AIM: Litigation is always a severe burden for every surgeon who is involved. The study aims to show the most important reasons for an allegation and how to prevent a lawsuit. METHODS: Based on the own experience as a medical advisor, ten medico-legal cases are analyzed and a systematic overview of the corresponding literature is given. RESULTS: Allegation for malpractice is not very frequent; in hernia surgery, <1% of the patients are involved. Furthermore, only in 20%–40% of these cases, the decision is in favor of the claimant. However, every case is associated with compensation ranging from roughly between $19,000 and $8,000,000. Totally the author had to perform 10 reports in legal cases for the court: In three cases, compensation had been refused, because informed consent had correctly been done, and the operative situs was clearly documented, and in the third case, the preoperative diagnostics and the operative performance had been according to the medical standard. The claim was successful in three patients because of technical failure, in two cases because of wrong indication, and in two cases because of delayed reoperation. DISCUSSION: There are five key features in the prevention of a lawsuit in surgery: (1) “informed consent:” Take the time, use a standard form, show pictures and make handwritten notes to explain in detail the indication for surgery, the technical performance of the planned intervention, and the steps of aftercare; (2) “technical performance” of the operation should follow the generally accepted medical standard. Deep knowledge of anatomy is an indispensable precondition of perfect operation; (3) a “delay in timely response” to a complication is not excusable; (4) “careful documentation” of all steps of the treatment may possibly avoid a legal case; and (5) “establishing an empathic relationship” between the surgeon and the patient and his/her relatives as well is essential for avoiding an accusation. CONCLUSION: Medico-legal implications in hernia surgery are rare, but a severe burden for every surgeon concerned and may be associated with damage to the reputation of the surgeon and high costs. The best ways of preventing such a disaster are the correct indications and operative performance according to the current medical standard and empathic aftercare.

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The presence of uterus in inguinal hernia sac is a rare condition, the cause for this disease has not been clarified, and the contributions to this condition could be multiple. In this report, we described a case of a 78-year-old multiparous female with left recurrent inguinal hernia, during the transabdominal preperitoneal repair (TAPP); the well-formed uterus was found in the hernia sac, and the uterus could only be completely reduced after the division of the left round ligament. To the best of our knowledge, there have been no reports in the literature on adult recurrent hernias containing well-formed uterus in adult females. The aim of this case report is to call attention to the proper management of round ligament when performing inguinal hernia repair in female patients.

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Laparoendoscopic hernia surgery in the Philippines has been constantly growing in terms of training, education, and skills acquisition. Since hernia surgery is one of the more common operations done by a general surgeon, it is important to know the current problems, pitfalls, and solutions in the training of a laparoendoscopic hernia surgeon. The pitfalls identified are the following: (1) absence of a standard curriculum for teaching laparoendoscopic hernia surgery, (2) no hernia centers for education and teaching, (3) inadequate hernia specialists who will train, (4) opportunities for laparoscopic hernia surgery education for surgeons and residents, (5) competency assessment of trained laparoendoscopic hernia surgeons, (6) centers and trainers for more advanced laparoendoscopic hernia surgery, and (7) lack of credentialing and auditing of laparoendoscopic hernia surgery outcomes. Hernia surgery is one of the fastest developing subspecialties in general surgery. With more complex operations being done and more advanced techniques being utilized. It is recommended that there has to be a standardized way of teaching and learning the different types of hernia surgical conditions and their management. From basic to advanced hernia operations, a standardized curriculum and a standardized form of teaching are recommended in order to have good outcomes. Finally, all of these have to evaluated and audited in order to assure good surgical outcomes for both the surgeon and the patients.

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BACKGROUND: Being cited by another article is valuable for scientific publications. Citation analysis of previously published papers by bibliometric methodology have been performed in different disciplines do date. The present study was done with the purpose of listing the most cited articles in the field of abdominal wall hernias, in other words herniology. MATERIALS AND METHODS: A search was conducted through all databases in the Web of Science to determine the most cited articles related to the abdominal wall hernias. RESULTS: The total number of citations of the top 100 articles in herniology was 26.316. The mean number of citations was 263.16. The top 100 articles originated from 13 countries, and were published in 37 journals. The most productive decade was 2000-2009 with 55 papers. Journal impact factors correlated with citation counts positively. Inguinal hernia and incisional hernia were the leading topics in 41 and 40 related articles. The number of the authors also did not show any correlation with citation counts. There was no relationship between the number of the cited references and the citations counts of the articles. CONCLUSION: Citation counts of the articles about abdominal wall hernias are somewhat lower than those in other fields. Most articles in the top 100 list are related to inguinal and incisional hernias. BACKGROUND: Being cited by another article is valuable for scientific publications. Citation analysis of previously published papers by bibliometric methodology have been performed in different disciplines do date. The present study was done with the purpose of listing the most cited articles in the field of abdominal wall hernias, in other words herniology. MATERIALS AND METHODS: A search was conducted through all databases in the Web of Science to determine the most cited articles related to the abdominal wall hernias. RESULTS: The total number of citations of the top 100 articles in herniology was 26.316. The mean number of citations was 263.16. The top 100 articles originated from 13 countries, and were published in 37 journals. The most productive decade was 2000-2009 with 55 papers. Journal impact factors correlated with citation counts positively. Inguinal hernia and incisional hernia were the leading topics in 41 and 40 related articles. The number of the authors also did not show any correlation with citation counts. There was no relationship between the number of the cited references and the citations counts of the articles. CONCLUSION: Citation counts of the articles about abdominal wall hernias are somewhat lower than those in other fields. Most articles in the top 100 list are related to inguinal and incisional hernias.

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PURPOSE: Complex abdominal wall hernia repairs present unique challenges for patients and surgeons, often requiring mesh placement. Biologic materials may be utilized in repairs with high risk for postoperative complications. Porcine dermal meshes (PDM) are among the most commonly utilized biologic grafts. Porcine hepatic biologic mesh (PHM) was developed due to its unique characteristics. This study investigates outcomes following acute ventral hernia repair with a porcine-derived hepatic biologic mesh (Miromesh^®) and porcine dermis (Strattice™) in a porcine animal model. MATERIALS AND METHODS: Twenty Yucatan pigs underwent hernia creation followed by immediate retrorectus ventral hernia repair and were survived for 1 (n = 4), 2 (n = 6), 6 (n = 5), or 12 (n = 5) months. Animals underwent excision of the anterior abdominal wall and immediate repair with both PDM and PHM positioned in the retrorectus space with 3 cm between grafts. Animals were survived and evaluated for tensiometric strength, histology, and protein analyses. RESULTS: Twenty animals underwent successful hernia creation and repair. Tensiometric strength was similar between repair groups at 1 (63.8 vs. 67.0 N, NS) and 2 months (80.0 vs. 76.1 N, NS), whereas at 6 (72.2 vs. 44.9 N, P= 0.01) and 12 months (66.7 vs. 46.3, P= 0.004), repair strength was greater in PHM. Histological evaluation demonstrated greater inflammation and fibrosis at 12 months in the PHM repairs. Collagen 1 deposition was greater in PHM at 1 (P = 0.1) and 2 (P = 0.015) months. There was no difference in collagen 3 deposition between groups. CONCLUSIONS: Ventral hernia repair with a porcine hepatic mesh results in greater repair strength than repair with porcine dermal grafts.

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AIM: The objective of this study is to elucidate the guideline conformity of surgical approach and mode of anesthesia for inguinal hernia (IH) treatment together with analysis of the outcomes on the implementation of “guideline-based treatment for IH” as a part of institutional hernia programme (IHP) in a single surgical unit. METHODS: This is a retrospective analysis of health records of the male patients who underwent surgery for IH at a single surgical center, during the period May 1, 2015–May 1, 2016, where the surgeons adhered to “guideline-based treatment for IH.” Health records of the patients who underwent surgery for IH from May 1, 2014, to April 30, 2015, too were collected for comparison. Data related to demographics, surgical approach, mode of anesthesia, and surgical complication were analyzed. RESULTS: Sixty-two male patients with a mean age of 33.5 (range: 22–54) years and 99 male patients with a mean age of 32.84 (range: 22–70) years have undergone IH repair before the IHP and during the IHP, respectively. The overall use of local anesthesia (LA) for unilateral IH had increased from 3.5% (n = 2) to 83.12% (n = 65) (P ≤ 0.0001) during IHP. The laparoscopic approach was used in 83.34% of patients with bilateral IH during IHP (P = 0.0007). All (n = 3) the recurrences following open repair were attempted to treat laparoscopically during the IHP. Laparoscopic approach was not utilized to treat IH before the IHP. Overall recurrence rate increased to 4.04 (n = 4) during IHP from 0% (P = 0.299). Overall complication rate increased from 3.22% (n = 2) to 8.08% (n = 8) during IHP (P = 0.319). CONCLUSION: Surgical approach and mode of anesthesia for IH treatment showed high conformity with the guidelines during the IHP. The increased recurrence and complication rates were statistically insignificant.

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