Use Of Lightweight Mesh Research Articles

An international survey of 1014 hernia surgeons: outcome of GLACIER (global practice of inguinal hernia repair) study.

The practice of inguinal hernia repair varies internationally. The global practice of inguinal hernia repair study (GLACIER) aimed to capture these variations in open, laparoscopic, and robotic inguinal hernia repair. A questionnaire-based survey was created on a web-based platform, and the link was shared on various social media platforms, personal e-mail network of authors, and e-mails to members of the endorsed organisations, which include British Hernia Society (BHS), The Upper Gastrointestinal Surgical Society (TUGSS), and Abdominal Core Health Quality Collaborative (ACHQC). A total of 1014 surgeons from 81 countries completed the survey. Open and laparoscopic approaches were preferred by 43% and 47% of participants, respectively. Transabdominal pre-peritoneal repair (TAPP) was the favoured minimally invasive approach. Bilateral and recurrent hernia following previous open repair were the most common indications for a minimally invasive procedure. Ninety-eight percent of the surgeons preferred repair with a mesh, and synthetic monofilament lightweight mesh with large pores was the most common choice. Lichtenstein repair was the most favoured open mesh repair technique (90%), while Shouldice repair was the favoured non-mesh repair technique. The risk of chronic groin pain was quoted as 5% after open repair and 1% after minimally invasive repair. Only 10% of surgeons preferred to perform an open repair using local anaesthesia. This survey identified similarities and variations in practice internationally and some discrepancies in inguinal hernia repair compared to best practice guidelines, such as low rates of repair using local anaesthesia and the use of lightweight mesh for minimally invasive repair. It also identifies several key areas for future research, such as incidence, risk factors, and management of chronic groin pain after hernia surgery and the clinical and cost-effectiveness of robotic hernia surgery.

Comparison of Early Postoperative Pain between Lightweight Mesh and Heavyweight Mesh in Lichtenstein Hernia Repair for Geriatric Patients at Rumah Sakit Siloam Karawaci from January 2018 - December 2019

<p><strong>Background: </strong>Inguinal hernias are one of the most often cases in surgery. Inguinal hernias are usually found in males rather than females. There are two types of meshes in inguinal hernia repairs: heavyweight and lightweight mesh. There were still a lot of differences in the outcome of each mesh that was used. Therefore, with various different post operative pain results from past research, the author expresses an interest to conduct a research on this topic towards geriatric patients<strong>.</strong></p><p><strong>Methods: </strong>In this cross-sectional comparative study, 45 patients using heavyweight mesh and 45 patients using lightweight mesh herniorrhaphy with Lichtenstein technique in inguinal hernias at RS Siloam Karawaci Lippo Village and RSU were reviewed retrospectively. Patient's data were taken from medical record using purposive-sampling method. Early Postoperative pain on day 1 until 7 were classified following the Visual Analogue Scale (VAS). Incidence of postoperative infection and seroma were assessed in both groups. Collected samples will be processed using Pearson's Chi-Squared test.</p><p><strong>Result: </strong>This study shows that there is a significant difference between the use of lightweight mesh in reducing moderate early postoperative pain for men above the age of 60 years old (p = 0.025) rather than the use of heavyweight mesh. Incidence of other postoperative complications such as infection and seroma have no statistically difference between both groups.</p><strong>Conclusions: </strong>The use of lightweight mesh has the advantage in reducing early postoperative pain from herniorrhaphy using Lichtenstein technique rather than heavyweight mesh in men above 60 years old.

Laparosopic treatment of strangulation of inguinal hernias

The aim – to improve the results of treatment of patients with strangulation inguinal hernias by laparoscopic technologies use in lightweight mesh implants, fixed themselves, technology electric fabrics [1–9].
 Materials and methods. A retrospective analysis of 125 videolaparoscopic surgery for inguinal hernia in 112 (89.6 %) men and 13 (10.4 %) of women aged 17–84 (57.0 ± 19.8) years for transabdominal preperetonial patch (TAPP) technique using different mesh implants at the Department of Surgery, anesthesiology and intensive care postgraduate education of the National Medical University named after A. A. Bogomolets, for the period from 2018 to 2020. Results and discussion. Recurrence [3] were in the first group and reasonable, in our opinion, insufficient size of mesh material. Further, using prostheses that were on a lower side 10 cm, recurrence was observed. Detection of hematoma was evacuated puncture under ultrasound. In 2 cases of hematoma encountered when using conventional polypropylene mesh were due to inadequate hemostasis. Hematoma using heavy monofilament polyester mesh with that fixed itself, caused by the brutality of the prosthesis surface damage and muscle-aponeurotic "platform" to which it is fixed. So when using light grids, fixed themselves, there was no bruising at all. Complications. 1. The use of lightweight mesh, fixed themselves laparoscopic treatment of strangulation hernia for TAPP technique avoids hematoma, reduce the amount of gray in the operation area, practically non- inguinal pain syndrome in the postoperative period. 2. The use of mesh implants, fixed themselves methodologies Electric soft tissue material can reduce transaction costs 2 times that fosters the popularization of laparoscopic approach.

Lightweight mesh is recommended in open inguinal (Lichtenstein) hernia repair: A systematic review and meta-analysis

BackgroundThe use of lightweight mesh for inguinal hernia repair has been suggested to be preferable compared with heavyweight mesh. Nevertheless, surgeons do not use lightweight mesh routinely, possibly owing to the higher price and lack of confidence in evaluation of previous evidence. The aim of this systematic review and meta-analysis is to update the available randomized controlled trials and provide a recommendation on the use of lightweight mesh or heavyweight mesh in open inguinal hernia repair. MethodsA literature search was conducted in May 2019 in MEDLINE, Embase and the Cochrane library for randomized controlled trials comparing lightweight (≤50 g/m2) and heavyweight (>70 g/m2) mesh in patients undergoing open (Lichtenstein) surgery for uncomplicated inguinal hernias. Outcomes were recurrences (overall, after direct or indirect repair), chronic pain (analyzing any and severe pain), and the feeling of a foreign body. The level of evidence was assessed using GRADE. Risk ratios and 95% confidence intervals were calculated by random effect meta-analyses. ResultsTwenty-one randomized controlled trials involving 4,576 patients (lightweight mesh 2,257 vs heavyweight mesh 2,319) were included. Follow-up ranged from 3 to 60 months. No difference between lightweight mesh and heavyweight mesh was determined for recurrence rates (lightweight mesh 42 of 2,068 and heavyweight mesh 34 of 2,132; risk ratios 1.22; 95% confidence interval, 0.76–1.96) or severe pain (lightweight mesh 14 of 1,517 and heavyweight mesh 26 of 1,591; risk ratios 0.73; 95% confidence interval, 0.38–1.41). A significant reduction was seen for any pain after lightweight mesh (234 of 1,603) compared with heavyweight mesh (322 of 1,683; risk ratios 0.78; 95% confidence interval, 0.64–0.96) and for the feeling of a foreign body (lightweight mesh 130 of 1,053 and heavyweight mesh 209 of 1,035; risk ratios 0.64; 95% confidence interval, 0.51–0.80). ConclusionLightweight mesh should be used in open (Lichtenstein) inguinal hernia repair.

Meta-Analysis of Randomized Controlled Trials Comparing Lightweight and Heavyweight Mesh for Laparoscopic Total Extraperitoneal Inguinal Hernia Repair

The aim of this study was to compare the outcomes of lightweight and heavyweight mesh on postoperative recovery in laparoscopic total extraperitoneal (TEP) inguinal hernia repair. PubMed, Embase, Science Citation Index, and the Cochrane Library were used to search for published clinical randomized controlled trials, which compared lightweight meshes with heavyweight meshes in TEP inguinal hernia repair. The outcomes were calculated as risk ratios with 95 per cent confidence intervals using RevMan 5.2. Eight randomized controlled trials were included. Compared with a heavyweight mesh, the lightweight mesh led to a higher incidence of recurrence (risk ratio = 2.52, 95% confidence interval 1.10-5.81; P = 0.03). There was no significant difference in chronic moderate to severe pain, foreign body sensation, and seroma. The use of lightweight mesh is not recommended for TEP inguinal hernia repair.

Comparative study between use of lightweight mesh versus heavyweight mesh in laparoscopic repair of inguinal hernia

Introduction Inguinal hernia repair with prosthetic mesh has become a standard practice; however, synthetic mesh can cause significant pain and interfere with patient activity. Lighter weight meshes (LWM) have been engineered that may be associated with fewer rates of complications and recurrence. Laparoscopic inguinal hernia repair has also significantly reduced postoperative recovery from inguinal hernia repair. Aim This study aimed to compare outcomes of laparoscopic transabdominal preperitoneal repair of inguinal hernia using LWM versus using heavyweight mesh (HWM). Materials and methods A prospective study was performed on 20 patients (10 in LWM group and 10 in HWM group) with unilateral primary inguinal hernia above 18 years old who underwent laparoscopic transabdominal preperitoneal inguinal hernia repair from July 2018 to October 2018. Postoperative complications such as pain, seroma, mesh infection, and recurrence were evaluated. Results LWM is superior to HWM regarding postoperative pain on the first postoperative day and after 1 week and earlier time to return to routine daily activities, but with longer operative time. However, there is no statistically significant difference between LWM group and heavy and HWM group regarding postoperative long-term complications including chronic groin pain, seroma formation, mesh infection, and recurrence after 6 months of follow-up. Conclusion LWM is superior to HWM in terms of postoperative pain and early return to routine activity but with longer operative time. Both meshes are similar in results regarding chronic pain, postoperative complications, and recurrence.

Immunological reaction and oxidative stress after light or heavy polypropylene mesh implantation in inguinal hernioplasty: A CONSORT-prospective, randomized, clinical trial.

The relationship between mesh weight and host tissue reaction has, so far, not been fully investigated. Lightweight meshes (LWM) are thought to give less inflammatory response compared with heavyweight meshes (HWM). The present study is a randomized, controlled, double-blind clinical trial performed in 61 patients who underwent an elective inguinal hernioplasty. The primary outcome of the study was to investigate the relationship between total amount of prosthetic material (polypropylene), immunological reaction, and oxidative stress. The study was double-blinded. Sixty-one patients were recruited for the study and randomly assigned to 2 groups (groups A and B). Levels of inflammation markers (interleukin-6 [IL-6] and tumor necrosis factor-α [TNF-α]) and oxidative stress markers (reduced glutathione [GSH] and lipid hydroperoxides [LOOH]) were determined preoperatively and after undergoing inguinal hernioplasty (after 6, 72, and 288 hours), respectively, with LWM and HWM. There was no significant difference in IL-6 levels between HWM and LWM (P = 0.3, 0.7, 0.8 after 6, 72, and 288 hours, respectively). A statistically significant difference was found after 72 hours for TNF-α (P = 0.01), for GSH after 6 hours (P < 0.01), and after 6 and 72 hours for LOOH (P = 0.05, 0.01, respectively). Oxidative stress occurred at earlier time points and was pore accentuated HWM versus LWM and prodromal to TNF-α increase.Also, in randomized clinical trial, the use of LWM gives advantages in terms of less inflammatory response when compared with HWM. Moreover, there is a significant higher oxidative stress after implantation of HWM. The intensity of oxidative stress seems to be strongly related to the amount of implanted polypropylene. (Trial registration number: NCT01090284).

Randomized clinical trial comparing lightweight or heavyweight mesh for mesh plug repair of primary inguinal hernia

The aim of this study was to assess whether the application of a lightweight mesh for mesh plug repair (MPR) for primary inguinal hernia could reduce chronic pain or other symptoms associated with the insertion of the prosthesis. Patients over 20 years of age with a unilateral primary inguinal hernia were eligible to participate in the study. The patients were randomly assigned to a lightweight mesh (LWM) or a heavyweight mesh (HWM) group. All the operations were performed under local anesthesia. The operative details, including the hernia type and the nerves that were identified, and the postoperative complications were recorded. All follow-up and outcome measures were obtained based on a physical examination and a questionnaire regarding pain and other symptoms at 1 week, 1, 3, 6, and 12 months after the surgery in a double-blinded manner. The use of LWM significantly reduced foreign body sensation after 12 months to one-third of the incidence reported for the use of HWM (5.8 vs. 17.9%; P = 0.013), while no significant differences were found in pain parameters, including the use of pain relief medications, between the groups throughout the study period. This study indicated that the use of LWM in the MPR decreases the incidence of foreign body sensation at 1 year after surgery for primary inguinal hernia. LWM may be preferable to MPR, similar to results described previously for Lichtenstein repair.

Systematic review and meta-analysis on heavy and lightweight polypropylene mesh in Lichtenstein inguinal hernioplasty

Recurrence and pain are the two most important outcomes after inguinal hernia surgery. The concept of lightweight or partially absorbable macroporous meshes was developed under the assumption that the observed pain rate could be decreased without increasing the number of recurrences. Few randomized trials were published to analyze their clinical value, and some concern was raised because of an increased risk of recurrence. A systematic review and a meta-analysis of RCTs were carried out to determine whether the use of lightweight meshes influenced the pain and recurrence rate after Lichtenstein hernioplasty. To assess the value of the lightweight mesh, an extensive literature search was performed. The random-effect meta-analysis model was used to correct for clinical diversity and methodological variations between studies. Recurrence rate, aspects of chronic pain and foreign body feeling at 6-60 months postoperatively were assessed. Eight prospective RCTs of good quality were identified. Analysis demonstrated no significant difference regarding recurrence (OR, 1.11; 95 % CI, 0.57-2.14; p = 0.77). No significant difference was observed concerning severe pain (OR, 0.99; 95 % CI, 0.48-2.02; p = 0.97). Description of any pain resulted in a significant improvement in the lightweight group (OR, 0.65; 95 % CI, 0.50-0.84; p = 0.001). The presence of foreign body feeling was favoring the lightweight group (OR, 0.62; 95 % CI, 0.41-0.94; p = 0.02). The use of lightweight mesh did not neither increase the recurrence rate nor reduce the incidence of severe pain. A significant reduction in foreign body feeling and overall pain rate in the postoperative period was recorded. Lightweight meshes could be considered as a material of choice in primary inguinal hernioplasty.

Randomized clinical trial of laparoscopic hernia repair comparing titanium-coated lightweight mesh and medium-weight composite mesh

The use of lightweight meshes in incisional hernia repair could have beneficial effects on quality of life. This study aimed to compare a new titanium-coated lightweight mesh with a standard composite mesh after laparoscopic incisional hernia repair. A randomized controlled single-center clinical trial was designed using the basic principle of one unit, one surgeon, one technique (midline incisional hernia with a laparoscopic approach), and two meshes: a lightweight titanium-coated mesh (group 1) and a medium-weight collagen-polyester composite mesh (group 2) used in 102 patients. The primary end points were pain and recurrence. The secondary end points were morbidity and patient outcomes (analgesic consumption, return to everyday activities). The postoperative complication rates were similar for the two meshes. Pain was significantly less common in group 1 than in group 2 at 1 month (P = 0.029) but was similar for the two groups at 6 months and 1 year. There was a significant difference between the two groups in the average use of analgesics: 6.1 days in group 1 versus 1.6 days in group 2 (P < 0.001). The lightweight group returned to everyday activities after 6.9 days versus 9.7 days for the composite group (P < 0.001). The rate of recurrence did not differ between the two groups at the 2-year follow-up evaluation. The light titanium-covered polypropylene mesh was associated with less postoperative pain in the short term, lower analgesic consumption, and a quicker return to everyday activities than the Parietex composite medium-weight mesh. The recurrence rates at 2 years showed no difference between the two groups.

Meta-analysis of randomized controlled trials comparing lightweight and heavyweight mesh for Lichtenstein inguinal hernia repair

Lichtenstein inguinal hernia repair is associated with a low incidence of recurrence; however, the use of heavyweight mesh has been linked with chronic pain and foreign body sensation. It is hypothesized that the use of lightweight mesh may reduce these problems. This study aims to use meta-analysis to compare lightweight and heavyweight mesh for Lichtenstein inguinal hernia repair. Information was gathered from randomized controlled trials that compared lightweight and heavyweight mesh for Lichtenstein inguinal hernia repair. The Cochrane Library, Medline, EMBASE, trial registries, conference proceedings and reference lists were searched. Primary outcome measures were chronic pain, foreign body sensation and hernia recurrence. Secondary outcome measures were duration of surgery, mean visual analogue scale (VAS) pain scores, surgical-site infection, testicular atrophy and haematoma/seroma. The pooled Peto odds ratio (OR) was calculated for categorical data and weighted mean difference (WMD) for continuous data. Six trials with 1936 hernias were included. Lightweight mesh was associated with reduced chronic pain (OR = 0.67, 95% CI = 0.50-0.90; p < 0.01) and foreign body sensation (OR = 0.43, 95% CI = 0.21-0.93; p < 0.05). Lightweight mesh was also associated with lower VAS pain scores at 3 months after surgery (WMD = -0.35, 95% CI = -0.39 to -0.31; p < 0.0001). There were no differences in hernia recurrence (OR = 1.19, 95% CI = 0.54-2.64; p = 0.66) or other post-operative complications between the two groups. The use of lightweight mesh in Lichtenstein inguinal hernia repair is associated with less chronic pain, and foreign body sensation compared with heavyweight mesh without any difference in recurrence.

Systematic review and meta-analysis of the use of lightweight versus heavyweight mesh in open inguinal hernia repair

The objective of this study was systematically to analyse published randomized trials comparing lightweight mesh (LWM) with heavyweight mesh (HWM) in open inguinal hernia repair. Randomized trials on LWM versus HWM were selected from the standard electronic databases. Reported outcomes were analysed systematically using RevMan. Pooled risk ratios were calculated for categorical outcomes, and mean differences for secondary continuous outcomes, using the fixed-effects and random-effects models for meta-analysis. Nine randomized trials containing 2310 patients were included. There was significant heterogeneity among trials. There was no difference in duration of operation, postoperative pain, recurrence rate, testicular atrophy and time to return to work between LWM and HWM groups. The two mesh types had a similar risk of perioperative complications, but LWM was associated with a reduced risk of developing chronic groin pain (risk ratio (RR) 0·61, 95 per cent confidence interval 0·50 to 0·74) and a reduced risk of developing other groin symptoms, such as stiffness and foreign body sensations (RR 0·64, 0·50 to 0·81). The use of LWM for open inguinal hernia repair was not associated with an increased risk of hernia recurrence. LWM reduced the incidence of chronic groin pain as well as the risk of developing other groin symptoms.

Sutureless hernioplasty with light-weight mesh and fibrin glue versus Lichtenstein procedure: a comparison of outcomes focusing on chronic postoperative pain

Groin hernia is one of the most common disease requiring surgical intervention (8-10% of the male population). Nowadays, the application of prosthetic materials (mesh) is the technique most widely used in hernia repair. Although they are simple and rapid to perform, and lower the risk of recurrence, these techniques may lead to complications. The aim of the present study is to assess the incidence and degree of chronic pain, as well as the impairment in daily life, in two procedures: (1) the "Lichtenstein technique" with polypropylene mesh fixed with non-absorbable suture, and (2) the "sutureless" technique carried out by using a partially absorbable mesh (light-weight mesh) fastened with fibrin glue. This was a study conducted over a period of 3 years from July 2006 to July 2009. A total of 148 consecutive male patients suffering from groin hernia were divided randomly into two groups: (1) Group A: patients operated with "sutureless" technique with partially absorbable mesh and plug fastened with 1 ml haemostatic sealant; (2) Group B: patients operated with Lichtenstein technique using non-absorbable mesh and plug anchored with polypropylene suture. Follow-up took place after 7 days, and 1, 6 and 12 months and consisted of examining and questioning patients about chronic pain as well as the amount of time required to return to their normal daily activities. No major complications or mortality were observed in either group. In group A there was a faster return to work and daily life activities. Six patients (7.8%) in group B suffered from chronic pain, whereas no patient in group A demonstrated this feature. Our experience shows that the combined use of light-weight mesh and fibrin glue gives significantly better results in terms of postoperative pain and return to daily life.

Multicentric observational study of pain after the use of a self-gripping lightweight mesh

Investigation in the field of inguinal hernia surgery is now focused on postoperative pain. The extended use of lightweight meshes and alternative methods of fixation may play a relevant role in the reduction of pain. In this study, a new self-gripping lightweight polypropylene mesh is tested. A multicentric, observational study was scheduled to prospectively evaluate this new mesh. Ten centers agreed to participate. Only primary, type 1 or 2 uncomplicated hernias in adults were included. The mesh was placed as a Lichtenstein procedure without any fixation. A complete pain questionnaire was followed at 1week, and at 1, 3 and 6months postoperatively. The principal goal of the study was to evaluate maximum pain score at 6months. Pain was assessed by a visual analog scale. A total of 256 patients were operated. Mean operative time was 35.6min; 76.2% of patients were operated in an ambulatory setting. There were a few postoperative complications: 2 wound infections, 17 seromas, 21 hematomas, 6 orchitis. The incidence of acute pain was 27.3% at week 1 and 7.5% at month 1. The incidence of chronic pain was 3.6% at month 3 and 2.8% at month 6. No recurrences or long-term complications were observed. This self-gripping mesh can be used safely in type 1 and 2 primary, uncomplicated inguinal hernia with minimal morbidity and most patients under ambulatory setting. The registered incidence of chronic pain is lower than 3%.

Laparoscopic Inguinal Hernia Repair in Men With Lightweight Meshes May Significantly Impair Sperm Motility

To compare quality of life and fertility aspects after laparoscopic inguinal hernia repair in men using a heavyweight or lightweight mesh. The use of lightweight meshes in laparoscopic inguinal hernia repair could have beneficial effects on quality of life and preservation of the spermatic structures due to a decreased foreign-body reaction. A total of 59 male patients planned for primary, unilateral or bilateral inguinal hernia repair were randomized between a standard polypropylene (Marlex) or lightweight mesh (Vypro II, TiMesh). Main outcome measures were fertility aspects, assessed preoperatively and at 1-year follow-up by semen analysis and scrotal ultrasonography. Secondary outcomes were quality of life (SF-36 and McGill Pain Questionnaire) and recurrence up to 1 year postoperatively. Patients operated on with a VyproII or TiMesh mesh exhibited a decreased sperm motility (vs. preoperatively) compared with Marlex patients, respectively -9.5% and -5.5% versus +2% (P = 0.013). When the results after uni- and bilateral hernia repair were analyzed separately, this difference only remained significant in the bilateral hernia subgroup: -10% for VyproII and -17% for TiMesh versus +1% for Marlex (P = 0.037). Other fertility parameters (sperm concentration, morphology, and alpha-glucosidase level) were unchanged. There were no differences at any study point between the 3 groups regarding quality of life. Only for resumption of sport activities was a small advantage noted for VyproII versus Marlex patients (P = 0.045). After 1 year, no recurrences were observed; 3 patients (6%) complained of chronic disabling pain. Our data suggest that the use of lightweight meshes for laparoscopic inguinal hernia repair in male patients negatively influences sperm motility, without any benefit on quality of life. These alterations might be important in a subgroup of young male patients operated on laparoscopically for a bilateral hernia. This study was registered in the clinicaltrials.gov database (ID number NCT00925067).

GS06 A PROSPECTIVE NON‐RANDOMIZED STUDY OF 737 CONSECUTIVE CASES OF LAPAROSCOPIC INGUINAL/FEMORAL HERNIA REPAIR: SUPERIORITY OF THE LAPAROSCOPIC EXTRAPERITONEAL APPROACH BY A SPECIALIST HERNIOLOGIST

Introduction Laparoscopic hernia repair remains controversial. This study aims to assess its safety and efficacy by a specialist herniologist.Materials and Methods A prospective assessment of all patients referred from 1st January 2002 to 31st December 2006 for laparoscopic extra‐peritoneal inguinal/femoral hernia repair was undertaken. Polypropylene mesh was used prior to June 2004 and light weight mesh after. Patients were followed up for 5 years.Results There were 737 hernias performed in 525 patients (including 34 recurrent and 78 Workers Compensation cases) with a median age of 51 years. Mean operation time was 48 minutes for unilateral and 65 minutes for bilateral. Mean follow‐up was 3 years with one recurrence. Conversion to open operation occurred in 4 patients. Day surgery was achieved in 92% of cases with most of those staying overnight for social reasons. There was no mortality. Morbidity was low: 2 cases of urinary retention, 1 case of minor urethral bleeding and 3 cases of pneumomediastinum. Return to work/resumption of full activities occurred at a mean of 14 days. Significant chronic pain occurred in 4 patients (1 with light weight mesh) and all settled with Carbamazepine or Neurontin.Conclusions Laparoscopic inguinal/femoral hernia repair can safely be performed as day cases with zero mortality, minimal morbidity, early resumption of physical activities and low recurrence. The use of light weight mesh resulted in fewer cases of chronic pain. Preoperative catheterization seemed to reduce incidence of urinary retention. Careful preoperative counseling achieved identical resumption of physical activities/work with Workers’ Compensation cases.