Imaging groin hernias

Clinical differentiation of direct inguinal hernias, indirect inguinal hernias, femoral and Spigelian hernias can be difficult particularly with small hernias and in obese patients. Diagnostic imaging can detect and characterize hernias more reliably, allow better surgical planning and possibly even prevent unnecessary surgery. Detection of complications occurring in groin hernias is also of importance. Hernial incarceration is particularly evident on ultrasound (US) performed during rest and abdomimal straining (Valsalva maneuver) in both the supine and erect postures. Hernial strangulation is visible both with US and with computed tomography (CT) with fluid appearing around the hernial sac contents.peer-reviewe

Laparoscopic repair of a large interstitially incarcerated inguinal hernia.

A 68 year old female presented for elective repair of an abdominal wall hernia. Preoperative CT imaging revealed a right inguinal hernia defect with hernia contents coursing cephalad between the external and internal abdominal oblique muscles. This was consistent with an interstitial inguinal hernia, a rare entity outside of post- traumatic hernias. At operation the hernia contents were reduced laparoscopically. The hernia was then repaired by transitioning to the totally extraperitoneal (TEP) approach using a 15cm X 15cm piece of polyester mesh. The patient had an uneventful recovery. Interstitial hernias are rare, difficult to diagnose and potentially dangerous if left untreated. There is no consensus on the ideal repair of these unique hernias. This represents a minimally invasive repair of an unusual hernia, with a novel approach to diagnose and manage the hernia and its redundant sac

Surgical Management of Inguinal Hernias at Bugando Medical Centre in Northwestern Tanzania: Our Experiences in a Resource-Limited Setting.

Inguinal hernia repair remains the commonest operation performed by general surgeons all over the world. There is paucity of published data on surgical management of inguinal hernias in our environment. This study is intended to describe our own experiences in the surgical management of inguinal hernias and compare our results with that reported in literature. A descriptive prospective study was conducted at Bugando Medical Centre in northwestern Tanzania. Ethical approval to conduct the study was obtained from relevant authorities before the commencement of the study. Statistical data analysis was done using SPSS software version 17.0. A total of 452 patients with inguinal hernias were enrolled in the study. The median age of patients was 36 years (range 3 months to 78 years). Males outnumbered females by a ratio of 36.7:1. This gender deference was statistically significant (P=0.003). Most patients (44.7%) presented late (more than five years of onset of hernia). Inguinoscrotal hernia (66.8%) was the commonest presentation. At presentation, 208 (46.0%) patients had reducible hernia, 110 (24.3%) had irreducible hernia, 84 (18.6%) and 50(11.1%) patients had obstructed and strangulated hernias respectively. The majority of patients (53.1%) had right sided inguinal hernia with a right-to-left ratio of 2.1: 1. Ninety-two (20.4%) patients had bilateral inguinal hernias. 296 (65.5%) patients had indirect hernia, 102 (22.6%) had direct hernia and 54 (11.9%) had both indirect and direct types (pantaloon hernia). All patients in this study underwent open herniorrhaphy. The majority of patients (61.5%) underwent elective herniorrhaphy under spinal anaesthesia (69.2%). Local anaesthesia was used in only 1.1% of cases. Bowel resection was required in 15.9% of patients. Modified Bassini's repair (79.9%) was the most common technique of posterior wall repair of the inguinal canal. Lichtenstein mesh repair was used in only one (0.2%) patient. Complication rate was 12.4% and it was significantly higher in emergency herniorrhaphy than in elective herniorrhaphy (P=0.002). The median length of hospital stay was 8 days and it was significantly longer in patients with advanced age, delayed admission, concomitant medical illness, high ASA class, the need for bowel resection and in those with surgical repair performed under general anesthesia (P<0.001). Mortality rate was 9.7%. Longer duration of symptoms, late hospitalization, coexisting disease, high ASA class, delayed operation, the need for bowel resection and presence of complications were found to be predictors of mortality (P<0.001). Inguinal hernias continue to be a source of morbidity and mortality in our centre. Early presentation and elective repair of inguinal hernias is pivotal in order to eliminate the morbidity and mortality associated with this very common problem

Gel-Electrophoresis and Diffusion of Ring-Shaped DNA

A model for the motion of ring-shaped DNA in a gel is introduced and studied by numerical simulations and a mean-field approximation. The ring motion is mediated by finger-shaped loops (hernias) that move in an amoeba-like fashion around the gel obstructions. This constitutes an extension of previous reptation tube treatments. It is shown that tension is essential for describing the dynamics in the presence of hernias. It is included in the model as long range interactions over stretched DNA regions. The mobility of ring-shaped DNA is found to saturate much as in the well-studied case of linear DNA. Experiments in polymer gels, however, show that the mobility drops exponentially with the DNA ring size. This is commonly attributed to dangling-ends in the gel that can impale the ring. The predictions of the present model are expected to apply to artificial 2D obstacle arrays (W.D. Volkmuth, R.H. Austin, Nature 358,600 (1992)) which have no dangling-ends. In the zero-field case an exact solution of the model steady-state is obtained, and quantities such as the average ring size are calculated. An approximate treatment of the ring dynamics is given, and the diffusion coefficient is derived. The model is also discussed in the context of spontaneous symmetry breaking in one dimension.Comment: 8 figures, LaTeX, Phys. Rev. E - in pres

Update of Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)) : Part B

In 2014 the International Endohernia Society (IEHS) published the first international "Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias". Guidelines reflect the currently best available evidence in diagnostics and therapy and give recommendations to help surgeons to standardize their techniques and to improve their results. However, science is a dynamic field which is continuously developing. Therefore, guidelines require regular updates to keep pace with the evolving literature. Methods For the development of the original guidelines all relevant literature published up to year 2012 was analyzed using the ranking of the Oxford Centre for Evidence-Based-Medicine. For the present update all of the previous authors were asked to evaluate the literature published during the recent years from 2012 to 2017 and revise their statements and recommendations given in the initial guidelines accordingly. In two Consensus Conferences (October 2017 Beijing, March 2018 Cologne) the updates were presented, discussed, and confirmed. To avoid redundancy, only new statements or recommendations are included in this paper. Therefore, for full understanding both of the guidelines, the original and the current, must be read. In addition, the new developments in repair of abdominal wall hernias like surgical techniques within the abdominal wall, release operations (transversus muscle release, component separation), Botox application, and robot-assisted repair methods were included. Results Due to an increase of the number of patients and further development of surgical techniques, repair of primary and secondary abdominal wall hernias attracts increasing interests of many surgeons. Whereas up to three decades ago hernia-related publications did not exceed 20 per year, currently this number is about 10-fold higher. Recent years are characterized by the advent of new techniques-minimal invasive techniques using robotics and laparoscopy, totally extraperitoneal repairs, novel myofascial release techniques for optimal closure of large defects, and Botox for relaxing the abdominal wall. Furthermore, a concomitant rectus diastasis was recognized as a significant risk factor for recurrence. Despite still insufficient evidence with respect to these new techniques it seemed to us necessary to include them in the update to stimulate surgeons to do research in these fields. Conclusion Guidelines are recommendations based on best available evidence intended to help the surgeon to improve the quality of his daily work. However, science is a continuously evolving process, and as such guidelines should be updated about every 3 years. For a comprehensive reference, however, it is suggested to read both the initially guidelines published in 2014 together with the update. Moreover, the presented update includes also techniques which were not known 3 years before

Patient awareness and symptoms from an incisional hernia

Incisional hernia is a common postoperative complication following open abdominal surgery with incidence varying between 3% and 20%.1 Approximately half of all incisional hernias are diagnosed within 1 year following surgery. In the United Kingdom alone, about 10,000 incisional hernia repairs are performed annually. Incisional hernia repairs are generally elective with emergency repair due to incarceration or strangulation constituting about 15% of repairs.1 Incisional hernia repair is not a low-risk operation and generally has relatively poor results due to chronic postoperative pain and high recurrence rates.2−3 Little has been published on patients' awareness of incisional hernia following open abdominal surgery. Moreover, there are very few publications on indications for incisional hernia repair and on the natural course of such hernias. The literature suggests that symptoms and complaints usually presented by patients include pain, discomfort, cosmetic complaints, skin problems, incarceration, strangulation, functional disability, and pulmonary dysfunction.4−6 The aim of this study was to investigate whether patients were aware that they had a hernia. In addition, we sought to determine symptoms for those who knew that they had an incisional hernia

Impact of NICE guidance on laparoscopic surgery for inguinal hernias: analysis of interrupted time series

After the introduction of Bassini's procedure in the late 19th century, methods of repairing hernias changed little until the 1990s, when synthetic mesh and laparoscopic methods arrived. In contrast to the open mesh technique, laparoscopic surgery remains uncommon. In January 2001, the National Institute for Clinical Excellence (NICE) issued guidance that stated, "For repair of primary inguinal hernia, open [mesh] should be the preferred surgical procedure." We describe patterns of surgical repair of inguinal hernias and assess the impact of NICE's guidance

Open ventral hernia repair with a composite ventral patch : final results of a multicenter prospective study

Background: This study assessed clinical outcomes, including safety and recurrence, from the two-year follow-up of patients who underwent open ventral primary hernia repair with the use of the Parietex (TM) Composite Ventral Patch (PCO-VP). Methods: A prospective single-arm, multicenter study of 126 patients undergoing open ventral hernia repair for umbilical and epigastric hernias with the PCO-VP was performed. Results: One hundred twenty-six subjects (110 with umbilical hernia and 16 with epigastric hernia) with a mean hernia diameter of 1.8cm (0.4-4.0) were treated with PCO-VP. One hundred subjects completed the two-year study. Cumulative hernia recurrence was 3.0% (3/101; 95%CI: 0.0-6.3%) within 24months. Median Numeric Rating Scale pain scores improved from 2 [0-10] at baseline to 0 [0-3] at 1 month (P<0.001) and remained low at 24months 0 [0-6] (P<0.001). 99% (102/103) of the patients were satisfied with their repair at 24months postoperative. Conclusions: The use of PCO-VP to repair primary umbilical and epigastric defects yielded a low recurrence rate, low postoperative and chronic pain, and high satisfaction ratings, confirming that PCO-VP is effective for small ventral hernia repair in the two-year term after implantation. Trial registration: The study was registered publically at clinicaltrials.gov (NCT01848184 registered May 7, 2013)

A multicenter prospective study of patients undergoing open ventral hernia repair with intraperitoneal positioning using the monofilament polyester composite ventral patch : interim results of the PANACEA study

This study assessed the recurrence rate and other safety and efficacy parameters following ventral hernia repair with a polyester composite prosthesis (Parietex™ Composite Ventral Patch [PCO-VP])