WARC Journal Club: Inguinal Hernia

de Goede B, et al. Watchful Waiting Versus Surgery of Mildly Symptomatic or Asymptomatic Inguinal Hernia in Men Aged 50 Years and Older: A Randomized Controlled Trial. Ann Surg. 2018 Jan;267(1):42-49.

Full-text for Emory users.

RESULTS: Between January 2006 and August 2012, 528 patients were enrolled, of whom 496 met the inclusion criteria: 234 were assigned to elective repair and 262 to watchful waiting. The mean pain/discomfort score at 24 months was 0.35 [95% confidence interval (CI) 0.28-0.41)] in the elective repair group and 0.58 (95% CI 0.52-0.64) in the watchful waiting group. The difference of these means (MD) was -0.23 (95% CI -0.32 to -0.14). In the watchful waiting group, 93 patients (35·4%) eventually underwent elective surgery and 6 patients (2·3%) received emergent surgery for strangulation/incarceration. Postoperative complication rates and recurrence rates in these 99 operated individuals were comparable with individuals originally assigned to the elective repair group (8.1% vs 15.0%; P = 0.106, 7.1% vs 8.9%; P = 0.668, respectively).

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Article of interest: Long-term Results of a RCT of a Nonoperative Strategy (Watchful Waiting) for Men With Minimally Symptomatic Inguinal Hernias

This week’s discussion included what are the best treatment options for asymptomatic and symptomatic inguinal hernias.


Fitzgibbons RJ Jr, Ramanan B, Arya S, et al. Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias. Ann Surg. 2013;258(3):508–515.

Results: Eighty-one of the 254 men (31.9%) crossed over to surgical repair before the end of the original study, December 31, 2004, with a median follow-up of 3.2 (range: 2-4.5) years. The patients have now been followed for an additional 7 years with a maximum follow-up of 11.5 years. The estimated cumulative CO rates using Kaplan-Meier analysis was 68%. Men older than 65 years crossed over at a considerably higher rate than younger men (79% vs 62%). The most common reason for CO was pain (54.1%). A total of 3 patients have required an emergency operation, but there has been no mortality.

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What is the impact of abdominal binder on seroma formation?

One discussion this week included the impact of abdominal binder on seroma formation.


Reference: Christoffersen MW, Olsen BH, Rosenberg J, Bisgaard T. Randomized clinical trial on the postoperative use of an abdominal binder after laparoscopic umbilical and epigastric hernia repair. Hernia. 2015 Feb;19(1):147-153. doi:10.1007/s10029-014-1289-6

Summary: Application of an abdominal binder is often part of a standard postoperative regimen after ventral hernia repair to reduce pain and seroma formation. However, there is lack of evidence of the clinical effects.

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Surgeon’s choice: TEP or TAPP for recurrent inguinal hernia repair?

One discussion involved the comparison of outcomes for TEP and TAPP for hernia repair.


Reference: Kockerling F, et al. TEP or TAPP for recurrent inguinal hernia repair-registered-based comparison of the outcome. Surgical Endoscopy. 2017 Oct;31(10):3872-3882. doi: 10.1007/s00464-017-5416-1

Summary: To date, no randomized trials have been conducted to compare the TEP vs TAPP outcome for recurrent inguinal hernia repair. Between September 1, 2009 and August 31, 2013 data were entered into the Herniamed Registry on a total of 2246 patients with recurrent inguinal hernia repair following previous open primary operation in either TAPP (n = 1,464) or TEP technique (n = 782).

  • TAPP group: recurrent repair was performed for n=974/1,464 (66.5%) patients after suture and n=490/1,464 (33.5%) after mesh repair.
  • TEP group: recurrent repair was performed for n=554/782 (70.8%) patients following previous suture repair and for n=228/782 (29.2%) after mesh repair.

No significant differences were found between the recurrent operations in TEP vs TAPP technique with regard to the intraoperative complications, complication-related reoperations, re-recurrence rates, rates of pain at rest, pain on exertion, or chronic pain requiring treatment. Unfavorable results were identified only with regard to the higher seroma rates associated with TAPP; these responded to conservative treatment.

In summary, both TEP and TAPP can be recommended as effective techniques for treatment of recurrent inguinal hernia following previous open primary operation. The decision to use one or the other technique should be based solely on the surgeon’s expertise. The registry study presented here thus confirms the recommendations in the guidelines on laparo-endoscopic treatment of recurrent inguinal hernia following previous open primary operation.

 

What is the effect of abdominal insufflation on deep vein flow?

One discussion this week involved the effect of abdominal insufflation on deep vein flow.


Reference: Yang C, Zhu L. Coagulation and deep vein flow changes following laparascopic total extraperitoneal inguinal hernia repair: a single-center, prospective cohort study. Surgical Endoscopy. 2019 Feb 11. doi: 10.1007/s00464-019-06700-6.

Summary: The authors observed morphologic change of the iliac vein during TEP procedure. The iliac vein was almost completely collapsed, which not only impaired venous return from the lower extremities but also caused vein distention. The acute distention caused vessel wall damage due to mechanical disruption of the endothelial lining. Vessel wall damage is one of Virchow’s triad in the pathogenesis of thrombosis.

In this study, activated coagulation and impaired deep venous flow implied that the TEP procedure had a certain degree of potential risk for DVT during the early postoperative period.

Sugarbaker vs Keyhole repair in parastomal hernias

One discussion this week involved the Sugarbaker repair vs Keyhole repair.


Reference: DeAsis FJ et al. Current state of laparoscopic parastomal hernia repair: a meta-analysis. World Journal of Gastroenterology. 2015 Jul 28;21(28):8670-8677. doi: 10.3748/wjg.v21.i28.8670

Summary:  The primary differences between keyhole repair and Sugarbaker repair are the orientation of the bowel and the presence of a slit in the mesh. In the modified Sugarbaker approach, the bowel is exteriorized through the side of the mesh, whereas in the Keyhole approach the bowel is inserted through a 2 to 3 cm slit in the center of mesh. Both methods apply the mesh intraperitoneally (DeAsis et al, 2015, p.8673).

DeAsis et al (2015) performed a systematic review of PubMed and Medline. The primary outcome analyzed was recurrence of parastomal hernia. Secondary outcomes were mesh infection, surgical site infection, obstruction requiring reoperation, death, and other complications.

In an analysis of 15 articles involving 469 patients, the recurrence rate was 10.2% (95%CI: 3.9-19.0) for the modified laparoscopic Sugarbaker approach, and 27.9% (95%CI: 12.3-46.9) for the keyhole approach. There were no intraoperative mortalities reported and six mortalities during the postoperative course.

The review concluded that the non-slit mesh modified Sugarbaker approach and the slit mesh Keyhole approach are currently the most reported options for laparoscopic repair. When choosing between the two, a modified Sugarbaker technique appears to be a superior method given the low recurrence rates compared to the keyhole technique if an ePTFE mesh is used (p.8676).

Types of abdominal wall mesh for hernia repair: a brief review

One discussion this week included abdominal wall mesh.


Reference: Cevasco M, Itani KMF. Ventral hernia repair with synthetic, composite, and biologic mesh: characteristics, indications, and infection profile. Surgical Infections. 2012 Aug;13(4):209-215. doi:10.1089/sur.2012.123.

Summary: Cevasco and Itani (2012) provide a succinct overview of available mesh materials, as well as their characteristics and special situations.

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