Surgical Technique and Chronic Postoperative Inguinal Pain in Patients Undergoing Open Inguinal Hernioplasty in Portugal: A Prospective Multicentric Cohort Study.

INTRODUCTION: Evidence about the advantage of Lichtenstein's repair, the guidelines' recommended technique, is scarce regarding postoperative chronic inguinal pain (CPIP). The primary aim of this study was to compare CPIP in patients undergoing Lichtenstein versus other techniques. METHODS: Prospective multicentric cohort study including consecutive adults undergoing elective inguinal hernia repair in Portuguese hospitals (October - December 2019). Laparoscopic and mesh-free hernia repairs were excluded. The primary outcome was postoperative pain at three months, defined as a score of ≥ 3/10 in the European Hernia Society Quality of Life score pain domain. The secondary outcome was 30-day postoperative complications. RESULTS: Eight hundred and sixty-nine patients from 33 hospitals were included. Most were men (90.4%) and had unilateral hernias (88.6%). Overall, 53.6% (466/869) underwent Lichtenstein's repair, and 46.4% (403/869) were treated with other techniques, of which 83.9% (338/403) were plug and patch. The overall rate of CPIP was 16.6% and 12.2% of patients had surgical complications. The unadjusted risk was similar for CPIP (OR 0.76, p = 0.166, CI 0.51 - 1.12) and postoperative complications (OR 1.06, p = 0.801, CI 0.69 - 1.60) between Lichtenstein and other techniques. After adjustment, the risk was also similar for CPIP (OR 0.83, p = 0.455, CI 0.51 - 1.34) and postoperative complications (OR 1.14, p = 0.584, CI 0.71 - 1.84). CONCLUSION: The Lichtenstein technique was not associated with lower CPIP and showed comparable surgical complications. Further investigation as- sessing long term outcomes is necessary to fully assess the benefits of the Lichtenstein technique regarding CPIP.

Reparo das hérnias abertas e laparoscópicas no Sistema Público de Saúde brasileiro. Estudo nacional baseado em dados populacionais em período de 11 anos / Open vs laparoscopic hernia repair in the brazilian public health system. an 11-year nationwide population-based study

ABSTRACT BACKGROUND: Abdominal wall hernia is one of the most common surgical pathologies. The advent of minimally invasive surgery raised questions about the best technique to be applied, considering the possibility of reducing postoperative pain, a lower rate of complications, and early return to usual activities. OBJECTIVE: To evaluate the frequency of open and laparoscopic hernioplasties in Brazil from 2008 to 2018, analyzing the rates of urgent and elective surgeries, mortality, costs, and the impact of laparoscopic surgical training on the public health system. METHODS: Nationwide data from 2008 to 2018 were obtained from the public health registry database (DATASUS) for a descriptive analysis of the selected data and parameters. RESULTS: 2,671,347 hernioplasties were performed in the period, an average of 242,850 surgeries per year (99.4% open, 0.6% laparoscopic). The economically active population (aged 20-59) constituted the dominant group (54.5%). There was a significant reduction (P<0.01) in open surgeries, without a compensatory increase in laparoscopic procedures. 22.3% of surgeries were urgent, with a significant increase in mortality when compared to elective surgeries (P<0.01). The distribution of laparoscopic surgery varied widely, directly associated with the number of digestive surgeons. CONCLUSION: This study presents nationwide data on hernia repair surgeries in Brazil for the first time. Minimally invasive techniques represent a minor portion of hernioplasties. Urgent surgeries represent a high percentage when compared to other countries, with increased mortality. The data reinforce the need for improvement in the offer of services, specialized training, and equalization in the distribution of procedures in all regions.

RESUMO CONTEXTO: Hérnias de parede abdominal são patologias cirúrgicas frequentes. O surgimento da cirurgia minimamente invasiva levantou questionamentos sobre a melhor técnica a ser aplicada, considerando a possível redução de dor pós-operatória e de complicações, e retorno precoce às atividades habituais. OBJETIVO: Avaliar frequência de hernioplastias abertas e laparoscópicas no Brasil entre os anos de 2008 e 2018, analisar taxas de cirurgias urgentes e eletivas, mortalidade, custos e o impacto do treinamento em cirurgia laparoscópica no sistema público de saúde. MÉTODOS Análise de banco de dados do registro de saúde pública (DATASUS) entre 2008 e 2018 para coleta dos dados e parâmetros selecionados. RESULTADOS: Foram realizadas 2.671.347 hernioplastias no período, média de 242.850 cirurgias/ano (99,4% abertas, 0,6% laparoscópicas). Predominou a faixa etária economicamente ativa (20-59 anos), 54,5% do total. Houve redução significativa das cirurgias abertas (P<0,01), sem aumento compensatório da laparoscopia. 22,3% das cirurgias foram de urgência, com aumento significativo da mortalidade em relação às cirurgias eletivas (P<0,01). Observou-se distribuição heterogênea da videolaparoscopia, diretamente relacionada com o número de cirurgiões digestivos. CONCLUSÃO: Este estudo apresenta pela primeira vez os dados populacionais das cirurgias de hérnia no Brasil. As técnicas minimamente invasivas representam uma parcela pouco significativa das hernioplastias. As cirurgias urgentes apresentam percentual elevado comparado a outros países, com aumento significativo na mortalidade, reforçando a necessidade de políticas que permitam aumento da oferta do serviço, treinamento especializado e equalização na distribuição dos procedimentos em todas as regiões.

Absorbable Polyglactin vs. Non-Cross-linked Porcine Biological Mesh for the Surgical Treatment of Infected Incisional Hernia.

BACKGROUND: The use of absorbable meshes during contaminated or infected incisional hernia (IH) repair is associated with high morbidity and recurrence rates. Biological meshes might be more appropriate but have been described in highly heterogeneous series. This study aimed at comparing the efficacy of absorbable vs. biological meshes for the treatment of contaminated or infected IH in a homogeneous series with a standardized technique. METHODS: Data of all patients operated on between 2008 and 2015 for contaminated or infected IH, using an absorbable (A) Vicryl® or a biological (B) Strattice® mesh, were reviewed. Patient characteristics, infectious complication rates, and recurrence-free outcome (RFO) were compared between the two groups. A propensity score methodology was applied to a Cox regression model to deal with unbalanced characteristics between groups. RESULTS: Patient demographics in A (n = 57) and in B (n = 24) were similar except that B patients had larger parietal defects (p < 0.001) and higher Center for Disease Control (CDC) wound class (p = 0.034). Patients in A had statistically significantly more postoperative early (61.4% vs. 33.3%, p = 0.03) and late (31.2% vs. 8.3%, p = 0.046) infectious complications. Six-, 12-, and 36-month RFO rates were 77%, 47%, and 24%, and 96%, 87%, and 82% in A and B, respectively, p < 0.001. Raw multivariable Cox regression analysis found that B (HR = 0.1, 95% CI [0.03-0.34], p < 0.001) was independently associated with prolonged RFO (HR = 0.091, 95% CI [0.045-0.180], p < 0.001). CONCLUSION: Biological meshes seem to be superior to absorbable meshes in patients with contaminated or infected incisional hernia. These results need to be confirmed by prospective randomized trials.

A Comparative Analysis of Single Umbilical Tangential Incision vs. Conventional Three-port Totally Extraperitoneal Inguinal Hernia Repair

PURPOSE: We have explored the question of what benefits SUTI-TEP can provide over conventional three-port TEP (C-TEP) surgery for the treatment of inguinal hernia. METHODS: One hundred forty cases (70 SUTI-TEP and 70 C-TEP) were reviewed in this study. SUTI-TEP procedure was carried out with SILS™ port as we reported before. Patient demographics and perioperative outcomes of SUTI-TEP were analyzed and compared with those of C-TEP. RESULTS: There was no conversion to open surgery or C-TEP in SUTI-TEP group. Median VAS immediate postoperatively was slightly higher in SUTI-TEP group, but it was statistically significant. POD 7th day pain after surgery were similar in both groups. Regarding the length of operation time, SUTI-TEP group (71.2 min) was significantly longer than that of the C-TEP group (41 min) (p<0.001). There was no major morbidity or mortality postoperatively in either group. There was also no recurrence or chronic pain during follow up. Patient overall satisfaction including cosmetic outcome was excellent in SUTI-TEP group. CONCLUSION: Although the longer operation time tends to be required, SUTI-TEP can provide better cosmesis and patient satisfaction, and also safety. That may be good indicator of the success of after surgery. Also we should not presume that one large incision causes less pain than small multiple incision because it is just single one. If there is more pain in one single wound, we should find the solution through the innovation of technology or preventive measures.

Long-term quality of life and functionality after ventral hernia mesh repair.

BACKGROUND: The absence of recurrence and pain are important for good quality of life (QoL) after ventral hernia mesh repair. We wanted to study long-term outcome after laparoscopic (LVHR) and open ventral hernia mesh repair (OVHR) using validated scales to measure QoL and functional outcome. METHODS: We conducted a single-center follow-up study of 194 consecutive patients after LVHR and OVHR between March 2000 and June 2010. Of these, 27 patients (13.9 %) died and 14 (7.2 %) failed to attend their follow-up appointment. Of 153 (78.9 %) patients who attended, 81 (52.9 %) patients had LVHR and 72 (47.1 %) patients had OVHR, including 11 conversions (surgery group). One hundred and twelve patients with non-recurrent ventral hernia were also enrolled consecutively as controls (non-surgery group). Quality of life was measured by the SF-36 short form questionnaire and functional outcome by the Activities Assessment Scale (AAS) with the revised Life Orientation Test to measure the influence of dispositional optimism on pain and functionality. Assessment of pain was done using a 100-mm visual analogue scale ruler anchored by word descriptors. RESULTS: Median time from hernia mesh repair to follow-up was 48 and 52 months after LVHR and OVHR, respectively. There were no long-term differences between LVHR and OVHR measured by SF-36 and AAS. Physical dimensions in SF-36: physical function, restrictions in physical function and bodily pain, were significantly better in the surgery group compared to the non-surgery group, but only for incisional hernia. Recurrence was associated with a significant reduction in QoL in all dimensions of SF-36 in both hernia repair cohorts. Chronic pain and impairment were closely related. Optimistic patients had less impairment than pessimistic patients. CONCLUSION: LVHR and OVHR reduce chronic pain and physical impairment and improve long-term QoL. Hernia recurrence and persistent pain reduce the beneficial effect of hernia surgery. Dispositional optimism can modulate QoL reporting and improve functionality.

Long term recurrence, pain and patient satisfaction after ventral hernia mesh repair.

AIM: To compare long term outcomes of laparoscopic and open ventral hernia mesh repair with respect to recurrence, pain and satisfaction. METHODS: We conducted a single-centre follow-up study of 194 consecutive patients after laparoscopic and open ventral hernia mesh repair between March 2000 and June 2010. Of these, 27 patients (13.9%) died and 12 (6.2%) failed to attend their follow-up appointment. One hundred and fifty-three (78.9%) patients attended for follow-up and two patients (1.0%) were interviewed by telephone. Of those who attended the follow-up appointment, 82 (52.9%) patients had received laparoscopic ventral hernia mesh repair (LVHR) while 73 (47.1%) patients had undergone open ventral hernia mesh repair (OVHR), including 11 conversions. The follow-up study included analyses of medical records, clinical interviews, examination of hernia recurrence and assessment of pain using a 100 mm visual analogue scale (VAS) ruler anchored by word descriptors. Overall patient satisfaction was also determined. Patients with signs of recurrence were examined by magnetic resonance imaging or computed tomography scan. RESULTS: Median time from hernia mesh repair to follow-up was 48 and 52 mo after LVHR and OVHR respectively. Overall recurrence rates were 17.1% after LVHR and 23.3% after OVHR. Recurrence after LVHR was associated with higher body mass index. Smoking was associated with recurrence after OVHR. Chronic pain (VAS > 30 mm) was reported by 23.5% in the laparoscopic cohort and by 27.8% in the open surgery cohort. Recurrence and late complications were predictors of chronic pain after LVHR. Smoking was associated with chronic pain after OVHR. Sixty point five percent were satisfied with the outcome after LVHR and 49.3% after OVHR. Predictors for satisfaction were absence of chronic pain and recurrence. Old age and short time to follow-up also predicted satisfaction after LVHR. CONCLUSION: LVHR and OVHR give similar long term results for recurrence, pain and overall satisfaction. Chronic pain is frequent and is therefore important for explaining dissatisfaction.