Is there a link between Spigelian and inguinal hernias? A case series.

INTRODUCTION: Spigelian hernias are among the rare primary ventral hernias. Diagnosis is often difficult, as many cases are asymptomatic. Spigelian and inguinal hernias are usually considered separately in current scientific literature. With this case series, we want to illustrate a possible relationship between the neighboring hernia types. METHODS: In this article, we report on a case series of Spigelian hernias that were operated on in five hernia centers in the period from January 1st, 2021 to October 31st, 2023. We have summarized all patient characteristics with previous operations and the result of the secondary operation. RESULTS: We report a case series with 24 Spigelian hernias, 15 of which have a connection to previous inguinal hernias. In these cases, however, it is not certain whether these are primarily overlooked or occult hernias or whether these Spigelian hernias have arisen secondarily, as a result of previous hernia surgery. With this case series, we would like to point out a possible connection between Spigelian hernia and inguinal hernia. Further studies are needed to shed more light on this entity and explain its genesis.

Improving surgical education in East Africa with a standardized hernia training program.

INTRODUCTION: Inguinal hernias are among the most common surgical diseases in Africa. The current International HerniaSurge Guidelines recommend mesh-based surgical techniques in Low Resource Settings (LRS). This recommendation is currently unachievable in large parts of Africa due to the unaffordability of mesh and lack of appropriate training of the few available surgeons. There is, therefore, a need for formal training in mesh surgery. There is an experience in Hernia Repair for the Underserved in Central and South America, however, inadequate evidence of structured training in Africa. MATERIAL AND METHODS: Since 2016, the aid Organizations, Surgeons for Africa and Operation Hernia have developed and employed a structured hernia surgical training program for postgraduate surgical trainees and medical doctors in Rwanda. This course consists of lectures on relevant aspects of hernia surgery and hands-on training in operating theatres. The lectures emphasize anatomy and surgical technique. All parts of the training were evaluated. Formal pre-course evaluation was conducted to assess the personal surgical experience of the trainees. RESULTS: Over a 3-year period, a structured hernia training programme was employed to train a total of 36 surgical trainees in both mesh and also non mesh hernia surgery. The key principle in this course is the continuous competence assessment and feedback. Evidence is provided to demonstrate improvement in surgical skills as well as knowledge of surgical anatomy which is essential to acquiring surgical competency. With self-assessment, expressed on a Likert scale, the participants could improve the theoretical knowledge about hernias from median 4.4 (on a scale of 1-10) before training to 8.4 after the training. The specific knowledge about anatomy could be improved in the same assessment from 4.8 before training to 8.1. after the training. After training course 12 of the 36 participants (33.33%) were able to carry out both suture- and mesh-based operations of simple inguinal hernias completely and independently. 20 of the 36 participants (55.55%) required only minimal supervision and only four participants (11.11%) required surgical supervision even after the completion of the course. CONCLUSION: We have demonstrated that, medical personnel in Africa can be trained in mesh and non-mesh hernia surgery using a structured training programme.

An in vitro study on the biocompatibility of fibroblasts in sterile and non-sterile low-cost and commercial meshes.

INTRODUCTION: Despite several successful studies with low-cost meshes (LCM) for the treatment of inguinal hernias in India and Africa, a nationwide application has not been possible for a variety of reasons. One problem is the special preparation and sterilization of these meshes-naturally, they should comply with international standards and demands, which is often difficult to achieve in Africa. Our primary approach was to determine whether there are differences in the biocompatibility of fibroblasts between non-sterile and sterile LCMs and commercial meshes (CM). MATERIALS AND METHODS: Two polyester CMs with different pore size and a polyester LCM were examined as both sterile and non-sterile. LCM was plasma sterilized at 60 °C and steam sterilized at 134 °C. Sterile and non-sterile meshes were soaked with an antibiotic (penicillin/streptomycin) and antimycotic solution (amphotericin B). Human fibroblasts from healthy subcutaneous tissue were used. Various tests for evaluating the growth behavior and cell morphology of human fibroblasts were conducted. Semiquantitative (light microscopy) and qualitative (scanning electron microscopy) analyses were performed after 1 week and again after 12 weeks. The metabolism of fibroblasts was checked by pH measurements and glucose analyses. Biocompatibility of fibroblasts on sterile and non-sterile meshes was carried out by luminescence methods (cell viability and apoptosis) as well as calorimetric methods for proliferation determination (BrDU assay) and cytotoxicity (LDH assay). RESULTS: Light and electron microscopy revealed a moderate growth of fibroblasts on all investigated mesh types. The results of glycolysis and the pH value were within the normal range for all sterile and non-sterile meshes. In biocompatibility studies, no elevated level of apoptosis was detected. The viability measurement of mitochondrial activity of fibroblasts showed a 50% inhibition of mitochondria in all nets, with the exception of non-sterile CM, whereas mitochondrial activity was increased in the non-sterile CM. A proliferation measurement (BrdU test) revealed different growth inhibition in the sterile and non-sterile meshes. This growth inhibition was significantly stronger, particularly for non-sterile CM light meshes, than it was for the non-sterile LCM. CONCLUSION: Again, our studies show no significant differences in biocompatibility of fibroblasts between expensive and low-cost meshes. In addition, we detected fibroblast growth even in sterile meshes, independent of the mesh group. To our knowledge, the present study is the first of its kind in terms of qualitative equivalence of sterile and non-sterile in vitro mesh samples. We do not wish to create future patient studies with non-sterilized meshes saturated with antibiotics/antimycotics. However, perhaps we can prove in future studies that under semi-sterile conditions with certain LCMs, wound infection rates can be acceptable.

In-vitro examination of the biocompatibility of fibroblast cell lines on alloplastic meshes and sterilized polyester mosquito mesh.

INTRODUCTION: The use of alloplastic implants for tissue strengthening when treating hernias is an established therapy worldwide. Despite the high incidence of hernias in Africa and Asia, the implantation of costly mesh netting is not financially feasible. Because of that various investigative groups have examined the use of sterilized mosquito netting. The animal experiments as well as the clinical trials have both shown equivalent short- and long-term results. The goal of this paper is the comparison of biocompatibility of human fibroblasts on the established commercially available nets and on sterilized polyester mosquito mesh over a period of 12 weeks. MATERIALS AND METHODS: Three commercially available plastic mesh types and a gas-sterilized mosquito polyethylenterephtalate (polyester) mesh were examined. Human fibroblasts from subcutaneous healthy tissue were used. Various tests for evaluating the growth behavior and the cell morphology of human fibroblasts were conducted. The semi-quantitative (light microscopy) and qualitative (scanning electron microscopy) analyses were performed after 1 week and then again after 12 weeks. The cell proliferation and cytotoxicity of the implants were investigated with the help of the 5'-bromo-2'-deoxyuridine (BrdU)-cell proliferation test and the LDH-cytotoxicity test. The number of live cells per ml was determined with the Bürker counting chamber. In addition, analyses were made of the cell metabolism (oxidative stress) by measuring the pH value, hydrogen peroxide, and glycolysis. RESULTS: After 12 weeks, a proliferation of fibroblasts on all mesh is documented. No mesh showed a complete apoptosis of the cells. This qualitative observation could be confirmed quantitatively in a biochemical assay by marking the proliferating cells with BrdU. The biochemical analysis brought the proof that the materials used, including the polyester of the mosquito mesh, are not cytotoxic for the fibroblasts. The vitality of the cells was between 94 and 98%. The glucose metabolism as well as the pH value of the fibroblasts showed no significant differences between the tested meshes. The examination of the oxidative stress via measurement of the H2O2 concentration showed values in the normal range for the commercially alloplastic meshes and the mosquito mesh. CONCLUSIONS: Our examination showed no significant difference with regard to biocompatibility between the officially approved and cost-intensive meshes and the sterilized (autoclaved) mosquito mesh. Due to the proven strength and stability of the mosquito mesh and their proven compatibility, the implantation of the sterilized mosquito mesh in additional in vivo studies must be considered. A wide-scale and cost-effective treatment of hernias could thus be guaranteed, not only in Third World countries.

Up-regulation of ICAM-1 during cold ischemia triggers early neutrophil infiltration in human pancreas allograft reperfusion.

BACKGROUND: Graft pancreatitis is induced by ischemia/reperfusion injury in which neutrophil infiltration is believed to be a crucial early event. This observation suggests the presence of adhesion molecules already at the time of reperfusion. Therefore, this study was performed to evaluate the pattern of ICAM-1 and P-Selectin expression on human pancreas allografts following cold ischemia and reperfusion. PATIENTS AND METHODS: We performed an analysis of pancreas biopsy specimens taken from 13 patients undergoing pancreas transplantation compared with pancreas specimens from 10 patients following resection. Cryostat sections were stained with monoclonal antibodies against CD11b, a neutrophil marker, and the adhesion molecules ICAM-1 and P-Selectin. RESULTS: Extensive infiltration of CD11b-positive cells was detected in venules and capillaries of pancreas allografts after reperfusion (18.38 +/- 0.87) compared with controls (T1 4.22 +/- 0.55) or with tissue specimens at about 10 hours of cold ischemia (2.60 +/- 0.35; P < .001). Similarly, the pattern of P-Selectin showed a moderate expression before organ harvest (1.54 +/- 0.21) and in samples during cold ischemia (1.46 +/- 0.24) followed by a significantly greater number of P-Selectin-positive cells after reperfusion (2.54 +/- 0.18; P = .005). ICAM-1 was only weakly expressed on the surface of the venular endothelium in all controls (0.77 +/- 0.12). In contrast to P-Selectin, ICAM-1 showed prominent up-regulation during cold ischemia (2.23 +/- 0.23; P < .001) with no further increase after reperfusion (2.23 +/- 0.17). CONCLUSION: The data suggested that ICAM-1 was already up-regulated during cold ischemia, possibly representing the mechanism of early neutrophil infiltration observed in human pancreatic ischemia/reperfusion injury.

[Microcirculatory failure of sublingual perfusion in septic-shock patients. Examination by OPS imaging and PiCCO monitoring]. / Sublinguale Mikrozirkulationsstörungen bei Patienten im septischen Schock: Untersuchungen mittels OPS-Imaging-System und PiCCO-Monitoring.

BACKGROUND: Haemodynamic monitoring of septic patients is impeded by the discrepancy between the macrohaemodynamics and the microcirculation of internal organs. Pulse contour analysis (PiCCO) provides new parameters for an improved assessment of the volume status of critically ill patients. However, changes in regional circulation, in particular those affecting the splanchnic perfusion, have proven to be especially important. The aim of our study was to compare macrohaemodynamic parameters (PiCCO) with microcirculation (OPS imaging) in severely septic patients with multiple organ failure. PATIENTS AND METHODS: In seven patients suffering from septic shock and multiple organ failure (APACHE II score > 25) repeated examinations at a twenty-four hour interval were carried out by PiCCO monitoring and OPS imaging. OPS data were recorded for twenty seconds at 6 different buccal and sublingual localisations, adequately reflecting microvascular perfusion of the liver and the small intestine. Data were videotaped for off-line analysis, calculating current velocity in small and large venules (< 25 and > 25 microm), as well as functional capillary density. RESULTS: Significant correlations were found for current velocity in small venules with systemic vascular resistance (r(2) = 0.252, p < 0.05), mean arterial blood pressure (r(2) = 0.259, p < 0.05), and pH value (r(2) = 0.265, p < 0.05). In addition, a significant correlation was found between the oxygen transport index and the density of small vessels (r(2) = 0.355; p < 0.05). CONCLUSION: According to our findings, data acquired through PiCCO monitoring may be used for a rough estimation of the microcirculation during severe sepsis and multiple organ failure. For an assessment of the local conditions of perfusion, however, there are limits in the use of the parameters that were the object of our research. For the measurement at localisations which are accessible non-invasively and representative of the splanchnic perfusion, OPS is the more accurate method for characterisation of the microcirculation, although a more extensive and time-consuming analysis is needed.

Effect of nitric oxide in ischemia/reperfusion of the pancreas.

BACKGROUND: Ischemia/reperfusion injury, and thus graft pancreatitis, remains a major problem in pancreas transplantation. Contradictory results about the role of nitric oxide (NO) in pancreatic ischemia/reperfusion have been reported; however, in none of the reports has a detailed comparison between inhibition of NO synthase and NO supplementation been carried out. METHODS: Vascular isolation of the pancreatic tail was performed in landrace pigs. After splenectomy catheters placed in the distal part of the splenic vessels allowed collection of the venous effluent and perfusion of the pancreatic tail. Three hours of complete warm ischemia was followed by 6 h of reperfusion. The effect of the NO donor sodium nitroprusside (SNP) and L-arginine was compared to a control group and NO synthase inhibition with L-NAME. RESULTS: Lipase in the venous effluent of the pancreas was significantly decreased in the SNP and the L-arginine groups. Vascular resistance was markedly elevated in the L-NAME group and reduced in the NO donor groups. Tissue pO2 after reperfusion was only significantly elevated in the SNP group. Granulocyte infiltration and also overall histological tissue injury were most severe in the control group followed by the L-NAME group, the SNP group, and the L-ARG group. CONCLUSION: The data show that supplementation of nitric oxide is clearly protective in pancreatic ischemia/reperfusion. However, inhibition of NO synthesis does not lead to an equally clear aggravation of tissue injury.

Impairment of microcirculation in the early reperfusion period predicts the degree of graft pancreatitis in clinical pancreas transplantation.

BACKGROUND: Graft pancreatitis is thought to be induced by ischemia/reperfusion. Animal experiments have suggested that an impaired microcirculation is crucial in this process. We have therefore studied the relevance of microcirculation in clinical pancreas transplantation. METHODS: In 17 patients undergoing pancreas transplantation, tissue pO2 was monitored continuously by an electrode implanted into the pancreatic tail. A catheter was inserted in the distal part of the splenic vein of the pancreas graft. After reperfusion blood samples were taken from this catheter and blood flow was measured by the venous outflow method. The degree of graft pancreatitis was assessed by peak-C-reactive protein (CRP) defined as highest CRP within 3 days after transplantation. RESULTS: Tissue pO2 increased within 5 min after reperfusion. Thereafter, in most patients a transient decrease was noted, indicating impairment of nutritive perfusion. During this period there was an increasing negative correlation between peak-CRP and tissue pO2 which was highly significant at 60 min after reperfusion (r=-0.70, P<0.002). Also donor age correlated significantly with peak-CRP (r=0.64, P<0.005) and to a somewhat lesser extend with tissue pO2 60 min after reperfusion (r= -0.55, P<0.03). CONCLUSION: These data show that the degree of organ damage in clinical pancreas transplantation is directly related to an impairment of microcirculation in the early reperfusion period. These data also support the idea that grafts from older donors have a higher probability to develop graft pancreatitis and that this might be due to an increased incidence of microcirculatory disturbances in these organs.