Mesh Repair Surgery Research Articles

Mesh repair of vaginal wall prolapse

BackgroundOver the last decade, mesh augmented surgical repair is being increasingly used in pelvic organ prolapse. Perigee and Apogee are comprehensive, single-use needle suspension kits that provide a standardized delivery method for mesh or graft-augmented repairs. This study has been carried out to study the safety and efficacy of the Perigee and Apogee mesh repair systems. Methods10 cases of posterior vaginal wall prolapse with or without Apical prolapse underwent Apogee mesh repair surgery and 10 cases of anterior vaginal wall prolapse underwent Perigee mesh repair surgery. Depending on the findings either Apogee or Perigee or both were used. Patients were followed up for complications of the surgery if any, and for the relief of the symptoms related to prolapse and associated symptoms of bowel/bladder dysfunction. Objective cure rate was prolapse < stage 1 as per the POPQ system. Data collected was statistically analyzed. ResultsThe objective and subjective cure rates were 100%. Postoperative complications were minor. No patient developed de novo urinary urge symptoms, stress urinary incontinence or UTI postoperatively. There were no operative complications like bladder injuries, hematoma and rectal injuries. The mean blood loss was 180 ml and the mean duration of surgery during the Apogee and Perigee mesh repair was 51.5 ± 2.99 min and 60.9 ± 4.65 min respectively. ConclusionIn the present study there was a significant improvement in the degree of prolapse after the mesh repair surgeries and the results were consistent even at 12 months follow up.

Who’s trusting in a truss?

Dear Sir, The British Hernia Society guidelines advice regarding the primary care management of inguinal hernias is that Hernia trusses should not be routinely used [1]. This is, however, a level D recommendation with most of the limited evidence for trusses in hernia management over 20 years old. This precedes many innovations in hernia repair such as the widespread use of the tension-free mesh repair and laparoscopic surgery. The advancement of surgical and anesthetic technique has led to fewer patients being considered ‘‘unfit’’ for either anesthetic or surgical reasons to undergo repair. Despite the widespread belief that the role of the truss is obsolete, hernia trusses continue to be produced and used in large numbers. In 1991, Goldman [2] received communication from two hernia truss suppliers E Sallis Ltd and Ellis, Son and Paramore Ltd, and estimated that total UK annual truss sales were approximately 40,000. Sallis have since bought Ellis, Son and Paramore. Recent personal communication with Sallis suggests that about 13,000 trusses continue to be supplied to the UK annually. Hernia trusses remain available on prescription. We sent freedom of information requests to establish the number of inguinal hernia trusses dispensed in the UK annually. In Scotland, 286 inguinal hernia trusses were dispensed in 2012, a fall from 927 in 1994. In Northern Ireland, 300 were dispensed in 2012, down from 452 in 1999. In England, inguinal hernia truss dispensing fell from 10,214 in 2003 to 4,304 in 2012. These figures may, however, be an underestimation of hernia truss use with the advent of the internet and the ability for UK customers to shop internationally with ease. As the British Hernia Society guidelines state the evidence base surrounding inguinal hernia truss use is limited. The two largest retrospective studies of truss wearer’s experience show mixed results, 53/85 patients in one study finding partial or complete relief of symptoms [3], while Law [4] found that 33/52 found the truss uncomfortable and it failed to control the hernia in 36/52 cases. A review of trusses in inguinal hernia management by Cheek et al. [5] concluded that ‘‘considering the frequency of use of trusses and the evidence for high incidence of inguinal hernia, the paucity of relevant research in this area is disconcerting’’. Given the significant number of inguinal hernia trusses still being used in the UK, the question of who is trusting in a truss remains unanswered. Perhaps an even more important question remains, are they trusting with good reason?

PHARMACOECNOMIC USE OF 750 MG CEFUROXIME INTRAVENOUSLY FOR INGUINAL HERNIA MESH REPAIR SURGERY ASSOCIATED INFECTIONS.

Main delineative of the present study was to ascertain the effectiveness of cefuroxime prophylaxis in restraining the postoperative wound infection during scavenging inguinal hernia mesh after furbish up surgery and also to equate single day with multiple day antibiotic prophylaxis during hospital stay and for monetary appraise. 326 patients with inguinal hernia were investigated and divided into two groups with 171 patients in group A and 155 in group B. Group A was treated with three intravenous doses just half an hour before surgery followed by two more doses with 8 hours interval and oral therapy of 500 mg of cefuroxime divided into two doses. Group B received six intravenous doses and followed by same oral therapy as of group A. Total therapy was carried out uninterrupted for 4 days in both groups. The outcomes of study indicated that 4.7% and 6.45% of the patients of group A and B explicated surgical site infections respectively, while the hospital detention of group A and B was 2.15 and 3.27 days respectively. Overall, the cost effectiveness of group A was 33% more frugal than Group B. It is concluded that there was no significant differences in one day and two days prophylaxis with cefuroxime in patients with inguinal hernia mesh repair surgery relative to post-operative surgical site infection. The risk of post-operative wound infection could therefore be efficaciously be contended by one day t.i.d treatment, eventually had salutary consequences on the hospital stay and cost obligingness of patient.

Surgical outcomes of anterior trans-obturator mesh and vaginal sacrospinous ligament fixation for severe pelvic organ prolapse in overweight and obese Asian women

The aim of this study is to compare the outcomes of patients who underwent surgical repair of advanced pelvic organ prolapse amongst with normal-weight, overweight and obese Asian women. Vaginal sacrospinous ligament fixation with anterior mesh repair as primary surgery was performed on 200 patients with advanced pelvic organ prolapse (POP-Q ≥ stage III). POP-Q < stage II was objective cure and subjective cure was based on POPDI-6 (questions 2 and 3). Patients completed the UDI-6, IIQ-7, POPDI-6, and PISQ-12 pre- and post-surgery. Outcome measures were observed in three categories of Asian BMI (normal weight 18.5 to 23.0 kg/m(2), overweight >23.0 to 27.5 kg/m(2), and obese ≥ 27.5 kg/m(2)). Postoperative data were available for 195 patients. Objective cure for the normal-weight, overweight, and obese were 93.0%, 92.5% and 90.6% respectively with an overall mean follow-up of 35.69 ± 18.97 months. The subjective cure was no different. All categories improved significantly with regard to anatomical outcome, UDI-6, IIQ-7, POPDI-6, PISQ-12 after primary surgery (p < 0.05) and none had recurrence requiring further surgery. However, obese patients have significantly less improvement in POPDI-6 (p <0.037) and PISQ-12 (p <0.005) compared with normal weight. There were no differences with regard to perioperative complications and the vaginal mesh exposure rate was 4.1%. There was no difference in the objective outcome of sacrospinous ligament fixation with anterior mesh repair surgery among the three Asian BMI categories; however, obese patients showed less improvement in POP symptoms and sexual function.

Paroxysmal hip pain

In January, 2007, a 58-year-old woman presented to our department with a 2-year history of severe paroxysmal hip pain. She had a 30-year history of anorexia nervosa. The pain originated near the pubis and radiated to the right or left hip, with right-sided pain being more frequent. The pain often occurred after urination or defecation, and lasted from several minutes to several hours. She could not walk because of the severity of the pain, and had to lie supine with the aff ected thigh fl exed to obtain some relief. Our patient had presented to emergency departments several times, receiving a diagnosis of psychogenic pain or osteoarthritis because of degenerative changes shown on hip radiographs. On examination, she was asymptomatic but severely emaciated with a height of 159 cm and weight of 32 kg (body-mass index 12·7 kg/m2). There was no tenderness, swelling, or restricted movement of her hip joints, making the diagnosis of degenerative arthritis unlikely. Just after examination, left-sided pain occurred on urination. Emergency CT of the pelvis showed intrusion of the bowel into the left obturator canal (fi gure). Her pain soon subsided, and elective surgery was scheduled. After 1 month, severe right-sided pain occurred and she had an emergency laparotomy. Bilateral obturator hernia was diagnosed and mesh repair surgery done. In August, 2009, at 32-month follow-up she had not experienced any pain since the operation. Obturator hernia is most common in emaciated elderly women between 70 and 90 years old. Women are aff ected six times more frequently than men because they have a wider pelvis with a larger obturator canal. Emaciation is an important risk factor because the loss of preperitoneal fat overlying the obturator canal increases the risk of herniation. Obturator hernia is relatively rare, with a reported incidence of 0·073% of all abdominal hernias and bilateral obturator hernia has an incidence of only 0·013%. The hernia is more common in multiparous women and Asians, and occurs less frequently on the left side because the sigmoid colon can cover the left obturator foramen, preventing herniation. The usual presention is with the clinical features of acute small bowel obstruction, but obstruction can also be partial and resolve spontaneously. Approximately one third of the patients have a history of intermittent previous attacks. Patients can present with groin, thigh, knee, or hip pain due to compression of the obturator nerve by the hernia (Howship-Romberg sign), which is seen in 15–50% of patients. The pain is exacerbated by extension, abduction, or medial rotation of the thigh, while fl exion usually relieves it. Our patient with bilateral hernia was relatively young, but she had severe emaciation due to anorexia nervosa. Bowel herniation induced the HowshipRomberg sign, resulting in her curious paroxysmal hip pain. Diagnosis of obturator hernia is challenging, although CT or ultrasonography can be useful, the correct diagnosis is made preoperatively in only 21·5% to 31·3% of cases. Diffi culty in establishing the diagnosis leads to a high mortality rate of up to 25%, so early accurate diagnosis is crucial. Although obturator hernia is a rare disease, it must be considered when any underweight woman, not only the elderly, complains of unexplained pain in the groin, thigh, knee, or hip.

Pelvic organ prolapse: Does the postoperative course of mesh-repair surgery differ in elderly women when compared with younger patients?

Pelvic organ prolapse (POP) is a common disease in elderly women. Among a wide range of possibilities in POP surgery, the use of partially absorbable meshes appears to be very promising. The problem concerning POP therapy in elderly patients has not yet been not sufficiently investigated. We enrolled 64 patients with POP stages 3 and 4. All patients underwent mesh-repair surgery and afterwards were stratified into two age groups. Data obtained from anamnesis, pelvic organ prolapse quantification (POP-Q) scale, dynamic MRI and prolapse quality of life (P-QoL) questionnaire were analysed and compared between both age groups. A total of 64 patients completed the study protocol. Outcome of the surgery was promising and comparable between both age groups. One recurrence of prolapse and one mesh erosion was reported. P-QoL showed a good overall satisfaction. Our data show that the surgical correction of POP with use of polypropylene mesh in elderly women appears to be a successful method with an acceptable morbidity, adverse events rate and high satisfaction of the patients.

Long-term results of hiatal hernia mesh repair and antireflux laparoscopic surgery

Laparoscopic antireflux surgery (LARS) represents the gold standard in the treatment of gastroesophageal reflux disease with or without hiatal hernia. It offers excellent long-term results and high patient satisfaction. Nevertheless, several studies have reported a high rate of intrathoracic wrap migration or paraesophageal hernia recurrence. To reduce the incidence of this complication, the use of prosthetic meshes has been advocated. This study retrospectively evaluated the long-term results of LARS with or without the use of a mesh in a series of patients treated from 1992 to 2007. From November 1992 to May 2007, 297 patients underwent laparoscopic antireflux surgery in the authors' department. Crural closure was performed by means of two or three interrupted nonabsorbable sutures for 93 patients (group A), by tailored 3 x 4-cm polypropylene mesh placement for 113 patients (group B), and by nonabsorbable suture plus superimposed tailored mesh for 91 patients (group C). The mean follow-up period for the entire group was 95.1 +/- 38.7 months, specifically 95.2 +/- 49 months for group A, 117.6 +/- 18 months for group B, and 69.3 +/-.17.6 months for group C. Intrathoracic Nissen wrap migration or hiatal hernia recurrence occurred for nine patients (9.6%) in group A, two patients (1.8%) in group B, and only one patient (1.1%) in group C. Esophageal erosion occurred in only one case (0.49%). Functional results and the long-term quality-of-life evaluation after surgery showed a significant and durable improvement with no significant differences related to the type of hiatoplasty. Over a long-term follow-up period, the use of a prosthetic polypropylene mesh in the crura for hiatal hernia proved to be effective in reducing the rate of postoperative intrathoracic wrap migration or hernia recurrence, with a very low incidence of mesh-related complications.

Long-term results of incisional hernia treatment

Ventral hernia is a common problem in general surgery practice. Incisional hernia can develop in 15-25% of patients after abdominal surgery. The aim of this study was to compare two different methods of incisional hernia surgery. A retrospective analysis of database of surgery department from 1997 to 2000 was performed. All patients were divided into two groups. The first group patients were operated using open suture repair (keel technique); the second group patients--using open mesh repair (onlay technique). Long-term follow-up was done by a mail questionnaire. A special questionnaire was sent to all patients. Postoperative evaluation included pain and discomfort in the abdomen, physical activity, and recurrence rate after operation. Statistical evaluation was conduced using descriptive analysis: the unpaired Student t test to compare parametric criterions between two study groups, Mann-Whitney U test to compare the unpaired nonparametric criterions between two study groups, and chi2 test to investigate nonparametric criterions between these groups. A total of 202 patients (51 males, 151 females) with incisional hernia were operated during 1997-2000. One hundred seventy-one patients were in the keel technique group, and 31 patients in the onlay technique group. There were no significantly differences in age and sex between these groups. The hospitalization time was significantly longer in the open mesh repair group. The postoperative complication (wound seroma and suppuration) rate was significantly higher in the onlay technique group. One hundred sixty-one patients (79.7%) answered the questionnaire (133 in the keel technique group, 28 the in onlay technique group). The patients' return to physical activity after surgery was significantly longer in the keel technique group. Forty-one patients (31%) had hernia recurrence in the keel technique group and 3 patients (11%) in the onlay technique group (P<0.05). There were no postoperative deaths in both groups. The rates of postoperative therapeutic complications and hernia recurrence are significantly lower after open mesh repair surgery. Return to normal physical activity after surgery is significantly longer after open suture repair surgery.