the Preferential Option for the Poor. CONCLUSIONS: HRFU has recorded HIC morbidity and mortality rates for hernia surgery in low and middle income countries and has initiated a new surgical training model for sustainability of effect.

Early report of a randomized comparative clinical trial of Strattice™ reconstructive tissue matrix to lightweight synthetic mesh in the repair of inguinal hernias.

PURPOSE: Biologic grafts are rarely used for inguinal herniorrhaphy. The aim of this study was to compare the clinical outcomes between patients undergoing a Lichtenstein's hernioplasty with a porcine mesh versus a standard synthetic. METHODS: A prospective, randomized, double-blinded multicenter, evaluation of inguinal hernia repair was conducted between 2008 and 2010. Lichtenstein hernioplasty was performed using Strattice™ or lightweight polypropylene (Ultrapro) mesh. Quality of life, pain, overall complication rate, and recurrence were measured. RESULTS: One hundred and seventy-two patients were randomized to Strattice™ (n = 84) or Ultrapro (n = 88). At 3 months postoperatively, there were no differences on the occurrence or type of wound events [RR: 0.98 (95% CI 0.52-1.86, p = 0.69), Strattice™ (15 events) vs. Ultrapro (16 events)]. The mean level of impairment caused by the hernia, assessed by Activities Assessment Scale (AAS), significantly decreased postoperatively in both groups at 3 months (31% Strattice™ and 37% Ultrapro). Patients in the Strattice group reported significantly less postoperative pain during postoperative days 1 through 3 compared to Ultrapro patients. However, the amount of postoperative pain at 3 months, as assessed by the mean worst pain score on a visual analog scale and the Brief Pain Index, was similar between groups (95% CI 1.0-29.3). No hernia recurrences were observed in either group. CONCLUSIONS: Strattice™ is safe and effective in repairing inguinal hernia, with comparable intra-operative and early postoperative morbidity to synthetic mesh. Long-term follow-up is necessary in order to know whether the clinical outcomes of Strattice are equivalent to standard synthetic mesh in patients undergoing Lichtenstein's hernioplasty.

Free hernia surgery for the underserved is possible in the United States.

INTRODUCTION: Inguinal hernia is one of the most common ailments known to mankind. When symptomatic it can severely affect the patient's quality of life. Nevertheless, the vast majority of inguinal herniorrhaphies are elective and, therefore, not available to uninsured patients who do not have the financial wherewithal to pay for the operation. Using the Surgery on Sunday model developed in Kentucky, hernia repair for the underserved developed a free clinic for hernia surgery, based on institutional commitment to the poor as well as the volunteer efforts of medical students and hospital personnel at all levels. METHODS: After consulting with Surgery on Sunday personnel, HRFU determined the number of in need patients by consulting with local free clinic physicians. Second, and most time consuming, was the application for the Federal Tort Claims Act (FTCA) medical legal protection. Under this law, all in hospital credentialed volunteer professionals are medico-legally protected if the surgery is performed in an associated free clinic. After FTCA application re-writes and committee meetings to work out logistics of the pre-op clinic, the follow-up clinic, enlistment of other volunteers such as transporters, translators, housekeeping for the ORs, a pharmacist, registration personnel and creation of HRFU hospital forms we established a surgery date. A memorandum of understanding was drafted and an agreement letter with the hospital system was co-signed. Fourteen patients were seen in the pre-operative clinic and two were placed on waiting list. Patients were operated upon using 3 operating rooms and a volunteer staff of 4 surgeons, 4 anesthesia personnel and 13 nurses. RESULTS: No surgical complications were encountered intra-operatively or in the recovery room, and all patients were discharged by 2:30 p.m. 1 week post-operatively one patient had severe incisional pain, two had operative site swelling, but there was no evidence of infection or hematoma, and one had a distal sac fluid collection. All patients returned for follow-up and were appreciative of the care provided. The enthusiasm and participation of the patients and staff both pre-operatively, the day of surgery and postoperatively was outstanding. CONCLUSION: On the basis of this result HRFU is prepared to assist other US hernia specialists and their respective hospitals to make Surgery on Sunday a possibility in their community.

Recommendations for reporting outcome results in abdominal wall repair: results of a Consensus meeting in Palermo, Italy, 28-30 June 2012.

BACKGROUND: The literature dealing with abdominal wall surgery is often flawed due to lack of adherence to accepted reporting standards and statistical methodology. MATERIALS AND METHODS: The EuraHS Working Group (European Registry of Abdominal Wall Hernias) organised a consensus meeting of surgical experts and researchers with an interest in abdominal wall surgery, including a statistician, the editors of the journal Hernia and scientists experienced in meta-analysis. Detailed discussions took place to identify the basic ground rules necessary to improve the quality of research reports related to abdominal wall reconstruction. RESULTS: A list of recommendations was formulated including more general issues on the scientific methodology and statistical approach. Standards and statements are available, each depending on the type of study that is being reported: the CONSORT statement for the Randomised Controlled Trials, the TREND statement for non randomised interventional studies, the STROBE statement for observational studies, the STARLITE statement for literature searches, the MOOSE statement for metaanalyses of observational studies and the PRISMA statement for systematic reviews and meta-analyses. A number of recommendations were made, including the use of previously published standard definitions and classifications relating to hernia variables and treatment; the use of the validated Clavien-Dindo classification to report complications in hernia surgery; the use of "time-to-event analysis" to report data on "freedom-of-recurrence" rather than the use of recurrence rates, because it is more sensitive and accounts for the patients that are lost to follow-up compared with other reporting methods. CONCLUSION: A set of recommendations for reporting outcome results of abdominal wall surgery was formulated as guidance for researchers. It is anticipated that the use of these recommendations will increase the quality and meaning of abdominal wall surgery research.

Incidence of diaphragmatic hernias following minimally invasive versus open transthoracic Ivor Lewis McKeown esophagectomy.

OBJECTIVES: To compare the incidence of post-operative hiatal herniation after open and minimally invasive Ivor Lewis McKeown esophagectomy for malignant disease. METHODS: All patients undergoing esophageal resection were entered into a prospectively maintained database. After Institutional Review Board approval, the database was queried to identify patients who underwent minimally invasive (MIE) and open transthoracic (TTE) Ivor Lewis McKeown esophagectomy (transthoracic three-hole) with gastric pull-up for malignant disease. The cohorts were compared for the incidence of hiatal hernia on routine CT scan for cancer surveillance. Data up to 24 months post-operatively was included. Patients undergoing trans-hiatal or hybrid procedures as well as intra-thoracic anastomosis were excluded as were patients in whom jejunum or colon was used for reconstruction. RESULTS: Between 2003 and 2009, 19 MIEs and 20 open TTEs met the inclusion criteria. There was no significant difference in age, co-morbidity, pathology or perioperative morbidity and mortality between the two groups. During routine follow-up, para-gastric hiatal hernia was noted on CT scan in 5(26%) patients following MIE at a mean of 13.8 months postoperatively, with incidence ranging from 3 to 20 months postoperatively (19, 20, 18, 3, and 9 months, respectively). Hernia contents in these patients were omentum in one case and colon in the other four cases. None of the patients undergoing TTE were noted to have herniation (P = 0.01). All hernias were asymptomatic; three were repaired electively. CONCLUSIONS: There was a significantly higher incidence of para-gastric hiatal hernia after Ivor Lewis McKeown minimally invasive esophagectomy compared to similar open procedures. Additional precautions to prevent para-gastric hernia should be taken during laparoscopic resection.

The design of an industry-sponsored randomized controlled trial to compare synthetic mesh versus biologic mesh for inguinal hernia repair.

PURPOSE: Biologic prostheses are designed to support tissue regeneration rather than just result in a strong scar plate, as is the case with synthetic mesh. It is not known if these newer materials will result in earlier return to normal activities and/or less post-herniorrhaphy groin pain. METHOD/STUDY DESIGN: A prospective, randomized, controlled, third-party-blinded multicenter trial was designed to compare the use of a non-cross linked porcine dermis biologic graft [Strattice(TM) Reconstructive Tissue Matrix (RTM), LifeCell, Branchburg, NJ] versus light weight, large pore polypropylene mesh (UltraPro(TM), Ethicon, Somerville, NJ). The study design called for recruitment of 170 men. These men are being followed for a minimum of 2 years. The primary aim of this study is to compare the safety and effectiveness of the two materials in a Lichtenstein inguinal hernia repair as measured by resumption of activities of daily living. Secondary outcomes include chronic pain, postoperative complications and the incidence of re-herniation at 12 and 24 months. RESULTS: This paper discusses the study design, patient recruitment and the current status of the clinical trial. The study involves nine medical centers, all with extensive experience in hernia repair. After 24 months of enrollment, 172 men were randomized and recruitment was then closed. All patients underwent elective repair of primary unilateral inguinal hernias as an outpatient operation. Follow up data are being collected. Data analyses are scheduled at 3, 12, and 24 months postoperatively. CONCLUSION: We report the design of a multi-center, third-party blinded, randomized clinical trial comparing a new surgical device with existing technology in the repair of inguinal hernias. We believe this investigator-designed and conducted trial could serve as a model for similar trials examining surgical devices performed in collaboration with industry.

Timing of traumatic lumbar hernia repair: is delayed repair safe? Report of two cases and review of the literature.

Fewer than 100 cases of traumatic lumbar hernias are described in the English literature. The herniation has been described as a consequence of a combination of local tangential shearing forces combined with an acute increase in intra-abdominal pressure secondary to sudden deceleration sustained during blunt abdominal trauma. Delayed diagnosis is not uncommon, as nearly a quarter of these are missed at initial presentation. These hernias are best managed by operative intervention; however, there is no well-defined treatment strategy regarding either the timing or the type of repair. Several approaches, including laparoscopy, have been described to repair these defects. Various techniques, including primary repair, musculoaponeurotic reconstruction, and prosthetic mesh repair, have been described. These repairs are usually complicated because of the lack of musculoaponeurotic tissue inferiorly near the iliac crest. We describe here two cases of traumatic lumbar hernia managed by initial watchful waiting and subsequent elective repair using a combined laparoscopic and open technique and one with and one without bone anchor fixation.

A randomized trial of the peri-operative use of COX-2 inhibitors in Lichtenstein herniorrhaphy.

INTRODUCTION: We present a randomized controlled trial to evaluate the value of the cyclo-oxygenase-2 (COX-2) inhibitor, rofecoxib, as an adjuvant for pain management for patients undergoing a conventional Lichtenstein inguinal herniorrhaphy. The drug was removed from the market coincidentally with the conclusion of the trial due to thrombotic complications. We believe that the data remains important, however, because of the imminent release of similar compounds with a better safety profile. No industry support was sought or accepted for this trial, with the exception of the study drug and an identical placebo preparation supplied by Merck in a completely unrestricted agreement. METHODS AND MATERIALS: Seventy-nine patients were recruited for the single-center randomized controlled double blinded trial, with 27 receiving placebo, 26 who received rofecoxib only in the post-operative period, and 26 who received rofecoxib both in the pre- and post-operative period. The patients were followed for 6 weeks with serial administration of the short form 36 health survey questionnaire (SF-36), visual analog scale (VAS) questionnaire, and activity restriction questionnaire. Statistical analysis was performed using multivariate generalized estimating equations in a blinded fashion. RESULTS: The mean pain over time decreased over the 6 weeks and was significantly lower in the group that received rofecoxib in the post-operative period than the other two groups (P = 0.02). The number of rescue narcotic medications taken by patients on day 1 were 3.0 (2.4) [mean (SD)] in the placebo group, 2.2 (1.7) (P < 0.001) in the post-operative only group, and 2.9 (2.3) (P = 0.37) in the peri-operative group. There was no statistical significance between the physical health composite scores or the mental health composite scores at 6 weeks. CONCLUSION: The use of post-operative rofecoxib decreases the amount of pain post-operatively after inguinal herniorrhaphy and decreases the number of rescue narcotic medications used, but it does not change the quality of life. This effect is lacking in the peri-operative group. There is no evidence to recommend the routine use of rofecoxib or similar COX-2 inhibitors after inguinal hernia surgery.

Intramesosigmoid hernia: a rare type of congenital internal hernia.

Intestinal obstruction from congenital internal hernias is a rare and often unsuspected problem. We report the case of a 66-year-old male with a rare type of congenital internal hernia causing bowel obstruction. He underwent successful laparoscopy-assisted surgical repair without bowel resection. Symptomatic congenital internal hernias usually present with intermittent or acute small-bowel obstruction without any history of previous abdominal surgery. Laparoscopy or hand-assisted laparoscopy can be useful tools for locating the region of pathology and enable minimally invasive surgical treatment.