Indirect Inguinal Hernia Patients Research Articles

Partially absorbable composite mesh versus non-absorbable polypropylene mesh in laparoscopic repair of inguinal hernia in a tertiary care center

Background: The choice of mesh is far more important than the technique used as a determinant of patient outcome. Randomized studies have compared polypropylene and modified composite mesh (polypropylene and polyglactin) and found decreased foreign body reactions and post-operative complications and improved long-term quality of life with the use of composite mesh. However, a limited number of studies have been done comparing the early outcomes such as inguinodynia, the presence of a seroma or hematoma, foreign body sensation, testicular problems, and the return to normal work activities. Aims and Objectives: The primary objective was to assess and compare the early outcome of non-absorbable polypropylene mesh vs. partially absorbable composite mesh in laparoscopic inguinal hernia repair. The secondary objective was to compare the complications associated with both types of mesh hernioplasty. Materials and Methods: A total of 50 cases of elective reducible indirect inguinal hernia patients admitted to the Department of Surgery, VIMSAR, Burla, were included in our study. The total group was split into Group A and Group B of 25 cases each. All patients underwent laparoscopic inguinal hernia repair transabdominal prepeitoneal. The partially absorbable composite lightweight meshes are used in Group A, and the non-absorbable polypropylene meshes are used in Group B. After surgery, comparison between the two groups was made on the basis of parameters such as age distribution, inguinodynia, analgesia, foreign body sensation, presence of a lump (hematoma or seroma), return to work activities, and recurrence. Results: The mean age of patients is 50.24 ± 12.994 years. The majority of the patients were in the age group of 51–60 years. Initially, there was no significant difference in transient neuralgia between the two groups, but after 6 weeks, Group A had significantly less pain. Foreign body sensation is significantly more in Group B, but later, this was not significant. Conclusion: Based on the results of this study, composite mesh may be recommended for use in laparoscopic inguinal hernia repair owing to the less pain, less foreign body sensation, and earlier return to work.

Profile of collagen prolines level of anterior rectus sheath tissue in indirect inguinal hernia: A cross-sectional study

IntroductionA hernia is a protrusion of an organ or tissue through an abnormal anatomical channel or opening. Epidemiological data indicated an increased prevalence of inguinal hernias in patients with connective tissue diseases. The biomechanical strength of connective tissue is highly dependent on the constituent of the matrix, including collagen. Fibroblasts produce and secrete procollagen containing high concentrations of proline and lysine. Collagen integrity plays an essential role in preventing hernia formation in the abdominal wall. To investigate the relationship between collagen proline levels of the anterior rectus sheath tissue in patients with lateral inguinal hernias (indirect inguinal hernia). MethodsThe study participants consisted of 67 inguinal hernia patients. A sample of anterior rectus tissue was obtained at the time of surgery, then being washed in a PBS buffer (pH 7.4). The measurement of collagen proline levels was subsequently carried out with enzyme linked immunosorbent assay (ELISA). ResultsAll study participants were male with mean age of 44 years, mean body mass index of 22.6 kg/m2 and mean onset of events of 27 months. Study subjects with reducible, irreducible, and incarcerated hernias were 45.7% (44/67 cases), 14.9% (10/67) and 19.4% (13/67), respectively. The mean proline level of the study subjects was 9.20. Correlation tests showed a correlation of proline levels and age (p = 0.001), body mass index (p = 0.006), and the onset of events (p = 0.023). Meanwhile, correlation of proline levels and occupation (p = 0.235) and clinical degree (p = 0.164) were not statistically significant. ConclusionPresence if relationship between proline levels with age, and onset of incidence among indirect inguinal hernia patients.

Self-fixating Parietex ProGrip mesh in inguinal and paraumbilical hernia repair

Background Inguinal hernia repair is the most frequently performed operation in general surgery. The standard method for inguinal hernia repair had changed little over a hundred years till using self-fixating Parietex ProGrip mesh. This mesh can be placed by an open approach which is becoming increasingly common in many countries. Objectives This study investigated the recent surgical treatment of open inguinal and paraumbilical hernia patients using self-fixating ProGrip Parietex mesh. Immediate complications reported were seroma, cellulitis, postoperative pain, mesh sepsis, testicular atrophy, and recurrence. Patients and methods This study was conducted between January 2015 and January 2017 at Al-Zahra Hospital Al Azhar University, and Al-Ameen Hospital, KSA with a 1 year follow-up. The patients underwent general, spinal, or epidural anesthesia. A dose of third-generation cephalosporin was administrated during the induction of anesthesia. Self-fixating Parietex ProGrip mesh with or without lateral slit with a rough surface placed on the floor of the inguinal canal for the repair of inguinal hernias or in subcutenous plane on anterior abdominal wall musculature in paraumbilical hernias. Results Self-fixating Parietex ProGrip mesh was used with a lateral slit for the spermatic cord, maked right and left for indirect inguinal hernia patients (69.79%) and direct hernia patients (27.01%). Self-fixating ProGrip Parietex mesh without slit with a rough surface was placed in the subcutaneous plane in patients with paraumbilical hernias (3.1%). Immediate complications such as seroma, cellulitis, and postoperative pain were studied. The mean operative time was ±35 min and the mean hospitalization discharge time was ±1.5 days. Conclusion The use of self-fixating Parietex ProGrip mesh technique for the repair of inguinal and paraumbilical hernias in this study seemed effective and safe, and is not associated with postoperative pain. No recurrence of hernia and no mesh sepsis were detected, with 1 year follow-up.

Genetic and functional analysis of the TBX3 gene promoter in indirect inguinal hernia

Inguinal hernia is a common developmental disease in children and most cases are indirect inguinal hernia (IIH). Genetic factors have been suggested to play important roles in IIH. Although IIH has been observed in several human syndromes, genetic causes and molecular mechanisms for IIH remain unknown. TBX3 is a member of the T-box family of transcription factors that are essential to the embryonic development. Human studies and animal experiments have demonstrated that TBX3 is required for the development of the heart, limbs, mammary glands and other tissues and organs. TBX3 gene expression has been detected in human fibroblast and tissues of abdominal wall. We speculated that TBX3 may be involved in the IIH formation. Since TBX3 activity is highly dosage-sensitive, a TBX3 gene promoter was genetically and functionally analyzed in IIH patients and ethnic-matched controls in this study. One heterozygous deletion variant (g.4820_4821del) was identified in one IIH patient, but in none of controls. The variant significantly decreased TBX3 gene promoter activities, likely by creating a binding site for sex-determining region Y (SRY), mobility group transcription factor. One heterozygous insertion variant (g.3913_3914ins) was only found in one control, which did not affect TBX3 gene promoter activities. Taken together, TBX3 gene variants may contribute to IIH as a rare risk factor by reducing TBX3 levels.

Two functional sequence variants of the GATA6 gene promoter in patients with indirect inguinal hernia.

Inguinal hernia is a common surgical disease, majority of which are indirect inguinal hernia (IIH). A positive family history has indicated that genetic factors play important roles in the IIH development. To date, genetic causes and underlying mechanisms for inguinal hernia remain largely unknown. During the embryonic development, GATA transcription factor 6 (GATA6) plays an essential role. Mutations in GATA6 gene and changed GATA6 levels have been associated with human diseases. As GATA6 acts in a dosage-dependent manner, we speculated that changed GATA6 levels, resulting from DNA sequence variants (DSVs) within the gene regulatory regions, may mediate the IIH development. In this study, the GATA6 gene promoter was genetically and functionally analyzed in IIH patients and ethnic-matched controls. Eleven DNA sequence variants (DSVs), including four SNPs and seven new variants, within the GATA6 gene promoter were identified. Two heterozygous DSVs, g.22168361C>A and g.22169106C>T, were identified in two IIH patients, but in none of controls. In cultured human fibroblast, these DSVs significantly reduced the GATA6 gene promoter activities. In addition, three heterozygous DSVs were only found in three controls. Five DSVs, including four SNPs and one new variant, were found in both IIH patients and controls with similar frequencies. Therefore, the DSVs within the GATA6 gene promoter may contribute to the IIH development as a risk factor by changing the GATA6 levels.

Functional sequence variants within the SIRT1 gene promoter in indirect inguinal hernia.

Inguinal hernia is a common surgical disease, for which genetic factors have been suggested to play a role. Sirtuin 1 (SIRT1), a highly conserved NAD-dependent class III deacetylase, has been implicated in human diseases. Since SIRT1 regulates differentiation and proliferation of human skeletal muscles and fibroblasts, we speculated that misregulation of SIRT1 gene, caused by DNA sequence variants (DSVs) within its regulatory regions, may contribute to inguinal hernia development. In this study, SIRT1 gene promoter was genetically and functionally analyzed in patients with indirect inguinal hernia (IIH) (n=139) and ethnic-matched healthy controls (n=148). Two heterozygous DSVs, g.69644213G>A and g.69644268T>A, and one single nucleotide polymorphism (SNP), g.69643707A>C (rs35706870), were found in IIH patients, but not in controls. Two closely-linked SNPs, g.69644217A>C (rs932658) and g.69644341G>C (rs2394443), were found in IIH patients with significantly higher frequency, compared to controls (P=0.006). The C alleles of the SNPs g.69644217A>C (rs932658) and g.69644341G>C (rs2394443) were associated with IIH (P=0.028, OR 1.600, 95%CI 1.049-2.439). These DSVs significantly altered the transcriptional activities of the SIRT1 gene promoter in cultured cells. Therefore, our data suggested that these DSVs may alter the transcriptional activities of SIRT1 gene promoter and change SIRT1 levels, contributing to IIH development as risk factors.

Genetic analysis of the TBX2 gene promoter in indirect inguinal hernia

Inguinal hernia is a common disease, majority of which are indirect inguinal hernia (IIH). A positive family history indicates that genetic factors play important roles in the IIH development. To date, genetic causes for IIH remain unknown. T-box transcription factor 2 (TBX2) is a major regulator in the morphogenesis and organogenesis. The human TBX2 gene is widely expressed in fetal and adult tissues, including muscle and connective tissues. Therefore, we speculated that altered TBX2 gene expression may be involved in the IIH formation. IIH patients (n = 129) and ethnic-matched healthy subjects (n = 198) were recruited for this study. The human TBX2 gene promoters were generated with PCR and directly sequenced to identify DNA sequence variants (DSVs). Furthermore, biological functions of the DSVs were examined with reporter gene constructs in cultured cells. Total six DSVs within the TBX2 gene promoter were identified. A heterozygous DSV (g.59476307G>C) was identified in an IIH patient, but in none of controls, which significantly decreased the TBX2 gene promoter activities. Another heterozygous DSV (g.59476704G>C) was only found in one control, which did not affect TBX2 gene promoter activities. Four DSVs, g.59476316C>A (rs73991913), g.59476415T>C (rs1476781), g.59476510G>C (rs4455026) and g.59476892C>T (rs2286524), all of which were single nucleotide polymorphisms, were found in both IIH patients and controls with similar frequencies. Our data suggested that the DSV within the TBX2 gene promoter was implicated in the IIH development as a rare cause.

Genetic analysis of the TBX1 gene promoter in indirect inguinal hernia

Inguinal hernia is a common disease, most cases of which are indirect inguinal hernia (IIH). Genetic factors play an important role for inguinal hernia. Increased incidences of inguinal hernia have been reported in patients with 22q11.2 microdeletion syndrome, which is mainly caused by TBX1 gene mutations. Thus, we hypothesized that altered TBX1 gene expression may contribute to IIH development. In this study, the human TBX1 gene promoter was genetically analyzed in children with IIH (n=100) and ethnic-matched controls (n=167). Functions of DNA sequence variants (DSVs) within the TBX1 gene promoter were examined in cultured human fibroblast cells. The results showed that two heterozygous DSVs were found, both of which were single nucleotide polymorphisms. One DSV, g.4248 C>T (rs41298629), was identified in a 2-year-old boy with right-sided IIH, but not in all controls, which significantly decreased TBX1 gene promoter activity. Another DSV, g.4199 C>T (rs41260844), was found in both IIH patients and controls with similar frequencies (P>0.05), which did not affect TBX1 gene promoter activity. Collectively, our data suggested that the DSV within the TBX1 gene promoter may change TBX1 level, contributing to IIH development as a rare risk factor. Underlying molecular mechanisms need to be established.

Study on intra-abdominal pressure in indirect inguinal hernia patients

To investigate intra-abdominal pressure (IAP) and its changes in patients with indirect inguinal hernia and non-hernia diseases. Supine IAP (SIAP), supine Valsava IAP (SVIAP), orthostatic IAP (OIAP) and orthostatic Valsava IAP (OVIAP) were measured by intra-vesicle pressure measurement in 19 indirect inguinal hernia patients and 20 non-hernia patients, respectively. The differences of IAP between orthostatic and supine position in quiescent condition (OSIAPD), before and after taking Valsava maneuver in supine position (SVIAPD) or in orthostatic position (OVIAPD), orthostatic and supine position when taking Valsava maneuver (OSVIAPD) were compared between the two groups. There was no significant differences in SIAP, OIAP, SVIAP, OSIAPD, SVIAPD between the two groups (P > 0.05). While patients with indirect inguinal hernia had higher OVIAP (P < 0.05). Significant differences in OVIAPD and OSVIAPD was found between the two groups (P < 0.05). The etiology of indirect inguinal hernia were related to orthostatic position, increasing IAP and changes of anatomic structures. The IAP is prone to elevated in patients with indirect inguinal hernia.

Prospective randomized single-center, single-blind Comparison of laparoscopic vs open repair of pediatric inguinal hernia

The repair of indirect inguinal hernia (IH) is one of the most common pediatric surgical procedures, and open surgery (OS) is the standard treatment. The aim of this study was to determine whether the recently developed laparoscopic repair (LR) of IH is superior to OS. Between February 2003 and February 2004, we randomly assigned 97 consecutive IH patients at our institution into OS and LR groups. Fourteen patients were excluded from the study for various reasons, leaving study population of 83 patients. After operation, multiple dressings were placed to blind observers to the operation type. Two pain scales, the children and Infants Postoperative Pain were used to assess postoperative pain. Acetaminophen (15 mg/kg/dose every 6 h) was given at a fixed pain score. Analgesic doses were compared. Parents also provided assessments of their children's recovery and wound appearance. The amount of acetaminophen taken by the OS group (n = 42) was 1.05 +/- 1.248 doses per patient, whereas the amount taken by the LR group (n = 41) was 0.54 +/- 0.84 dose per patient (p = 0.032; 95% confidence interval 0.45-0.976). Laparoscopy detected 11 more bilateral hernias (p = 0.006). Although the operative times did not differ significantly for bilateral hernias (39.08 +/- 13.37 min vs 34.0 +/- 11.31 min, p = 0.623), it did differ for unilateral hernias (18.38 +/- 5.71 vs 23.25 +/- 6.26 min, p = 0.001). Five contralateral hernias were detected in the OS group on follow-up, but none were found in the LR group (p = 0.026). The scores given by parents for recovery and wound appearance were higher in the LR group (p = 0.05). As compared with IH patients who undergo open surgery, those who have a laparoscopic repair suffer less pain, and their recovery and wound cosmesis are more satisfactory. With LR, contralateral hernias can be detected and repaired in a single operative procedure. This procedure takes slightly longer for unilateral than for bilateral hernias.

Comparison of the Plasma and Hernia Sac Tissue Copper Levels in Direct and Indirect Inguinal Hernia Patients

Although the inguinal hernia is among the most commonly encountered and well-described health problems all over the world, the etiology is still controversial. The aim of this study was to compare the plasma and hernia sac tissue copper levels in direct and indirect inguinal hernia patients. Plasma and hernia sac tissue copper levels obtained from patients operated under spinal anesthesia with primary direct (group I, n = 55, 45 male, mean age = 45.68 yr) and indirect (group II, n = 55, 40 male, mean age = 38.57 yr) hernias were detected by atomic absorption spectrophotometer. Significantly lower plasma and hernia sac tissue copper levels were detected in group I in comparison to group II (p < 0.001). Both plasma and hernia sac tissue copper levels were significantly lower in males when we compare the patients according to their sex characteristics, including both direct and indirect hernia groups (p < 0.05 and p < 0.01, respectively). Age was not a significant factor. The plasma and hernia sac tissue copper levels were significantly lower in direct hernia patients in comparison to indirect hernia patients. Copper is a cofactor of lysyl oxidase, an important enzyme in collagen tissue metabolism, so there might be a defect in the collagen synthesis of direct hernia patients because of the decreased activity of the lysyl oxidase. Further investigations are necessary to clarify this concept.

Quantitative analysis of collagen and elastic fibers in the transversalis fascia in direct and indirect inguinal hernia.

Our previous studies demonstrated structural and quantitative age-related changes of the elastic fibers in transversalis fascia, which may play a role in inguinal hernia formation. To verify whether there were differences in the extracellular matrix between direct and indirect inguinal hernia, we studied the amount of collagen and elastic fibers in the transversalis fascia of 36 male patients with indirect inguinal hernia and 21 with direct inguinal hernia. Transversalis fascia fragments were obtained during surgical intervention and underwent histological quantitative analysis of collagen by colorimetry and analysis of elastic fibers by histomorphometry. We demonstrated significantly lower amounts of collagen and higher amounts of elastic fibers in transversalis fascia from patients with direct inguinal hernia compared to indirect inguinal hernia patients. The transversalis fascia from direct inguinal hernia patients showed structural changes of the mature and elaunin elastic fibers, which are responsible for elasticity, and lower density of oxytalan elastic fibers, which are responsible for resistance. These changes promoted loss of resiliency of the transversalis fascia. These results improve our understanding of the participation of the extracellular matrix in the genesis of direct inguinal hernia, suggesting a relationship with genetic defects of the elastic fiber and collagen synthesis.