Mesh versus suture for elective primary umbilical hernia open repair: a systematic review and meta-analysis.

PURPOSE: Recent guidelines indicate the use of mesh in UHR for defects > 1 cm, as it reduces recurrence, with 10% recurrence rate compared to up to 54.5% with primary closure. However, Nguyen et al. shows that primary closure is still widely performed in UHR, especially for small defects (1-2 cm), for which there is no published data to determine the optimal approach. In addition, previous meta-analysis by Madsen et al. comparing mesh repair with primary closure in UHR didn't exclude emergency conditions and recurrent hernias; also, didn't report subgroup analysis on hernia defect size. Thus, we aimed to perform a systematic review and meta-analysis comparing the mesh repairs vs. primary closure of the defect in an open elective primary UHR. METHODS: We searched for studies comparing mesh with suture in open UHR in PubMed, Scopus, Cochrane, Scielo, and Lilacs from inception until October 2023. Studies with patients ≤ 18 years old, with recurrent or emergency conditions were excluded. Outcomes were recurrence, seroma, hematoma, wound infection, and hospital length of stay. Subgroup analysis was performed for: (1) RCTs only, and (2) hernia defects smaller than 2 cm. We used RevMan 5.4. for statistical analysis. Heterogeneity was assessed with I² statistics, and random effect was used if I² > 25%. RESULTS: 2895 studies were screened and 56 were reviewed. 12 studies, including 4 RCTs, 1 prospective cohort, and 7 retrospective cohorts were included, comprising 2926 patients in total (47.6% in mesh group and 52.4% in the suture group). Mesh repair showed lower rates of recurrence in the overall analysis (RR 0.50; 95% CI 0.31 to 0.79; P = 0.003; I2 = 24%) and for hernia defects smaller than 2 cm (RR 0.56; 95% CI 0.34 to 0.93; P = 0.03; I2 = 0%). Suture repair showed lower rates of seroma (RR 1.88; 95% CI 1.07 to 3.32; P = 0.03; I2 = 0%) and wound infection (RR 1.65; 95%CI 1.12 to 2.43; P = 0.01; I2 = 15%) in the overall analysis, with no differences after performing subgroup analysis of RCTs. No differences were seen regarding hematoma and hospital length of stay. CONCLUSION: The use of mesh during UHR is associated with significantly lower incidence of recurrence in a long-term follow-up compared to the suture repair, reinforcing the previous indications of the guidelines. Additionally, despite the overall analysis showing higher risk of seroma and wound infection for the mesh repair, no differences were seen after subgroup analysis of RCTs. STUDY REGISTRATION: A review protocol for this systematic review and meta-analysis was registered at PROSPERO (CRD42024476854).

Use of rainbow trout skin treated with glutaraldehyde as a mesh for abdominal hernioplasty in rats.

PURPOSE: To test the use of rainbow trout skin as a surgical mesh in abdominal hernioplasties in rats. METHODS: The experiment involved 20 Wistar rats receiving implants of trout skin processed for disinfection in 0.5% glutaraldehyde and preserved in 100% glycerin. The animals were divided into four groups, divided at 7, 15, 30, and 90 days postoperatively. Clinical and infrared thermography evaluations were performed, and after euthanasia, assessments of adhesion formations and sample collection for histological evaluation were conducted. RESULTS: The implant was observed to be intact, ensuring the integrity of the abdominal wall, support for the viscera, and normal mobility for the rats for up to 90 days. Low rates of clinical alterations were observed, with an intense inflammatory reaction up to day 7, chronic inflammation and the onset of angiogenesis at day 15, and a low inflammatory reaction with collagenous infiltrate and fibrosis at day 30. At day 90, the implants showed a collagenous and fibrotic infiltrate with a minimal inflammatory infiltrate. CONCLUSIONS: The surgical mesh of trout skin performed well, making it a potential alternative for surgical procedures in muscle aponeurotic corrections in the abdominal wall.

Heavyweight versus non-heavyweight mesh in ventral hernia repair: a systematic review and meta-analysis.

PURPOSE: There is considerable variability among surgeons regarding the type of mesh used in ventral hernia repair. There has been an increasing incidence of mesh fractures with lightweight (LW) and mediumweight (MW) meshes. However, HW mesh has been associated with a greater foreign body sensation and chronic pain. This meta-analysis aims to compare the outcomes of HW and non-heavyweight (NHW) meshes in ventral hernia repair. METHODS: We systematically reviewed the PubMed, Embase, Cochrane, and Scopus databases to identify studies comparing HW with NHW meshes in hernia repair. Outcomes analyzed included hernia recurrence, seroma, hematoma, foreign body sensation, postoperative pain, and wound infection. We performed two subgroup analyses focusing on randomized controlled trials and open retromuscular repairs. Statistical analysis was performed using RevMan 5.4. RESULTS: We screened 1704 studies. Nine studies were finally included in this meta-analysis and comprised 3001 patients from 4 RCTs and 5 non-randomized. The majority of patients (57.1%) underwent open retromuscular repair. HW mesh was significantly associated with increased in foreign body sensation (OR 3.71; 95% CI 1.40-9.84; p = 0.008), but there was no difference in other outcomes. In RCTs analysis, there was no difference between meshes. In open retromuscular repairs, HW mesh was associated with more seromas (OR 1.48; 95% CI 1.01-2.17; p = 0.05). CONCLUSION: Our study found that HW mesh was associated with more foreign body sensation. Also, open retromuscular repairs analysis showed that HW was associated with more seromas. Further randomized studies are needed to understand better the role of HW mesh in ventral hernia repair.

Risk factors associated to incisional hernia in stoma site after stoma closure: A systematic review and meta-analysis.

BACKGROUND: This study aims to identify which risk factors are associated with the appearance of an incisional hernia in a stoma site after its closure. This in the sake of identifying which patients would benefit from a preventative intervention and thus start implementing a cost-effective protocol for prophylactic mesh placement in high-risk patients. METHODS: A systematic review of PubMed, Cochrane library, and ScienceDirect was performed according to PRISMA guidelines. Studies reporting incidence, risk factors, and follow-up time for appearance of incisional hernia after stoma site closure were included. A fixed-effects and random effects models were used to calculate odds ratios' estimates and standardized mean values with their respective grouped 95% confidence interval. This to evaluate the association between possible risk factors and the appearance of incisional hernia after stoma site closure. RESULTS: Seventeen studies totaling 2899 patients were included. Incidence proportion between included studies was of 16.76% (CI95% 12.82; 21.62). Out of the evaluated factors higher BMI (p = 0.0001), presence of parastomal hernia (p = 0.0023), colostomy (p = 0,001), and end stoma (p = 0.0405) were associated with the appearance of incisional hernia in stoma site after stoma closure, while malignant disease (p = 0.0084) and rectum anterior resection (p = 0.0011) were found to be protective factors. CONCLUSIONS: Prophylactic mesh placement should be considered as an effective preventative intervention in high-risk patients (obese patients, patients with parastomal hernia, colostomy, and end stoma patients) with the goal of reducing incisional hernia rates in stoma site after closure while remaining cost-effective.

ONLAY VERSUS RIVES-STOPPA TECHNIQUES IN THE TREATMENT OF INCISIONAL HERNIAS.

BACKGROUND: In the surgical correction of large incisional hernias, the use of a prosthesis is essential in most cases regardless of the technique chosen. The preference is for the polypropylene prosthesis. AIMS: To compare the onlay and Rives-Stoppa techniques in the correction of incisional hernias, their immediate results, complications, advantages, and disadvantages. METHODS: Two groups of patients with incisional hernias were analyzed, submitted to the onlay (19 patients) and Rives-Stoppa (17 patients) techniques, and that used polypropylene prostheses. General epidemiological variables, perioperative data variables, and postoperative complications were assessed. RESULTS: The patients' epidemiologic profile was similar between both groups. The majority were women (58.4%), with a mean age of 65.5 years and a previous mean body mass index of 41.5 kg/m². The Rives-Stoppa technique was employed in most patients (52.7%). Those submitted to the onlay technique had longer abdominal drainage time and longer hospital stay, as well as a higher incidence of seromas and surgical wound infection. CONCLUSIONS: The incisional herniorrhaphy technique with the placement of a pre-peritoneal polypropylene mesh by the Rives-Stoppa technique was superior to the onlay due to lower rates of drain use, hospital stay, and postoperative complications.

Primary abandon of hernia sac for inguinoscrotal hernias: a safe way to cut corners.

INTRODUCTION: Inguinoscrotal hernias (ISH) pose a challenge to surgeons with consistently higher rates of postoperative complications and recurrence rates. The aim of this study is to report our initial experience and early results with a new technique for inguinoscrotal hernia repair. METHODS: A review of a prospectively maintained multi-center database was conducted in patients who underwent minimally invasive repair using the "primary abandon-of-the-sac" (PAS) technique for inguinoscrotal hernias from March 2021 to July 2022. Demographics and outcomes were analyzed. Univariate analysis and multivariate logistic regression were performed. RESULTS: A total of 76 minimally invasive inguinal hernia repairs were performed. In 70 patients (92%) C-PAS was used as the technique to abandon the sac while in the remaining 6 patients, "pirate-eye-patch" technique was used. Median hernia ring was 3 (IQR 2.5-3.5) cm and median hernia sac was 9.5 (8-10.8) cm. Median operative time was 70 min (IQR 56-96). Seroma was present in 22 (28.9%) patients 7 days after surgery. Most had seroma only in the inguinal area (n = 19; 25%). Thirty days after surgery, 12 (15.8%) patients still had seroma in the inguinal area and 6 (7.9%) in the inguinoscrotal area. Ninety days after surgery, four (5.3%) patients had inguinal seroma, 2 (2.6%) scrotal seromas and 3 (3.9%) inguinoscrotal seromas. The size of the hernia sac was not associated with seroma formation 7 days after surgery (OR 1.06; 95% CI 0.89-1.2; P = 0.461) in the multivariate logistic regression. BMI was also not associated with seroma formation (OR 0.8; 95% CI 0.74-1.06; P = 0.2). CONCLUSIONS: Planned abandon of the hernia sac is an interesting alternative and is associated with a low rate of complications and acceptable seroma formation rates.

Management and outcomes of obturator hernias: a systematic review and meta-analysis.

PURPOSE: Obturator Hernia (OH) is a rare type of abdominal wall hernia. It usually occurs in elderly women with late symptomatic presentation, increasing mortality rates. Surgery is the standard of care for OH, and laparotomy with simple suture closure of the defect is commonly used. Given the rarity of this disease, large studies are lacking, and data to drive management are still limited. This systematic review and meta-analysis aimed to describe current surgical options for OHs, with a focus on comparing the effectiveness and safety of mesh use with primary repair. METHODS: PubMed, EMBASE, and Cochrane were searched for studies comparing mesh and non-mesh repair for OH. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. RESULTS: One thousand seven hundred and sixty studies were screened and sixty-seven were thoroughly reviewed. We included 13 observational studies with 351 patients surgically treated for OH with mesh or non-mesh repair. One hundred and twenty (34.2%) patients underwent mesh repair and two hundred and thirty-one (65.81%) underwent non-mesh repair. A total of 145 (41.3%) underwent bowel resection, with the majority having a non-mesh repair performed. Hernia recurrence was significantly higher in patients who underwent hernia repair without mesh (RR 0.31; 95% CI 0.11-0.94; p = 0.04). There were no differences in mortality (RR 0.64; 95% CI 0.25-1.62; p = 0.34; I2 = 0%) or complication rates (RR 0.59; 95% CI 0.28-1.25; p = 0.17; I2 = 50%) between both groups. CONCLUSION: Mesh repair in OH was associated with lower recurrence rates without an increase in postoperative complications. While mesh in clean cases is more likely to offer benefits, an overall recommendation regarding its use in OH repair cannot be made due to potential bias across studies. Given that many OH patients are frail and present emergently, the decision to use mesh is complex and should consider the patient's clinical status, comorbidities, and degree of intraoperative contamination.

Drain placement in retromuscular ventral hernia repair: a systematic review and meta-analysis.

PURPOSE: Drain placement in retromuscular ventral hernia repair is controversial. Although it may reduce seroma formation, there is a concern regarding an increase in infectious complications. We aimed to perform a meta-analysis on retromuscular drain placement in retromuscular ventral hernia repair. METHODS: We performed a literature search of Cochrane, Scopus and PubMed databases to identify studies comparing drain placement and the absence of drain in patients undergoing retromuscular ventral hernia repair. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics. RESULTS: 3808 studies were screened and 48 were thoroughly reviewed. Four studies comprising 1724 patients were included in the analysis. We found that drain placement was significantly associated with a decrease in seroma (OR 0.34; 95% CI 0.12-0.96; P = 0.04; I2 = 78%). Moreover, no differences were noted in surgical site infection, hematoma, surgical site occurrences or surgical site occurrences requiring procedural intervention. CONCLUSIONS: Based on the analysis of short-term outcomes, retromuscular drain placement after retromuscular ventral hernia repair significantly reduces seroma and does not increase infectious complications. Further prospective randomized studies are necessary to confirm our findings, evaluate the optimal duration of drain placement, and report longer-term outcomes.

Bilateral inguinal transabdominal pre-peritoneal laparoscopic hernioplasty associated to bilateral laparoscopic varicocelectomy in the same intervention: a feasibility study.

INTRODUCTION: Inguinal hernia and varicocele are common conditions in male population. Laparoscopy brings the opportunity to treat them simultaneously, through the same incision. However, there are different opinions about the risks for testicular perfusion of multiple procedures in the inguinal region. In this study, we assessed the feasibility of simultaneous laparoscopic procedures by studying clinical and surgical outcomes of patients undergoing bilateral inguinal hernioplasty using the transabdominal preperitoneal (TAPP) technique with and without concomitant bilateral laparoscopic varicocelectomy (VLB). METHODS: a sample of 20 patients from the University Hospital of USP-SP with indirect inguinal hernia and varicocele with indication for surgical correction was selected. Patients were randomized into two groups, 10 undergoing TAPP (Group I) and 10 undergoing simultaneous TAPP and VLB (Group II). Data regarding total operative time, complications and postoperative pain was gathered and analyzed. RESULTS: there was no statistical difference between groups regarding total operative time and postoperative pain. Only one complication (spermatic cord hematoma) was observed in Group I and no complications were observed in Group II. CONCLUSIONS: simultaneous TAPP and VLB in was shown to be effective and safe, which provides a basis for conducting studies on larger scales.

Microbiology of chronic mesh infection.

PURPOSE: Mesh infection following hernia repair is one of the most dreaded complications of hernia surgery. Mesh sinus, infected seromas, mesh extrusion, and mesh-related enteric fistulas are common complications associated with synthetic mesh. This study aimed to review the microbiota of mesh infection in 100 patients submitted to mesh explantation. METHODS: We reviewed the charts of patients presenting with a history of mesh infection lasting or arising six months or more after mesh placement. All patients who submitted to abdominal wall repair with complete removal of an infected mesh and presenting a positive culture were included. The microbiology analysis was based on positive cultures obtained from the fluids and tissues surrounding the mesh or positive cultures of the mesh. Microorganisms were divided into gram-positive or gram-negative, aerobic or anaerobic, and fungi. RESULTS: Pure aerobic gram-positive cultures were encountered in 50% of the patients, followed by a combination of aerobic gram-positive/gram-negative (8%) and pure gram-negative cultures (6%). Anaerobes were recovered from 31% of patients. Fungi were recovered from 6%. Staphylococcus aureus was identified in 64% of cultures, with methicillin-resistant Staphylococcus aureus present in 42% and methicillin-sensitive Staphylococcus aureus in 22%. Among aerobic gram-negative infections, six (17%) were caused by multi-resistant bacteria, including Pseudomonas aeruginosa, Proteus mirabilis, Acinetobacter baumanii, Klebsiella pneumoniae complex, and Enterobacter cloacae complex. CONCLUSION: Staphylococcus aureus plays a significant role in the pathogenesis of synthetic mesh infection. Staphylococcus aureus, isolated in 64% of cultures, accounted for most single bacterial infections and was the prevalent germ in mesh sinus and infected seromas. Gram-negative infection occurred in 35%. Anaerobes occurred in 31%, commonly encountered in polymicrobial infections. Most fungi cultures happened in patients with enteric fistulas.

Short-term complications after onlay versus preperitoneal mesh repair of umbilical hernias: a prospective randomized double-blind trial.

PURPOSE: To compare the incidence of surgical site occurrences (SSOs) following onlay versus preperitoneal mesh placement in elective open umbilical hernia repairs. METHODS: This study presents a secondary analysis of a randomized double-blind trial conducted on female patients with primary umbilical hernias admitted to a general hospital, in a residency training program setting. Fifty-six subjects were randomly assigned to either onlay (n=30) or preperitoneal (n=26) mesh repair group. Data on baseline demographics, past medical history, perioperative details, postoperative pain (visual analogue scale (VAS)), wound-related complications, and recurrence were assessed using a standardized protocol. RESULTS: No statistically significant differences were observed between groups regarding patients' demographics, comorbidities, or defect size. Operative time averaged 67.5 (28-110) min for onlay and 50.5 (31-90) min for preperitoneal repairs, p=.03. The overall rate of SSOs was 21.4% (n=12), mainly in the onlay group (33% vs 7.7%; p=0.02, 95% CI 0.03-0.85) and mostly due to seromas. There were no between-group significant differences in postoperative VAS scores at all timepoints. After a maximum follow-up of 48 months, one recurrence was reported in the onlay group. By logistic regression, the onlay technique was the only independent risk factor for SSOs. CONCLUSION: The presented data identified a decreased wound morbidity in preperitoneal umbilical hernia repairs, thus contributing to the limited body of evidence regarding mesh place selection in future guidelines. Further cases from this ongoing study and completion of follow-up are expected to also compare both techniques in terms of long-term outcomes. TRIAL REGISTRATION NUMBER: Brazilian Registry of Clinical Trials (ReBEC) UTN code: U1111-1205-0065 (date of registration: March 27, 2018).

Preaponeurotic endoscopic repair (REPA) indication in men could be controversial.

PURPOSE: To evaluate the outcomes of REPA and establish if any differences in complications and evolution are present between males and females. METHODS: A retrospective study including consecutive patients operated by REPA approach between November 2017 and April 2019 was conducted. Demographic data, operative times, postoperative complications, and hospital stay were analyzed. The EuraHS-QoL score was used to assess postoperative pain, daily activity constraints, and aesthetic discomfort. The results were compared between sexes. Statistical analysis was performed using SPSS 19. RESULTS: Fifty-four patients were included and 53.7% were male. Patients had a mean age of 50.7 years and a mean BMI of 28.7. The average RAD (Rectus Abdominis Diastasis) size was 2.6 cm (range of 2-5 cm). Seroma was significantly more frequent in males, with an incidence of 55.2 and 24% for females (p = 0.02). Three cases required reintervention (5.5% of total cases), which corresponded to a cystic seroma, an abdominal wall hematoma, and a hernia recurrence. The three cases were males and a p value of 0.04 was obtained when comparing reintervention rates between males and females. No cases of surgical wound infection nor cutaneous necrosis were recorded. No conversions were needed. The mean postoperative pain was 2.25, the mean daily activity constraints score was 2.63, and the degree of aesthetic discomfort was 1.23 with no significant differences between groups. CONCLUSION: The correction of small midline defect associated with minor RAD using REPA seems feasible and reproducible. REPA had achieved good results in females, but in males, the outcomes were poorer.

EARLY INCISIONAL HERNIA AFTER LIVER TRANSPLANTATION: RISK FACTORS AND HERNIA REPAIR RESULTS.

BACKGROUND: Liver transplantation is a complex and valuable therapy. However, complications that burden postoperative quality of life, such as incisional hernia, are to be better elucidated, such as risk factors and prophylactic measures. AIM: This study aimed to define the rate of incisional hernia in patients who underwent liver transplantation in a population in southern Brazil and to assess the related risk factors in order to establish measures for prior optimization and specific prophylactic care in the future. METHODS: Patients undergoing adult Liver transplantation from January 2004 to November 2020 were retrospectively analyzed, assessing demographic features, surgical outcomes, and predisposing factors. RESULTS: Among 261 liver transplantation patients included, incisional hernia was diagnosed in 71 (27.2%). Of the 71 incisional hernia patients, 28 (39.4%) developed IH during the first post-transplant. Majority of the patients were male (52/71, 73.2%); of the 71 patients, 52 had hepatitis C virus (HCV) and 33 (46.5%) had hepatocellular carcinoma (HCC). Male gender (p=0.044), diabetes mellitus (p=0.008), and acute cellular rejection (p<0.001) were risk factors for IH. In all, 28 (39.4%) patients were submitted for hernia repair with mesh, with a recurrence rate of 17.8%. CONCLUSION: Incisional hernia after liver transplantation is a relatively common problem associated with male gender, diabetes, and acute cellular rejection. This is a problem that should not be trivialized in view of the complexity of liver transplantation, as it can lead to a reduction in quality of life as well as jeopardize late liver transplantation results and lead to incarceration and strangulation.

ONLAY VERSUS SUBLAY TECHNIQUES FOR INCISIONAL HERNIA REPAIR: 30-DAY POSTOPERATIVE OUTCOMES.

BACKGROUND: The development of an incisional hernia is a common complication following laparotomy. It also has an important economic impact on healthcare systems and social security budget. The mesh reinforcement of the abdominal wall was an important advancement to increase the success of the repairs and reduce its long-term recurrence. The two most common locations for mesh placement in ventral hernia repairs include the premuscular (onlay technique) and retromuscular planes (sublay technique). However, until now, there is no consensus in the literature about the ideal location of the mesh. AIM: The aim of this study was to compare the two most common incisional hernia repair techniques (onlay and sublay) with regard to the complication rate within the first 30 days of postoperative care. METHOD: This study analyzes 115 patients who underwent either onlay or sublay incisional hernia repairs and evaluates the 30-day postoperative surgical site occurrences and hernia recurrence for each technique. RESULTS: We found no difference in the results between the groups, except in seroma formation, which was higher in patients submitted to the sublay technique, probably due to the lower rate of drain placement in this group. CONCLUSION: Both techniques of mesh placement seem to be adequate in the repair of incisional hernias, with no major difference in surgical site occurrences.

LAPAROSCOPIC INGUINAL HERNIA REPAIR: THE LONG-TERM ASSESSMENT OF CHRONIC PAIN AND QUALITY OF LIFE.

BACKGROUND: Laparoscopic approaches to inguinal hernia repair include transabdominal extraperitoneal and transabdominal preperitoneal, both of which are widely performed and employ mesh. Indicators of success for these surgical procedures include incidence of complications, time to return to daily activities, incidence of postoperative chronic pain, and the long-term postoperative patient satisfaction. OBJECTIVE: This study aimed to evaluate and compare long-term postoperative incidence of chronic pain and overall quality of life among patients undergoing transabdominal extraperitoneal or transabdominal preperitoneal inguinal hernia repair. METHODS: This was a retrospective cross-sectional study. Medical records were analyzed, and the SF-36 questionnaire and Visual Analog Scale were applied to assess quality of life and chronic pain in patients undergoing laparoscopic inguinal hernia repair between January 2017 and February 2021. RESULTS: A total of 167 patients status post laparoscopic inguinal hernia repair, who were 3 months postoperatively or longer, were included in the study. Among the early complications seen, seroma was most common in the transabdominal preperitoneal group (p=0.04). Subsequently, 40 of the initial 167 patients answered to the survey instrument (SF-36 and Visual Analog Scale). Mean patient-reported pain (Visual Analog Scale score) was statistically similar between groups, with 1.29 for transabdominal preperitoneal and 1.68 for transabdominal extraperitoneal (p=0.92). In the domains evaluated by the SF-36, there was no significant difference between the samples. CONCLUSION: Both transabdominal extraperitoneal and transabdominal preperitoneal techniques for hernia repair have similar results in the late postoperative period regarding quality of life and prevalence of chronic pain. They are also comparable in terms of major early postoperative complications, except for seroma, with a higher incidence in patients undergoing transabdominal preperitoneal.

ARE THERE DIFFERENCES IN CHRONIC PAIN AFTER LAPAROSCOPIC INGUINAL HERNIA REPAIR USING THE TRANSABDOMINAL TECHNIQUE COMPARING WITH FIXATION OF THE MESH WITH STAPLES, WITH GLUE OR WITHOUT FIXATION? A CLINICAL RANDOMIZED, DOUBLE-BLIND TRIAL.

BACKGROUND: Regarding postoperative pain, it remains unclear whether non-fixation of the polypropylene prosthesis in transabdominal preperitoneal inguinal hernia repair produces the same outcomes as mesh fixation with glue or tackers. In addition, hernia recurrence is another aspect to be assessed in the comparison between non-fixation and mesh-fixation techniques (tackers and glue). AIMS: This study aimed to evaluate the incidence, quality of pain, and recurrence in patients undergoing laparoscopic inguinal hernioplasty (transabdominal preperitoneal) technique, comparing the fixation of the mesh with tackers versus with glue versus without fixation. METHODS: This is a prospective, double-blind study in which 63 patients presenting with primary unilateral inguinal hernia underwent laparoscopic transabdominal preperitoneal inguinal hernia repair and were randomized into three groups: no mesh fixation (n=21), mesh tacked (n=21), and mesh fixed with fibrin glue (n=21). Patients also responded to questionnaires in order to assess pain and pain quality and were followed up for 2 years. RESULTS: Neither mesh-fixation nor non-fixation techniques were found to affect postoperative chronic pain (p=0.535), but patients undergoing tacker fixation reported more pain descriptors (p=0.0021) and a higher pain index (p=0.002) on the McGill scale in the first 15 postoperative days (T0 and T1). No hernia recurrences were observed. CONCLUSIONS: Both mesh-fixation techniques (tackers and glue) used with the transabdominal preperitoneal approach did not influence the onset of inguinodynia, but tacker fixation was more likely to increase patient sensitivity to pain. Mesh placement without fixation produced the same pain and recurrence outcomes as mesh-fixation techniques. Also, no recurrence was observed in patients without mesh fixation in this study. Consequently, it has become an alternative therapy deserving consideration for hernia repair.

¿Supuración crónica o pseudoquiste infectado? Una complicación de la eventroplastia con malla / Chronic suppuration or infected pseudocyst? A complication of incisional hernia repair with mesh

RESUMEN Las infecciones crónicas posteriores a reparaciones de la pared abdominal pueden presentarse como colecciones que involucran a la malla y suelen obligar a su extracción, mientras que los pseudoquistes son colecciones estériles con una gruesa pared fibrótica que debe ser extirpada para lograr la curación. Presentamos una paciente de 75 años con antecedente de eventroplastia, que consultó por un tumor abdominal de 6 meses de evolución, con características imagenológicas de pseudoquiste parietal. Durante la operación se encontró una malla preperitoneal no integrada a los tejidos y rodeada de "biofilm" y líquido turbio. La prótesis se retiró fácilmente y la aponeurosis, muy engrosada, se cerró borde a borde. El posoperatorio transcurrió sin incidentes y el cultivo desarrolló estafilococo aureus sensible a trimetoprima-sufametoxazol. Seis meses después, la evolución fue favorable y sin signos de recidiva.

ABSTRACT Chronic infections after abdominal wall repairs may present as collections involving the mesh which usually require removing the mesh, while pseudocysts are sterile collections with a thick fibrotic wall that must be removed to achieve healing. We report the case of a 75-year-old female patient with a history incisional hernia repair who sought medical advice due to an abdominal tumor which appeared 6 months before consultation with imaging tests suggestive of an abdominal wall pseudocyst. Surgery revealed a preperitoneal mesh without tissue integration surrounded by biofilm and cloudy fluid. The mesh was easily removed and the edges of the thick aponeurosis were sutured. The postoperative period evolved uneventful and the fluid culture was positive for staphylococcus aureus sensitive to trimethoprim-sufamethoxazole. Six months later the patient evolved with favorable outcome without recurrence.

Complications Reported to the Food and Drug Administration: A Cross-sectional Comparison of Urogynecologic Meshes.

IMPORTANCE: The U.S. Food and Drug Administration uses the Manufacturer and User Facility Device Experience database to evaluate the safety of urogynecologic meshes; however, reports on individual meshes have not been characterized. OBJECTIVE: The aim of the study was to compare complications among available urogynecologic meshes reported to the Manufacturer and User Facility Device Experience database. STUDY DESIGN: This study is a cross-sectional analysis of medical device reports (MDRs) of urogynecologic mesh from January 2004 to March 2019, using the Reed Tech Navigator (LexisNexis), which codes MDRs. The percentage of reports containing specific complaints (not an adverse event rate) were compared with χ 2 tests with Dunn-Sidak correction. Correlations with time on market, mesh weight, stiffness, and porosity were determined. RESULTS: The 34,485 reports examined included 6 transvaginal meshes, 4 sacrocolpopexy meshes, and 10 midurethral slings. Most reported events were pain, erosion, and infection. For transvaginal prolapse, less than 10% of Uphold Lite (Boston Scientific) reports contained pain or erosion versus greater than 90% of Prolift/Prolift+M (Ethicon, P < 0.001). For sacrocolpopexy mesh, greater than 90% of Gynemesh (Ethicon; Prolift in vaginal form) reports included erosion and pain versus less than 60% for Artisyn (Ethicon), Restorelle (Colpoplast), and Upsylon (Boston Scientific, P < 0.0001). For slings, Gynecare TVT Obturator had the highest proportion of erosion and pain complaints. Heavier sling meshes had more reports. When Ascend (Caldera Medical), an outlier with only 5 reports, was excluded, transvaginal mesh stiffness correlated strongly with number of reports. For transvaginal meshes, number of reports correlated with time on market (ρ = 0.8, P = 0.04). CONCLUSIONS: Individual meshes have different properties with different complication profiles, which should inform mesh development and use. Gynemesh MDRs included pain and erosion more frequently than others. Comprehensive registries are needed.

Effects of Oral Zafirlukast, Sildenafil, or Pirfenidone on the Formation of Postsurgical Intra-Abdominal Adhesions in an Experimental Rat Model.

INTRODUCTION: Intra-abdominal adhesions' main etiology is surgical procedures that commonly require reintervention. Oral treatments with sildenafil, zafirlukast, and pirfenidone have yielded decreased severity of fibrotic phenomena secondary to the introduction of foreign material. This study aimed to evaluate the efficacy of oral zafirlukast, sildenafil, or pirfenidone treatment on reducing or preventing intra-abdominal adhesions in an experimental rat model. METHODS: Four groups, each of 10 male Wistar rats weighing 250-300 g, were used. A midline laparotomy was used to excise an area of 1.5 × 1.5 cm and reconstructed with polypropylene mesh fixed to the abdominal wall. After 12 h, oral doses of zafirlukast (1.25 mg/kg, group B), sildenafil (15 mg/kg, group C), or pirfenidone (500 mg/kg, group D) were given every day for 8 days. The control group, A, received no treatment. At day 9, animals were reoperated. The implant was resected after ethically approved euthanasia, and specimens were fixed in 10% formaldehyde for histopathology. RESULTS: Control group A yielded adhesions with greater fibrovascular density and neighboring organ involvement than the other groups (p = 0.001), as well as intense inflammatory infiltrates and numerous granulomas (p = 0.04). Adhesions in group C had less fibrovascular density (p = 0.03) with decreased serosal injuries (p = 0.001) and less organ involvement. Group D had reduced adhesions without organ involvement (p < 0.01) and less inflammatory infiltrates, collagen fibers, and foreign body granulomas than group B or C (p < 0.01). CONCLUSIONS: Oral administration of these agents did not prevent adhesions but ameliorated them. Oral pirfenidone offered the best performance and could be recommended for human use.