Simulation and study of the geometric parameters in the inguinal area and the genesis of inguinal hernias

We are interested in studying the genesis of a very common pathology: the human inguinal hernia. How the human inguinal hernia appears is not definitively clear, but it is accepted that it is caused by a combination of mechanical and biochemical alterations, and that muscular simulation plays an important role in this. This study proposes a model to explain how some physical parameters affect the ability to simulate the region dynamically and how these parameters are involved in generating inguinal hernias. We are particularly interested in understanding the mechanical alterations in the inguinal region because little is known about them or how they behave dynamically. Our model corroborates the most important theories regarding the generation of inguinal hernias and is an initial approach to numerically evaluating this affection.     

Simulation and study of the geometric parameters in the inguinal area and the genesis of inguinal hernias

We are interested in studying the genesis of a very common pathology: the human inguinal hernia. How the human inguinal hernia appears is not definitively clear, but it is accepted that it is caused by a combination of mechanical and biochemical alterations, and that muscular simulation plays an important role in this. This study proposes a model to explain how some physical parameters affect the ability to simulate the region dynamically and how these parameters are involved in generating inguinal hernias. We are particularly interested in understanding the mechanical alterations in the inguinal region because little is known about them or how they behave dynamically. Our model corroborates the most important theories regarding the generation of inguinal hernias and is an initial approach to numerically evaluating this affection.     

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.     

Herniography in symptomatic patients following inguinal hernia repair.

Patients with symptoms at the site of a previous inguinal hernia repair may constitute a diagnostic dilemma. The usefulness of herniography in the assessment of these patients was evaluated at 54 symptomatic sites in 46 subjects. Ten persistent or recurrent hernias were shown by herniography, only 2 of which were definitely detected on physical examination. The herniogram was normal at 44 sites, of which, on physical examination, 5 were equivocal and 1 was diagnosed as a definite hernia. On the unoperated-on or asymptomatic side, a total of 14 hernias were shown herniographically. Of these hernias, 8 were not detected on physical examination. Herniography was found to be more sensitive than physical examination in detecting hernias at the symptomatic, previously operated-on sites, as well as at the unoperated-on or asymptomatic sites. When a herniogram provides corroborative evidence that hernia has not recurred, the need for reexploration may be eliminated.     

Peritoneal fine structure of inguinal hernia: a scanning electron microscope study

Mesothelial cells of the normal human peritoneum of the anterior abdominal wall are covered with numerous surface microvilli. These cells become partially denuded inside the sacs of direct and indirect inguinal hernias and so lose the protective property the microvillar covering may impart on them. These mesothelial cells of hernial sacs also acquire an extensive surface coat of fibrin-like material, presumably due to the loss of that protective property, which may as a result subject them to adhesions. There is a considerable collagen build-up in the subserosal fibrous tissue of sacs of both direct and indirect inguinal hernias. Such a build-up is at variance with the accepted current surgical concept which suggests a defect in collagen synthesis, rather than a build-up, as the cause of direct hernia.     

Genital oedema in patients treated by continuous ambulatory peritoneal dialysis: an unusual presentation of inguinal hernia.

Four patients receiving continuous ambulatory peritoneal dialysis presented with scrotal or labial oedema but no detectable cough impulse. Two of the patients later developed clinical evidence of inguinal hernia, and in the other two inguinal hernias were found at operation. These cases suggest that genital oedema occurring in a patient receiving continuous ambulatory peritoneal dialysis is a sign of a small inguinal hernia which may not be detectable clinically.     

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.     

Sliding indirect inguinal hernia

From 2 per cent to 5 per cent of all indirect inguinal hernias are of the sliding variety. (Sliding hernias are those in which part of the wall of the sac is formed by a viscus.) The proportion of sliding hernias is even higher in the aged. Hernias of this kind are found almost exclusively in males and usually on the left side. Preoperative diagnosis is not essential if the surgeon can recognize the lesion at operation and knows how to repair it properly. The LaRoque technique in which the peritoneal cavity is entered above the internal ring allows accurate definition of the pathological anatomy and effective repair of the hernia. It should be used in all true sliding indirect inguinal hernias.     

High Incidence of Scrotal Hernias in a Closed Colony of FVB Mice

Although inguinal hernias are rarely reported to occur in mice, a high incidence of scrotal hernias was observed in a closed breeding colony of FVB/N mice. Unilateral or bilateral hernias occurred in more than 20% of the male mice in the colony that were available for necropsy over 3 inbred and 1 outcross generations; no female mice were affected. Organs commonly present within the hernial sac included the cecum and seminal vesicles. Hernias did not adversely affect the fertility or lifespan of the affected male mice. Although the condition was heritable, no clear pattern of transmission was evident.During development, the testes descend from the abdominal cavity through the inguinal canal and into the scrotum, guided by the processus vaginalis. In primates and carnivores, the processus vaginalis is largely or entirely obliterated during late gestation.¹³ When correct closure fails to occur, a hernial sac may travel through the deep inguinal ring to create an inguinal hernia.¹⁶ Protrusion of a hernial sac containing abdominal organs into the scrotum results in scrotal hernia, a severe and potentially dangerous form of inguinal hernia. In rodents, the inguinal canal is very short and the processus vaginalis remains patent throughout life, allowing the testes to pass freely between the scrotum and abdomen.¹³ Despite this potential pathway for herniation of abdominal organs, scrotal hernias have rarely been reported to occur in laboratory mice.Spontaneous inguinal hernias have rarely been reported in either male or female mice. Inguinal hernias occur in intact but not castrated male mice treated with estrogenic compounds and in intact female mice treated with testosterone or bearing testicular grafts.^1,2,10 Both male and female C57BL/6 mice that fail to express fibulin 3 develop multiple large hernias, including inguinal hernias.¹⁴ In these mice, herniation occurs at the myopectineal orifice, through the external inguinal ring. Female mice transgenic for insulin-like factor 3 develop inguinal hernias with 100% penetrance.¹¹ A recent report described a high incidence of lateral femoral hernias in an inbred colony of FVB/NHsd mice; the condition predominantly affected female mice.¹⁵ This phenomenon was attributed to genetic drift in a closed colony. We now report on another situation in which many hernias were noted in inbred FVB/N mice. In the present case, scrotal hernias occurred in a high proportion of FVB/N mice maintained in a closed breeding colony.     

Outpatient Adult Inguinal Hernia Repair

Repair of adult inguinal hernia has been done on an outpatient basis at our surgical facility for the past six years. In 616 consecutive repairs, complications have been remarkably few: one patient was electively admitted to hospital, two hernias have recurred and one patient needed to be catheterized. Patient acceptance has been enthusiastic.     

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.     

Prion gene haplotypes of U.S. cattle

Background

Inguinal and scrotal hernias are of great concern to pig producers, and lead to poor animal welfare and severe economic loss. Selection against these conditions is highly preferable, but at this time no gene, Quantitative Trait Loci (QTL), or mode of inheritance has been identified in pigs or in any other species. Therefore, a complete genome scan was performed in order to identify genomic regions affecting inguinal and scrotal hernias in pigs. Records from seedstock breeding farms were collected. No clinical examinations were executed on the pigs and there was therefore no distinction between inguinal and scrotal hernias. The genome scan utilised affected sib pairs (ASP), and the data was analysed using both an ASP test based on Non-parametric Linkage (NPL) analysis, and a Transmission Disequilibrium Test (TDT).

Results

Significant QTLs (p < 0.01) were detected on 8 out of 19 porcine chromosomes. The most promising QTLs, however, were detected in SSC1, SSC2, SSC5, SSC6, SSC15, SSC17 and SSCX; all of these regions showed either statistical significance with both statistical methods, or convincing significance with one of the methods. Haplotypes from these suggestive QTL regions were constructed and analysed with TDT. Of these, six different haplotypes were found to be differently transmitted (p < 0.01) to healthy and affected pigs. The most interesting result was one haplotype on SSC5 that was found to be transmitted to hernia pigs with four times higher frequency than to healthy pigs (p < 0.00005).

Conclusion

For the first time in any species, a genome scan has revealed suggestive QTLs for inguinal and scrotal hernias. While this study permitted the detection of chromosomal regions only, it is interesting to note that several promising candidate genes, including INSL3, MIS, and CGRP, are located within the highly significant QTL regions. Further studies are required in order to narrow down the suggestive QTL regions, investigate the candidate genes, and to confirm the suggestive QTLs in other populations. The haplotype associated with inguinal and scrotal hernias may help in achieving selection against the disorder.     

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.     

人造血干细胞人源化小鼠的疝气表型分析

目的研究成年雄性人源化小鼠个体出现疝气症状的原因和对人源化小鼠的影响。方法利用显微注射法构建人造血干细胞人源化小鼠,对疝气表型特征、小鼠行为、生理和病理变化进行了研究。结果 2月龄雄性人源化小鼠出现直接性疝气症状,腹股沟区致密结缔组织结构减少可能是疝气形成的主要原因。疝气小鼠同时伴有耐力和运动协调性下降,但疝气对小鼠的繁殖系统无显著影响。结论雄性人造血干细胞人源化小鼠具有显著的疝气症状,其发生机理有待进一步研究。     

The long-term effect of mesh bioprosthesis in inguinal hernia repair on testicular nitric oxide metabolism and apoptosis in rat testis

Polypropylene mesh is the most widely used material in inguinal hernia repair. Although polypropylene mesh is known as an inert material, it is experimentally proven that mesh generates a chronic inflammatory tissue reaction. The aim of the present study was to investigate the long-term effects of polypropylene mesh material used in inguinal hernia operations on testicular function, testicular nitric oxide (NO) metabolism and germ cell-specific apoptosis in rats. The study comprised 40 male rats that were randomly allocated into two groups. In group 1, the left spermatic cord was elevated and a 0.5 x 1 cm polypropylene mesh was placed behind the left inguinal spermatic cord and group 2 consisted of the sham-operated controls. Blood samples were taken at 6 months preoperatively and postoperatively after to assess luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels for hormonal evaluation. Testicular NO was evaluated by the Griess method, apoptosis by a TUNEL method and inducible nitric oxide synthase (iNOS) and endothelial NOS (eNOS) expressions by immunohistochemical staining. Mild (+) eNOS expression was observed in all specimens. Mild (+) iNOS expression was only detected in ipsilateral testis of the mesh-implanted study group. Apoptotic cells were not detected in any samples. We are of the opinion that long-term polypropylene mesh implantation has no effect on testicular hormonal function and only a limited effect on nitric oxide levels and this effect is not sufficient to cause apoptosis in testis that could lead to infertility. It seems that mesh implantation is a reliable method in inguinal hernia repair; however, further work is required by more sensitive methods to fully elucidate the potential testicular damage.     

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.     

Antimicrobial resistance of Escherichia coli isolates from broiler chickens and humans

Background

Inguinal hernias are usually caused by a congenital defect, which occurs as a weakness of the inguinal canal. Porcine β-glucuronidase gene (GUSB) was chosen as functional candidate gene because of its involvement in degradation of hyaluronan within gubernacular tissue during descent of testes. Since a genome-wide linkage analysis approach has shown evidence that two regions on porcine chromosome 3 (SSC 3) are involved in the inheritance of hernia inguinalis/scrotalis in German pig breeds, GUSB also attained status as a positional candidate gene by its localization within a hernia-associated chromosomal region.

Results

A contig spanning 17,157 bp, which contains the entire GUSB, was assembled. Comparative sequence analyses were conducted for the GUSB gene locus. Single nucleotide polymorphisms (SNPs) located within the coding region of GUSB were genotyped in 512 animals. Results of transmission disequilibrium test (TDT) for two out of a total of five detected SNPs gave no significant association with the outcome of hernia in pigs.

Conclusion

On the basis of our studies we are able to exclude the two analyzed SNPs within the porcine GUSB gene as causative for the transmission of inguinal hernia.     

Total RNA-isolation of abdominal hernia of rats for quantitative real-time reverse transcription (RT) PCR assays

Increasing complications in incisional hernia surgery call for novel treatments. A gene expression analysis of injured tissues displays important parameters for tissue regeneration. Until today, no reliable method has been described for a quantitative gene expression analysis of hernia tissues. In this work, a protocol is described for the isolation of DNA-free total RNA of incisional hernias for the first time. Moreover, real-time RT PCR assays for collagen type I and III and TGF-beta1 are demonstrated for relative gene expression analyses. Both methods enable relative gene expression analyses of hernia tissues for the first time.     

Mechanical properties of mosquito nets in the context of hernia repair

The paper deals with issue of applying mosquito nets as implants in hernia repair, which have already been used in resource-poor developing countries. Uniaxial tensile tests have been conducted on polyester mosquito meshes in two orthogonal directions. Non-linear elastic constitutive laws parameters have been identified to be applied in dense net material models. Mechanical performance of tested mosquito nets has been compared with properties of commercial implants used in treatment of hernia and with properties of human tissue. This study contributes to mechanical knowledge of hernia repair issue by investigation of cheaper alternative to commercial implants.     

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。