Flank hernia and bulging after open nephrectomy: mesh repair by flank or median approach? Report of a novel technique.

Flank incisions may be associated with flank hernias, which may be complicated with incarceration and strangulation. Furthermore, they may cause a significant limitation of the patient's quality of life. In the period 1997-2006 we performed 15 flank hernia repairs with a prosthetic mesh implantation. From 1997 to 2001 hernias were managed with a standardized mesh implantation through the initial flank incision (seven cases, flank group). Since 2001 we have adopted a novel operative approach in eight patients. Through a median laparotomy and following a transabdominally reduction of the hernia sac, a prosthetic polypropylene mesh [Prolene, Vypro or UltraPro, Ethicon Endo-Surgery (Europe) GmbH, Norderstedt, Germany] overlapping the midline was placed in a sublay technique (median group). The perioperative complication rate was comparable and they consisted mostly of postoperative seromas. A patient from the flank group developed a hernia recurrence two months after surgery. Thirteen patients participated in the annual follow-up for a total follow-up time of five years. In this period we observed only one additional case of hernia recurrence: a patient of the flank group presented with a 3 cm hernia recurrence at the proximal end of the previous operative incision. No recurrence was observed in the median group. As a result the novel technique for open repair of flank incisional hernias we present permits a remodelling of the abdominal wall and is associated with excellent postoperative results.

Sexual function before and after mesh repair of inguinal hernia.

AIM: Several factors having an influence on the quality of life after an inguinal hernia repair have been studied, yet little has been reported on sexual function before and after this operation. METHODS: In a prospective follow-up study from January 1999 to July 2002, 210 men and 14 women were asked to answer an anonymous questionnaire of 40 questions before elective inguinal hernia repair to assess pre- and postoperative sexual function (preoperatively, 3 months postoperatively and every 6 months afterwards). Inguinal hernia repair was performed using a standardized Plug and Patch mesh technique. RESULTS: Fifty-two (23.2%) patients mentioned preoperative sexual dysfunction related to the groin hernia. Postoperatively, the surgical repair had a positive influence on the sexual function in these patients. Thirty-six (16%) patients complained of postoperative sexual dysfunctions, which improved or disappeared over the next few months. All patients suffered surgical complications, which were surgically treated in six cases. Symptoms specifically associated with inguinal hernias can cause certain limitations in the sexual life. CONCLUSIONS: In most cases, and in the absence of postoperative complications, the operative repair can lead to a recovery of the sexual life in patients with preoperative sexual dysfunction, while, in most cases, it does not affect patients with a preoperative normal sexual life.

Prevention of catheter disconnection after laparoscopic adjustable gastric banding.

In a consecutive series of 138 laparoscopic adjustable gastric bandings (LAGB) we observed disconnection of the gastric band catheter at the site of the port connector in 17 patients. During operative revision we established a new port position with a minimal distance of 10 cm between the connector and the entrance of the catheter to the abdominal cavity. Using this technique no complications and no catheter disruptions occurred during a median followup period of 25 months.

Inguinal hernia: obligatory indication for elective surgery? A prospective assessment of quality of life before and after plug and patch inguinal hernia repair.

BACKGROUND: Incarcerated inguinal hernia may be treated effectively by recent surgical techniques with a low rate of complications, but it is unclear whether quality of life is improved by elective inguinal hernia repair. Therefore we investigated the quality of life before and after inguinal hernia repair using plug and patch technique. PATIENTS AND METHODS: Quality of life was prospectively assessed in 123 patients before and 3 months after plug and patch inguinal hernia repair using the Short Form 36 questionaire and a visual analog scale. All patients complained preoperatively of pain associated with the clinical findings of inguinal hernia (visual analog scale: reduced quality of life 6.8+/-2.7; reduced daily activity: 5.5+/-2.6). Clinical characteristics (operation times, in-hospital stay, complications, need for pain medication) were documented. Inclusion criteria were patients with symptomatic inguinal hernia, scheduled for elective unilateral inguinal hernia repair by plug and patch technique. RESULTS: There were no major in-hospital complications. At 3 months no recurrences of inguinal hernia or late onset complications were observed; seven patients complained of dumbness, and eight felt pressure at the operation site with a tendency for resolving pain within this time. At 3 months patients had a significantly improved quality of life regarding freedom from pain, vitality, and physical activity compared to preoperatively. CONCLUSIONS: Plug and patch repair of unilateral inguinal hernia improves quality of life with a very low rate of procedural complications. Regarding freedom from pain, vitality, and physical activity there is significant improvement as compared to preoperatively. Therefore inguinal hernia repair should be intended in all elective cases and plug and patch repair appears as an excellent technique to improve quality of life.

Polyurethane-covered dacron mesh versus polytetrafluoroethylene DualMesh for intraperitoneal hernia repair in rats.

PURPOSE: Abdominal hernia repair using the intraperitoneal implantation of a prosthesis requires mesh with impervious properties, such as expanded polytetrafluoroethylene (ePTFE). A newly developed polyurethane-covered polyester mesh with impervious properties has recently been introduced as a less expensive alternative to PTFE, and we compare these materials herein. METHODS: The adhesion formation and stability of intraperitoneal abdominal hernia repairs with DualMesh (macroporous ePTFE mesh with a microporous component) and PolyesterComposite (the newly developed polyurethane-covered Dacron mesh) were compared in a rat model. Forty rats were randomly divided into two groups; ten animals from each group were killed after 14 days, and the other ten after 90 days. RESULTS: The number and intensity of adhesions were comparable in the PolyesterComposite and PTFE groups. Loose adhesions were seen in 13 animals and appeared only selectively at the fixation sutures. Both PolyesterComposite and PTFE induced the formation of a smooth neoperitoneum on the intraperitoneal surface and showed a complete ingrowing of the prosthesis in the surrounding tissue. There were no significant differences between the prostheses in terms of clinical herniation pressure and hydroxyproline concentration. CONCLUSIONS: PolyesterComposite and PTFE are both suitable prostheses for intrapertoneal implantation, but PolyesterComposite is less expensive, which is an important advantage for clinical use.

Adhesions after intraperitoneal mesh repair in pigs: Prolene" vs. Vypro".

BACKGROUND: Newly developed meshes with low weight and large pores such as Vypro (Ethicon, Norderstedt) were exactly adapted to the physiology of the human abdominal wall and proved to reduce chronic inflammatory processes. It was hypothesized that the reduced inflammatory response to a Vypro mesh would lead to reduced adhesion formation following intraperitoneal implantation in comparison with a Prolene mesh (Ethicon). MATERIALS AND METHODS: To test this hypothesis, 20 25-kg pigs underwent resection of a 10 x 10-cm section of the full-thickness anterior abdominal wall, excluding subcutaneous and cutaneous surface. The fascial defect was repaired using a 20 x 20-cm piece of either Vypro or Prolene mesh, which was sutured in inlay position with 4-0 Prolene single sutures at the edges. The main endpoint was the presence and degree of intra-abdominal adhesions to the mesh after 3 months. The amount of adhesions was calculated as a percentage of the mesh square and classified into four grades. RESULTS: There were no significant differences in the amount and grade of adhesions between the groups. Adhesions were less intensive in the Vypro group, but this difference was not significant. Dense adhesions between the liver and the mesh and small-bowel obstruction were observed only in the Prolene group. CONCLUSIONS: From the results of this study, Prolene and Vypro meshes cannot be recommended for intraperitoneal placement in hernia surgery because of their adhesion potential and risk of bowel obstruction.

Trevira mesh: a promising new implant for the treatment of abdominal hernias.

BACKGROUND: Trevira (polyethylene terephthalate) has been in clinical use for more than 20 years, serving as implant material with minimal foreign body reaction for the replacement of the cruciate ligaments of the knee. An animal (pig) trial was performed to ascertain whether a Trevira mesh offers any advantages over currently employed meshes like Prolene for abdominal hernia repair. METHODS: In 12 mini-pigs 10 x 10 cm of the musculofascial abdominal layer was resected preserving the peritoneum. Subsequently, a 15 x 15 cm synthetic mesh was implanted (Prolene, Ethicon, Norderstedt, Germany, or Trevira, Telos GmbH, Marburg, Germany, in six animals each) using sublay technique. The main focus was on the extent of the chronic foreign body reaction. This was assessed by a pathologist who paid special attention to the presence of foreign body giant cells after 2 and 6 months. A further assessment was made of shrinkage of the implant as a result of foreign body reaction. RESULTS: The number of giant cells after two months was significantly higher with the Prolene implant than with the Trevira implant (Prolene 2.2+/-0.4, Trevira 0.8+/-0.2, per fixed microscopic field; P<0.05). After 6 months the number of giant cells associated with the Prolene implants rose further, while it remained relatively constant for those of Trevira (Prolene 4.6+/-1.3, Trevira 1.1+/-0.5; P<0.05). No significant difference was noted over time between the two types of implant with regard to shrinkage (2 months: Prolene 0.8+/-0.3 cm(2), Trevira 0.6+/-0.4 cm(2); 6 months: Prolene 1.3+/-0.6 cm(2), Trevira 1.1+/-0.5 cm(2)). CONCLUSION: In this animal study Trevira mesh demonstrated a high biocompatibility with a low foreign body reaction; it appears to be a promising new implant for the treatment of hernias.

Postoperative comfort after plug-and-patch repair of recurrent inguinal hernia.

OBJECTIVE: To evaluate postoperative comfort after the plug-and-patch repair. DESIGN: Prospective observational study. SETTING: University hospital, Germany. SUBJECTS: From July 1995 until August 2000, 93 consecutive patients with recurrent inguinal hernia were operated on using the plug-and-patch technique. MAIN OUTCOME MEASURES: Postoperative comfort assessed by pain (visual analogue score), analgesic requirements, duration of hospital stay, and restriction of daily activities. RESULTS: Postoperative pain decreased continuously from the morning of the first postoperative day (median VAS: 5.4; range 1.2-6.9) until day 13 (VAS <1). The median amount of analgesics given to the patients for 4 days was dipyrone 5.2 g (range 2.1-8.4). Median duration of hospital stay was 5 (2-14) days, limitation of daily activities 6 days (range 3-17) and 34 patients who were employed had returned to work after 21 days (range 8-42). CONCLUSIONS: Plug-and-patch repair offers a high degree of comfort to patients with recurrent inguinal hernia.