RESUMO

Aim: Hernia registries report that guidelines are not always implemented by general surgeons and suggest that the success rate of this procedure is higher in hernia specialty centers. There are many definitions of hernia centers, but their objectives consist of improving healthcare by homogenizing the clinical practice. We performed a systematic review and meta-analysis to analyze hernia centers' definitions and compare hernia centers with non-specialized centers. Material and Methods: Cochrane Central, Scopus, Scielo, and PubMed were systematically searched for studies defining a hernia center or comparing hernia centers and non-specialized centers. Outcomes assessed were recurrence, surgical site events, hospital length of stay (LOS), and operative time. We performed subgroup analyses of hernia type. Statistical analysis was performed with R Studio. Results: 3,260 studies were screened and 88 were thoroughly reviewed. Thirteen studies were included. Five studies defined a hernia center and eight studies, comprising 141,366 patients, compared a hernia center with a non-specialized center. Generally, the definitions were similar in decision-making and educational requirements but differed in structural aspects and the steps required for the certification. We found lower recurrence rates for hernia centers for both inguinal (1.08% versus 5.11%; RR 0.21; 95% CI 0.19 to 0.23; p < 0.001) and ventral hernia (3.2% vs. 8.9%; RR 0.425; 95% CI 0.28 to 0.64; p < 0.001). Hernia centers also presented lower surgical site infection for both ventral (4.3% vs. 11.9%; RR 0.435; 95% CI 0.21 to 0.90; p = 0.026) and inguinal (0.1% vs. 0.52%; RR 0.15; 95% CI 0.02 to 0.99; p = 0.49) repair. Conclusion: Our systematic review and meta-analysis support that a hernia center establishment improves postoperative outcomes data. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024522263, PROSPERO CRD42024522263.

RESUMO

PURPOSE: Recent guidelines indicate the use of mesh in UHR for defects > 1 cm, as it reduces recurrence, with 10% recurrence rate compared to up to 54.5% with primary closure. However, Nguyen et al. shows that primary closure is still widely performed in UHR, especially for small defects (1-2 cm), for which there is no published data to determine the optimal approach. In addition, previous meta-analysis by Madsen et al. comparing mesh repair with primary closure in UHR didn't exclude emergency conditions and recurrent hernias; also, didn't report subgroup analysis on hernia defect size. Thus, we aimed to perform a systematic review and meta-analysis comparing the mesh repairs vs. primary closure of the defect in an open elective primary UHR. METHODS: We searched for studies comparing mesh with suture in open UHR in PubMed, Scopus, Cochrane, Scielo, and Lilacs from inception until October 2023. Studies with patients ≤ 18 years old, with recurrent or emergency conditions were excluded. Outcomes were recurrence, seroma, hematoma, wound infection, and hospital length of stay. Subgroup analysis was performed for: (1) RCTs only, and (2) hernia defects smaller than 2 cm. We used RevMan 5.4. for statistical analysis. Heterogeneity was assessed with I² statistics, and random effect was used if I² > 25%. RESULTS: 2895 studies were screened and 56 were reviewed. 12 studies, including 4 RCTs, 1 prospective cohort, and 7 retrospective cohorts were included, comprising 2926 patients in total (47.6% in mesh group and 52.4% in the suture group). Mesh repair showed lower rates of recurrence in the overall analysis (RR 0.50; 95% CI 0.31 to 0.79; P = 0.003; I2 = 24%) and for hernia defects smaller than 2 cm (RR 0.56; 95% CI 0.34 to 0.93; P = 0.03; I2 = 0%). Suture repair showed lower rates of seroma (RR 1.88; 95% CI 1.07 to 3.32; P = 0.03; I2 = 0%) and wound infection (RR 1.65; 95%CI 1.12 to 2.43; P = 0.01; I2 = 15%) in the overall analysis, with no differences after performing subgroup analysis of RCTs. No differences were seen regarding hematoma and hospital length of stay. CONCLUSION: The use of mesh during UHR is associated with significantly lower incidence of recurrence in a long-term follow-up compared to the suture repair, reinforcing the previous indications of the guidelines. Additionally, despite the overall analysis showing higher risk of seroma and wound infection for the mesh repair, no differences were seen after subgroup analysis of RCTs. STUDY REGISTRATION: A review protocol for this systematic review and meta-analysis was registered at PROSPERO (CRD42024476854).

RESUMO

PURPOSE: Individual studies indicate poorer outcomes for smokers after hernia repair. Previous meta-analyses have examined the impact of smoking on specific outcomes such as recurrence and surgical site infection, but there has been a lack of comprehensive consensus or systematic review on this subject. Addressing this gap, our study undertakes a systematic review and meta-analysis to assess the impact of smoking on the outcomes of ventral hernia repair (VHR) and inguinal hernia repair. SOURCE: A thorough search of Cochrane Central, Scopus, SciELO, and PubMed/MEDLINE, focusing on studies that examined the effect of smoking on inguinal and VHR outcomes was conducted. Key outcomes evaluated included recurrence, reoperation, surgical site occurrences (SSO), surgical site infection (SSI), and seroma. PRINCIPAL FINDINGS: Out of 3296 screened studies, 42 met the inclusion criteria. These comprised 25 studies (69,295 patients) on VHR and 17 studies (204,337 patients) on inguinal hernia repair. The analysis revealed that smokers had significantly higher rates of recurrence (10.4% vs. 9.1%; RR 1.48; 95% CI [1.15; 1.90]; P < 0.01), SSO (13.6% vs. 12.7%; RR 1.44; 95% CI [1.12; 1.86]; P < 0.01) and SSI (6.6% vs. 4.2%; RR 1.64; 95% CI [1.38; 1.94]; P < 0.01) following VHR. Additionally, smokers undergoing inguinal hernia repair showed higher recurrence (9% vs. 8.7%; RR 1.91; 95% CI [1.21; 3.01]; P < 0.01), SSI (0.6% vs. 0.3%; RR 1.6; 95% CI [1.21; 2.0]; P < 0.001), and chronic pain (9.9% vs. 10%; RR 1.24; 95% CI [1.06; 1.45]; P < 0.01) rates. No significant differences were observed in seroma (RR 2.63; 95% CI [0.88; 7.91]; P = 0.084) and reoperation rates (RR 1.48; 95% CI [0.77; 2.85]; P = 0.236) for VHR, and in reoperation rates (RR 0.99; 95% CI [0.51; 1.91]; P = 0.978) for inguinal hernias between smokers and non-smokers. Analysis using funnel plots and Egger's test showed the absence of publication bias in the study outcomes. CONCLUSION: This comprehensive meta-analysis found statistically significant increases in recurrence rates, and immediate postoperative complications, such as SSO and SSI following inguinal and VHR. Also, our subgroup analysis suggests that the MIS approach seems to be protective of adverse outcomes in the smokers group. However, our findings suggest that these findings are not of clinical relevance, so our data do not support the necessity of smoking cessation before hernia surgery. More studies are needed to elucidate the specific consequences of smoking in both inguinal and ventral hernia repair. PROSPERO REGISTRATION: ID CRD42024517640.

RESUMO

PURPOSE: The transinguinal preperitoneal (TIPP) technique is an open approach to groin hernia repair with posteriorly positioned mesh supposed to reduce recurrence rates. However, transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) techniques have similar mesh positioning with the advantages of minimally invasive surgery (MIS). Hence, we performed a systematic review and meta-analysis comparing TIPP and MIS for groin hernia repair. SOURCE: Cochrane, Embase, Scopus, Scielo, and PubMed were systematically searched for studies comparing TIPP and MIS techniques for groin hernia repair. Outcomes assessed were recurrence, chronic pain, surgical site infection (SSI), seroma, and hematoma. We performed a subgroup analysis of TAPP and TEP techniques separately. Statistical analysis was performed with R Studio. PRINCIPAL FINDINGS: 81 studies were screened and 19 were thoroughly reviewed. Six studies were included, of which two compared TIPP with TEP technique, two compared TIPP with TAPP, and two compared TIPP with both TEP and TAPP techniques. We found lower recurrence rates for the TEP technique compared to TIPP (0.38% versus 1.19%; RR 2.68; 95% CI 1.01 to 7.11; P = 0.04). Also, we found lower seroma rates for TIPP group on the overall analysis (RR 0.21; P = 0.002). We did not find statistically significant differences regarding overall recurrence (RR 1.6; P = 0.19), chronic pain (RR 1.53; P = 0.2), SSI (RR 2.51; P = 0.47), and hematoma (RR 1.29; P = 0.76) between MIS and TIPP. No statistically significant differences were found in the subgroup analysis of TAPP technique for all the outcomes. CONCLUSION: Our systematic review and meta-analysis found no differences between TIPP and MIS approaches in the overall analysis of recurrence, SSI, and chronic pain rates. Further research is needed to analyze individual techniques and draw a more precise conclusion on this subject. PROSPERO REGISTRATION: ID CRD42024530107, April 8, 2024.

Assuntos

RESUMO

INTRODUCTION: Inguinoscrotal hernias (ISH) pose a challenge to surgeons with consistently higher rates of postoperative complications and recurrence rates. The aim of this study is to report our initial experience and early results with a new technique for inguinoscrotal hernia repair. METHODS: A review of a prospectively maintained multi-center database was conducted in patients who underwent minimally invasive repair using the "primary abandon-of-the-sac" (PAS) technique for inguinoscrotal hernias from March 2021 to July 2022. Demographics and outcomes were analyzed. Univariate analysis and multivariate logistic regression were performed. RESULTS: A total of 76 minimally invasive inguinal hernia repairs were performed. In 70 patients (92%) C-PAS was used as the technique to abandon the sac while in the remaining 6 patients, "pirate-eye-patch" technique was used. Median hernia ring was 3 (IQR 2.5-3.5) cm and median hernia sac was 9.5 (8-10.8) cm. Median operative time was 70 min (IQR 56-96). Seroma was present in 22 (28.9%) patients 7 days after surgery. Most had seroma only in the inguinal area (n = 19; 25%). Thirty days after surgery, 12 (15.8%) patients still had seroma in the inguinal area and 6 (7.9%) in the inguinoscrotal area. Ninety days after surgery, four (5.3%) patients had inguinal seroma, 2 (2.6%) scrotal seromas and 3 (3.9%) inguinoscrotal seromas. The size of the hernia sac was not associated with seroma formation 7 days after surgery (OR 1.06; 95% CI 0.89-1.2; P = 0.461) in the multivariate logistic regression. BMI was also not associated with seroma formation (OR 0.8; 95% CI 0.74-1.06; P = 0.2). CONCLUSIONS: Planned abandon of the hernia sac is an interesting alternative and is associated with a low rate of complications and acceptable seroma formation rates.

Assuntos

RESUMO

BACKGROUND: Poly-4-hydroxybutyrate (P4HB) is a naturally occurring polymer derived from transgenic E. coli bacteria with the longest degradation rate when compared to other available products. This polymer has been manufactured as a biosynthetic mesh to be used as reinforcement when repairing a variety of abdominal wall defects. OBJECTIVE: We aim to describe our center initial experience with this mesh and discuss the possible indications that may benefit from the use of P4HB mesh. METHODS: This is a descriptive retrospective study of patients who underwent abdominal wall repair with a P4HB mesh from October 2018 to December 2020 in a single, large volume, academic center. RESULTS: A total of 51 patients (mean age 54.4 years, range 12-89) underwent abdominal wall reconstruction with a P4HB mesh between October 2018 and December 2020. The mean BMI was 30.5 (range 17.2-50.6). Twenty-three (45%) patients had a prior hernia repair at the site. We grouped patients into six different indications for the use of P4HB mesh in our cohort: clean-contaminated, contaminated or infected field (57%), patient refusal for permanent meshes (14%), those with high risk for post-operative infection (12%), visceral protection of second mesh (10%), recurrence with related chronic pain from mesh (6%), and children (2%). Median follow-up was 105 days (range 8-648). Two patients had hernia recurrence (4%) and 8 (16%) patients developed seroma. CONCLUSION: P4HB mesh is a safe and a viable alternative for complex hernias and high-risk patients with a low complication rate in the short-term.

Assuntos

RESUMO

ABSTRACT Background Poly-4-hydroxybutyrate (P4HB) is a naturally occurring polymer derived from transgenic E. coli bacteria with the longest degradation rate when compared to other available products. This polymer has been manufactured as a biosynthetic mesh to be used as reinforcement when repairing a variety of abdominal wall defects. Objective: We aim to describe our center initial experience with this mesh and discuss the possible indications that may benefit from the use of P4HB mesh. Methods: This is a descriptive retrospective study of patients who underwent abdominal wall repair with a P4HB mesh from October 2018 to December 2020 in a single, large volume, academic center. Results: A total of 51 patients (mean age 54.4 years, range 12-89) underwent abdominal wall reconstruction with a P4HB mesh between October 2018 and December 2020. The mean BMI was 30.5 (range 17.2-50.6). Twenty-three (45%) patients had a prior hernia repair at the site. We grouped patients into six different indications for the use of P4HB mesh in our cohort: clean-contaminated, contaminated or infected field (57%), patient refusal for permanent meshes (14%), those with high risk for post-operative infection (12%), visceral protection of second mesh (10%), recurrence with related chronic pain from mesh (6%), and children (2%). Median follow-up was 105 days (range 8-648). Two patients had hernia recurrence (4%) and 8 (16%) patients developed seroma. Conclusion: P4HB mesh is a safe and a viable alternative for complex hernias and high-risk patients with a low complication rate in the short-term.

RESUMO Contexto: 4-Polihidroxibutirato (P4HB) é um polímero natural derivado da E. coli transgênica que tem a mais longa taxa de degradação quando comparado a outros produtos. Este polímero é manufaturado como uma tela biossintética a ser usada como um reforço no reparo de uma variedade de defeitos de parede abdominal. Objetivo: O objetivo deste estudo é descrever nossa experiência inicial com esta tela e discutir suas possíveis indicações. Métodos: Estudo retrospectivo e descritivo com pacientes que foram submetidos a cirurgia de reconstrução de parede abdominal de outubro de 2018 a dezembro de 2020 em um grande centro acadêmico. Resultados: Cinquenta e um pacientes, média de 54,4 anos (12-89) foram submetidos a reconstrução da parede abdominal com tela de P4HB entre outubro de 2018 e dezembro de 2020. O índice de massa corpórea médio foi de 30,5 kg/m2(17,2-50,6). Vinte e três pacientes (45%) tinham cirurgia prévia de hérnia no mesmo local. Nós agrupamos pacientes em seis diferentes indicações para o uso da tela de P4HB: campo limpo-contaminado, contaminado, infectado (57%), recusa do paciente em telas permanentes (14%), pacientes com alto risco de infecção no pós-operatório (12%), proteção visceral de contato com outra tela (10%), recidiva da hérnia associada com dor crônica relacionada a tela anterior (6%) e pacientes pediátricos (2%). O seguimento mediano foi de 105 dias (8-648). Dois pacientes tiveram recidiva (4%) e 8 (16%) desenvolveram seroma. Conclusão: O uso da tela de P4HB se mostrou uma alternativa segura e viável com baixa taxa de complicações para estes pacientes no curto prazo.

RESUMO

Abdominal wall (AW) hernias are a common problem faced by general surgeons. With an essentially clinical diagnosis, abdominal hernias have been considered a simple problem to be repaired. However, long-term follow-up of patients has shown disappointing results, both in terms of complications and recurrence. In this context, preoperative planning with control of comorbidities and full knowledge of the hernia and its anatomical relationships with the AW has gained increasing attention. Computed tomography (CT) appears to be the best option to determine the precise size and location of abdominal hernias, presence of rectus diastase and/or associated muscle atrophy, as well as the proportion of the hernia in relation to the AW itself. This information might help the surgeon to choose the best surgical technique (open vs MIS), positioning and fixation of the meshes, and eventual need for application of botulinum toxin, preoperative pneumoperitoneum or component separation techniques. Despite the relevance of the findings, they are rarely described in CT scans as radiologists are not used to report findings of the AW as well as to know what information is really needed. For these reasons, we gathered a group of surgeons and radiologists to establish which information about the AW is important in a CT. Finally, a structured report is proposed to facilitate the description of the findings and their interpretation.

Assuntos

RESUMO

INTRODUCTION: the botulinum toxin A (BTA) has been used to achieve a chemical component separation, and it has been used with favorable outcomes for the repair of complex ventral hernia (CVH) with and without loss of domain (LD). The aim of this study is to describe our early experience with the chemical component separation in the United Sates. METHODS: a retrospective observational study of all patients who underwent ventral hernia repair for CVH with or without LD between July 2018 and June 2020. Preoperative BTA was injected in all patients via sonographic guidance bilaterally, between the lateral muscles to achieve chemical denervation before the operation. Patient demographics, anatomical location of the hernia, perioperative data and postoperative data are described. RESULTS: 36 patients underwent this technique before their hernia repair between July 2018 to June 2020. Median age was 62 years (range 30-87). Median preoperative defect size was 12cm (range 6-25) and median intraoperative defect size was 13cm (range 5-27). Median preoperative hernia sac volume (HSV) was 1338cc (128-14040), median preoperative abdominal cavity volume (ACV) was 8784cc (5197-18289) and median volume ration (HSV/ACV) was 14%. The median OR time for BTA administration was 45 minutes (range 28-495). Seroma was the most common postoperative complication in 8 of the patients (22%). Median follow up was 43 days (range 0-580). CONCLUSION: preoperative chemical component separation with BTA is a safe and effective adjunct to hernia repair in CVH repairs where a challenging midline fascial approximation is anticipated.

Assuntos

RESUMO

Background: The Lichtenstein repair has long been heralded as the gold standard for unilateral primary inguinal hernias. However, minimally invasive surgery (MIS) repairs have gained popularity over the past decades given its advantages in recurrent, bilateral, and now even in primary inguinal hernias. We aim to further explore the perception of different techniques among surgeons internationally. Methods: A questionnaire was posted in three closed groups for surgeons and residents on Facebook® and surgical groups on WhatsApp®. It was also e-mailed to members of the following surgical societies: Mexican Society of Surgery, Brazilian Hernia Society, Asia Pacific Hernia Society, and European Hernia Society. Descriptive and basic comparative statistical analyses were performed. Results: In total, 874 surgeons answered the survey: 759 (86.9%) were male and 418 (47.8%) were from North America, 735 (84.1%) had completed training and 605 (69.2%) considered themselves hernia specialists. If safety profiles of inguinal herniorrhaphy were equal, 533 (61%) would choose MIS. Laparoscopic transabdominal preperitoneal ranked first among preferred techniques if the cost of all techniques was the same. Safety of the procedure followed by experience of the surgeon is the most influential factors. Lastly, hernia specialists were more likely to choose an MIS technique (P < .0001). Conclusion: When an international sample of 874 attending and trainee surgeons were surveyed about what technique they would prefer to repair their own uncomplicated unilateral inguinal hernia, most chose MIS. Safety of the procedure and the surgeon's experience were the most important factors in choosing a surgical technique.

Assuntos