Groin Recurrence Research Articles

Achievements, Investigations in Gynecologic Oncology Explored

Achievements, Investigations in Gynecologic Oncology Explored

Invited Commentary

In this issue of The Annals, Wang and colleagues [1Wang Y. Wu B. Li J. Dong L. Wang C. Shu X. Impact of aortic insufficiency on ascending aortic dilatation and adverse aortic events after isolated aortic valve replacement in patients with a bicuspid aortic valve.Ann Thorac Surg. 2016; 101: 1707-1715Abstract Full Text Full Text PDF Scopus (36) Google Scholar] reported follow-up data of a large cohort of consecutively treated patients who underwent isolated aortic valve replacement (AVR) surgery for bicuspid aortic valve (BAV) disease. The authors should be congratulated for their efforts to determine the fate of proximal aortopathy in BAV patients stratified on the pattern of aortic valve dysfunction, namely, BAV–aortic stenosis versus BAV–aortic insufficiency (AI). Indeed, there is an emerging evidence of the coexistence of distinct clinical entities of BAV disease, namely, those presenting with predominant aortic valve stenosis (ie, BAV stenosis phenotype) and those presenting with predominant aortic insufficiency and dilation of the aortic root (ie, BAV root phenotype). Given the evident paucity of homogeneous phenotype-specific reporting of outcomes in BAV disease, the current report [1Wang Y. Wu B. Li J. Dong L. Wang C. Shu X. Impact of aortic insufficiency on ascending aortic dilatation and adverse aortic events after isolated aortic valve replacement in patients with a bicuspid aortic valve.Ann Thorac Surg. 2016; 101: 1707-1715Abstract Full Text Full Text PDF Scopus (36) Google Scholar] is of great clinical value and should be a good example for future BAV studies. The major focus of this paper is on a cohort of BAV patients presenting with aortic valve insufficiency and aortic root involvement (ie, root phenotype). Wang and colleagues [1Wang Y. Wu B. Li J. Dong L. Wang C. Shu X. Impact of aortic insufficiency on ascending aortic dilatation and adverse aortic events after isolated aortic valve replacement in patients with a bicuspid aortic valve.Ann Thorac Surg. 2016; 101: 1707-1715Abstract Full Text Full Text PDF Scopus (36) Google Scholar] found a significantly increased ascending aortic growth rate and higher prevalence of aortic events in BAV-AI patients, which is in line with our previous data [2Girdauskas E. Disha K. Rouman M. Espinoza A. Borger M.A. Kuntze T. Aortic events after isolated aortic valve replacement for bicuspid aortic valve root phenotype: echocardiographic follow-up study.Eur J Cardiothorac Surg. 2015; 48: e71-e76Crossref PubMed Scopus (41) Google Scholar, 3Girdauskas E. Rouman M. Disha K. et al.Aortic dissection after previous aortic valve replacement for bicuspid aortic valve disease.J Am Coll Cardiol. 2015; 66: 1409-1411Crossref PubMed Scopus (47) Google Scholar] and therefore indicate the genetic origin of BAV-AI associated aortopathy. In retrospect, these data show convincingly that the historically reported increased risk of aortic events in BAV disease is mainly due to the mixing of such root phenotype patients in the analyzed heterogeneous BAV cohorts. The congenital nature of aortopathy in root phenotype patients is further supported by common phenotypic features (ie, young male BAV patients) and involvement of adjacent cardiac structures—marked enlargement of aortoventricular junction, involvement of anterior mitral leaflet (ie, WAMBIRE complex [4Sievers H.H. Invited commentary.Ann Thorac Surg. 2009; 87: 82Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar]), defects/aneurysms of membranous interventricular septum, and coexistent coronary anomalies. Similar to other well-known connective tissue disorders, several noncardiac manifestations (eg, skeletal deformities, recurrent groin hernia, and cerebral arterial aneurysms) have been previously reported in BAV insufficiency cohorts. Prospective trials aiming to clarify the underlying gene expression and biomarker patterns in BAV root phenotype patients are under way, and their results are awaited eagerly. The proof of congenital background of BAV-AI associated aortopathy will undoubtedly change our current understanding of BAV disease complex and make this distinct entity to become a firm part in the novel BAV nomenclature. Impact of Aortic Insufficiency on Ascending Aortic Dilatation and Adverse Aortic Events After Isolated Aortic Valve Replacement in Patients With a Bicuspid Aortic ValveThe Annals of Thoracic SurgeryVol. 101Issue 5PreviewAberrant flow pattern and congenital fragility bestows bicuspid aortic valve (BAV) with a propensity toward ascending aorta dilatation, aneurysm, and dissection. Whether isolated aortic valve replacement (AVR) can prevent further dilatation in BAV ascending aorta and what indicates concurrent aortic intervention in the case of valve operation remain controversial. Full-Text PDF

Location of recurrent groin hernias at TEP after Lichtenstein repair: a study based on the Swedish Hernia Register.

To investigate which type of hernia that has the highest risk of a recurrence after a primary Lichtenstein repair. Male patients operated on with a Lichtenstein repair for a primary direct or indirect inguinal hernia and with a TEP for a later recurrence, with both operations recorded in the Swedish Hernia Register (SHR), were included in the study. The study period was 1994-2014. Under the study period, 130,037 male patients with a primary indirect or direct inguinal hernia were operated on with a Lichtenstein repair. A second operation in the SHR was registered in 2236 of these patients (reoperation rate 1.7%). TEP was the chosen operation in 737 in this latter cohort. The most likely location for a recurrence was the same as the primary location. If the recurrences change location from the primary place, we recognized that direct hernias had a RR of 1.51 to having a recurrent indirect hernia compared to having a direct recurrence after an indirect primary hernia repair. Recurrent hernias after Lichtenstein are more common on the same location as the primary one, compared to changing the location.

Should Groin Recurrence Still Be Considered as a Palliative Situation in Vulvar Cancer Patients?: A Brief Report.

To assess survival after groin recurrence in patients with vulvar cancer in the transition period of the implementation of the sentinel lymph node biopsy procedure. Recurrence of groin metastases in vulvar cancer patients is assumed to be lethal. It is unknown if early detection of relapse and multimodal treatment strategies improve the outcome of patients with groin recurrence. Multicenter retrospective cohort study of patients with recurrent vulvar cancer who presented with groin and/or pelvic lymph node metastases between 2000 and 2014 at 3 tertiary referral hospitals. Our primary outcome was to assess survival after groin recurrence of vulvar cancer and the influence of multimodal treatment. All analyses were done using Stata 12 (Stata Corporation, College Station, Tex). Hazard ratios (HRs) and their corresponding 95% confidence intervals were calculated using a Cox proportional hazards model. We identified 30 patients with a median time from diagnosis to groin recurrence of 10 months. The median follow-up of patients who were alive at the time of analysis was 22 months (range, 9-123 months). A Kaplan-Meier estimate showed an overall survival rate of 50% after 7 years. Patients with multimodal groin relapse treatment performed better than those with single-mode treatment (HR, 0.25; P = 0.037). Lymph node metastases at diagnosis were also associated with lower survival (HR, 6.11; P = 0.020). We observed a trend toward lower survival with a tumor size greater than T1 (HR, 2.55; P = 0.111). The time from diagnosis to groin recurrence had no influence on survival (HR, 0.99; P = 0.561). Close follow-up visits for at least 2 years are important to detect recurrent disease in groin and pelvic lymph nodes. Treatment of recurrent groin metastases should no longer be considered as a palliative situation--given that one half of the patients will have long-term survival after multimodal treatment strategies.

The Risk of Contralateral Non-sentinel Metastasis in Patients with Primary Vulvar Cancer and Unilaterally Positive Sentinel Node.

In patients with primary vulvar cancer and bilateral sentinel lymph node (SLN) biopsy, bilateral complete inguino-femoral lymphadenectomy (LAE) is recommended, even in cases with only unilaterally positive SLN by most guidelines. The risk of contralateral non-SLN metastasis is unclear. All patients with primary vulvar cancer receiving an SLN dissection with radioactive tracer±blue dye at the University Medical Center Hamburg-Eppendorf between 2001 and 2013 were retrospectively evaluated. Median follow-up was 33months. A total of 140 patients were included; 124 with bilateral and 16 with unilateral SLN dissection. A median number of two SLNs (range 1-7) per groin were dissected. Overall, 53 (53/140, 37.9%) patients received a complete inguino-femoral LAE, 41 of whom (77.4%) had previously presented with a positive SLN (33 unilaterally, 8 bilaterally). Of the 33 patients with unilaterally positive SLN, 28 (84.9%) underwent complete bilateral inguino-femoral LAE despite a contralateral negative SLN. Of these patients, none presented a contralateral non-SLN metastasis (0/28, 0%) in full dissection; however, one developed groin recurrence in the initially SLN-negative, fully dissected groin after 19months (1/28, 3.6%). In case of bilateral SLN biopsy for clinically node-negative disease and only unilaterally positive SLN, the risk for contralateral non-SLN metastases appears to be low. These data support the omission of contralateral LAE to reduce surgical morbidity.

Repeat sentinel lymph node procedure in patients with recurrent vulvar squamous cell carcinoma is feasible

ObjectiveStandard treatment of primary T1 squamous cell carcinoma (SCC) of the vulva <4cm consists of wide local excision (WLE) and sentinel lymph node (SLN) procedure of the groin(s). In case of a local recurrence WLE and inguino femoral lymphadenectomy (IFL) is generally recommended. In this study we assessed the feasibility of repeat SLN procedure in patients with recurrent vulvar SCC who were not able or willing to undergo IFL. MethodsA retrospective study was performed in consecutive patients with recurrent vulvar SCC who underwent a repeat SLN procedure between 2006 and 2014. We present the clinical and pathological outcomes. The study conforms to the STROBE guidelines. ResultsA total number of 27 patients aged 35–87years at first diagnosis of SCC of the vulva were identified. Median follow-up after 2nd surgery was 27.4 (range 2–96) months. In 78% of patients and in 84% of the groins the repeat SLN procedure was successful. No structured questionnaires were used to describe details on the repeat SLN procedures but in general the gynecologic oncologists experienced repeat SLN procedures more challenging compared to primary procedures. There were no groin recurrences documented. ConclusionsOur findings suggest that it is feasible to perform a repeat SLN procedure in recurrent vulvar SCC, but the procedure appears technically more challenging compared to primary setting, resulting in a lower SLN identification rate.

Groin Recurrences in Node Negative Vulvar Cancer Patients After Sole Sentinel Lymph Node Dissection.

This study aimed to evaluate the recurrence rates after sole sentinel dissection in vulvar cancer and describe characteristics of groin recurrences. All vulvar cancer cases between 2008 and 2014 were reviewed. Inclusion criteria were restricted to lymph node-negative patients, sole sentinel lymph node dissection (SLND), and tumor diameter less than 4 cm. In all patients, Tc-99m nanocolloid was used for preoperative SLN imaging. Regularly, planar lymphoscintigraphy and single-photon emission computed tomography with computed tomography were performed. Ultrastaging was routinely conducted on all negative lymph nodes. Of 140 vulvar cancer cases, 30 node-negative patients underwent sole SLND and met inclusion criteria. Keratinizing squamous cell carcinoma was determined in final histology in 20/30 (66.7%) patients and the mainly diagnosed tumor stage was pT1b (21/30, 70%). Three perioperative complications occurred. On average, 4.6 (1-9) SLNs were dissected per patient and 2.5 (1-6) per each groin, respectively. During a median follow-up of 43.5 (4-75) months, 5/30 (16.7%; 95% confidence interval, 7.3%-33.6%) local recurrences occurred. In addition, 2/30 (6.6%; 95% confidence interval, 1.9%-21.3%) groin recurrences were identified within a period of 12 months after the primary surgery. Both patients had large (>2 cm) midline tumors. Despite surgical as well as adjuvant treatment of the recurrent disease, both patients with groin recurrences died. Sentinel lymph node dissection is a safe and feasible alternative in early vulvar cancer. But false-negative sentinel carry a high risk of mostly fatal groin recurrences. Especially, midline tumors larger than 2 cm have to be treated with caution, because they are mostly found in cases with groin recurrences after sole SLND.

A prospective randomised controlled trial comparing chronic groin pain and quality of life in lightweight versus heavyweight polypropylene mesh in laparoscopic inguinal hernia repair.

BACKGROUND:The aim of our study was to compare chronic groin pain and quality of life (QOL) after laparoscopic lightweight (LW) and heavyweight (HW) mesh repair for groin hernia.MATERIALS AND METHODS:One hundred and forty adult patients with uncomplicated inguinal hernia were randomised into HW mesh group or LW mesh group. Return to activity, chronic groin pain and recurrence rates were assessed. Short form-36 v2 health survey was used for QOL analysis.RESULTS:One hundred and thirty-one completed follow-up of 3 months, 66 in HW mesh group and 65 in LW mesh group. Early post-operative convalescence was better in LW mesh group in terms of early return to walking (P = 0.01) and driving (P = 0.05). The incidence of early post-operative pain, chronic groin pain and QOL and recurrences were comparable.CONCLUSION:Outcomes following laparoscopic inguinal hernia repair using HW and LW mesh are comparable in the short-term as well as long-term.

Chronic groin pain, discomfort and physical disability after recurrent groin hernia repair: impact of anterior and posterior mesh repair.

Chronic pain and physical disability are well-known problems after primary groin hernia surgery, but the outcome after recurrent hernia surgery is much less known. To study the impact of anterior mesh repair (AMR) and posterior mesh repair (PMR) on chronic pain and disability after first recurrent groin hernia surgery in a population-based cohort derived from the Swedish Hernia Register. Consecutive unilateral, first and second recurrent hernia repairs, registered between 1998 and 2007, were included. Follow-up was performed in 2009 based on the Inguinal Pain Questionnaire (IPQ) and selective clinical examination, comparing prevalence of pain between AMR, endoscopic (E-PMR) and open posterior mesh repairs (O-PMR) after first recurrent repair. Chronic pain after a second recurrent repair was analysed. Altogether 671 first recurrent repairs were analysed: 329 AMRs, 161 E-PMRs and 181 O-PMRs. IPQ response rate was 70.6%. If the index repair was anterior, the E-PMR was associated with a lower risk of chronic pain and disability compared to AMR [OR 0.54 (CI 0.30-0.97), p = 0.039]. The risk of chronic pain increased after a second recurrent repair. A surgeon's annual volume >5 O-PMRs was related to a lower risk compared to ≤5 [OR 0.42 (CI 0.19-0.94), p = 0.034]. Endoscopic repair for first recurrent groin hernia surgery, after an index anterior repair, was associated with less chronic pain, discomfort and disability compared to anterior approach. Chronic pain increased after a second recurrent repair. A high surgeon's volume reduced the risk of chronic pain after open posterior mesh repair.

Laparoscopic Totally Extraperitoneal Groin Hernia Repair Using a Self-Gripping Mesh: Clinical Results of 235 Primary and Recurrent Groin Hernias.

Compared with open surgery, laparoscopic groin hernia repair has been shown to significantly reduce postoperative pain. However, chronic pain remains a problem with the laparoscopic approach, affecting approximately 10% of patients. The purpose of this study was to evaluate clinical outcomes following the use of Parietex ProGrip™ (Covidien, Dublin, Ireland) self-gripping mesh during laparoscopic totally extraperitoneal groin hernia repair. Data were collected prospectively from 145 male and 15 female patients with 235 inguinal hernias. All patients underwent repair by the laparoscopic totally extraperitoneal approach using Parietex ProGrip mesh. During follow-up ranging from 5 to 24 months, complications, pain score, patient satisfaction, and recurrence were analyzed. All patients were discharged on the day of surgery or the next morning. There were no immediate complications or returns to the operating room. Delayed postoperative complications included minor bruising to the genital region (3 cases), hematoma/seroma (1 case), and wound infection (1 case). The mean follow-up was 15 months, at which time there were no reports of hernia recurrence and 99% of patients were satisfied with their hernia repair. One patient (0.63%) reported severe pain (numeric rating scale score of >7), and 4 patients (2.5%) reported intermittent mild pain on exertion. The results of this study suggest that the use of a self-gripping mesh during the laparoscopic totally extraperitoneal approach is a promising and effective technique for repairing both primary and recurrent inguinal hernias.

Spontaneous rupture of incisional hernia–A rare entity

Background Spontaneous rupture of an abdominal hernia is very rare and usually occurs in incisional or recurrent groin hernia. It is a potentially fatal but preventable clinical condition demanding emergency surgery to prevent further obstruction, strangulation of bowel and to cover its contents to prevent fistulisation. It should be managed by primary repair if there is only minimal contamination, and by secondary repair if grossly contaminated.

The number of removed lymph nodes by inguinofemoral lymphadenectomy: impact on recurrence rates in patients with vulva carcinoma.

Inguinal lymph node (LN) metastasis is a crucial prognostic factor in vulva carcinoma. The aim of this study was to determine the prognostic value of the number of resected LNs in patients with vulvar carcinoma on recurrence rates. This retrospective study includes patients with vulvar squamous cell carcinoma who underwent inguinofemoral lymphadenectomy (IFL) between 1998 and 2011. Dissected groins were stratified by the number of removed lymph nodes (<6 LNs versus ≥6 LNs) or inguinal LN metastasis (pN- versus pN+) and analyzed according to groin, local and distance recurrence rates. In total 45 patients were identified and 79 groins were eligible for this analysis. 11 patients underwent ipsilateral IFL and 34 bilateral IFL. The median age was 58years (range 31-80). The median tumor size was 2cm (range 0.1-7.9). A median of 8 (range 0-19) LNs were resected per groin. Overall in 11 groins LN metastases were found. Groin recurrences occurred in four patients, local recurrence in six patients and distant metastasis in one patient. We did not observe any significant improvement in groin recurrence rates, local recurrence rates and distant recurrence rates if more than six LNs were removed per groin. Notably, patients with LN metastasis did not show higher recurrence rates compared to unaffected LNs. In this cohort we demonstrated that resection of more than six LNs per groin does not improve the recurrence rates in patients with carcinoma of the vulva. Further prospective studies with more individuals are needed to evaluate the role of resected LNs in vulvar carcinoma.

Groin surgery and risk of recurrence in lymph node positive patients with vulvar squamous cell carcinoma

ObjectivesTreatment of groin metastasis in vulvar squamous cell carcinoma (VSCC) patients consists of surgery, often combined with (chemo)radiotherapy, and is associated with significant morbidity. Our aim was to compare the risk of groin recurrence and morbidity in patients with lymph node positive VSCC after standard full inguinofemoral lymphadenectomy (IFL) versus less radical debulking of clinically involved lymph nodes or removal of sentinel nodes only followed by radiotherapy. MethodsA retrospective cohort study of 68 patients with primary VSCC and proven lymph node metastasis to the groin(s) was conducted. Patients were divided into three subgroups by type of initial groin surgery (84 groins): sentinel node (SN), IFL, and debulking of clinically involved nodes. Most patients (82%) received adjuvant radiotherapy. Overall survival was analyzed using time dependent cox regression. Analysis of morbidity and groin recurrence-free time was performed per groin with the generalized estimating equation model and Kaplan Meier method. ResultsThere was no significant difference in the risk of developing a groin recurrence (SN 25%, debulking 16%, IFL 13%, p=0.495). Despite the fact that more patients received radiotherapy after debulking (90% vs 67%), the complication rate was significantly lower (p=0.003) compared to IFL, especially regarding lymphocysts and lymphedema (p=0.032 and p=0.002 respectively). ConclusionsThe risk of groin recurrence was similar in all treatment groups. Debulking of clinically involved lymph nodes was related to a significant lower risk of complications compared to IFL. These findings support that the preferred treatment of patients with clinically involved lymph nodes is debulking followed by radiotherapy.

Sentinel nodes in vulvar cancer: Long-term follow-up of the GROningen INternational Study on Sentinel nodes in Vulvar cancer (GROINSS-V) I

ObjectiveIn 2008 GROINSS-V-I, the largest validation trial on the sentinel node (SN) procedure in vulvar cancer, showed that application of the SN-procedure in patients with early-stage vulvar cancer is safe. The current study aimed to evaluate long-term follow-up of these patients regarding recurrences and survival. MethodsFrom 2000 until 2006 GROINSS-V-I included 377 patients with unifocal squamous cell carcinoma of the vulva (T1,<4cm), who underwent the SN-procedure. Only in case of SN metastases an inguinofemoral lymphadenectomy was performed. For the present study follow-up was completed until March 2015. ResultsThe median follow-up was 105months (range 0–179). The overall local recurrence rate was 27.2% at 5years and 39.5% at 10years after primary treatment, while for SN-negative patients 24.6% and 36.4%, and for SN-positive patients 33.2% and 46.4% respectively (p=0.03). In 39/253 SN-negative patients (15.4%) an inguinofemoral lymphadenectomy was performed, because of a local recurrence. Isolated groin recurrence rate was 2.5% for SN-negative patients and 8.0% for SN-positive patients at 5years. Disease-specific 10-year survival was 91% for SN-negative patients compared to 65% for SN-positive patients (p<.0001). For all patients, 10-year disease-specific survival decreased from 90% for patients without to 69% for patients with a local recurrence (p<.0001). ConclusionsSurvival is very good for patients with a negative SN, but still 36% of these patients, as well as 46% of the patients with a positive SN, will have a local recurrence. Although a local recurrence is treated with curative intent, the disease-specific survival of these patients decreases significantly.

Biologic mesh versus synthetic mesh in open inguinal hernia repair: system review and meta-analysis.

Biologic meshes are mostly used for abdominal wall reinforcement in infected fields, but no consensus has been reached on its use for inguinal hernia repairing. The purpose of this study was to compare biologic mesh with synthetic mesh in open inguinal herniorrhaphy. A systematic literature review and meta-analysis was undertaken to identify studies comparing the outcomes of biologic mesh and synthetic mesh in open inguinal hernia repair. Published studies were identified by the databases PubMed, EMBASE and the Cochrane Library. A total of 382 patients in five randomized controlled trials were reviewed (179 patients in biologic mesh group; 203 patients in synthetic mesh group). The two groups did not significantly differ in chronic groin pain (P = 0.06) or recurrence (P = 0.38). The incidence of seroma trended higher in biologic mesh group (P = 0.03). Operating time was significantly longer with biologic mesh (P = 0.03). There was no significant difference in hematomas (P = 0.23) between the two groups. From the data of this study, biologic mesh had no superiority to synthetic mesh in open inguinal hernia repair with similar recurrence rates and incidence of chronic groin pain, but higher rate of seroma and longer operating time. However, this mesh still needs to be assessed in a large, multicentre, well-designed randomized controlled trial.

Indications and risk factors for midurethral sling revision.

To determine the indications and risk factors for needing midurethral sling revision in a cohort of women undergoing midurethral sling placement. This was a case-control study of all women undergoing midurethral sling placement for stress urinary incontinence (SUI) between January 2003 and December 2013. Cases were patients who underwent midurethral sling placement followed by sling revision (incision, partial or complete excision). Controls were patients who underwent sling placement only. Once all subjects had been identified, the electronic medical record was queried for demographic and perioperative and postoperative data. Of 3,307 women who underwent sling placement, 89 (2.7%, 95% CI 1.9 - 3.4) underwent sling revision for one or more of the following indications: urinary retention (43.8%), voiding dysfunction (42.7%), recurrent urinary tract infection (20.2%), mesh erosion (21.3%), vaginal pain/dyspareunia (7.9%), and groin pain (3.4%). The median time from the index to the revision surgery was 7.8 months (2.3 - 17.9 months), but was significantly shorter in patients with urinary retention. The type of sling placed (retropubic or transobturator) was not associated with indication for revision. Patients who underwent revision surgery were more likely to have had previous SUI surgery (adjusted odds ratio 4.4, 95% CI 1.7 - 6.5) and to have undergone concomitant vaginal apical suspension (adjusted odds ratio 2.4, 95% CI 1.4 - 4.5). The rate of sling revision after midurethral sling placement was 2.7%. Urinary retention and voiding dysfunction were the most common indications. Patients with a history of previous SUI surgery and concomitant apical suspension at the time of sling placement may be at higher risk of requiring revision surgery.

Management of chronic recurrent osteitis pubis/pubic bone stress in a Premier League footballer: Evaluating the evidence base and application of a nine-point management strategy

Background/AimThe aim of this paper was to use a clinical example to describe a treatment strategy for the management of recurrent chronic groin pain and evaluate the evidence of the interventions. MethodsA professional footballer presented with chronic recurrent OP/PBS. The injury was managed successfully with a nine-point programme –1. Acute pharmacological management.2. Tone reduction of over-active structures.3. Improved ROM at hips, pelvis and thorax.4. Adductor strength.5. Functional movement assessment.6. Core stability.7. Lumbo-pelvic control.8. Gym-based strengthening.9. Field-based conditioning/rehabilitation.The evidence for these interventions is reviewed. ResultsThe player returned to full training and match play within 41 and 50 days, respectively, and experienced no recurrence of his symptoms in follow up at 13 months. ConclusionThis case report displays a nine-point conservative management strategy for OP/PBS, with non-time dependent clinical objective markers as the progression criteria in a Premier League football player.

Laparoscopic Versus Open Preperitoneal Mesh Repair of Inguinal Hernia: an Integrated Systematic Review and Meta-analysis of Published Randomized Controlled Trials.

The objective of this article is to systematically analyse the randomized, controlled trials comparing open (OPPR) versus laparoscopic (LPPR) preperitoneal mesh repair of inguinal hernia. Randomized, controlled trials comparing OPPR versus LPPR of inguinal hernia were analysed systematically using RevMan®, and combined outcomes were expressed as odds ratio (OR) and standardized mean difference (SMD). Ten randomized trials evaluating 1286 patients were retrieved from the electronic databases. There were 606 patients in the OPPR repair group and 680 patients in the LPPR group. There was significant heterogeneity among trials (p < 0.0001). Therefore, in the random effects model, LPPR was associated with longer operative time and relatively lesser postoperative pain in the case of the trans-abdominal preperitoneal approach. Statistically, both OPPR and LPPR were equivalent in terms of developing chronic groin pain, recurrence and postoperative complications. OPPR of inguinal hernia is associated with shorter operative time and comparable with LPPR (both total extraperitoneal and trans-abdominal preperitoneal approaches) in terms of risk of chronic groin pain, recurrence and complications.

The impact of type of mesh repair on 2nd recurrence after recurrent groin hernia surgery.

According to the Swedish Hernia Register (SHR), the reoperation rate is more than doubled after recurrent groin hernia repair compared with primary repair. The aim was to study the impact of type of mesh repair used in recurrent groin hernia surgery on a 2nd recurrence in a population-based cohort derived from the SHR. All 1st recurrent hernia repairs in the south-west region of Sweden, registered in SHR between 1998 up to 2007 were included. A questionnaire was sent in 2009. Patients stating a new lump or persisting problems were examined. A 2nd recurrence was identified as a 2nd reoperation or at physical examination. The incidence was analysed comparing anterior mesh repair (AMR) and posterior mesh repairs (PMR) (endoscopic and open). Eight hundred and fifteen recurrent operations in 767 patents were analysed, 401 AMRs and 414 PMRs. PMR had a lower 2nd recurrence rate compared with AMR (5.6 vs. 11.0 %) (p = 0.025). An increased risk [3.21 (CI 1.33-7.44) (p = 0.009)] of a subsequent 2nd recurrence was seen after anterior index repair followed by AMR and a decreased risk [0.08 (CI 0.01-0.94) (p = 0.045)] after posterior index repair followed by AMR. PMR in recurrent groin hernia surgery was associated with a lower 2nd recurrence rate compared to anterior. A posterior approach for 1st recurrent operation is recommended after an anterior index repair and an anterior approach after a posterior index operation.

An Experience of Short-Term Results of Laparoscopic Inguinal Hernioplasty Using 3D Mesh in a Developing Country

Background: The experience of short term results of laparoscopic inguinal hernia repair using 3D mesh in a developing country is reviewed. Methods: From January 2012 to February 2014, 53 patients underwent laparoscopic inguinal hernioplasty. A retrospective case series of 53 consecutive patients undergoing TEP/TAPP by a single surgical team was followed prospectively with a focused physical examination and interview. 4 out of 53 patients had recurrent hernia following open repairs and 49 had primary hernias. Data collected included operative time, intraoperative bleeding, intraoperative difficulties, immediate postoperative pain, chronic groin pain, recurrence, sensory disturbance, activity or occupational limitation and personal satisfaction. Results: All the patients were male aged 32 to 75 years with a mean age of 53.5 years. Mean operative time was 37.4 minutes; intraoperative dissection, blood loss were less; and immediate postoperative pain was negligible as assessed by VAS. There was no mortality or major morbidity. Mean follow-up was 12 months (2 to 18 months). Follow-up was completed by interview and physical examination. Hernia was not found to recur during the follow up period. Chronic pain occurred in 2 patients (3.7%), which was mild in nature. Ninety-seven percent of patients were satisfied with their repair and would or had recommended TEP/TAPP to others using 3D Mesh. Conclusions: Short-term results of TEP/TAPP hernia repair using 3D mesh demonstrated to be an effective and safe procedure with low prevalence of chronic pain that is generally of a mild, infrequent nature. It was also concurred that there is decrease in operative time. Manipulation of mesh was significantly reduced. Intraoperative bleeding and use of post operative analgesia was reduced considerably. There was no recurrence, however the cost of the mesh increased the overall cost of the procedure acting as a limiting factor in a developing country.