Prosthetic Inguinal Hernia Repair Research Articles

SJLA_2024_A16: Unusual Complications of Open Preperitoneal Tension-Free Inguinal Hernia Repair

Background: The purpose of this study is to report two patients referred to our hospital after developing unusual complications attributed to prior open preperitoneal tension-free inguinal hernia repair. Methods: Case # 1 A 75-year-old male developed a left proximal thigh abscess requiring incision and drainage 5 years after open prosthetic, preperitoneal inguinal hernia repair with single-layer mesh. A pelvic computed tomography (CT) scan demonstrated an abscess in the left inguinal preperitoneal space as well as diverticulosis but no diverticulitis. A colonoscopy was negative for any additional findings. The patient underwent groin exploration, debridement of the inguinal canal and sinus tract, and mesh resection followed by JP drain placement. The inguinal defect was repaired utilizing the should ice technique. Intraoperative cultures revealed penicillin-resistant Staphylococcus aureus. The drain was removed on postoperative day nine, and his recovery remains uneventful without hernia recurrence or infectious complications at 11-month follow-up. Case # 2 An 82-year-old man developed progressive left lower extremity edema and disabling claudication 1 month after open prosthetic inguinal hernia repair with a bilayer disc mesh. Venous duplex imaging revealed compression of the left common femoral and external iliac veins. A CT angiogram demonstrated left external iliac and common femoral artery thrombosis and a 5.2 cm fluid collection consistent with hematoma. An inferior vena cava filter was placed. The common femoral artery was controlled after initial exploration revealed a common femoral artery pseudoaneurysm. The mesh was densely adherent to the external iliac vein and was thus not resected. The common femoral artery pseudoaneurysm was repaired and the profunda femoris artery over sewn. An external iliac to superficial femoral artery 8 mm Polytetrafluoroethylene bypass graft was placed. The patient was discharged on systemic anticoagulation without claudication on postoperative day thirteen. Results: Laparoscopic inguinal hernia repair and novel, open techniques and mesh devices have popularized the placement of mesh in the preperitoneal space. Acute, severe vascular complications and latent infectious complications can occur after open, preperitoneal tension-free inguinal hernia repair and may require remedial surgery. CT scans and angiogram pictures are available. Discussion: Laparoscopic inguinal hernia repair and novel, open techniques and mesh devices have popularized the placement of mesh in the preperitoneal space. Acute, severe vascular complications and latent infectious complications can occur after open, preperitoneal tension-free inguinal hernia repair and may require remedial surgery. CT scans and angiogram pictures are available. Conclusion: Laparoscopic inguinal hernia repair and novel, open techniques and mesh devices have popularized the placement of mesh in the preperitoneal space. Acute, severe vascular complications and latent infectious complications can occur after open, preperitoneal tension-free inguinal hernia repair and may require remedial surgery. CT scans and angiogram pictures are available.

Jejunal volvulus within an inguinal hernia sac like as an extremely rare cause of acute mechanical gastrointestinal obstruction in adults: First literature report.

Introduction and importanceSmall bowel volvulus (SBV) represents a rare and life-threatening cause of gastrointestinal obstruction among adults. SBV can be classified as primary and secondary subtypes. Preoperative diagnosis of SBV is a challenge because of the absence of pathognomonic clinical, radiographic and laboratory findings. Surgery represents the correct treatment of SBV.Case presentationA 69-year-old Caucasian male presented to the Emergency Department with a two-day history of abdominal pain, inability to pass gas or stool, nausea, vomiting. Physical examination revealed abdominal distension, generalized abdominal pain without guarding or rebound tenderness, a partially reducible and painless right inguinal hernia. Laboratory tests reported neutrophilic leukocytosis. Abdominal computed tomography revealed massive gastroduodenal dilatation with pneumoperitoneum and small bowel loops in the right inguinal sac. The patient underwent exploratory laparotomy: a jejunal volvulus (JV) located within the right inguinal hernia sac, causing gastrointestinal obstruction, was devolvulated and a right prosthetic inguinal hernia repair was also performed. The patient was discharged on the 10th postoperative day.Clinical discussionSecondary SBV is due to any congenital or acquired lesions and rarely occurs among adults in Western countries. This is the first literature report of a JV located within an inguinal hernia sac causing gastrointestinal obstruction.ConclusionSecondary JV represents an extremely rare abdominal emergency necessitating early diagnosis to prevent the development of intestinal ischemia, bowel necrosis and peritonitis. Diagnosis of JV needs a high index of suspicion and may be facilitated by imaging, often it is made intraoperatively. Surgery represents the appropriate treatment of JV.

Inguinal Hernia: Defect Obliteration with the 3D Dynamic Regenerative Scaffold Proflor™

Prosthetic inguinal hernia repair presents significant challenges. Some of these, such as mesh fixation and quality of the biologic response, are still debated among surgeons. For example, there is no strong consensus regarding a specific condition that characterizes the surgical procedure during herniorrhaphy. This issue concerns management of the hernia defect, which in conventional hernia repair with flat meshes remains patent. However, a critical analysis of typical postoperative complications after inguinal hernia repair reveals that some of these adverse events are related to patency of the hernial opening. Postoperative discomfort, pain with specific movements and even hernia recurrence can be caused by incomplete or defective management of the hernia defect. For this reason, a deeper understanding of this topic would be useful for improving postoperative outcomes. A recently updated concept for inguinal hernia repair takes this technical aspect into consideration. It is based on the use of a newly developed 3D scaffold—ProFlor™ (Insightra Medical, Inc., Clarksville, TN, USA)—that is intended to be deployed into the defect. This novel hernia repair device has interesting and original features, such as dynamic responsivity in compliance with inguinal movement, fixation-free mode and regenerative behavior that counteracts the degenerative effects of the disease. Another additional proprietary feature of this 3D scaffold is the full and permanent obliteration of the defect, which is a crucial aspect to improve outcomes by avoiding the typical adverse effects of this surgical procedure. Obliteration of the hernia defect with the 3D dynamic regenerative scaffold ProFlor™ appears to be superior to coverage by means of static (passive) flat meshes/plugs used in conventional hernia repair. This report highlights the principles of this procedural approach.

Neo-nervegenesis in 3D dynamic responsive implant for inguinal hernia repair. Qualitative study.

Prosthetic repair of inguinal hernias is one of the most performed surgical procedures. Nevertheless, high rates of complications affect the surgical treatment. Implant fixation, poor-quality tissue ingrowth and mesh shrinkage seem to be involved in postoperative complications, discomfort and chronic pain following inguinal hernia repair. To address these issues a multilamellar shaped 3D dynamic responsive prosthesis has been developed. This new implant, positioned fixation-free to obliterate the hernia opening, thanks its inherent dynamic compliance during inguinal movements, has demonstrated to induce an enhanced biological response. The ingrowth of newly formed muscle fibers, arteries and veins in a surrounding of viable connective tissue could be evidenced into the implant fabric. This appears to be quite different from the fibrotic plaque, typical biologic response of conventional meshes. In addition to myocytes and vessels, newly ingrown nerves have also been detected in the prosthetic structure. The aim of this investigation was to determine by examining biopsy specimens excised from patients who underwent hernia repair with the 3D dynamic implant, quantity and quality of the neural ingrowth within the implant fabric in the short, medium, and long term post-implantation. Newly formed nervous structures were found in biopsy specimens, from multiple spots of nerve clusters evidenced in the short-term along the increased level of neural maturation in the midterm, until the nerves showed complete in all components in the long-term. The development of highly specialized nervous tissue in the 3D prosthesis seems to finalize the regenerative biologic response that is expected for the treatment of a degenerative disease, as, in fact, inguinal hernia is. Re-growth of the typical tissue components of the groin evidenced in the 3D dynamic prosthesis seems to effectively revert the degenerative source of inguinal hernia into regeneration of the vanished tissue components of the groin.

Mesh-related visceral complications following inguinal hernia repair: an emerging topic.

The use of meshes in inguinal hernia repair (IHR) has gained popularity but new complications have been observed. Mesh-related visceral complications (MRVCs) are generally considered rare and hence are not studied in depth. We carried out a thorough literature search and collected 101 clinical reports published from 1992 to 2018. The reported complications seem to have tripled in the last decade. Ninety-seven cases met the inclusion criteria and they were subdivided into four groups (group A-onlay IHR, group B-3-D IHR, group C-preperitoneal IHR, group D-laparoscopic IHR) to be analyzed, according to the herniorraphy technique. Every prosthetic IHR can be followed by MRVCs but, according to the present review, the highest incidence is related to laparoscopic repairs, the lowest to Lichtenstein technique. Time-to-event was shorter in case of preperitoneal position of the prosthesis than when the mesh was implanted over the transversalis fascia. Urinary bladder involvement predominantly occurred after laparosopic IHR. A pathogenic correlation between the most frequently complained clinical signs and the previous mesh herniorraphy was rarely reported. The diagnosis was generally made at laparotomy, which was usually performed asan emergency. Removing the infected mesh and resecting or suture repairing the involved viscera was the challenging surgical treatment. Prevention of MRVCs after inguinal hernia repair appears to be an important significantissue. It is important to pay attention to the choice of a proper implantation site, avoiding direct contact between the mesh and viscera, and to select a proper device.

Benefits of pre-emptive analgesia by local infiltration at day-case general anaesthetic open inguinal hernioplasty.

Introduction The open prosthetic repair of inguinal hernias under local anaesthesia (LA) is well established, with the concept of intraoperative 'pre-emptive analgesia' evolving so that patients are as comfortable as possible. We used a peri-incisional LA solution in patients undergoing day-case inguinal hernioplasty under general anaesthesia (GA) and recorded use of analgesia in the immediate postoperative period. Methods In this observational cohort study, 100 consecutive unselected men underwent open inguinal hernia repair as a day case. Of these, 75 underwent repair under GA and 25 with peri-incisional LA solution (equal mixture of 0.5% bupivacaine and 1% lignocaine with 1:200,000 adrenaline). Analgesia prescribed at induction, for maintenance and after cessation of anaesthesia was scored in accordance with the World Health Organization (WHO) analgesic ladder. Results The median age in the GA group was 59 years (range: 25-89 years) and in the GA+LA group, it was 62 years (range: 27-88 years). Of the 100 patients, 82 underwent a mesh plug repair by seven surgeons whereas 18 underwent a flat (Lichtenstein) mesh repair by two surgeons. WHO analgesic induction and postoperative scores were significantly lower in the GA+LA group (p=0.034 and p<0.001 respectively). There was also a significant difference in use of postoperative antiemetics (23% vs 0% in the GA only and GA+LA cohorts respectively, p=0.020). Six patients (8%) in the GA group failed day-case discharge criteria. Conclusions Patients undergoing contemporary day-case GA inguinal hernioplasty with pre-emptive LA solution infiltration require lower levels of postoperative opioid analgesia and antiemetics. These cases are less likely to fail discharge criteria for planned day surgery.

Long-term Follow-up of a Randomized Controlled Trial of Lichtenstein's Operation Versus Mesh Plug Repair for Inguinal Hernia

To compare long-term results of Lichtenstein's operation versus mesh plug repair for open inguinal hernia repair. The technique of best choice in open prosthetic inguinal hernia repair remains a subject of ongoing debate. In this prospective, randomized controlled multicenter trial, patients with primary or recurrent inguinal hernias were randomized to undergo either Lichtenstein's operation or mesh plug repair. The primary endpoint was the long-term recurrence rate. Secondary endpoints included chronic pain, sensibility disorders, and reoperation rate. In total, 697 hernias in 594 patients were randomized (297 patients per group). At a median follow-up of 6.5 years, 528 (76%) operated hernias in 444 (75%) patients were clinically evaluated. The recurrence rate was similar in both groups [mesh plug: 21/268 hernias = 7.8%; Lichtenstein: 21/260 hernias = 8.1%; adjusted odds ratio (OR): 0.92; 95% confidence interval (CI): 0.51, 1.68; P = 0.795]. We did not find a significant difference for chronic pain (Visual Analog Scale score >3) (OR: 0.58; 95% CI: 0.31, 1.09; P = 0.088) and sensory testing (17% vs 20% of patients; OR: 0.53; 95% CI: 0.21, 1.37; P = 0.190) between the 2 groups. There were less reoperations in the mesh plug than in the Lichtenstein's operation group (OR: 0.43; 95% CI: 0.22, 0.85; P = 0.016). The long-term results of this trial indicate not enough evidence for differences in recurrence, chronic pain, and sensibility disorders between mesh plug repair and Lichtenstein's operation but a lower likelihood for reoperation for mesh plug repair. Estimates for all endpoints were statistically not significant or based on large CIs. ClinicalTrials.gov Identifier: NCT01637818.

Early Complications of Prosthetic Inguinal Hernia Repair

Objectives: to evaluate the use of mesh repair in inguinal hernia and its early complications. Patients & Methods: prospective study, in the period from January 2004 to January 2005. Ninety-one patients who had mesh repair for inguinal hernia in the Ribat University Hospital (Sudan) were the base for this study. Results: tension-free mesh repair was done for 87 males and 4 females. Three patients developed seroma, two patients developed haematoma and one patient developed superficial wound infection. Early recurrence (6 months) was not seen in this study. Conclusions: mesh repair for inguinal hernia is a simple, safe and effective procedure with minimum early complications. Keywords : Inguinal Hernia, Mesh Repair, Complications. Sudan Journal of Medical Sciences Vol. 3 (3) 2008: pp. 207-210

Prevention of Surgical Site Infection After Open Prosthetic Inguinal Hernia Repair: Efficacy of Parenteral Versus Oral Prophylaxis with Amoxicillin‐Clavulanic Acid in a Randomized Clinical Trial

The aim of this prospective study was to compare the efficacy of oral versus parenteral prophylactic amoxicillin-clavulanic acid for preventing surgical site infection after open prosthetic mesh repair of inguinal hernia. A total of 480 inguinal-hernia patients were randomly assigned to two groups. Group I (n = 240) received 1.313 g oral amoxicillin-clavulanic acid 2 hours before operation, and group II (n = 240) received 1.2 g of the same drug combination intravenously approximately 30 minutes before surgery. Patients were examined four times during 1 year of follow-up (at 7-10 days, 4-6 weeks, 6 months, and 12 months postoperation), and data related to surgical site infections were collected. Seventy-two patients were excluded due to confounding factors during and after the operation. There were no statistically significant differences between group I (final n = 208) and group II (final n = 200) with respect to age, sex distribution, body mass index, American Anesthesiology Association grade, frequencies of different hernia types, duration of surgery, and the experience levels of the principal surgeon in the operations. One of the 208 (0.5%) patients in group I and 3 of the 200 (1.5%) patients in group II developed superficial surgical site infections (p > 0.05). None of the infections required mesh removal. There were no deep surgical site infections in either group, and there was one case of hernia recurrence in each group. For patients undergoing open prosthetic repair of inguinal hernia, oral amoxicillin-clavulanic acid is safe, significantly less costly, and equally effective in preventing surgical site infection as the same dose given parenterally.

Recurrences after prosthetic repair of inguinal hernias by the lichtenstein technique

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

Invited comment on Kama, et al:Factors affecting recurrence in tension-free hernioplasties and Bal�n, et al:Reccurrence after prosthetic repair of inguinal hernias by the Lichtenstein technique

Invited comment on Kama, et al:Factors affecting recurrence in tension-free hernioplasties and Bal�n, et al:Reccurrence after prosthetic repair of inguinal hernias by the Lichtenstein technique

Laparoscopic repair of inguinal hernias using a totally extraperitoneal prosthetic approach.

This report describes a laparoscopic procedure for prosthetic repair of inguinal hernias using an extraperitoneal approach. A total of 51 primary direct and indirect hernias were repaired in this series, including 11 recurrent and 12 bilateral hernias. Operative time for this laparoscopic procedure was similar to that of the comparable open surgery and no unusual complications were noted. All patients were discharged the day following surgery and returned to work within 7 days.