Management of a primary Grynfeltt's hernia.

Lumbar hernia is a rare disease, which can be acquired spontaneously or secondarily (post-traumatically, postoperatively…) or congenitally. It results from the existence of areas of weakness between the different muscles forming the posterior abdominal wall: the deep-seated Grynfeltt triangle and the superficial Jean-Louis Petit triangle.

Hernia Mesh Complications: Management of Mesh Infections and Enteroprosthetic Fistula.

The potential consequences of mesh infection mandate careful consideration of surgical approach, mesh selection, and preoperative patient optimization when planning for ventral hernia repair. Intraperitoneal mesh, microporous or laminar mesh, and multifilament mesh typically require explantation, whereas macroporous, monofilament mesh in an extraperitoneal position is often salvageable. Delayed presentation of mesh infection should raise the suspicion for enteroprosthetic fistula when intraperitoneal mesh is present. When mesh excision is necessary, the surgeon must carefully consider both the risk of recurrent infection as well as hernia recurrence when deciding on single-stage definitive reconstruction versus primary closure with delayed reconstruction.

Delayed prosthetic seroma: a localized inflammatory response to COVID vaccination and infection?

We present a patient whom we believe developed a late abdominal mesh collection in response to COVID-19 mRNA vaccination booster and COVID-19 infection. A polypropylene mesh was placed during her right breast reconstruction operation 2 years ago where she underwent a right transverse abdominis rectus muscle (TRAM) free flap. She recovered uneventfully from this operation. This lady, though vaccinated, developed respiratory symptoms and tested positive for COVID-19 infection 3 days after her booster injection. She then noticed right-sided abdominal swelling 3 days after the onset of respiratory symptoms. She only presented 1 month later due to a 7-day history of pain at the site of abdominal swelling. A computed tomography scan confirmed the presence of a seroma, and she underwent ultrasound-guided percutaneous drainage. A COVID Antigen Rapid Test of the fluid returned positive, though the PCR swab returned negative. There have been no published reports of periprosthetic mesh seroma after COVID-19 vaccination or infection to date. We wanted to share our experience so that other surgeons may be aware of this potential presentation given the current ongoing pandemic. Level of evidence: Level V, risk/prognostic.

Open preperitoneal vs. open anterior repair for the treatment of emergency femoral hernia: a bicentric retrospective study.

PURPOSE: The aim of this study is to compare the postoperative results, in terms of complications and recurrence, between the anterior and open preperitoneal approaches in emergency femoral hernia. METHODS: This bi-centric retrospective cohort study included patients who underwent emergency femoral hernia repair between January 2010 and December 2018. Postoperative complications and recurrence were analyzed comparing anterior and open preperitoneal approaches. The predictors of complications, mortality and recurrence were investigated using multivariate logistic regression. RESULTS: A total of 204 patients met the inclusion criteria. Open anterior approach was performed in 128 (62.7%) patients and open preperitoneal was performed in 76 (37.3%). Open preperitoneal approach was associated with lower rates of recurrence (P = 0.033) and associated midline laparotomies (P = 0.006). Multivariable analysis identified patients with chronic nephropathy (OR, 3.801; 95%CI, 1.034-13.974; P = 0.044), preoperative bowel obstruction (OR, 2.376; 95%CI, 1.118-5.047; P = 0.024) and required midline laparotomy (OR, 12.467; 95%CI, 11.392-102.372; P = 0.030) as risk factors for complications and ASA ≥ III (OR, 7.820; 95%CI, 1.279-47.804; P = 0.026), COPD (OR, 5.064; 95%CI, 1.188-21.585; P = 0.028), necrotic contents (OR, 36.968; 95%CI, 4.640-294.543; P = 0.001), and required midline laparotomy (OR, 11.047; 95%CI, 1.943-62.809; P = 0.007). as risk factors for 90-day mortality. Male gender (OR, 4.718; 95%CI, 1.668-13.347; P = 0.003) and anterior approach (OR, 5.292; 95%CI, 1.114-25.149; P = 0.036) were risk factors for recurrence. CONCLUSION: Open preperitoneal approach may be superior to anterior approach in the emergency setting because it can avoid the morbidity of associated midline laparotomies, with a lower long-term recurrence rate.

Open Emergent Groin Hernia Repair: Anterior or Posterior Approach?

Introduction: The current literature has not yet provided a definitive conclusion on the best emergency groin hernia repair. The aim of this study was first to compare the short and long-term outcomes between open preperitoneal and anterior approach in emergency groin hernia repair and second to identify risk factors for postoperative complications, mortality, and recurrence. Materials and Methods: This retrospective cohort study included patients who underwent emergency groin hernia repair between January 2010 and December 2018. Short and long-term outcomes were analyzed comparing approach and repair techniques. The predictors of complications and mortality were investigated using multivariate logistic regression. Cox regression multivariate analysis were used to explore risk factors of recurrence. Results: A total of 316 patients met the inclusion criteria. The most widely used surgical techniques were open preperitoneal mesh repair (34%) and mesh plug (34%), followed by Lichtenstein (19%), plug and patch (7%) and tissue repair (6%). Open preperitoneal mesh repair was associated with lower rates of recurrence (p = 0.02) and associated laparotomies (p < 0.001). Complication and 90-day mortality rate was similar between the techniques. Multivariable analysis identified patients aged 75 years or older (OR, 2.08; 95% CI, 1.14-3.80; p = 0.016) and preoperative bowel obstruction (OR, 2.11; 95% CI, 1.20-3.70; p = 0.010) as risk factors for complications and Comprehensive Complication Index ≥26.2 as risk factor for 90-day mortality (OR, 44.76; 95% CI, 4.51-444.59; p = 0.01). Female gender was the only risk factor for recurrence. Conclusion: Open preperitoneal mesh repair may be superior to other techniques in the emergency setting, because it can avoid the morbidity of associated laparotomies, with a lower long-term recurrence rate.

Risk of Hernia Mesh Explantation following Early Versus Late Onset Skin and Soft Tissue Infection.

To estimate the relative risk of explantation in patients with skin and soft tissue infection onset within 90 days of hernia surgery, compared with days 91-365 and after 1 year. BACKGROUND: Infectious complications occurring after hernia repair with synthetic mesh require prolonged treatment, and eventual mesh explantation. Little is known whether early versus late onset infection is associated with differential risk of mesh removal, and whether treatment with long-term antibiotics or debridement are associated with mesh salvage. METHODS: This was a retrospective observational cohort study. We obtained data on all inguinal, umbilical, and ventral hernia repairs with implanted synthetic mesh performed in Veterans Affairs hospitals during 2008-2015. Participants without a 5-year infection after hernia surgery were excluded. Logistic regression estimated the association of mesh explantation with exposure to mesh-related infection during postoperative days 0-90, versus days 91-365 versus after 1 year. Additional covariates included any subsequent abdominal operation, antibiotic administration, and incision and drainage (I&D) or debridement procedures. RESULTS: One thousand eight hundred eighty-five patients underwent index hernia repair and developed a skin and soft tissue infection within 5 years. Infection onset during days 91-365 was associated with increased explantation risk (OR, 1.62; 95% CI, 1.04-2.48), as was increased antibiotic use (OR, 1.04; 95% CI, 1.03-1.05) and surgical treatments (OR, 3.74; 95% CI, 3.02-4.67). Subsequent abdominal operation was associated with lower explantation risk (OR, 0.46; 95% CI, 0.33-0.61). CONCLUSIONS: Early infections may be more suitable for conservative management. Later-onset infections have lower probability of mesh salvage and should be considered for earlier explantation to save the patients prolonged courses of antibiotics and surgical interventions.

Migración de la malla a la unión gastroesofágica: una complicación infrecuente de la reparación de una hernia hiatal gigante / Mesh migration into the gastroesophageal junction: a rare complication of giant hiatal hernia repair

Resumen El reparo de la hernia hiatal es un tema de debate debido a las posibles complicaciones asociadas que han cambiado a través de los años. En la literatura se reportan complicaciones asociadas al procedimiento hasta en un 30 % de los casos. Las complicaciones diferentes a la recurrencia y a largo plazo son infrecuentes, reportadas en menos del 9 % de los casos. La inclusión de la malla protésica en el esófago es una rara complicación y solo se han reportado pocos casos sobre esta. Entre los factores asociados a este desenlace se encuentran descritos: el material protésico, la técnica quirúrgica y la tensión de la malla sobre el tejido intervenido; sin embargo, es difícil establecer asociaciones directas de cada factor dado que la literatura actual solo cuenta con reportes de casos. A continuación, se muestra el caso clínico de un paciente, quien, después de una reparación de hernia hiatal con malla, presenta la inclusión de material protésico en el esófago; se aborda el diagnóstico y el manejo de la misma.

Abstract Hiatal hernia repair has been a subject of debate due to the possible associated complications that have changed over the years. The literature reports up to 30% of cases with complications associated with the procedure. Complications other than recurrence and long-term complications are rare and reported in less than 9% of cases. The migration of the prosthetic mesh into the esophagus is a rare complication and only a few cases have been reported. The factors associated with this outcome include prosthetic material, surgical technique, and mesh tension on the intervened tissue. However, it is difficult to establish direct associations of each factor since the current literature has only case reports. The following is a clinical case of a patient in whom the prosthetic material migrated into the esophagus after a hiatal hernia repair with mesh. The diagnosis and treatment offered are discussed.

Outcomes of primary and recurrent inguinal hernia repair with prosthetic mesh in a single region over 15 years.

BACKGROUND: Sutured inguinal hernia repairs are now uncommon, with evidence suggesting that those augmented with mesh are associated with a lower recurrence rate. We aimed to explore the suggestion that the established use of mesh does indeed lower the rate of operation for recurrence in a single National Health Service region. METHOD: We collected retrospective Office of Population Censuses and Surveys coded data across one region of all primary and recurrent inguinal hernia repairs over 15 years (2004-2019). Electronic records of recurrent repairs were scrutinised to identify year and type of previous primary repair. RESULTS: In total, 7,234 repairs were performed during this time, of which 289 (4%) were for symptomatic recurrence. Operations for primary repair increased year on year (111 in 2004 to 402 in 2019). Frequency of operation for recurrent herniation declined with increasing use of mesh (8.8% in 2004 to 3.5% in 2019). The majority of repairs (73%) for recurrence were by an open approach. As opposed to an open mesh repair, a primary laparoscopic repair was associated with an earlier recurrence. CONCLUSIONS: Inguinal hernia repairs are increasing in frequency but operations for later symptomatic recurrence following an open primary prosthetic mesh repair are not.

Laparoscopic perineal hernia repair following pelvic exenteration: a case report.

BACKGROUND: Acquired perineal hernia is a rare complication following extensive pelvic surgery. Radiotherapy is also a predisposing factor. Perineal hernia can cause chronic perineal pain, bowel obstruction, urinary disorders and a cosmetically disfiguring defect. The treatment of perineal hernia is surgical, usually consisting of mesh repair via an abdominal or perineal approach. CASE PRESENTATION: We present a case report and a surgical video of a 42-year-old woman with history of a squamous cell carcinoma. This patient had 3 recurrences since the diagnosis and a symptomatic perineal hernia. Complete regression of the recurrent malignancy allowed us to treat the perineal hernia. We performed laparoscopic repair with prosthetic mesh in this patient who had undergone multiple surgeries and radiotherapy, while preserving the omental flap that was used to reconstruct the posterior part of the vagina. CONCLUSION: There is no consensus concerning the preferred surgical approach, perineal or laparoscopic, as no study has demonstrated the superiority of either of these approaches. Laparoscopic repair for an acquired perineal hernia is safe and feasible. However, further studies including randomized trials are required to precisely evaluate the best surgical approach and type of mesh.

Comparison of Mesh and Barbed Suture for Laparoscopic Nephrosplenic Space Ablation in Horses.

Nephrosplenic space (NSS) ablation has been demonstrated to be an effective technique for prevention of left dorsal displacement of the large colon and multiple laparoscopic techniques, among which ablation with mesh or with a barbed suture, have been proposed. Our objective was to compare two laparoscopic techniques for closure of the NSS in twenty-eight horses diagnosed with nephrosplenic entrapment. Medical records of horses that had laparoscopic NSS ablation in two referral centers between 2017-2019 were retrieved. Duration of surgery, complications, and short- and long-term follow-up information were collected and compared. Costs were also calculated and compared. All horses met the inclusion criteria: 9 had NSS ablation with a mesh implant (group M), 19 with barbed suture material (group B). One horse in group B had recurrent colic after discharge. At control laparoscopy after 5 months, the NSS resulted in still not being ablated because of a failure of the suture. In group M, three horses had recurrent colic. One was successfully treated medically, one died of unknown causes and the third required a second laparoscopic suturing at 3-6 months because of failure of the mesh implant. The mean time of surgery and costs were lower in group B compared to group M. The barbed suture technique was faster, more cost-effective and had a lower complication rate than the mesh implant.

Perineal hernia repair after abdominoperineal rectal excision with prosthetic mesh-a single surgeon experience.

AIM: Extralevator abdominoperineal excision for rectal cancer is associated with an increased incidence of perineal hernia. The purpose of this study was to determine clinical outcome following perineal hernia repair with prosthetic mesh by a perineal open approach. METHODS: We present a case series of 10 patients who underwent 12 repairs of their hernia using a prosthetic mesh placed by a perineal open technique. Patients were identified from a prospectively maintained database and their case records were retrieved along with their imaging and analysed retrospectively. RESULTS: Perineal hernia incidence in our series is 10%. The median age was 73 ± 5.9 years. No gender predilection was found. The median time interval between extralevator abdominoperineal excision and surgical repair of perineal hernia was 25.3 months. The surgical approach was perineal with the use of a double layer prosthetic mesh. The recurrence ratio was 30% (n = 3). Overall morbidity was also 30% with no major complications (Clavien-Dindo I-II). Recurrence following primary repair was diagnosed in a median time interval of 28.3 ± 16.57 months. Two patients had repeat surgery to treat their recurrence. CONCLUSIONS: Our small series supports the use of a prosthetic mesh repair of perineal hernias through a perineal approach. It is safe and effective with complication rates similar to those previously reported.

The results of open preperitoneal prosthetic mesh repair for acutely incarcerated or strangulated inguinal hernia: a retrospective study of 146 cases.

BACKGROUND: Tension-free hernia repair has been regarded as the gold-standard treatment for selected inguinal hernias, but the use of prosthetic mesh in acutely incarcerated or strangulated inguinal hernias is controversial. Our aim was to evaluate the safety and efficacy of open prosthetic mesh repairs for emergency inguinal hernias. METHODS: Patients with acutely incarcerated or strangulated inguinal hernias who underwent open preperitoneal prosthetic mesh repairs during 2013 to 2016 at our department were included. Patients' characteristics, operative details, results, and complications were retrospectively analyzed. RESULTS: During a 4-year period, 146 cases who met the inclusion criteria were enrolled in our study. There were 127 males and 19 females of median age 75 years (range 19-95 years). The hernia was indirect inguinal in 104 (71.2%) patients, direct inguinal in 18 (12.3%), and femoral hernia in 24 (16.5%). Bowel resection was necessary in 20 patients (13.7%). Complications occurred in 15 (10.3%) patients, including wound infection in 6 (4.1%), scrotal hematoma in 2 (1.4%), bleeding in 1 (0.7%), deep vein thrombosis (DVT) in 2 (1.4%), and chest infection in 4 (2.7%). No mesh-related infections were detected. There were 2 mortalities. During the median follow-up of 26 months (range 6-53 months) 2 recurrences occurred, but there were no deaths or further infections. CONCLUSION: Open preperitoneal prosthetic mesh repair can be safely performed in patients with incarcerated or strangulated inguinal hernia without contaminated hernia content. Mesh repair is not contraindicated in patients with bowel resection.

Multifunctional prosthetic polyester-based hybrid mesh for repairing of abdominal wall hernias and defects.

This study involves the design, development and evaluation of a new multifunctional prosthetic mesh for treatment of abdominal wall defects without complications. The developed prosthetic mesh is a hybrid platform of both synthetic and natural materials with its backbone consisting of a synthetic commercial polyester fabric (CPF) to provide the required mechanical integrity. The CPF mesh was coated by a natural biodegradable, biocompatible and antimicrobial layer of chitosan (CS) incorporating phenytoin (PH)-loaded pluronic nanomicelles for healing promotion, and ciprofloxacin (CPX)-alginate polyelectrolyte complex-based microparticles as antibacterial agent. The prosthetic mesh was optimized and evaluated in-vitro and in-vivo. The optimum PH-loaded micelles had particle size of 95.42 nm, polydispersity index of 0.41, zeta potential of -18 and entrapment efficiency of 89.4%, while the optimum CPX microcomplexes had particle size of 1292.0 nm, polydispersity index of 0.8, zeta potential of -20.1, complexation efficiency of 81.1%, and minimum inhibitory concentration of 0.25 µg/ml and 0.125 µg/ml against Staphylococcus aureus and Pseudomonas aeruginosa, respectively. In-vivo study on abdominal wall defect dog model was conducted, followed by implantation of the proposed prosthetic meshes. The developed mesh depicted an efficient healing with excellent biocompatibility, and could be an ideal and feasible alternative prosthesis with many advantages such as low cost, inertness, mechanical stability, pliability, low infection rate, limited modification by body tissues, sterilizability, non-carcinogenicity, limited inflammatory reaction, hypoallergenic as well as minimal complications.

A primary inferior lumbar hernia misdiagnosed as a lipoma.

Lumbar hernias can be superior (Grynfelt) and inferior (Petit). Inferior lumbar hernias are extremely rare and, therefore, are associated with diagnostic difficulty. We present a case of a primary spontaneous inferior lumbar hernia in a 79-year-old woman that was initially diagnosed as a large lipoma on ultrasound. The first operation was abandoned and an open mesh repair was conducted. Lumbar hernias can be primary acquired (55%), secondary acquired (25%) or congenital (20%). Cross-sectional imaging by CT or MRI appears to be the gold standard in diagnosis as ultrasound may lead to misdiagnosis. Strangulation, incarceration and obstruction are recognised complications, requiring prompt surgical intervention. There are currently no guidelines for surgical managements, although laparoscopic surgery may give the best results. In view of the scarcity of published cases, we aim to add to the literature to raise the index of suspicion and to promote prompt surgical management of lumbar hernias.

The Use of Prosthetic Mesh in the Emergency Management of Acute Incarcerated Inguinal Hernias.

INTRODUCTION: Tension-free hernia repair has been regarded as a gold standard treatment for selected inguinal hernias, but the use of prosthetic mesh in acute incarcerated inguinal hernias is controversial. Our study focused on evaluating the safety and efficacy of the prosthetic mesh repair for emergency cases. METHODS: Patients with acute incarcerated inguinal hernias who underwent emergency prosthetic mesh repair during 2009 to 2014 at our department were included. Patient characteristics, operative approaches and results, and complications were retrospectively analyzed. RESULTS: A total of 167 patients were included in our study. One hundred and twenty-two patients underwent open surgery while the remaining 45 patients underwent transabdominal preperitoneal laparoscopic approach. The hernia was indirect inguinal in 133 patients (79.6%), direct inguinal in 15 patients (9.0%), and femoral in 19 patients (11.4%). The overall wound infection rate of these patients was 3%. Nonviable intestinal resection was performed in 25 patients (8.4%), only 2 of whom underwent wound infection. Another 3 patients who developed wound infection had viable hernia content. There was no mesh-related infection. There was no statistically significant difference in wound infection rates between patients with viable hernia contents and those with nonviable contents ( P < .05). CONCLUSION: The use of the prosthetic mesh in the treatment of acute incarcerated inguinal hernia is safe and effective. Nonviable intestinal resection cannot be regarded as a contradiction of the mesh repair.

Pitfalls and clinical recommendations for the primary lumbar hernia based on a systematic review of the literature.

PURPOSE: The lumbar abdominal wall hernia is a rare hernia in which abdominal contents protrude through a defect in the dorsal abdominal wall, which can be of iatrogenic, congenital, or traumatic origin. Two anatomical locations are known: the superior and the inferior lumbar triangle. The aim of this systematic review is to provide a clear overview of the existing literature and make practical clinical recommendations for proper diagnosis and treatment of the primary lumbar hernia. METHODS: The systematic review was conducted according to the PRISMA guidelines. A systematic search in PubMed, MEDLINE, and EMBASE was performed, and all studies reporting on primary lumbar hernias were included. No exclusion based on study design was performed. Data regarding incarceration, recurrence, complications, and surgical management were extracted. RESULTS: Out of 670 eligible articles, 14 were included and additional single case reports were analysed separately. The average quality of the included articles was 4.7 on the MINORS index (0-16). Risk factors are related to increased intra-abdominal pressure. CT scanning should be performed during pre-operative workup. Available evidence favours laparoscopic mesh reinforcement, saving open repair for larger defects. Incarceration was observed in 30.8% of the cases and 2.0% had a recurrence after surgical repair. Hematomas and seromas are common complications, but surgical site infections are relatively rare. CONCLUSION: The high risks of incarceration in lumbar hernias demand a relatively fast elective repair. The use of a mesh is recommended, but the surgical approach should be tailored to individual patient characteristics and risk factors.

The use of prosthetic mesh for abdominal wall repairs: A semi-systematic-literature review.

Following abdominal wall surgery, incisions are commonly sutured, stapled, or glued together by primary intention. Developments within the field of tissue engineering have led to the use of prosthetic meshes, with over 20 million meshes implanted each year worldwide. The function of the mesh is to hold together abdominal wall incisions and repair abdominal hernias. This has been demonstrated to be highly effective in some individuals; however, some patients have experienced postoperative complications, including dehiscence with further abdominal herniation (viscera protruding through the abdominal wall). Little is currently known about why these complications occur in a subset of patients who have had prosthetic mesh implants in abdominal wall repairs; therefore, this literature review examined existing studies identified via six electronic databases. A total of 463 studies were identified, of which 13 were included in this review. The results identified that the prosthetic mesh is highly successful in a large proportion of patients who have had a had a hernia repair in a range of locations; however, the prosthetic mesh has long-term complications, with rejection being observed in a subset of patients. The reason why the prosthetic is being rejected is still largely unknown, and therefore, further investigation needs to be carried out.

Risk of recurrence following mesh associated incisional hernia repair using the retromuscular technique in patients with relevant medical conditions.

BACKGROUND: Incisional hernia is a common problem following open abdominal surgery. Hernia repair in patients with relevant medical conditions is a topic of controversy due to the high risk of morbidity and recurrence. We investigated the risk of recurrence in patients with relevant medical conditions managed with a prosthesis in the retromuscular position. METHODS: A retrospective review of the data of patients undergoing midline incisional hernia repair was performed. The outcomes of patients with relevant concomitant medical conditions defined as ASA scores >2 were compared with those of healthier patients with ASA scores ≤2. RESULTS: 115 patients including 41 with ASA >2 and 74 with ASA ≤2 were included for analysis. There were no statistically significant differences amongst both groups with regard to the size of the hernia defect, the duration of surgery (123.0 ± 71 vs. 149.0 ± 92 min, p = 0.73), the incidence of postoperative seroma (14.6% vs. 29.7%, p = 0.07), postoperative hematoma (12.2% vs. 4.1%, p = 0.10) and surgical site infection (14.6% vs. 8.1%, p = 0.27). No statistically significant difference was seen amongst both groups with respect to the rate of long-term recurrence after a median follow-up of 63.0 ± 36 months (12.2% vs. 6.8%, p = 0.32). CONCLUSION: Relevant medical condition alone cannot be seen as a contraindication for midline incisional hernia repair using the retromuscular technique. Rates of morbidity and long-term recurrence following mesh-associated closure are not difference from those of healthier patients.

Biomechanical Modeling of Prosthetic Mesh and Human Tissue Surrogate Interaction.

Surgical repair of hernia and prolapse with prosthetic meshes are well-known to cause pain, infection, hernia recurrence, and mesh contraction and failures. In literature, mesh failure mechanics have been studied with uniaxial, biaxial, and cyclic load testing of dry and wet meshes. Also, extensive experimental studies have been conducted on surrogates, such as non-human primates and rodents, to understand the effect of mesh stiffness, pore size, and knitting patterns on mesh biocompatibility. However, the mechanical properties of such animal tissue surrogates are widely different from human tissues. Therefore, to date, mechanics of the interaction between mesh and human tissues is poorly understood. This work addresses this gap in literature by experimentally and computationally modeling the biomechanical behavior of mesh, sutured to human tissue phantom under tension. A commercially available mesh (Prolene®) was sutured to vaginal tissue phantom material and tested at different uniaxial strains and strain rates. Global and local stresses at the tissue phantom, suture, and mesh were analyzed. The results of this study provide important insights into the mechanics of prosthetic mesh failure and will be indispensable for better mesh design in the future.