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  Citation statistics : Table of Contents
   2019| April-June  | Volume 2 | Issue 2  
    Online since May 10, 2019

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Current state of repair of large hiatal hernia
David I Watson
April-June 2019, 2(2):39-43
Large hiatus hernias are encountered with increasing frequency in aging Western populations. If certain steps are followed, repair can be safely and reliably achieved using laparoscopic approaches. However, surgeons disagree about some key steps, including the use of mesh for repair of the hiatus, lengthening of the esophagus, and the addition of a fundoplication. A narrative review of literature pertinent to laparoscopic repair of large hiatus hernia was undertaken, with priority given to information available from randomized trials. All surgeons agree that the hiatal sac should be fully dissected from the chest to reduce the stomach, and the majority add a fundoplication of some sort. Opinions diverge significantly for the addition of a Collis procedure or the use of mesh. Evidence cited to support these opinions can be prioritized differently by different individuals, and the same evidence is often be cited to support either view. Nevertheless, randomized trials of mesh versus sutured hiatal repair have yielded divergent outcomes, with the more recent studies reporting longer term outcomes failing to support the use of mesh. Surgeons seeking “anatomical perfection” will often add a Collis procedure and are more likely to use mesh. However, the alternative view is that patient satisfaction with the clinical outcome should be prioritized. When this view is taken, a Collis procedure is rarely required. The author concludes that surgeons should aim to keep this operation simple, and an approach which prioritizes careful dissection to protect hiatal structures, followed by sutured repair will deliver a good clinical outcome for most patients.
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Surgery for incarcerated inguinal hernia: Outcomes with Lichtenstein versus open preperitoneal approach
Cuihong Jin, Yingmo Shen, Jie Chen, Fuqiang Chen, Min Liu, Fan Wang, Fenglin Zhao
April-June 2019, 2(2):44-49
BACKGROUND AND AIM: Incarcerated inguinal hernia comprises a significant portion of surgical emergencies, and represents about 5%–15% of all operated inguinal hernias. Tension-free repair with mesh placement is the preferred technique for elective surgery due to its low recurrence rate. However, limited information is available on the usage of synthetic mesh in the emergent treatment because of the potentially infected surgical fields, especially in case of concomitant bowel resection. The aims of this study were to evaluate the results of mesh-based emergency hernioplasty and compare the outcomes of incarcerated inguinal hernia repair with synthetic mesh in Lichtenstein or open preperitoneal approach and to identify the risk factors for postoperative complications. METHODS: A total of 151 patients with incarcerated inguinal hernia that underwent surgery between January 2013 and December 2017 were included in this retrospective study. Demographics, surgical details, and outcomes such as surgical-site infection and recurrence were collected. Univariate analysis was employed to identify risk factors for overall complications. RESULTS: A total of 61 patients received Lichtenstein hernial repair, whereas 90 patients received open preperitoneal repair. Overall morbidity occurred in 21 patients. There was no significant difference between the two groups in terms of postoperative complications. Univariate risk factors for overall complications were age >65 years, duration of incarceration ≥8 h, American Society of Anesthesiologists grade ≥III, cardiopathy, bronchial asthma, indirect inguinal hernia, and strangulation. In multivariate analysis, no risk factors were found associating with a higher rate of overall morbidity. CONCLUSION: As for incarcerated inguinal hernia, both Lichtenstein and open preperitoneal approach with mesh are safe and effective.
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A Spigelian hernia: Single-center experience in an uncommon hernia
Mohamed Ali Chaouch, Karim Nacef, Asma Chaouch, Mohamed Ben Khalifa, Moez Boudokhane
April-June 2019, 2(2):59-62
BACKGROUND: A Spigelian hernia is rare. Diagnosis and treatment remain controversial, mainly because of its unusual presentation. The aim of this study was to report the outcomes of open treatment of eight rare cases and to evaluate our experiences in managing this condition. PATIENTS AND METHODS: We performed a retrospective and descriptive study about operated patients for Spigelian hernia in our department of surgery between 2002 and 2016. RESULTS: Eight patients were enrolled. The mean age was 52.25 years. There was a female predominance. All cases presented hernia risk factors. A painful abdominal mass presented the reason for consultation in four cases. Two of our patients had an associated inguinal hernia and one other had an umbilical hernia. In three cases, the hernia was strangulated. The diagnosis was confirmed by clinical examination in two cases and using radiological examinations in six cases. The content was a small bowel in four cases, epiploic in three cases, and colic in one case. A sublay mesh repair was performed in five cases and a primary suture in three cases. No recurrences were detected after 2 years of follow-up. CONCLUSION: Spigelian hernia is underestimated. Open sublay mesh repair is feasible and safe. It ensure a great short and long term results. The open approach is feasible and safe to treat this condition.
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Teaching and learning of laparoendoscopic hernia surgery in India: A challenge – problems and solutions
Mahesh C Misra, Asuri Krishna, Aditya Baksi, Virinder K Bansal
April-June 2019, 2(2):63-69
INTRODUCTION: One German surgeon (Eric Mühe in 1985)* and three French surgeons** (Philippe Mouret in 1987, Jacque Perissat in 1989, and Dubois F in 1990) are credited with having performed first* laparoscopic cholecystectomy and first** video-assisted laparoscopic cholecystectomy, respectively. Laparoscopic cholecystectomy became the procedure of choice (gold standard) for benign symptomatic gallbladder disease as well as asymptomatic gallbladder stones in India. There have been adoption and acceptance for laparoendoscopic incisional/ventral hernia repair. Actually, laparoendoscopic repair of incisional/ventral hernia, laparoscopic solid organ removal (spleen and adrenal), and laparoscopic fundoplication (gold standard) have been standard of care even in the absence of Level 1 evidence over the past three decades. AIM: However, acceptance, adoption, adaptation, and performance of laparoendoscopic groin hernia surgery have been slow over the past three decades among practicing surgeons and surgical trainees. RESULTS: The laparoendoscopic groin hernia repair has yet not gained the same status as for the procedures mentioned above (VS). The reasons are multifactorial and relate to obtaining adequate and proper training covering laparoendoscopic groin hernia repair. The first and foremost reason is that endoscopic repair of groin hernia is considered an advanced laparoscopic procedure as opposed to open hernia repair. Preceptorship–proctorship (PP) model, which worked extremely effectively for teaching and learning of laparoscopic cholecystectomy, could not be established for groin hernia yet. There is no effective simulator developed for any of the standardized techniques, i.e., totally extraperitoneal (TEP) and/or transabdominal preperitoneal repair (TAPP). The complications, for example, intestinal obstruction and major vascular injury, which were never seen during open era, also brought about criticism as well hampered the growth of laparoendoscopic groin hernia repair. In emerging economies such as India and other Asian countries, high cost of laparoendoscopic repair (tacker and specialized meshes) has been responsible for reduced penetration among practicing surgeons and patients. Therefore, the laparoendoscopic repair of groin hernia has been limited to major metropolitan corporate hospitals and small number of tertiary care public hospitals in metropolitan cities. The advantages of minimally invasive approaches for the repair of groin hernias have not benefited the masses in rural and semi-urban geographic areas of India. CONCLUSION: Training opportunities for the teaching and learning laparoendoscopic repair of groin hernia have remained limited for vast majority of practicing surgeons and surgical trainees in India. With development of cadaveric (TEP and TAPP) and live anesthetized animal model (TAPP), it has been possible to establish training opportunities for practicing surgeons at few institutions. We also recommend and encourage expert surgeons to provide training opportunities for those who wish to learn the surgical skills of laparoendoscopic repair of groin hernia by giving their time for PP model. Furthermore, establishment of specialized hernia centers will go a long way to fill this void.
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Amyand hernia: A case report and literature review
Tian Jiyu, Wei Shibo, Qin Dailei, Guo Zhiwei, Yan Yuhao, Li Xian, Li Hangyu
April-June 2019, 2(2):70-73
Amyand hernia is a rare form of inguinal hernia wherein the appendix is in the hernial sac. Moreover, the incidence of Amyand hernia is reportedly three times higher in children than in adults. Here, we report a case of Amyand hernia in the right groin of a 55-year-old patient admitted to our hospital. We describe our approach to the diagnosis and treatment of Amyand hernia in this case. Altogether, we conclude that reasonable individualized diagnosis and treatment for Amyand hernia according to the patient's conditions is warranted in such cases.
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Prophylactic antibiotic for open mesh repair of inguinal hernia; from principe to nécessité
Keerthi Rajapaksha, Anuruddha Herath, L J. C M. Silva, MJ D. Anandappa, T M. I. G. Bandara
April-June 2019, 2(2):50-53
PURPOSE: The use of prophylactic antibiotics (PAs) in open mesh repair (MR) of inguinal hernia (IH) is controversial. Clean surgeries do not require PA. However, prosthetic implants may require PA. As a part of quality improvement project, “guideline-based treatment for IH” where the European Hernia Society guidelines were adapted and PA was administered only if necessary, not as a routine for open MR of IH since May 1, 2015. The aim of this study was to assess the practice in the use of PA in open MR of IH and the outcome at a single surgical unit. METHODS: This is a retrospective analysis of health records of all the male patients who underwent open MR of IH at a single surgical center, during the period from May 1, 2015 to May 1, 2016, where it was considered not to administer PA routinely, but to only when required (de nécessité). Data of patients who underwent open MR of IH during the period May 1, 2014–April 30, 2015, where PA was administered routinely (de principe) for open MR of IH, were collected for comparison. Demographic, immune-compromised status, operation techniques, PA, and surgical site infections data were analyzed. RESULTS: There were 62 and 78 male patients who underwent open MR of IH during PA de principe and PA de necessite periods, respectively. The mean ages were 38.32 (range 21–74) and 35.51 (range 21–70) years, respectively, during PA de principe and PA de necessite. There were no patients with immunocompromised status. PA usage has reduced from 96.8% (n = 60) during the PA de principe to 11.5% (n = 9) during PA de nécessité period. Surgical site infection rate was 1.6% and 1.3%, respectively, during PA de principe and PA de nécessité periods. CONCLUSION: In a low-risk environment, open MR of IH can be carried out without PA in a majority of patients.
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Transcutaneous electrical nerve stimulation and analgesia following inguinal hernioplasties – Preliminary report
Victoria Santa Marķa, Magali Chahdi Beltrame, Sebastian Cirio, Federico Gorganchian
April-June 2019, 2(2):54-58
INTRODUCTION: Inguinal hernioplasty is the most common surgical procedure. Although it is a low-risk surgery, it may present significant postoperative pain. Pharmacological pain relief may result in adverse effects. A double-blind, randomized, prospective, controlled study was conducted to evaluate if transcutaneous electrical nerve stimulation (TENS) analgesia applied during the first 24 h following a Lichtenstein inguinal hernia repair reduces the use of pain relievers in the short-term postoperative period. MATERIALS AND METHODS: A preliminary sample of 24 patients was gathered, according to inclusion and exclusion criteria. Two groups were studied: treatment and control. TENS was applied at a frequency of 100 Hz on the surgical area every 4 h. Both groups received a dose of analgesia during recovery from anesthesia. On-demand intravenous administration of tramadol 50 mg was prescribed during the postoperative period. An electrical muscle stimulator was also placed to the control group, but it was not turned on. Postoperative pain was assessed using the visual analog scale and by the amount and frequency of required pharmacological rescue analgesia. RESULTS: The mean postoperative pain was calculated based on the treatment administered. For the control group, the average was 5.1 (confidence interval [CI]: 3.84–6.35), whereas for the treatment group, it was 0.62 (CI: 0.22–1.01) (P < 0.001). Moreover, requests for rescue analgesia were compared: the TENS-treated group did not ask for rescue analgesia, whereas 57% of the control group requested it (P < 0.001). DISCUSSION: Postoperative analgesia demands a multimodal approach which effectively relieves pain with minimum adverse effects but that is also safe and may be self-administered. Although results are preliminary, in this study we have found a significant difference when using TENS as postoperative analgesia in terms of levels of pain and request for analgesia.
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The breakthrough on evaluation and treatment in incisional hernia with loss of domain
Dailei Qin, Shibo Wei, Jiyu Tian, Zhiwei Guo, Xian Li, Yuhao Yan, Hangyu Li
April-June 2019, 2(2):33-38
Part of the patients with incisional hernia (IH) suffered from constipation or even circulatory impairment, which is called large IH with loss of domain (LOD) or giant IH. For now, there is still controversy about the definition and pathomechanism of the LOD; meanwhile, there is no clear criterion for evaluating and treating patients with LOD. A systematic search of the literature was implemented in PubMed and the Cochrane database by using the keywords “IH, abdominal wall function(AWF), LOD” and got 60 publications finally. First, there is still no unified definition for LOD, but we found that it was translated into a situation that abdominal content can hardly be reduced with AWF deficiency in 2018th Chinese Guidelines. Second, we concluded that poor abdominal wall contraction caused by muscular atrophy or fibrillation after large area aponeurosis released shall be important pathomechanism of LOD. Third, we found that there are different methods for evaluating LOD, while the activity evaluation may be most useful. Finally, component separation technique (CST), bridge repair or utotransplantation have been recommended in many publications for variable condition. The definition of LOD is better to be divided into the functional deficiency and the anatomical defect just like Chinese guidelines. The pathomechanism of LOD was actually based on anatomical destruction of abdominal wall contraction system. The activity evaluation may be the most convenient method mentioned in the publications. CST was strongly recommended to be used in giant hernia, the defect of which can be hardly closed. Patients who have IH with LOD are proposed to receive hernioplasty as early as possible because of the impendency to reconstruct the large defect on the abdominal wall as well as restoration of the AWF. Surgeons may select appropriate CST to repair IH according to the length of the defect.
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