Abordaje multidisciplinario del dolor inguinal crónico luego de hernioplastia inguinal / Multidisciplinary approach to chronic postoperative inguinal pain

RESUMEN Antecedentes: el dolor inguinal crónico posoperatorio representa una complicación que altera la ca lidad de vida después de la hernioplastia inguinal. Su incidencia es variable con informes de hasta el 16%. Objetivo: describir el tratamiento y los resultados en pacientes con dolor inguinal crónico luego de una hernioplastia inguinal con malla. Material y métodos: estudio descriptivo, observacional y retrospectivo. Se definió como dolor ingui nal crónico posoperatorio la presencia de dolor inguinal por daño nervioso o afectación del sistema somatosensorial tisular que persiste por más de 6 meses luego de la cirugía inicial. Se revisaron las historias clínicas de los pacientes que cursaban el posoperatorio de hernioplastia inguinal convencio nal y laparoscópica en el período 2010-2018. Se realizó la encuesta EuraHS Quality of life score antes y después del abordaje terapéutico multidisciplinario para evaluar cambios en el dolor y restricción de la actividad física. Los resultados fueron analizados y comparados. Resultados: se identificaron 8 pacientes con dolor inguinal crónico posoperatorio grave. El 100% fue evaluado por el Servicio de tratamiento del dolor y requirieron 3 o más fármacos para manejo del do lor. Posteriormente requirieron bloqueo guiado por tomografía computarizada a causa de la persisten cia de los síntomas. Se realizaron 3 (50%) exploraciones quirúrgicas con retiro de material protésico y 2 triples neurectomías. Se observó una disminución estadísticamente significativa (p < 0,05) en el dolor en reposo, dolor durante la actividad y dolor que experimentaron en la última semana. Conclusión: el abordaje multidisciplinario y escalonado permitiría seleccionar a los pacientes que se beneficiarán con el tratamiento quirúrgico.

ABSTRACT Background: Chronic postoperative inguinal pain represents a complication that alters the quality of life after inguinal hernioplasty. Its incidence is variable with reports of up to 16%. Objective: To describe the treatment and results in patients with chronic inguinal pain after an inguinal hernioplasty with mesh. Material and methods: Descriptive, observational and retrospective study. The postoperative chronic inguinal pain was defined as the presence of inguinal pain due to nerve damage or involvement of the somatosensory tissue system that persists for more than 6 months after the initial surgery. The medical records of patients in the postoperative period of conventional and laparoscopic inguinal hernioplasty in the period 2010-2018 were reviewed. The EuraHS Quality of life score pre and post multidisciplinary therapeutic approach was used to evaluate changes in pain and restriction of physical activity. The results were analyzed and compared. Results: 8 patients with severe chronic postoperative inguinal pain were identified. 100% were eva luated by the pain management service and required 3 or more drugs for pain management. Sub sequently, they required block guided by computed tomography due to persistence of symptoms. 3 (50%) surgical examinations were performed with removal of prosthetic material and 2 triple neurec tomies. A statistically significant decrease (p <0.05) was observed in pain at rest, pain during activity and pain experienced in the last week. Conclusion: The multidisciplinary and step up approach would allow selecting the patients who will benefit from the surgical treatment.

Understanding the patient perspective after ventral hernia repair.

PURPOSE: More than 350,000 ventral hernia repairs are performed in the U.S. each year. However, long-term quality of life of patients living with hernia repair is less known. Follow-up using patient-reported outcomes (measures) is an important representation of the patient experience and can inform quality improvements of hernia treatments. This study aims to understand the patients' experience after ventral hernia repair, to enhance quality of care and long-term hernia treatment outcomes. METHODS: To better understand long-term outcomes of ventral hernia repair and to enhance an existing PRO tool, two rounds of semi-structured interviews and focus groups were conducted. In total, 22 patients who had ventral hernia repair were enrolled. The patient perspectives obtained were grouped into themes to inform the further development of the PRO tool. Data were transcribed and analyzed using atlas.ti and Microsoft Word. RESULTS: Ten major themes were identified in this analysis. Patients' quality of life was impacted by hernia repairs and hernia recurrences, including chronic pain, effects on daily activities and social relationships, and the challenge in finding new treatments. The lack of provider-patient communication and patient understanding of hernia repairs highlighted the need for providing patients with more comprehensive information regarding repair options and outcomes prior to surgery. CONCLUSION: PRO assessments and meaningful communications between the physician and the patient can provide a comprehensive benefit-risk assessment prior to surgery, and may also improve patient understanding of what to expect during recovery from surgery.

Postoperative Recovery in Frail, Pre-frail, and Non-frail Elderly Patients Following Abdominal Surgery.

BACKGROUND: The objective of this study is to explore the association between frailty and surgical recovery over a 6-month period, in elderly patients undergoing elective abdominal surgery. METHODS: A total of 144 patients were categorized as frail, pre-frail, and non-frail based on five criteria: weight loss, exhaustion, weakness, slowness, and low activity. Recovery to preoperative functional status (activities of daily living (ADL) and instrumental activities of daily living (IADL)), cognition, quality of life, and mental health was assessed at 1, 3, and 6 months postoperatively. A repeated measure logistic regression was used to analyze the effect of frailty on recovery over time. The effect of frailty on hospitalization outcomes was also evaluated. RESULTS: Mean age was 78 ± 5 years with 17.4% of patients categorized as frail, 60.4% pre-frail, and 22.2% non-frail. At 6 months, the percent of patients who had recovered to preoperative values were: ADL 90%; IADL 76%; cognition 75.5%; mental health 66%; and quality of life 70%. While more frail patients experienced adverse hospitalization outcomes and fewer had recovered to preoperative functional status, these differences were not found to be statistically significant. Overall, frailty status was not significantly associated with the trajectory of recovery or hospitalization outcomes. CONCLUSION: Strong, institutional commitment to quality surgical care, as well as appropriate strategies for older patients, may have mitigated the impact of frailty on recovery. Further research is needed to examine the role of frailty in the surgical recovery process.

Current practice patterns for postoperative activity restrictions in children.

BACKGROUND: Postoperative activity restrictions are designed to prevent undue stress on a recent repair and minimize the risk of surgical complication, however, there is little evidence to support certain restrictions in clinical practice. For the pediatric population, there is a paucity of formal evaluations of postoperative activity restrictions, and little is known about current practice patterns among pediatric surgeons. This study aimed to describe national practice patterns of pediatric surgeons for postoperative activity recommendations following three common general surgical procedures. METHODS: A 7-item survey was sent to all American Pediatric Surgical Association (APSA) members regarding surgeon practice of recommended activity restrictions for school attendance, participation in playground or gym, participation in contact sports, and heavy lifting in children following 3 procedures: exploratory laparotomy, laparoscopic appendectomy, and inguinal hernia repair. Information on type and duration of clinical practice was also collected for each surgeon. Descriptive and bivariate analyses were performed. RESULTS: The survey was completed by 293 pediatric surgeons for a response rate of 28.9%. There was wide national variability in the recommended activity restrictions for children <12 years old among pediatric surgeons. Following laparoscopic appendectomy, 30.7%, 51.9% and 47.8% of surgeons recommends restriction of gym, contact sports, and heavy lifting for 2-3 weeks respectively, but 26.7%, 19.8%, and 22.2% do not recommend any restriction whatsoever of these three activities. Following inguinal hernia repair, 31.7%, 49.1% and 44.4% of surgeons recommend restriction of gym, contact sports, and heavy lifting for 2-3 weeks, but 30.8%, 30.8%, and 29.2% do not recommend any restriction of these three activities. Only 22% of surgeons change their activity restriction recommendations for children ≥12 years old, this decision was not associated with surgeon years in practice or type of practice. CONCLUSIONS: There is considerable variability in surgeon recommendations for activity restrictions following three general surgery procedures in children. While activity restrictions are rooted in the physiology of wound healing, there is little evidence to support the benefit of these restrictions in clinical practice. In addition, activity restriction may have unintended deleterious effects on a child's psychosocial well-being and quality of life. Further investigation should be pursued to understand the utility of activity restrictions in children and their impact on clinical outcomes and patient quality of life. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: Level V, expert opinion.

Postoperative Rehabilitation May Reduce the Risk of Readmission After Groin Hernia Repair.

Thirty-day readmission after surgery has been proposed as a quality-of-care indicator. We explored the effect of postoperative rehabilitation on readmission risk after groin hernia repair. We used the French National Discharge Database to identify all index hospitalizations for groin hernia repair in 2011. Readmissions within 30 days of discharge were clinically classified in terms of their relationship to the index stay. We used logistic regression to adjust the risk of readmission for patient, procedure and hospital factors. Among 122,952 index hospitalizations for inguinal hernia repair, 3,357 (2.7%) related 30-day readmissions were recorded. Reiterated analyses indicated that readmission risk was consistently associated with patient complexity: age (per year after 60 years, OR 1.03, 95% CI 1.02-1.03, P < 0.001), hospitalization within the previous year (OR 1.56, 95% CI 1.44-1.69, P < 0.001), and increasing severity and combination of co-morbidities. Postoperative rehabilitation was identified as a protective factor (OR 0.56, 95% CI 0.46-0.69, P < 0.001). Older patients and those with greater comorbidity are at elevated risk of readmission after inguinal hernia repair. Postoperative rehabilitation may reduce this risk. Further studies are warranted to confirm the protective effect of postoperative rehabilitation.

Impact of Abdominal Wall Hernias and Repair on Patient Quality of Life.

BACKGROUND: The modified Activities Assessment Scale (AAS) is a 13-question abdominal wall quality of life (AW-QOL) survey validated in patients undergoing ventral hernia repair (VHR). No studies have assessed AW-QOL among individuals without abdominal wall pathology. The minimal clinically important difference (MCID) of the modified AAS and its implications for the threshold at which VHR should be offered also remain unknown. Our objectives were to (1) establish the AW-QOL of patients with a clinical abdominal wall hernia versus those with no hernia, (2) determine the MCID of the modified AAS, and (3) identify the baseline quality of life (QOL) score at which patients derive little clinical benefit from VHR. METHODS: Patient-centered outcomes data for all patients presenting to General Surgery and Hernia Clinics October-December 2016 at a single safety-net institution were collected via a prospective, cross-sectional observational study design. Primary outcome was QOL measured using the modified AAS. Secondary outcome was the MCID. RESULTS: Patients with no hernia had modified AAS scores of 81.6 (50.4-94.4), while patients with a clinically apparent hernia had lower modified AAS scores of 31.4 (12.6-58.7) (p < 0.001). The MCID threshold was 7.6 for a "slight" change and 14.9 for "definite" change. Above a modified AAS score of 81, the risk of worsening a patient's QOL by surgery is higher than the chances of improvement. CONCLUSIONS: VHR can improve 1-year postsurgical AW-QOL to levels similar to that of the general population. The MCID of the modified AAS is 7.6 points. Patients with high baseline scores should be counseled about the lack of potential benefit in QOL from elective VHR.

Prevalence of Surgical Repair for Athletic Pubalgia and Impact on Performance in Football Athletes Participating in the National Football League Combine.

PURPOSE: To examine the prevalence and impact of athletic pubalgia (AP) surgery in elite American football athletes participating in the National Football League (NFL) Combine. METHODS: Results from 1,311 athletes participating in the Combine from 2012 to 2015 were evaluated. Athletes with a history of AP repair were identified using the NFL Combine Database. Athlete history and available imaging was reviewed. NFL performance based on draft status, games played, games started, and current status in the NFL was gathered using publicly available databases. Statistical analysis was performed to detect for significant associations between athlete history and NFL performance in the presence of AP repair and pelvic pathology on postsurgical magnetic resonance imaging (MRI). RESULTS: AP repair was identified in 4.2% (n = 55) of athletes. MRI was performed in 35% (n = 19 of 55) with AP repair, of which 53% (n = 10 of 19) had positive pathology. Athletes with repair were not at risk of playing (P = .87) or starting (P = .45) fewer regular season games, going undrafted (P = .27), or not being on an active NFL roster (P = .51). Compared with athletes with negative imaging findings, positive pathology on MRI did not have a significant impact on games played (P = .74), games started (P = .48), draft status (P = .26), or being on an active roster (P = .74). Offensive linemen (P = .005) and athletes with a history of repair within 1 year of the Combine (P = .03) had a significantly higher risk of possessing positive pathology on MRI. CONCLUSIONS: Athletes with a history of successful AP surgery invited to the NFL Combine and those with persistent pathology on MRI are not at increased risk for diminished performance in the NFL. Offensive linemen and athletes less than 1 year out from surgery have a higher risk for positive MRI findings at the pubic symphysis. LEVEL OF EVIDENCE: Level IV, prognostic study-case series.

La anestesia local con sedación como técnica de primera elección en la cirugía de hernia inguinal en régimen ambulatorio: rápida recuperación postoperatoria, alta seguridad y optimización de recursos / Local anesthesia with sedation as elective procedure in day ucise groin hernioplasty: quick postoperative recovery, high security and saving resources

Introducción: La anestesia local con sedación (ALS) se considera la técnica ‘gold estándar’ en la hernioplastia inguinal unilateral abierta, a pesar de que la anestesia raquídea (AR) sigue siendo la técnica más empleada en la práctica clínica diaria. La ALS parece aportar importantes ventajas con respecto a la AR, especialmente en el ámbito de la cirugía sin ingreso (CSI). El objetivo de este trabajo es demostrar los beneficios de ALS frente a AR en la hernioplastia inguinal en cuanto a los tiempos postoperatorios y las complicaciones postoperatorias en una unidad quirúrgica que realiza el 100 % de su actividad en régimen de Cirugía Mayor Ambulatoria (CMA). Material y método: 25 pacientes sometidos a hernioplastia inguinal con ALS y 25 con AR fueron incluidos en un estudio observacional retrospectivo comparativo. El estado clínico (ASA), el tipo de anestesia, los tiempos de recuperación en la Unidad de Recuperación Postanestésica (URPA), en la Unidad de Readaptación al Medio (URM) y durante su convalecencia en domicilio fueron comparados. Se registró cualquier complicación detectada en el periodo postoperatorio hasta el alta definitiva en ambos grupos. Resultados: Todos los pacientes fueron intervenidos según lo previsto. El tiempo de estancia media en URPA y URM, así como el tiempo transcurrido para recuperar la actividad normal tras la intervención, fueron significativamente inferiores en el grupo ALS. Las complicaciones fueron menos frecuentes y menos severas en el grupo ALS. Conclusión: Este trabajo afianza la ALS como técnica más adecuada que la AR para la intervención de hernia inguinal unilateral abierta en régimen de CMA (AU)

Introduction: Local anesthesia with sedation (LAS) is the ‘gold standar’ anesthetic technique in open groin hernioplasty, even if raquidea anesthesia (RA) is actually the most frequent anesthesia technique at the moment. LAS could contribute several advantages in this procedure especially in day case surgery. The main goal of this report is to show the benefits of LAS for groin hernioplasty regarding postoperative recovery times and outcomes in an only outpatient surgery unit. Material and methods: A 25 LAS group and a 25 RA group were enrolled in this observational retrospective comparative study. The clinical status (ASA), anesthetic technique, the Postanesthetic recovery Unit (PARU) recovery time, time before discharge, and time required to normal activity were compared. Any postoperative outcome was recorded. Results: All patients were operated as planned. Recovery times were shorter in the LAS group. Outcomes were more infrequent as well less severe in the LAS group. Conclusion: This report demonstrates that LAS is the most suitable anesthetic technique for unilateral open groin herniorraphy in Day case (AU)

Repair of large incisional hernias. To drain or not to drain. Randomized clinical trial

ABSTRACT PURPOSE: To evaluate the occurrence of seroma and surgical wound infection after surgery. METHODS: A total of 42 individuals with large incisional hernias were subjected toonlay mesh repair. Following the mesh placement, the participants were randomly allocated to two groups. In group 1, closed-suction drains were placed in the subcutaneous tissue, while progressive tension sutures were performed in group 2. The participants were subjected to clinical and ultrasound assessment to detect seroma and surgical wound infection at three time-points after surgery. RESULTS: The occurrence of seroma at the early, intermediate or late assessments was respectively 19.0%, 47.6%, 52.4% in group 1 and 28.6%, 57.1%, 42.9% in group 2 and was not significantly different between groups (p 0.469; 0.631; 0.619). Surgical wound infection occurred 19% in group 1 and 23.8% in group 2, without a significant difference between the groups (p>0.999). CONCLUSION: The frequency of seroma and infection did not exhibit significant differences between individuals subjected to onlay mesh repair of large incisional hernias with drains or progressive tension sutures without drainage.

Complex Abdominal Wall Reconstruction: A Novel Approach to Postoperative Care Using Physical Medicine and Rehabilitation.

BACKGROUND: Abdominal wall defects remain a significant cause of morbidity and mortality in the United States. Postoperative rehabilitation programs have been used consistently in many surgical subspecialties with exceptional results. Such programs have proven to decrease the total time patients require to resume daily activities. The authors describe a systematic rehabilitation protocol developed with the physical medicine and rehabilitation department that has significantly decreased recurrence rates in patients undergoing complex abdominal wall reconstruction. METHODS: A retrospective analysis was carried out on patients presenting for open repair of an abdominal wall defect performed by a single surgeon. Over a 5-year period, there were 275 consecutive patients divided into two similar groups: one group consisted of 137 patients that received abdominal wall rehabilitation; a second group of 138 patients did not. Patient demographics including body mass index, number of hernia defects, number of previous repairs/abdominal operations, defect size, operative time, blood loss, and postoperative complications including recurrence were collected. RESULTS: Patients enrolled in the abdominal wall rehabilitation program were found to have fewer recurrences at follow-up, with statistical significance compared with those that were not enrolled in the program. CONCLUSIONS: The implementation of the abdominal wall rehabilitation program has resulted in a decrease in recurrence rates following complex abdominal wall hernia repair and reconstruction. This is an innovative system that uses rehabilitation and physical therapy to enhance the psychosocial and occupational status of patients by improving recurrence rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Repair of large incisional hernias. To drain or not to drain. Randomized clinical trial.

PURPOSE: To evaluate the occurrence of seroma and surgical wound infection after surgery. METHODS: A total of 42 individuals with large incisional hernias were subjected toonlay mesh repair. Following the mesh placement, the participants were randomly allocated to two groups. In group 1, closed-suction drains were placed in the subcutaneous tissue, while progressive tension sutures were performed in group 2. The participants were subjected to clinical and ultrasound assessment to detect seroma and surgical wound infection at three time-points after surgery. RESULTS: The occurrence of seroma at the early, intermediate or late assessments was respectively 19.0%, 47.6%, 52.4% in group 1 and 28.6%, 57.1%, 42.9% in group 2 and was not significantly different between groups (p 0.469; 0.631; 0.619). Surgical wound infection occurred 19% in group 1 and 23.8% in group 2, without a significant difference between the groups (p>0.999). CONCLUSION: The frequency of seroma and infection did not exhibit significant differences between individuals subjected to onlay mesh repair of large incisional hernias with drains or progressive tension sutures without drainage.

Meta-analysis of randomized controlled trials comparing Lichtenstein and totally extraperitoneal laparoscopic hernioplasty in treatment of inguinal hernias.

BACKGROUND: Finding the optimal approach to repair an inguinal hernia is controversial. Therefore, for the scientific evaluation of the total extraperitoneal (TEP) and Lichtenstein mesh techniques for the repair of inguinal hernia, meta-analyses of randomized controlled trials are necessary. METHODS: A complete literature search was conducted in the Cochrane Controlled Trials Register Databases, Pubmed, Embase, International Scientific Institute databases, and Chinese Biomedical Literature Database in various languages. RESULTS: Randomized controlled trials (13), including 3279 patients, were retrieved from the electronic databases. The Lichtenstein group was associated with a shorter operating time; however, results show that TEP repair enabled patients a shorter time to return to work, less chronic pain compared with Lichtenstein operation. There was no significant difference in seromas, wound infections, or neuralgia. There are no statistically significant difference in terms of hernia recurrence when the follow-up time is ≤3 y. When follow-up time is >3 y, TEP repair shows a higher recurrence rate compared with Lichtenstein repairs. CONCLUSIONS: There was insufficient evidence to determine the greater effectiveness between TEP and Lichtenstein mesh techniques. In future research, it is necessary for subgroup analyses of unilateral primary hernias, recurrent hernias, and simultaneous bilateral repair to be conducted to define the indications for the TEP approach.

[Prenatal diagnosis of and therapy for congenital diaphragmatic hernia]. / Pränatale Diagnostik und Therapie bei kongenitaler Zwerchfellhernie.

Congenital diaphragmatic hernia is a malformation presenting with varying degrees of severity. An accurate prediction of outcome is crucial for parental counselling and therapeutic planning. In selected cases, foetal endoscopic tracheal occlusion (FETO) can improve foetal outcome. Timely referral to a highly specialised centre is important when the requirement for extracorporeal membrane oxygenation (ECMO) is expected.

[Lichtenstein versus Lichtenstein plus plug in prosthetic inguinal hernia repair: preliminary results of a prospective randomized controlled trial]. / Lichtenstein versus Lichtenstein plus pluf dans les cures prothétique des hernies inguinales: résultats préliminaires d'une étude contrôlée prospective randomisée.

BACKGROUND: Mesh- based hernioplasties became the reference in inguinal hernia repair. AIM: To evaluate the results of combining a conic Plug to the Lichtenstein Mesh for inguinal hernia repair. METHODS: Between January 2007 and January 2009 we included 50 patients with primary or recurrent inguinal hernia in a prospective comparative randomized controlled trial. The randomization concerned the association of the conic Plug to the Lichtenstein Mesh. The primary objectives were to establish if any differences in operation time, postoperative pain response and/or postoperative recovery time, chronic pain and recurrence could be detected between the 2 groups. All patients were seen and data were collected after 2 weeks, 6 months and 2 years. RESULTS: Twenty two patients were treated by Lichtenstein Mesh (group A) and we associated the conic Plug to 28 patients (group B). The mean age was 56 years. Forty three patients were discharged after 24 hours. The postoperative pain was low with visual analogue scores ≤ 5 for 48 patients. One patient had residual pain treated efficiency with medical treatment. No recurrence in the 2 groups in 2 years outcome. There were no significant differences between the 2 groups. CONCLUSION: Results of the Lichtenstein plus Plug technique are similar to the Lichtenstein results. There were no significant differences between the 2 groups concerning early or late complications. The recurrence will be revaluated after 5 and 10 years outcome.

Radially expanding laparoscopic trocar ports significantly reduce postoperative pain in all age groups.

BACKGROUND: Trocar entry points have been identified as a significant source of pain after laparoscopic surgery. This is particularly true of the larger 12-mm ports that require deep fascial closure to avoid port-site herniation. We investigated whether using radially expanding trocars not requiring fascial closure compared to conventional cutting trocars for the 12-mm port in transabdominal preperitoneal (TAPP) hernia repairs had any effect on postoperative analgesic requirements and return to work or normal activity. METHODS: The number of days analgesia was required postoperatively and the number of days taken to return to normal activity was recorded for 143 consecutive patients who underwent TAPP hernia repair by a single experienced laparoscopic surgeon. Exactly the same operative technique was used in these patients with the exception of the 12-mm port site entry. In group 1 (104 patients), a conventional cutting trocar was used requiring deep fascial closure. In group 2 (39 patients), a radially expanding trocar was used and the fascial defect was not closed. RESULTS: Analgesia was required for an average of 10.5 days in group 1 and 2.4 days in group 2 (P < 0.001). The average time to return to work or to normal activity was 23.4 days in group 1 and 15.6 days in group 2 (P = 0.004). There was no significant difference between the two groups with respect to the patients' age, sex, or operating time. CONCLUSION: Using the laparoscopic TAPP hernia repair as a standardised operation, changing from 12-mm fascial port closure to a technique that uses port dilation (not requiring a potentially "tight" deeper fascial closure) in a similar group of patients shows that there is a significant reduction in postoperative analgesic requirement and an earlier return to productive work or normal lifestyle. Perhaps dilating ports should replace those larger 10-, 12-, and 15-mm ports that require deeper sutures in all laparoscopic surgical operations.