Bilateral Groin Hernia Research Articles

Prospective randomized clinical trial comparing lightweight mesh and heavyweight polypropylene mesh in endoscopic totally extraperitoneal groin hernia repair

The purported advantage of lightweight large-pore meshes is improved biocompatibility that translates into lesser postoperative pain and earlier rehabilitation. However, there are concerns of increased hernia recurrence rate. We undertook a prospective randomized clinical trial to compare early and late outcome measures with the use of a lightweight (Ultrapro) mesh and heavyweight (Prolene) mesh in endoscopic totally extraperitoneal (TEP) groin hernia repair. A prospective study was performed on 402 patients (191 in Ultrapro and 211 in Prolene group) with bilateral groin hernias who underwent endoscopic TEP groin hernia repair from March 2006 to June 2007. All operations were performed by five consultants following a standardized operative protocol. Chronic groin pain and hernia recurrence were evaluated as primary outcome measures. Secondary outcome measure were early postoperative pain, operative time, number of fixation devices required to fix the mesh, return to normal daily activities of work, seroma, and testicular pain. At 1-year follow-up, incidence in Ultrapro versus Prolene group for chronic groin pain was 1.6% vs. 4.7% (p = 0.178) and recurrence was 1.3% vs. 0.2% (p = 0.078). In Ultrapro versus Prolene group, mean visual analogue score for postoperative pain at day 7 was 1.07 vs. 1.31 (p = 0.00), mean return to normal activities was 1.82 vs. 2.09 days (p = 0.00), and mean number of fixation devices per patient required to fix the mesh was 4.22 vs. 4.08 (p = 0.043). Lightweight meshes appear to have advantages in terms of lesser pain and early return to normal activity. However, more patients had hernia recurrence with lightweight meshes, especially for larger hernias. We surmise that the lightweight meshes have greater tendency to get displaced from their intended position during desufflation at the conclusion of endoscopic TEP repair.

Hernia Endotrainer: Results of Training on Self-Designed Hernia Trainer Box

Repair of groin and ventral hernias are among the technically difficult endoscopic procedures where the role of laparoscopic surgery is fast emerging. We have designed a laparoscopic simulator trainer box for hernia surgery, which closely mimics the complex endoscopic procedure, and good results can be achieved by training on these trainer boxes. The endotrainer box was self-designed to repair bilateral groin hernia, and an incisional hernia, such that it can be used for multiple repairs. Forty candidates were trained with the trainer box for 2 days over two hernia training programs, and an objective assessment of the result was done by global and task-specific scoring for transabdominal preperitoneal (TAPP) and intraperitoneal onlay mesh (IPOM) repair of groin and incisional hernia, respectively. There was a significant improvement in the global (10.15 on day 1 and 12.85 on day 2) and task-specific score for TAPP (3.55 on day 1 and 5.83 on day 2) and IPOM repair (4.4 on day 1 and 6.4 on day 2). Cheaper endotrainer boxes can be self-designed for complex endoscopic surgeries such as hernia repair. The training with these trainer boxes under the supervision of experienced surgeons shows good results and can be used for surgical residents and practicing surgeons who are exposed to basic laparoscopic skills.

MRI and Pathology in Persistent Postherniotomy Pain

Persistent postherniotomy pain impairs everyday life in 5% to 10% of patients. MRI can potentially be useful in the investigation of pathogenic mechanisms and guide surgeons in mesh removal and neurectomy. No study has investigated interobserver agreement or MRI-specific findings in persistent postherniotomy pain. Thirty-two patients with persistent postherniotomy pain > 1 year after uni- or bilateral groin hernia repair and 6 pain-free postherniotomy controls were MRI scanned, resulting in a total of 32 painful groins, 15 pain-free operated groins, and 29 pain-free unoperated groins scanned. Two blinded observers separately assessed groins using a predefined list of possible MRI pathology and anatomic landmarks. Primary outcomes included interobserver agreement assessed by calculating kappa-coefficients. Secondary outcomes included frequency of MRI pathology in painful groins versus unoperated and pain-free groins. Interobserver agreement was poor, ranging from kappa = 0.24 to 0.55 ("fair" to "moderate") except for "contrast enhancement in groin" (kappa = 0.69, substantial). Pathologic changes in the form of "contrast enhancement in groin," "edema," and "spermatic cord caliber increased" were significantly more often seen in painful versus unoperated groins (p < 0.02). No significant difference was seen when painful and pain-free operated groins were compared (p < 0.05). No pathologic finding was specific or seen in all painful groins. Interobserver agreement is low and MRI-assessed pathology unspecific for persistent postherniotomy pain. Additional studies are required on interobserver agreement for pathology before MRI can be recommended as guidance and indication for surgical treatment of persistent postherniotomy pain.

Operation der beidseitigen Leistenhernie – Sequenziell oder simultan?

Surgery of inguinal hernia has changed dramatically with the introduction of tension-free hernia repair. There is still some controversy regarding the treatment of bilateral inguinal hernia, but simultaneous operation has gained popularity. The purpose of the present paper is to evaluate recent publications regarding treatment of bilateral inguinal hernia. For this article, the "Cochrane Database of Systematic Reviews", "BMJ Clinical Evidence", "Pubmed" and "Embase" were searched using the search terms "simultaneous", "bilateral", "inguinal" and "hernia". Number of patients, recurrence rate, complications, study type and authors' conclusions were evaluated. Analysis of the literature showed relevant results in two reviews of the "Cochrane Database", 4 items in "BMJ Clinical Evidence" and 17 clinical studies. No study showed a difference between recurrence and complication rate (simultaneous bilateral vs. unilateral repair). Recurrence rates were from 0.3 to 19 % (bilateral) and from 0.7 to 15 % (unilateral). Complications were defined heterogeneously and were in a range from 2.5 to 26.7 % (bilateral) and from 3 to 21 % (unilateral). All operative procedures (open suture: Shouldice; open mesh: Lichtenstein, Stoppa; laparoscopic techniques: TAPP / TEP) are adequate for the repair of bilateral hernia. The simultaneous operation of bilateral hernia is safe and effective. Postoperative pain and length of reconvalescence are comparable to those of the unilateral operation. Only symptomatic bilateral groin hernias should be operated. If no difficulties such as obesity and giant hernia are expected, bilateral hernias should be repaired simultaneously. The choice of the operative method should be made in accordance to the centre's standard procedure. A special operation for bilateral hernias is neither necessary nor justified.

Total extraperitoneal (TEP) mesh repair of inguinal hernia in the developing world: comparison of low-cost indigenous balloon dissection versus direct telescopic dissection: a prospective randomized controlled study

Creation of extraperitoneal space during TEP repair requires an expensive commercially available balloon. Fifty-six patients suffering from uncomplicated primary unilateral or bilateral groin hernia were randomized into two groups; group 1--indigenous balloon dissection and group 2--direct telescopic dissection. There were 55 males and 1 female, with an average age of 49 years; 50% of the inguinal hernias were bilateral. Creation of extraperitoneal space was considered as satisfactory in majority of patients (94.6%) with satisfactory anatomical delineation. Peritoneal breach was noticed during dissection in 36 (64.3%) patients. There was one (3.8%) conversion of TEP to TAPP in group 2. Distance between pubic symphysis to umbilicus was an important factor, which affected the easiness of dissection. In patients with this distance <or=14 cm lateral placement of ports was considered for easy use of graspers. The incidence of scrotal edema was significantly higher in group 2 as compared with group 1 (p < 0.01). Patients with indirect inguinal hernias in group 2 presented with a greater number of scrotal edema. Pain score on VAS at 6 h after surgery was significantly higher in group 2 (p < 0.021). Patients with age <65 years, bilateral hernias, and indirect hernias had a correlation with higher pain score at 6 h. Of the patients, 17.9% developed seroma in group 1 versus 64.3% in group 2 (p < 0.001). Anatomical delineation of inguinal area and dissection in the extraperitoneal space in TEP repair was equally satisfactory with both low-cost indigenous balloon (group 1) and telescopic dissection (group 2). Balloon dissection was associated with significantly reduced postoperative pain at 6 h, scrotal edema, and seroma formation. However at 3 months follow-up balloon dissection did not offer significant advantage over direct telescopic dissection in the overall long-term outcome of TEP repairs. If balloon dissection is considered useful for the beginner, low-cost indigenous balloon may be used to avoid higher cost of commercially available balloon dissector with added early advantages.

Volume of procedures and risk of recurrence after repair of groin hernia: national register study

Objective To determine whether the association between volume and outcome found in major surgery also holds true for a minor operation.Design Review of outcomes after hernia surgery in Sweden.Setting Surgical...

Marlex Mesh Prefix Plug Hernioplasty Retrospective Analysis of 865 Operations

For 5 years (January 1998 to November 2002) our department has applied the Marlex Mesh Perfix Plug hernioplasty. This article demonstrates the experience gained in operative and postoperative aspects, costs, and outcome along with the results of a follow-up analysis. Altogether, 801 patients (749 males, 52 females) were operated on Sixty-four males had bilateral groin hernias, so the total number of hernioplasties amounted to 865. A total of 19 hernias were recurrent, 297 were direct, 545 were indirect or scrotal (or both) 21 were femoral, and 2 were Spigelian. Fifty-three operations were performed on an emergency basis. Preoperative routine use of antibiotics was minimized throughout the years. Operating time fluctuated from 20 to 25 min (30-40 minutes for recurrent hernias), and the postoperative hospital stay was 28 hours (6-72) hours. The complication rate was 5% and the recurrence rate less than 1%. Early patient mobilization and return to everyday activities (1-2 weeks) was encouraged. The follow-up of 95% of the patient population lasted 12 to 60 months and was performed at 1 week, 1 month, 1 year, and yearly thereafter. The technique demonstrates less overall postoperative pain, discomfort, and complications combined with a remarkably low recurrence rate. The rapid rehabilitation with great patient comfort and decreased operating room time, resulting in lower financial costs, have led us nowadays to repair all types of inguinal hernias, femoral and recurrent ones, using this technique.

Simultaneous repair of bilateral groin hernias using local anaesthesia: a review of 199 cases with a five-year follow-up

There has been controversy concerning the simultaneous repair of bilateral groin hernias and the method of anaesthesia. A consecutive series of 199 bilateral inguinal hernias was repaired by the Lichtenstein non-tension mesh technique over a two-year period (1997-98). In 96% of them local anaesthesia was used. These were reviewed after five years. There were no increased recurrence or infection rates, with both between 0.5-1%. Pulmonary and urinary complications did not occur. The cost of this technique is substantially less than sequential or laparoscopic operations. The reasons advanced for sequential repair of bilateral hernias have been the lower risks of infection and recurrence. Neither of these fears is evident from this study. Furthermore, the use of local anaesthesia permits the operation to be done in a day care clinic. Simultaneous bilateral repair of inguinal hernias using local anaesthesia is as effective as sequential repair, at lower cost and with less total time off work.

Early Postoperative Evaluation of Groins After Laparoscopic Total Extraperitoneal Repair of Inguinal Hernias

Minimally invasive laparoscopic total extraperitoneal (LTEP) repair of bilateral and/or recurrent groin hernias has been popularized as one of the procedures of choice in the past decade. The early postoperative course is uneventful in most cases. A few patients, however, will develop temporary postoperative groin swelling. The aim of our study was to evaluate clinical and sonographic findings in the groin during the early postoperative period following LTEP. One hundred and five consecutive patients with primary bilateral (n = 90), recurrent unilateral (n = 12), and primary unilateral (n =3) groin hernias operated on during an 18-month period underwent clinical and sonographic examination two to three weeks after LTEP. On clinical examination, a localized groin swelling was found in 21 patients (20%). The most frequent sonographic findings were localized groin collections compatible with seroma or hematoma, found in 35 patients (33%). Hypoechoic diffuse tissue swelling around the mesh, lipomas, and residual hernias was found in four patients each (4%). None of the patients with hypoecoic mass had any clinical manifestations postoperatively. Extraperitoneal close suction drains were left for 8-12 hours in 46 patients. The average volume of fluid drained was 62 mL (range, 30-200 mL). There was no correlation between the use of suction drains and the frequency of fluid collections detected on sonography. Cord lipoma was detected postoperatively in four patients and was excised in one using an open anterior approach. Residual or recurrent hernia was detected postoperatively on sonography in four patients, but only one developed a symptomatic and clinically detectable hernia during eight months of follow-up. Overall, postoperative ultrasonographic findings following LTEP repair were found in 37% of patients. Clinical and sonographic findings such as localized fluid collections compatible with seroma or hematoma are common following LTEP. Postoperative suction drains did not reduce the frequency of sonographically detected collections. The clinical relevance of suspected postoperative hernia detected on sonography without clinical manifestations remains uncertain, and has to be determined on long-term follow-up.

Early Postoperative Evaluation of Groins After Laparoscopic Total Extraperitoneal Repair of Inguinal Hernias

Background: Minimally invasive laparoscopic total extraperitoneal (LTEP) repair of bilateral and/or recurrent groin hernias has been popularized as one of the procedures of choice in the past decade. The early postoperative course is uneventful in most cases. A few patients, however, will develop temporary postoperative groin swelling. The aim of our study was to evaluate clinical and sonographic findings in the groin during the early postoperative period following LTEP. Method: One hundred and five consecutive patients with primary bilateral (n = 90), recurrent unilateral (n = 12), and primary unilateral (n =3) groin hernias operated on during an 18-month period underwent clinical and sonographic examination two to three weeks after LTEP. Results: On clinical examination, a localized groin swelling was found in 21 patients (20%). The most frequent sonographic findings were localized groin collections compatible with seroma or hematoma, found in 35 patients (33%). Hypoechoic diffuse tissue swelling around the mesh, lipomas, and residual hernias was found in four patients each (4%). None of the patients with hypoecoic mass had any clinical manifestations postoperatively. Extraperitoneal close suction drains were left for 8–12 hours in 46 patients. The average volume of fluid drained was 62 mL (range, 30–200 mL). There was no correlation between the use of suction drains and the frequency of fluid collections detected on sonography. Cord lipoma was detected postoperatively in four patients and was excised in one using an open anterior approach. Residual or recurrent hernia was detected postoperatively on sonography in four patients, but only one developed a symptomatic and clinically detectable hernia during eight months of follow-up. Overall, postoperative ultrasonographic findings following LTEP repair were found in 37% of patients. Conclusion: Clinical and sonographic findings such as localized fluid collections compatible with seroma or hematoma are common following LTEP. Postoperative suction drains did not reduce the frequency of sonographically detected collections. The clinical relevance of suspected postoperative hernia detected on sonography without clinical manifestations remains uncertain, and has to be determined on long-term follow-up.

Anterior tension-free repair under local anesthesia of abdominal wall hernias in continuous ambulatory peritoneal dialysis patients.

A 10-year experience of abdominal wall hernia repair performed with anterior tension-free mesh or plug technique under local anesthesia in end-stage renal failure patients submitted to continuous ambulatory peritoneal dialysis (CAPD) is described in order to assess the safety and effectiveness of this approach. Between January 1993 and December 2002, 18 hernia repairs were performed under local anesthesia in 16 patients (14 males and two females) with a mean age of 70 years (48-78). One umbilical and three unilateral inguinal hernias were observed and repaired before starting peritoneal dialysis (PD), while two umbilical, eight unilateral, and two bilateral groin hernias developed and were then treated during PD. Repairs were performed electively in all but one case, which was an emergency operation for strangulation. An ipsilateral scrotal swelling was also present in two indirect unilateral inguinal hernias. In these cases, the hernia sac was ligated before entering, while in the others it was simply dissected and inverted. Patients were discharged the same day or the day after surgery. No local or general immediate or late complications occurred. CAPD in subjects operated on during PD treatment was resumed the same day of surgery. In no instance was hernia recurrence or leak of dialysis solution observed at follow-up examinations. The absence of surgical and general complications and the nearly immediate resumption of PD indicate the anterior tension-free repair under local anesthesia as a safe and effective technique for CAPD patients even in an ambulatory or day-surgery setting.

Outcome of repair of bilateral groin hernias: a prospective evaluation of 1,487 patients.

To find out whether simultaneous repair of bilateral hernias increases the risk of recurrence compared with unilateral repair. Prospective study. Swedish hospitals participating in the Swedish Hernia Register (SHR). Prospective collection of data from the SHR, 1992-1999 inclusive. The Cox proportional hazard test was used for calculating odds ratio (OR). Hernia repairs were followed up in a life table fashion until re-operation for recurrence or death of the patient. 33416 unilateral and 1487 bilateral operations on 2974 groin hernias were found. Direct hernias were more common in the bilateral than in the unilateral group, 1,825, 61% compared with 13,336, 40%, (p < 0.0001). A laparoscopic method was used for 1774 (60%) of bilateral and 3285 (10%) unilateral repairs, and 455 bilateral operations (31%) were done as day cases compared with 18376 (55%) unilateral ones (p < 0.0001 for both comparisons). The cumulative incidence of reoperation at three years for groin hernias after bilateral and unilateral repair was 4.1% (95% confidence interval 3.1% to 5.1%) and 3.4% (95% Cl 3.1% to 3.7%, respectively. After adjustment for other risk factors, the OR for reoperation for recurrence after bilateral repair was 1.2 (95% CI 0.9 to 1.5) with unilateral repair as reference. The OR for reoperation after laparoscopic bilateral repair compared with open bilateral repair was 0.9 (95% CI 0.6 to 1.4). Simultaneous repair of bilateral hernias does not increase the risk of reoperation for recurrence and there is no significant difference in the risk of reoperation after bilateral repair using open or laparoscopic techniques.

Radical Prostatectomy in Patients with Previous Groin Hernia Repair Using Synthetic Nonabsorbable Mesh

Objective: Identification of patients in whom the perineal route is the optimal approach to perform radical prostatectomy. Material and Methods: During 1992–1999, 376 patients with prostate cancer underwent radical perineal prostatectomy. Four patients were identified in whom the perineal approach was indicated because of previous bilateral groin hernia repair using synthetic meshes. In addition, 1 patient underwent perineal prostatectomy elsewhere for similar reasons. Results: The perineal approach offered an uneventful surgical solution for an adequate and straightforward radical perineal prostatectomy without complications and without biochemical recurrence during the follow-up. Conclusion: Radical perineal prostatectomy is suggested to be the optimal approach in patients with previous bilateral groin hernia repair using synthetic, nonabsorbable meshes.

Recurrences after prosthetic repair of inguinal hernias by the lichtenstein technique

We report a 3.4% incidence of hernial recurrence (all recurrences were reoperated) after inguinal hernia repair by the Lichtenstein technique: 14 reoperated recurrences (in 13 patients) in a series of 440 inguinal hernias (375 primary and 65 recurrent) in 379 patients (62 bilateral) over 5 years (1994–1998). Some 2/3 of all recurrences appeared within a year of surgery. Eleven of these patients were operated on for bilateral and/or recurrent groin hernia, and eleven also showed at least one risk factor for recurrence, such as obesity and other general diseases (specially pulmonary and hepatic). The incidence of recurrence was 0.7% (2 in 272) for primary unilateral hernia, 3.8% for primary bilateral hernia (2 in 52), 11.1% for recurrent unilateral hernia (5 in 45) and 40% for recurrent bilateral hernia (4 in 10). Recurrences were 5 indirect hernias, 4 direct hernias and 5 femoral hernias. Indirect recurrence was attributed to technical errors, but femoral and direct hernias seem to be the consequence of a poor indication for the Lichtenstein technique. Log-rank tests showed very significant statistical differences (p<0.01) in the risk of hernial recurrence between recurrent and primary hernias. We suggest that certain conditions should be contraindications for the standard Lichtenstein technique (bilateral groin hernia, recurrent hernia, obesity, chronic pulmonary and liver disease), and propose for these either a preperitoneal repair or some modifications of the Lichtenstein technique (an extremely floppy mesh and simultaneous femoral repair with the mesh).

Simultaneous mesh repair of bilateral groin hernia: A comparison of laparoscopic and open techniques

SummaryThe optimal management of bilateral groin hernia remains contentious. We report a prospective study of all patients undergoing simultaneous mesh repair of bilateral groin hernia during a 1 year period at a single institution. Cases managed by open surgery were compared with those undergoing laparoscopic repair; duration of hospital stay and complication rate were the main end-points. 51 patients were studied; 18 had open surgery and 33 had a laparoscopic procedure. The patients in the laparoscopic group had a shorter hospital stay (median saving of 2.5 nights). Postoperative complications (predominantly haematoma, infection and urinary retention) were more common in the open surgery group (p < 0.01). There were no recurrences over the study period. In summary, laparoscopic repair was associated with a shorter hospital stay and lower postoperative complication rate when compared with conventional open surgery. We would commend this procedure as the operation of choice for the management of bilateral groin hernia.

Preperitoneal bilateral inguinal herniorrhaphy

Background: Simultaneous repair of bilateral inguinal hernia remains controversial. Methods: Seventy-two consecutive patients underwent a preperitoneal prosthetic repair of bilateral groin hernia; 25 via laparoscopy. ASA classification, Nyhus type, hospitalization, convalescence time, and cost were examined. Mean follow-up was 36 and 12 months for the conventional and laparoscopic group respectively. Results: Sixty-nine patients were available for long-term follow-up. Average hospital stay, recurrence rate, perioperative urinary retention, transient thigh neuralgia, and return to normal activities were 48 hours, 5%, 9%, 6%, and 22 days as compared to 4 hours, 6%, 20%, 12%, and 9 days for the conventional and laparoscopic group respectively. The cost for laparoscopic repair was $500 greater. Conclusions: The preperitoneal approach to repair of bilateral hernias demonstrates an acceptable recurrence rate with low long-term morbidity. Experience with conventional preperitoneal technique greatly facilitates transition to laparoscopic repair.

Endocrine management of breast cancer

The first report that the ovaries influenced the development of the normal human female breast, is to be found in a case record from St Bartholomew's Hospital, London, dated 1775. The surgeon Percival (later Sir Percival) Pott had removed the normal ovaries of a twenty-three-year old girl during the repair of bilateral groin hernias, in which they had become entrapped. He reported that the patient had “enjoyed good health ever since” but that … “Her breasts, which were large, are gone, nor has she ever menstruated since the operation, which is now some years” (Pott 1775).

Bilateral Groin Hernia in a Female Infant: Case Report

Bilateral Groin Hernia in a Female Infant: Case Report