Groin Repair Research Articles

Use of HugoTM RAS in General Surgery: The First 70 Cases at a German Centre and a Systematic Review of the Literature.

Introduction: The versatile open modular design of the newly introduced robotic platform HugoTM RAS is expected to allow its rapid spread in general surgery. However, the system is not yet approved for use in oesophageal and HPB-surgery and is not licensed worldwide. The aim of this work was to review the current spectrum of general surgical procedures that may be feasibly and safely performed with Hugo. Methods: We retrospectively reviewed our own series and performed a systematic review of all the published reports of general surgical procedures performed with this system in the literature. Results: Seventy patients underwent general surgery with Hugo at our institution, and another 99 patients were reported in the literature. The most common procedures were colorectal (n = 55); cholecystectomy (n = 44); repair of groin, ventral and hiatal hernias (n = 34); upper GI (n = 28); adrenalectomy (n = 6); and spleen cyst deroofing (n = 2). No device-related complications were reported. Arm collisions and technical problems were rare. The docking and console times improved in all series. The port positions and robotic arm configurations varied among authors and depended on the surgical indication, patient characteristics and surgeon's preference. Conclusions: A wide spectrum of general surgical procedures has been safely and effectively performed with the Hugo RAS, even by robotically inexperienced teams with a limited choice of instruments. Technical improvements to the system and the introduction of robotic energy devices may help Hugo evolve to a vital alternative to established robotic systems.

Laparoscopic modified e-tep repair of concomitant inguinal and ventral hernias.

Laparoscopic hernia repair in recent times has gained the most acceptance among both the surgical community and the patient groups, as it has proven benefits of lesser postoperative hospital stay and less pain scores. The incidence of both inguinal and ventral hernias has increased significantly in the present days. Various methods have been postulated by different surgical groups for repairing the same but no there is no standard consensus on managing concomitant inguinal and ventral hernias. The conventional e-TEP requires an extensive dissection with increased operative time. We present our experience in managing cases with both inguinal and primary M2/M3 and W1 ventral hernias with or without divarication of recti using a modified up to down approach for inguinal hernia followed by down to up approach for the ventral hernia, from a tertiary care center in South India. We managed 16 cases with simultaneous incidence of inguinal and primary M2/M3 and W1 ventral hernias with or without divarication of recti between January 2022 and November 2023. Institute ethical committee clearance and informed consent was obtained from all the 16 patients. They were all subjected to an extra peritoneal repair of both the hernias. All the demographic data, intraoperative data, postoperative complications and follow up were digitally stored. All patients were followed up for six months after surgery. Out of 16 patients, 15 were males and 1 was female. The mean age was 48years and the mean BMI of all the patients was 29.2kg/m2. The postoperative recovery was smooth in all patients and being discharged within 24h after surgery. The pain scores of all patients were significantly lower than patients who underwent intraperitoneal repair. e-TEP hernia repair is gaining popularity and has amused the hernia surgical community. Our method of e-TEP RS repair in cases with concomitant inguinal and primary M2/M3 W1 ventral hernias with or without divarication helps in addressing both the hernias in the extra-peritoneal space. Our technique reduces the area of dissection needed for mesh placement and preserves the integrity of abdominal musculature in the upper abdomen when compared with the conventional technique. It further allows extension of the e-TEP inguinal space into the Rectro rectus space without much alteration in the port arrangement allowing simultaneous repair of groin and umbilical hernias. Good knowledge of anatomy and laparoscopic skills are pertinent for safe and effective hernia repair by this technique.

Evaluation, Diagnosis and Management of Persisting Pain Post Sportsman’s Groin Repair

Evaluation, Diagnosis and Management of Persisting Pain Post Sportsman’s Groin Repair

Ergonomic Laparoscopic Surgical Repair of three large external herniae through just three optimally placed working ports – A Case report with Review of Literature

Currently, hernia repair is the most frequent procedure performed by general surgeons. Like many other abdominal operations, the laparoscopy revolution has influenced the surgical repair of external herniae as well. Laparoscopic repair of groin and ventral hernia have become more and more popular over the years. Ventral herniae are mostly repaired trans-peritoneally while groin herniae can be repaired both trans- as well as extra-peritoneally. Herein, we describe the case of a 60-year old man who presented to us with large umbilical and large bilateral inguinal herniae. All the three large external herniae were repaired laparoscopically, through just 3 carefully selected trocar sites. The purpose of this paper is to highlight the importance of ergonomics in optimum laparoscopic trocar placement, so as to achieve maximum results with minimum number of port sites.

Risk of Reoperation for Recurrence After Elective Primary Groin and Ventral Hernia Repair by Supervised Residents

Surgical training involves letting residents operate under supervision. Since hernia repair is a common procedure worldwide, it is a frequent part of the surgical curriculum. To assess the risk of reoperation for recurrence after elective primary groin and ventral hernia repair performed by supervised residents compared with that by specialists. This nationwide register-based cohort study included data from January 2016 to September 2021. Patients were followed up until reoperation, emigration, death, or the end of the study period. The study used data from the Danish Inguinal and Ventral Hernia Databases linked with data from the Danish Patient Safety Authority's Online Register via surgeons' unique authorization ID. The cohort included patients aged 18 years or older who underwent primary elective hernia repairs performed by supervised residents or specialists for inguinal, femoral, epigastric, or umbilical hernias. Hernia repairs were divided into the following 4 groups: Lichtenstein groin, laparoscopic transabdominal preperitoneal (TAPP) groin, open ventral, and laparoscopic ventral. Hernia repairs performed by supervised residents vs specialists. Reoperation for recurrence, analyzed separately for all 4 groups. A total of 868 specialists and residents who performed 31 683 primary groin and 7777 primary ventral hernia repairs were included in this study. The median age of patients who underwent hernia repair was 60 years (IQR, 48-70 years), and 33 424 patients (84.7%) were male. There was no significant difference in the adjusted risk of reoperation after Lichtenstein groin hernia repair (hazard ratio [HR], 1.26; 95% CI, 0.99-1.59), laparoscopic groin hernia repair (HR, 1.01; 95% CI, 0.73-1.40), open ventral hernia repair (HR, 0.89; 95% CI, 0.61-1.29), and laparoscopic ventral hernia repair (HR, 2.96; 95% CI, 0.99-8.84) performed by supervised residents compared with those by specialists. There was, however, a slightly increased unadjusted, cumulative reoperation rate after Lichtenstein repairs performed by supervised residents compared with those by specialists (4.8% vs 4.2%; P = .048). The findings of this study suggest that neither open nor laparoscopic repair of groin and ventral hernias performed by supervised residents appeared to be associated with a higher risk of reoperation for recurrence compared with the operations performed by specialists. This indicates that residents may safely perform elective hernia repair when supervised as part of their training curriculum.

13 Risk Documentation in Consent Form of Open Inguinal Hernia Repair

Abstract Introduction Inguinal hernia repair is amongst the most commonly performed general surgical operations. The high case load of groin repair in our hospital has the potential to have high risk of medical legal complications. The importance of discussing these potential complications with patients, allowing them to make informed decisions about their care, and clearly documenting them during the consent process, is clear. Aim We aimed to assess the quality and consistency of consent forms for open inguinal hernia repairs with emphasis on the risks being documented. Objectives Measure the compliance of Trust consent forms with (RCS) and British Hernia Society (BHS) 2016 guidelines and European Hernia Society (EHS) International guidelines for Groin Hernia Management (2019). Method Retrospective consent form analysis was carried out for all (38) open inguinal hernia repairs done during July-September 2020. The documentation of 13 pre-determined risks, was analysed, some specific to open inguinal hernia repairs, others general surgical complications. Results A total of 38 Trust consent forms were audited. Infection (100%) and bleeding (95%) were the most commonly documented risks. The documentation of chronic infection/abscess formation (5%), numbness (60%), testicular atrophy (31%) and scarring (34%) all increased compared to the two previous audit phases, the latter two significantly so. Unfortunately, many of the risks audited (8/13) showed a decrease in compliance with documentation with only two of the examined risks meeting the standard or ‘partially’ meeting it. Notably, recurrence and damage to other structures documentation dropped by over 10% (17% drop and 31% drop, respectively).

Arthroscopic Correction of Femoroacetabular Impingement for Concomitant Inguinal Disruption in Athletes With Dual Pathology

Background: Inguinal disruption and femoroacetabular impingement (FAI) are well-recognized sources of groin pain in athletes; however, the relationship between inguinal disruption and FAI remains unclear. In cases of dual pathology, where both entities coexist, there is no definitive consensus regarding which pathology should be prioritized for treatment in the first instance. Purpose: (1) To examine the 2-year effectiveness and clinical outcome in athletes presenting with dual pathology in which the FAI component alone was treated with arthroscopic deformity correction. (2) To compare 2-year patient-reported outcome measures between athletes undergoing only hip arthroscopy (HA) and athletes undergoing groin repair and HA. Study Design: Cohort study; Level of evidence, 3. Methods: All patients undergoing HA for the treatment of FAI with concomitant clinical signs of inguinal disruption at initial consultation were between 2010 and 2016 were included in this study. Inclusion criteria were male sex, age <40 years, and involvement in competitive sporting activity. Athletes with previous HA on the symptomatic side, Tönnis grade >1, or lateral center-edge angle <25° were excluded. Revision HA or subsequent groin surgery was documented. Outcome evaluation consisted of validated patient-reported outcome measures (modified Harris Hip Score; University of California, Los Angeles Activity Scale; 36-Item Short Form Health Survey; Western Ontario and McMaster Universities Osteoarthritis Index) completed preoperatively and a minimum 2 years postoperatively. The minimal clinically important difference was assessed by using a distribution-based technique (SD, 0.5) and an anchor-based technique (percentage of possible improvement). Level of satisfaction and return to play were assessed. Results: A total of 113 cases of dual pathology were included in 91 patients with a mean ± SD age of 26.3 ± 5.1 years. The index surgical procedure was HA for 104 cases (92%) and groin repair for 9 (8%). For patients undergoing HA as the index procedure, 98.1% (102/104 cases) were successfully followed up to establish survivorship. In 89.2% (91/102 cases), no additional groin surgery was required. In 11 cases (10.8%), additional groin surgery was required for persisting inguinal-related groin pain. At 2 years after the operation, there was no difference for any patient-reported outcome measure (P > .099), improvement from baseline (P > .070), or proportion of cases achieving the minimal clinically important difference (P > .120) between the HA-only group and the group undergoing HA and groin repair at any stage. There was also no difference between groups in terms of return-to-play rate (P = .509) or levels of satisfaction (pain, P = .204; performance, P = .345). Conclusion: In patients with dual pathology, treatment of the FAI component alone using arthroscopic hip surgery results in a successful outcome without need for groin repair in 89.2% of cases. No statistical difference in clinical outcome 2 years after surgery was observed between athletes undergoing 1 procedure (HA alone) and those undergoing 2 procedures (HA and groin repair at any stage).

Management of hernial orifices in robotic inguinal hernia repair

The development of a postoperative seroma after endoscopic transabdominal (TAPP) or extraperitoneal (TEP) groin repair is a frequent problem. Although seromas are usually only mildly symptomatic, the swelling that develops postoperatively often causes patients to feel insecure and worried. In the literature some technical approaches to reduce the incidence of postoperative seroma are described. This technical note deals with the authors’ approach in the management of large medial and lateral hernial orifices during robotic r-TAPP procedures using DaVinci Xi technology with the aim of seroma prophylaxis.

One-stop routing for surgical interventions: a cost-analysis of endoscopic groin repair.

Single-visit (SV) totally extraperitoneal (TEP) inguinal hernia repair is an efficient service without impairment of safety or complication rate. Data on the economic impact of this approach are rare. The aim of this study was to compare the costs between the SV TEP and the regular TEP in an employed healthy population from a hospital and societal point of view. Retrospectively collected hospital costs and prospectively collected societal costs were obtained from patients treated between July 2016 and January 2018. Outcome measures consisted of all documented institutional care, productivity loss and medical consumption. For analysing the hospital costs, a total of 116 SV patients were matched to 116 regular patients. The hospital costs of a mean SV patient were €1148.78 compared to €1242.84 for a regular patient, with a mean difference of €94.06. Prospective analyses of 50 SV patients and 50 regular patients demonstrated higher societal costs for a mean regular patient (€2188.33) compared to a mean SV patient (€1621.44). The mean total cost difference between a SV TEP repair and a regular TEP repair equalled €660.95 corresponding to a 19.3% decrease in costs. This comprehensive cost-analysis showed that in an employed, healthy population, the SV TEP repair outprices the regular TEP repair, with savings of €660.95 per patient, reflecting a 19.3% decrease in costs. This routing is mainly interesting from a societal point of view as the difference is mainly impacted by a decrease in societal costs.

Outcome of the "Manchester Groin Repair" (Laparoscopic Totally Extraperitoneal Approach With Fibrin Sealant Mesh Fixation) in 434 Consecutive Inguinal Hernia Repairs.

Introduction: This study looks at the outcome of 352 patients that underwent the “Manchester groin repair” in the period from 2007 to 2016. The effect of laterality on chronic groin pain and the reduction of pain scores post-surgery are evaluated as well as the rate of hernia recurrence for the inguinal hernia repairs.Methods: The “Manchester groin repair” is a modification of a laparoscopic totally extra-peritoneal approach with fibrin sealant mesh fixation. Data were collected prospectively. In addition to demographic data and the European Hernia Society classification grading of each hernia, pain scores were assessed prior to surgery and at 4–6 weeks post-operatively using a ten-point visual analog pain scale. Data were collected on a bespoke database and differences between time-points analyzed by non-parametric Wilcoxon signed rank tests with Kruskal-Wallis rank sum test for three-group comparisons. Significance was at the P < 0.05 level. The study was undertaken as an institutional audit.Results: Three hundred and fifty two patients underwent TEP repair as per the “Manchester Groin Repair” modification during the period of interest with a median follow-up period of 109.5 (IQR 57.0–318.5) weeks. Of these 274 (77.8%) were for the repair of true hernias and 78 (22.2%) were for inguinal disruptions.All inguinal hernia repairs patients were evaluated (254 m, 20 f); median [interquartile range] age 50 (39–65) years. There were 75 right inguinal hernias (27.4%), 39 Left inguinal hernias (14.2%), and 160 bilateral inguinal hernias (58.4%), giving a total of 434 hernia repairs. During follow-up there were 6 recurrences (1.4%).Of the 274 patients evaluated, 145 (52.9%) had both pre and post-operative pain scores available. Median pre-operative pain score was 5 [IQR 4–7]. Median post-operative pain score was 1 [IQR 1–2]. This difference was significant (P < 0.001). Pre-operative pain scores were higher for those with a bilateral hernia (median 6 vs. 5 and 4, respectively; P = 0.005), but there was no difference in post-operative scores (P = 0.347). One patient (0.3%) presented with chronic groin pain (pain after 3 months).Conclusion: This study demonstrates that the “Manchester groin repair” provides an excellent repair with a low rate of recurrence and low incidence of chronic pain. Longer-term evaluation and larger patient series will add to the understanding of the role of this procedure in groin hernia repair.

Delayed discharge in day-case inguinal hernia and groin repair

Delayed discharge in day-case inguinal hernia and groin 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.

An investigation on the mechanism of contralateral manifestations after unilateral herniorrhaphy in children based on laparoscopic evaluation

Background/Purpose No straightforward theoretical descriptions explaining the discrepant incidences of metachronous contralateral hernia and positive contralateral patent processus vaginalis (cPPV) exist. The indications for contralateral groin repair are still not clearly defined. Methods During laparoscopic herniorrhaphy, the intraoperative appearances of the internal inguinal rings (IIRs) were characterized and classified in 211 children with symptomatic unilateral inguinal hernias. A total of 125 boys and 86 girls with 130 right-sided and 81 left-sided indirect inguinal hernias were examined. The morphological appearances of the IIRs in patients with cPPV were compared before and after the ligation of the symptomatic IIRs. Results Of 211 children, 108 (51%) had positive cPPV findings. The cPPVs had significantly smaller orifices and shorter lengths than those on the side of the symptomatic hernia. Among these children, 24 (22%) patients exhibited morphological changes in their cPPVs, characterized by an upward movement of the overlying peritoneal veil after the closure of the symptomatic hernia. Conclusion Metachronous contralateral hernia might occur because of morphological changes to the cPPV resulting from closure of the symptomatic IIRs. The predicted incidence of contralateral hernia in this series was 11.2%.

Longterm Results of a Prospective Study of 225 Femoral Hernia Repairs: Indications for Tissue and Mesh Repair

Femoral hernias are uncommon, and there are relatively few clinical studies of longterm outcomes after repair. Although the McVay repair has been classically described, the infrainguinal plug technique has gained popularity in recent years. Evidence supporting these repairs is sparse. A prospective study of elective femoral hernia repairs was done at the Shouldice Hospital from June 1999 until June 2003. The tissue-based complete groin repair (CGR) and a preperitoneal mesh repair were performed for specific indications. Patients were followed annually for 5 years to examine for recurrences and complications. Two hundred fifty-six patients were enrolled, with 225 completing 5 years of followup. Median age was 55 years, and hernias on the right side were more common (63.1%). Concurrent inguinal hernias were found in 115 patients (51%), and 41 (18.2%) had a previous inguinal hernia repair. A complete groin repair was performed in 120 patients and a preperitoneal mesh repair in 78. The remaining had an infrainguinal mesh repair. The overall recurrence rate was 3.1%, with a median time to recurrence of 12 months. There was no significant difference between mesh and suture repairs. Chronic postoperative pain was experienced by 20 patients (8.9%). Femoral hernias can be repaired electively with a tissue-based or a preperitoneal mesh technique, with durable longterm results. Mesh repair is indicated for recurrent femoral hernias, inguinofemoral hernias, prevascular hernias, association with concurrent direct hernias, and, if tension is anticipated, with complete groin repair. Infrainguinal mesh repair is used only when there has been a successful previous inguinal hernia repair.

Experimental comparison of type of Tissucol dilution and composite mesh (Parietex) for laparoscopic repair of groin and abdominal hernia: observational study conducted in a university laboratory

The primary objective of this observational study was to determine the best possible dilution of fibrin glue (Tissucol) to employ for prosthesis fixing in laparoscopic treatment of abdominal wall defects and, secondly, to assess its feasibility and safety. This study was carried out in a university experimental animal laboratory in accordance with all international laws, ethics regulations and quality criteria associated with animal experiments. The tests were carried out on two pigs, using four samples of mesh (Parietex). All meshes were fixed using two different Tissucol dilutions (standard with distilled water and that with calcium chloride). Follow-up evaluations were at 15 days after 30 days, with the latter consisting of traction tests and a biopsy for histological analysis. No post-operative complications were observed. The collagen-coated polyester meshes showed 0% adhesions, and reperitonealization had ensued after 15 days. We saw no shrinkage or migration of any of the meshes. Histopathological analyses confirmed a greater stability, greater tissue integration and the largest number of fibroblasts in meshes fixed with a 1/10 Tissucol dilution without calcium chloride. This observational study using animals showed that the 1/10 standard dilution - not that with calcium chloride - provided the best fixation and integration and prevented the formation of intraperitoneal adhesions, provided a hydrophilic collagen film-covered mesh was used.

Coskun repair of inguinal hernia: is it really new?

We read with interest, the recent prospective study by Coskun et al. [1] describing a method of open inguinal hernia repair using endogenous tissues and a comparison with anterior (Lichtenstein) and preperitoneal mesh repairs. Dr. Coskun discussed placation of the transversalis fascia with a single row of sutures followed by a second layer of sutures between the inguinal ligament and the conjoint tendon, a technique that has been dismissed as ‘‘corrupted Bassini’’. The series’ cumulative recurrence rate was 1.6% and did not affect the endogenous repair patients which had a median follow-up of 36 months. Dr.Coskun and his colleagues concluded that the method was as effective as mesh repair [1], despite level A evidence demonstrating superiority of mesh repair over Shouldice repair (the best of non-mesh repairs) [2–4]. Fifty percent of inguinal hernia recurrences first appear 5 years after surgery [5]; many patients are lost of follow-up including those who seek care from other surgeons when their hernias recur. A 10-year follow-up is considered a truly reliable measure of a repair’s durability [5]. The follow-up in Dr. Coskun’s series is too short to allow any firm conclusions about the ultimate durability of the repair described. The telephone interviews used for those who did not attend the clinic must be considered as not very reliable [6, 7] because recurrences are best diagnosed by physical examination [5]. Coskun et al. claim superiority of their endogenous repair over mesh techniques but do not discuss disorders of collagen metabolism in patients with hernia, a lifelong risk factor. Morphologic and molecular investigations in hernia patients underscore the significance of impaired wound healing, suggesting that the use of prosthetic mesh can influence hernia recurrence [8]. Coskun notes no other technique utilizing a two-layer repair consisting of plication of the transversalis fascia with a first row of sutures followed by approximation of the conjoint tendon and the inguinal ligament [1]. We are aware of two published repair methods that are very similar to the one used by Dr.Coskun: (1) the wellknown Ponka approach includes closure of the transversalis fascia followed by approximation of the transverses abdominis arch medially and the iliopubic tract and inguinal ligament laterally [9]. (2) the Gilmore groin repair which is typically used to repair the so-called ‘‘sportsman’s hernia’’ consists of a layer of interrupted sutures in the transversalis fascia, and a second suture line between the conjoint tendon and the inguinal ligament [10]. These publications suggest that the repair principles proposed by Dr. Coskun are not new. The length and method of follow-up in the series of Coskun et al. [1] do not support the conclusion that the two-layer endogenous repair they describe carries a recurrence risk equal or better than the Lichtenstein and preperitoneal mesh repairs. The current understanding about collagen deficiencies in patients with hernia [8] suggests that alloplastic rather than endogenous repairs should be preferred.

British contributions to modern herniology of the groin

Traditional disdain for groin repair stifled recognition of British innovations. Some, relating to modern herniology, are remembered herein. Morton (1841) and Mackay (1889) showed the epigastric artery piercing Cooper's transversalis fascia (1807). Bilaminarity (Cooper, 1807) was confirmed in 1992 (Read). Thomson's iliopubic tract (1838) became part of Nyhus' repair (1960) [derived from McEvedy's repair (1950)] and laparoscopy (Ger, 1982). Retzius' space (Edinburgh, 1858) with Lister's antisepsis (1865) enabled preperitoneal herniorrhaphy (Annandale, 1876). He participated (1873) in intraperitoneal release of incarceration and reducible protrusions (Tait 1883). Cheyne's pectineus muscle plug (1893) preceded Kelly's marble prosthesis for femoral herniation (1898). Cheatle (1920) introduced posterior preperitoneal repair-ignored, rediscovered (Henry, 1936), and adopted (1952) at the Mayo clinic. Calne (1967) pioneered retrorectus Mersilene and was followed by Stoppa (1969) and Wantz (1989). Brandon (1945) blamed failure of modified Bassini's herniorrhaphies on closure at the intermediate inguinal ring instead of the internal. A similar mechanism may explain interstitial recurrence (Gilbert, 2003) after Amid-Lichtenstein repair. Lytle (1896-1986) described a muscle shutter at the internal ring, course of genitofemoral nerve, and orifice of femoral canal. Russell's congenital saccular theory (1906) was questioned by Keith (1924). Acquired connective-tissue pathology was later shown to play a systematic role in adult groin herniation (Read, 1970), confirmed by Jackson and colleagues (1996) and others.

Reoperation as surrogate endpoint in hernia surgery. A three year follow-up of 1565 herniorrhaphies.

Analysis of reoperation and recurrence rates three years after repair of groin hernias. Prospective audit by questionnaire and selective follow-up. Eight Swedish hospitals. All groin hernia operations done during 1992 on patients between the ages of 15 and 80 years. Postoperative complications, reoperation for recurrence, and recurrence. During 1992, 1565 hernia operations were done. The postoperative complication rate was 8% (125/1565). At 36 months postoperatively 108 recurrences had already been reoperated on, six patients with recurrences were on the waiting list for reoperation and a further 36 recurrences had been detected at follow-up. The interhospital variation in recurrence rate ranged from 3% to 20%. Postoperative complications, recurrent hernia, direct hernia and hospital catchment area over 100000 inhabitants were all factors associated with an increased relative risk of recurrence. The recurrence rate exceeded the reoperation rate for recurrence by almost 40% which should be taken into account if the reoperation rate is used as the endpoint after repairs of groin hernia. An audit scheme, based on prospective recording, reoperation rate, and (periodic) calculation of the recurrence rate may be used to identify risk factors for recurrence and areas in need of improvement.

Open mesh versus non-mesh for repair of femoral and inguinal hernia.

Inguinal hernia repair is the most frequent operation in general surgery. Until recently the standard procedure has been open musculo-aponeurotic repair using sutures under tension to close the defect but 'tension-free' repair using prosthetic mesh is becoming increasingly common in many countries. The purpose of this review is to evaluate open mesh techniques in comparison with open non-mesh techniques for the surgical repair of groin hernia. Electronic databases were searched and further trials were sought from the reference lists of reports of known trials. Through the EU Hernia Trialists Collaboration authors of identified randomised controlled trials were asked for information on any other trials known to them. There was no language restriction. Studies were eligible for inclusion if they were randomised or quasi-randomised trials comparing either a) open mesh with open non-mesh repair of groin hernia or b) open flat mesh repair with plug and mesh repair of groin hernia. For each outcome the results were derived using data from the best available source. The majority of data for this review came from individual patient data (IPD) supplied by the trialists. When these were unavailable data came from additional aggregated information or from published trial reports. All trials were analysed using the 'intention to treat' principle. Twenty trials comparing open mesh with open non-mesh repair were identified. Open mesh methods, on average, took 7-10 minutes less to perform than Shouldice procedures, but took 1-4 minutes longer than other non-mesh methods. There were no clear differences between mesh and non-mesh groups for haematomas, seromas or wound/superficial infections. Three serious operative complications were reported after open mesh repair and three following non-mesh repair. Overall, those in the mesh groups had a shorter length of hospital stay and quicker return to usual activities, but this pattern was not observed for all trials. There was a suggestion that persisting pain was less frequent after mesh repair than after non-mesh repair but this result was dependent on one trial and data were not available for 11 trials. There was no evidence of a difference between the groups with respect to persisting numbness. Fewer hernia recurrences were reported after mesh repair (Peto OR: 0.37, 95% CI: 0.26 to 0.51). There were too few data to reliably address differential effects for patients with recurrent, bilateral or femoral hernias. Two trials comparing flat mesh with plug and mesh were identified. There was no clear evidence of differences between the groups. There is evidence that the use of open mesh repair is associated with a reduction in the risk of recurrence of between 50% and 75%. Although the trials were heterogeneous there is also some evidence of quicker return to work and of lower rates of persisting pain following mesh repair.

Gilmore's groin repair in athletes.

Incapacitating groin pain is a frequent problem among athletes and its etiology may be multifactorial. A specific clinical syndrome relating to injury to the lower abdominal wall has been described and successfully treated by O. J. Gilmore. This paper presents our results of 100 consecutive groin repairs in 85 young athletes using a diagnostic and therapeutic strategy similar to Gilmore's. Ninety-six percent of our patients returned to competitive sport within 15 weeks; we suggest that this is an appropriate therapeutic intervention for athletes who develop chronic incapacitating groin pain.