Bilateral Hernias in the Female

An experience with 216 bilateral hernias in female patients is reviewed. The condition is rare, occurring only once in every 250 patients admitted for a hernia repair. Bilateral primary indirect inguinal hernias were the most frequent type. Bilateral primary femoral hernias were quite rare while bilateral primary direct inguinal hernias were even more uncommon. Other rare bilateral combinations are briefly described. The incidence in children is given.Etiological factors are discussed, emphasizing the strong posterior wall of the inguinal canal in females.Two per cent of patients developed a recurrent hernia; one per cent of hernias recurred. No recurrence following a bilateral primary indirect inguinal hernia repair and no “femoral” recurrence following inguinal repair were recorded.     

The surgical repair of inguinal and femoral hernias

This paper is based on 15,000 hernia repairs performed by the author at the Shouldice Hospital, Toronto. Experience with more than 75,000 consecutive herniorrhaphies performed in this hospital from 1945 to 1970 is reviewed in four parts — statistics, including recurrence rates; the management of the patient with a primary uncomplicated hernia, emphasizing in particular the preoperative phase, the sedation given, the local anesthetic used in 95% of cases and the postoperative phase; the technique of repair of a primary inguinal hernia; and a review of experience with primary and recurrent femoral hernias, emphasizing the different problems in men and women, and describing the technique of femoral repair.     

Volume of procedures and risk of recurrence after repair of groin hernia: national register study

Objective To determine whether the association between volume and outcome found in major surgery also holds true for a minor operation.Design Review of outcomes after hernia surgery in Sweden.Setting Surgical units registered with the Swedish hernia register, which in 2004 covered about 95% of all hernia operations in Sweden.Participants 86 409 patients over 15 years, who underwent 96 601 unilateral or bilateral groin hernia repairs (94 077 inguinal and 2524 femoral) in 1996-2004 at the participating surgical units.Main outcome measure Re-operation for recurrence.Results There was a significantly higher rate of re-operation in surgeons who carried out 1-5 repairs a year than in surgeons who carried out more repairs. There was no association between outcome and further increases in volume. Although about half of surgeons in Sweden who repair hernias are low volume operators, they performed only 8.4% of all repairs.Conclusions Sweden’s numerous low volume hernia surgeons perform such a small proportion of all operations that the impact of their inferior results on the nationwide re-operation rate is minimal. Volume indicates an approximate minimum value for the number of hernia repairs a surgeon should do each year but the outcome in surgeons who carry out more than that number disqualifies volume as an indicator of proficiency.     

Risk of incarceration of inguinal hernia among infants and young children awaiting elective surgery

Background

We determined the rate of incarceration of inguinal hernia among infants and young children waiting for elective surgery and examined the relation to wait times. We also explored the relation between wait times and the use of emergency department services before surgery.

Methods

We used linked data from administrative databases to identify infants and children less than 2 years of age who underwent surgical repair of an inguinal hernia between Apr. 1, 2002, and Mr. 31, 2004. We determined the rate of hernia incarceration during the wait for surgery and stratified the risk by patient age and sex. We used logistic regression analysis to examine factors associated with hernia incarceration and wait times.

Results

A total of 1065 infants and children less than 2 years old underwent surgical repair of an inguinal hernia during the study period. The median wait time was 35 days (interquartile range 17–77 days). Within 30 days after diagnosis, 126 (11.8%) of the patients had at least 1 emergency department visit; 23.8% of them presented with hernia incarceration. The overall rate of hernia incarceration was 11.9%. The rate was 5.2% with a wait time of up to 14 days (median time from diagnosis to first emergency department visit), as compared with 10.1% with a wait time of up to 35 days (median wait time to surgery) (p < 0.001). Factors associated with an increased risk of incarcerated hernia were age less than 1 year (odds ratio [OR] 2.07, 95% confidence interval [CI] 1.32–3.23), female sex (OR 1.75, 95% CI 1.04–2.93) and emergency department visits (1 visit, OR 2.73, 95% 1.65–4.50; ≥ 2 visits, OR 3.77, 95% CI 1.89–7.43). Children less than 1 year old who waited longer than 14 days had a significant 2-fold risk of incarcerated hernia (OR 1.92, 95% CI 1.11–3.32).

Interpretation

A wait time for surgery of more than 14 days was associated with a doubling of the risk of hernia incarceration among infants and young children with inguinal hernia. Our data support a recommendation that inguinal hernias in this patient population be repaired within 14 days after diagnosis.Inguinal hernias in infants and young children are a result of a failure of the processus vaginalis to close.¹ Once diagnosed, an inguinal hernia should be promptly repaired on an elective basis to prevent the risk of hernia incarceration. Incarceration occurs in about 12% of infants and young children with an inguinal hernia. The incidence is highest (approaching 30%) among infants (< 1 year old).² Boys who experience incarceration of an inguinal hernia have a 30% risk of testicular atrophy that may affect future fertility.³Many countries are struggling with long wait times for elective surgical procedures.^4–6 To date, research has been skewed toward examining wait times for surgery and other medical or diagnostic care in adults.^7–10 Prolonged wait times for surgery to repair hernias have not been associated with adverse outcomes in adults,¹¹ but the effect of prolonged wait times in children has not been well studied.^1,12We conducted this study to examine the relation between wait times for elective surgery and the risk of incarceration of inguinal hernia in infants and young children. We also explored the relation between wait times and the use of emergency department services before surgery.     

局麻下无张力修补腹股沟疝56例分析

目的总结无张力疝修补治疗腹股沟疝56例的效果。方法局麻下、使用聚丙烯编织而成的平片对56例各类腹股沟疝患者进行无张力修补治疗。结果与在硬麻或全麻下与传统的修补方法相比,具有手术适应证广、方法简单、创伤小,恢复快,并发症少和复发低率。结论应用国产的平片修补腹股沟疝效果良好,价格便宜,局麻下施行无张力疝修补术适合在基层医院推广。     

The Totally Extraperitoneal Method versus Lichtenstein's Technique for Inguinal Hernia Repair: A Systematic Review with Meta-Analyses and Trial Sequential Analyses of Randomized Clinical Trials

Background

Lichtenstein''s technique is considered the reference technique for inguinal hernia repair. Recent trials suggest that the totally extraperitoneal (TEP) technique may lead to reduced proportions of chronic pain. A systematic review evaluating the benefits and harms of the TEP compared with Lichtenstein''s technique is needed.

Methodology/Principal Findings

The review was performed according to the ‘Cochrane Handbook for Systematic Reviews’. Searches were conducted until January 2012. Patients with primary uni- or bilateral inguinal hernias were included. Only trials randomising patients to TEP and Lichtenstein were included. Bias evaluation and trial sequential analysis (TSA) were performed. The error matrix was constructed to minimise the risk of systematic and random errors. Thirteen trials randomized 5404 patients. There was no significant effect of the TEP compared with the Lichtenstein on the number of patients with chronic pain in a random-effects model risk ratio (RR 0.80; 95% confidence interval (CI) 0.61 to 1.04; p = 0.09). There was also no significant effect on number of patients with recurrences in a random-effects model (RR 1.41; 95% CI 0.72 to 2.78; p = 0.32) and the TEP technique may or may not be associated with less severe adverse events (random-effects model RR 0.91; 95% CI 0.73 to 1.12; p = 0.37). TSA showed that the required information size was far from being reached for patient important outcomes.

Conclusions/Significance

TEP versus Lichtenstein for inguinal hernia repair has been evaluated by 13 trials with high risk of bias. The review with meta-analyses, TSA and error matrix approach shows no conclusive evidence of a difference between TEP and Lichtenstein on the primary outcomes chronic pain, recurrences, and severe adverse events.     

腹腔镜腹股沟疝修补术患者术后出血及二次手术相关因素分析

目的:探讨影响腹腔镜腹股沟疝修补术患者术后出血及二次手术相关因素。方法:回顾性分析行腹腔镜腹股沟疝修补术的6632例患者的临床资料,将凝血病、抗凝治疗或抗血小板治疗的829例患者归入风险组(n=829),其他患者归为对照组(n=5803),收集并比较二组患者的手术方式、年龄、性别、美国麻醉师协会(ASA)分级、疝缺损面积(I-III级)、一期手术与二次手术等患者资料,进行一年随访;采用多变量分析影响患者继发性出血及并发症所致二次手术的相关因素。结果:风险组的术后出血发生率显著高于对照组(4.22%vs 1.26%,P0.001),所有患者术后出血发生率为1.63%。影响术后继发性出血的其它负面因素有:开放式腹股沟疝术式、年龄增加、较高ASA分级、二次手术、男性和较大的疝缺损。风险组与并发症相关的二次手术发生率显著高于对照组(2.65%vs 1.14%,P0.001),所有患者与并发症相关的二次手术发生率为1.32%。影响患者并发症所致二次手术负面因素有:双侧手术、较高ASA分级、凝血病与抗凝治疗和抗血小板治疗、高龄,保护因素包括:较小的疝缺损面积与腹腔镜手术式。结论:行腹腔镜腹股沟疝手术患者术后出血性及并发症相关的二次手术的风险小于行开放术式患者。     

THE LARGE INGUINAL RING—Its Significance in the Diagnosis of Inguinal Hernia

A large external inguinal ring is often reported by a medical examiner as a “potential hernia.” This finding may cause the subject to be denied job opportunities and may make him apprehensive about many normal activities.The author believes that unless a sac is present and is causing symptoms that necessitate surgical relief, the term hernia should not be used, regardless of how it is qualified. The ordinary intraabdominal stresses due to coughing, sneezing, etc. increase intraabdominal tension more than heavy lifting, except with loads of nearly the body''s own weight. The lifetime effect of such stresses can contribute to the development of a direct hernia, but most of these cannot be eliminated.     

Marlex? Mesh in Incisional and Inguinal Herniorrhaphy

Marlex® mesh was used in 31 cases of inguinal herniorrhaphy and in 15 cases incisional herniorrhaphy in a five-year period. In 14 of the inguinal and six of the incisional cases the hernias were recurrent. Marlex® mesh was used in one case to reenforce the transthoracic repair of eventration of the diaphragm, and in another to reenforce the transthoracic repair of an esophageal hiatal hernia.There were no recurrences. In one case after inguinal herniorrhaphy the mesh was removed because of persistent drainage. Wound infections occurred in two patients with incisional herniorrhaphy, and two others had the accumulation of serous fluid subcutaneously necessitating aspiration of fluid.     

Longitudinal Treatment Outcomes of Microsurgical Treatment of Neurosensory Deficit after Lower Third Molar Surgery: A Prospective Case Series

Objective

To prospectively evaluate the longitudinal subjective and objective outcomes of the microsurgical treatment of lingual nerve (LN) and inferior alveolar nerve (IAN) injury after third molar surgery.

Materials and Methods

A 1-year longitudinal observational study was conducted on patients who received LN or IAN repair after third molar surgery-induced nerve injury. Subjective assessments (“numbness”, “hyperaesthesia”, “pain”, “taste disturbance”, “speech” and “social life impact”) and objective assessments (light touch threshold, two-point discrimination, pain threshold, and taste discrimination) were recorded.

Results

12 patients (10 females) with 10 LN and 2 IAN repairs were recruited. The subjective outcomes at post-operative 12 months for LN and IAN repair were improved. “Pain” and “hyperaesthesia” were most drastically improved. Light touch threshold improved from 44.7g to 1.2g for LN repair and 2g to 0.5g for IAN repair.

Conclusion

Microsurgical treatment of moderate to severe LN injury after lower third molar surgery offered significant subjective and objective sensory improvements. 100% FSR was achieved at post-operative 6 months.     

腹股沟疝腹腔镜下修补术与无张力修补术应用于老年患者的综合疗效研究

目的:腹股沟疝是外科中最常见的疾病之一,手术治疗是腹股沟疝的惟一可靠方法。腹腔镜下腹股沟疝修补术,尤其是完全腹膜外腹腔镜(Totally Extra-preperioneal Prosthetic,TEP)疝修补术,已经成为腹股沟疝治疗的"金标准"。然而,针对65岁以上老年人群,心血管基础疾病较多,全麻风险大,TEP术式疗效是否优于无张力疝修补术还未有报道,本研究拟探讨针对老年人腹股沟疝修补的最佳手术方式。方法:排除两种修补术明确的禁忌症患者,对研究入组的92例≥65岁腹股沟疝老年患者,根据手术方式(TEP术或无张力疝修补术)进行分组,术后分别统计:(1)围手术期评价指标(手术时间、术中出血量、手术并发症、疼痛等级、离床活动时间、住院时间及住院总费用);(2)远期随访指标(术后2年内的慢性疼痛和复发情况)。综合评估腹腔镜下修补术与无张力修补术应用于老年腹股沟疝气治疗的综合疗效。结果:TEP术相比于无张力疝术只显示出在平均减少20 m L出血量及缓解术后24小时1个AVS疼痛数量级的优势(P0.01);在术后下床活动时间、手术时间、术后96小时疼痛指数、围手术期并发症、住院天数、慢性疼痛指数及远期疗效等主要评价指标中均与无张力修补术相当(P0.05);但却大大增加了手术费用(P0.01)。结论:针对≥65岁腹股沟疝老年患者,尤其是基础疾病多,对医疗费用敏感的人群,开展无张力修补术仍不失为目前最佳选择。     

Is Postoperative Wound Infection Following Simple Inguinal Herniorrhaphy a Predisposing Cause of Recurrent Hernia?

The significance of postoperative wound infection in simple inguinal herniorrhaphy was studied in a series of almost 26,000 simple inguinal herniorrhaphies. There was a recurrence rate of about 1% in uninfected cases and 4% in infected cases. The wound infection rate was 1.8%. Of about 2500 patients with recurrent inguinal hernia admitted to the Shouldice Hospital, Toronto, following an initial operation of elsewhere, about 4% gave a history of postoperative wound infection. Postoperative wound infection after simple inguinal herniorrhaphy increased the risk of a subsequent recurrent hernia about four times. However, in more than 95% of cases other etiological factors were responsible for the recurrence. No relation between infection and type of recurrent inguinal hernia subsequently developing was demonstrable.     

Incidence of Incisional Hernia after Cesarean Delivery: A Register-Based Cohort Study

Objective

To estimate the incidence of incisional hernias requiring surgical repair after cesarean delivery over a 10-year period.

Methods

This population- and register-based cohort study identified all women in Denmark with no history of previous abdominal surgery who had a cesarean delivery between 1991 and 2000. The cohort was followed from their first until 10 years after their last cesarean delivery within the inclusion period or until the first of the following events: hernia repair, death, emigration, abdominal surgery, or cesarean delivery after the inclusion period. For women who had a hernia repair, hospital records regarding the surgery and previous cesarean deliveries were tracked and manually analyzed to validate the relationship between hernia repair and cesarean delivery. Data were analyzed with a competing risk analysis that included each cesarean delivery.

Results

We identified 57,564 women who had had 68,271 cesarean deliveries during the inclusion period. During follow-up, 134 of these women had a hernia requiring repair. Of these 68 (51% [95% CI 42–60%]) were in a midline incision although the transverse incision was the primary approach at cesarean delivery during the inclusion period. The cumulated incidence of a hernia repair within 10 years after a cesarean delivery was 0.197% (95% CI 0.164–0.234%). The risk of a hernia repair was higher during the first 3 years after a cesarean delivery, with an incidence after 3 years of 0.157% (95% CI 0.127–0.187%).

Conclusions

The overall risk of an incisional hernia requiring surgical repair within 10 years after a cesarean delivery was 2 per 1000 deliveries in a population in which the transverse incision was the primary approach at cesarean delivery.     

Randomised controlled trial of laparoscopic versus open mesh repair for inguinal hernia: outcome and cost

Objective: To compare tension-free open mesh hernioplasty under local anaesthetic with transabdominal preperitoneal laparoscopic hernia repair under general anaesthetic. Design: A randomised controlled trial of 403 patients with inguinal hernias. Setting: Two acute general hospitals in London between May 1995 and December 1996. Subjects: 400 patients with a diagnosis of groin hernia, 200 in each group. Main outcome measures: Time until discharge, postoperative pain, and complications; patients’ perceived health (SF-36), duration of convalescence, and patients’ satisfaction with surgery; and health service costs. Results: More patients in the open group (96%) than in the laparoscopic group (89%) were discharged on the same day as the operation (χ²=6.7; 1 df; P=0.01). Although pain scores were lower in the open group while the effect of the local anaesthetic persisted (proportional odds ratio at 2 hours 3.5 (2.3 to 5.1)), scores after open repair were significantly higher for each day of the first week (0.5 (0.3 to 0.7) on day 7) and during the second week (0.7 (0.5 to 0.9)). At 1 month there was a greater improvement (or less deterioration) in mean SF-36 scores over baseline in the laparoscopic group compared with the open group on seven of eight dimensions, reaching significance on five. For every activity considered the median time until return to normal was significantly shorter for the laparoscopic group. Patients randomised to laparoscopic repair were more satisfied with surgery at 1 month and 3 months after surgery. The mean cost per patient of laparoscopic repair was £335 (95% confidence interval £228 to £441) more than the cost of open repair. Conclusion: This study confirms that laparoscopic hernia repair has considerable short term clinical advantages after discharge compared with open mesh hernioplasty, although it was more expensive.

Key messages

• In the 4 hours after surgery laparoscopic hernia repair with general anaesthesia causes more pain than open repair with local anaesthesia (mainly because of the anaesthesia used) and necessitates longer stay in hospital. Laparoscopic hernia repair, however, causes less pain than open hernia repair during the first 2 weeks after discharge
• Laparoscopic hernia repair results in fewer episodes of wound infection, persistent local pain, genital swelling, numbness, and constipation than open repair. Urinary disturbances are more common after laparoscopic than after open repair
• Patients’ perception of health 1 month after the operation (assessed with the SF-36) and satisfaction with treatment is superior for laparoscopic patients who also have a shorter period of convalescence after surgery
• The health service cost of day case laparoscopic repair is £335 more than the cost of open mesh hernioplasty performed on a day case basis

     

充填式无张力疝修补术及并发症防治

目的：探讨无张力疝修补术的应用价值及及并发症防治的意义。方法：回顾性分析填充式无张力疝修补术治疗腹股沟疝52例的临床资料。结果：全组手术时间（46±22）min,切口均一期愈合,术后3～7d出院,并发症发生率仅1．9％,随访无复发。结论：无张力疝修补术创伤小、疼痛轻、恢复快,是治疗腹股沟疝的最佳术式,熟练的技术和规范化操作是预防并发症发生的关键。     

Quality of life changes after inguinal hernia repair using anterior rectus sheath--a preliminary study

Chronic pain is the most serious long-term complication after groin hernia repair. The aim of this preliminary research was to assess the quality of life before and after standard tension-free mesh repair and new method of tension-free inguinal hernia repair using anterior rectus sheath. Total of 62 patients were evaluated. Anterior rectus sheath method was performed in 29 patients and in 33 patients standard mesh repair was used (Lichtenstein repair). Quality of life was assessed before and after the surgery using short-form SF-36 questionnaire (QualityMetric Inc.), adjusted for Croatian language. There were statistically significant improvements in bodily pain and general health scores in both groups. Patients operated using mesh technique also demonstrated statistically significant improvements in social functioning and emotional role. Similarly, patients in whom inguinal hernia was repaired using anterior rectus sheath had significantly better postoperative scores for physical functioning and role physical scores. Quality of life assessment demonstrated good ability to differentiate between several independent aspects of quality of life. Anterior rectus sheath repair significantly improved quality of life and was shown to be similar to mesh repair in the aspect of physical functioning.     

Genome-wide association study using deregressed breeding values for cryptorchidism and scrotal/inguinal hernia in two pig lines

Background

Cryptorchidism and scrotal/inguinal hernia are the most frequent congenital defects in pigs. Identification of genomic regions that control these congenital defects is of great interest to breeding programs, both from an animal welfare point of view as well as for economic reasons. The aim of this genome-wide association study (GWAS) was to identify single nucleotide polymorphisms (SNPs) that are strongly associated with these congenital defects. Genotypes were available for 2570 Large White (LW) and 2272 Landrace (LR) pigs. Breeding values were estimated based on 1 359 765 purebred and crossbred male offspring, using a binary trait animal model. Estimated breeding values were deregressed (DEBV) and taken as the response variable in the GWAS.

Results

Heritability estimates were equal to 0.26 ± 0.02 for cryptorchidism and to 0.31 ± 0.01 for scrotal/inguinal hernia. Seven and 31 distinct QTL regions were associated with cryptorchidism in the LW and LR datasets, respectively. The top SNP per region explained between 0.96% and 1.10% and between 0.48% and 2.77% of the total variance of cryptorchidism incidence in the LW and LR populations, respectively. Five distinct QTL regions associated with scrotal/inguinal hernia were detected in both LW and LR datasets. The top SNP per region explained between 1.22% and 1.60% and between 1.15% and 1.46% of the total variance of scrotal/inguinal hernia incidence in the LW and LR populations, respectively. For each trait, we identified one overlapping region between the LW and LR datasets, i.e. a region on SSC8 (Sus scrofa chromosome) between 65 and 73 Mb for cryptorchidism and a region on SSC13 between 34 and 37 Mb for scrotal/inguinal hernia.

Conclusions

The use of DEBV in combination with a binary trait model was a powerful approach to detect regions associated with difficult traits such as cryptorchidism and scrotal/inguinal hernia that have a low incidence and for which affected animals are generally not available for genotyping. Several novel QTL regions were detected for cryptorchidism and scrotal/inguinal hernia, and for several previously known QTL regions, the confidence interval was narrowed down.

Electronic supplementary material

The online version of this article (doi:10.1186/s12711-015-0096-6) contains supplementary material, which is available to authorized users.     

“La vasovasostomie de Shaeer”: comparaison de la voie intra-péritoneale et voie extra-péritoneale en cas d’obstruction inguinale du canal déférent

Introduction

Iatrogenic obstruction of the vas deferens within the inguinal canal can be managed by direct onsite vasovasostomy. However, in cases with large defect of the vas, the anastomosis may be under tension. Dissecting through the site of a previous hernia repair is tedious, and may lead to recurrence of the hernia.

Aim of the Work

The present work reports on an alternative technique that avoids the latter drawbacks.

Patients and Methods

A total of 15 patients with azoospermia due to inguinal obstruction of the vas deferens underwent bilateral repair. Ten cases were operated upon using the classical transperitoneal approach. Under laparoscopic vision, the pelvic vas was rendered intra-peritoneal and its lateral-most end was clipped at the internal inguinal ring, cut and extruded from the abdomen through a port in the external inguinal ring. Vasovasostomy was performed, bridging the retrieved stump of the pelvic vas with the scrotal vas. Five patients were operated upon through the extraperitoneal approach.

Results

By the end of one year. Nine out of the 15 cases showed an average sperm concentration of 17±3.5 million/ml.

Conclusion

Pelvi-scrotal vasovasostomy (PSVV) or Shaeer’s vasovasostomy can be offered as a cost-effective and successful alternative or supplement to intracyto-plasmic sperm injection (ICSI), for cases with iatrogenic large defects of the vas deferens within the inguinal canal. The transperitoneal approach is more convenient in postherniotomy and post-herniorrhaphy cases.     

“Shaeer’s vasovasostomy” for bypassing inguinal obstruction of the vas deferens: intra-peritoneal versus extraperitoneal approaches

Introduction

Latrogenic obstruction of the vas deferens within the inguinal canal can be managed by direct onsite vasovasostomy. However, in cases with large defect of the vas, the anastomosis may be under tension. Dissecting through the site of a previous hernia repair is tedious, and may lead to recurrence of the hernia.

Aim of the Work

The present work reports on an alternative technique that avoids the latter drawbacks.

Patients and Methods

A total of 15 patients with azoospermia due to inguinal obstruction of the vas deferens underwent bilateral repair. Ten cases were operated upon using the classical transperitoneal approach. Under laparoscopic vision, the pelvic vas was rendered intraperitoneal and its lateral-most end was clipped at the internal inguinal ring, cut and extruded from the abdomen through a port in the external inguinal ring. Vasovasostomy was performed, bridging the retrieved stump of the pelvic vas with the scrotal vas. Five patients were operated upon through the extraperitoneal approach.

Results

By the end of one year. Nine out of the 15 cases showed an average sperm concentration of 17±3.5 million/ml.

Conclusion

Pelvi-scrotal vasovasostomy (PSVV) or Shaeer’s vasovasostomy can be offered as a cost-effective and successful alternative or supplement to intracytoplasmic sperm injection (ICSI), for cases with iatrogenic large defects of the vas deferens within the inguinal canal. The transperitoneal approach is more convenient in post-herniotomy and post-herniorrhaphy cases.