A. R. Wijsmuller

Nerve management during open hernia repair

Peroperative identification and subsequent division or preservation of the inguinal nerves during open hernia repair may influence the incidence of chronic postoperative pain.

Long-term follow-up of a randomized clinical trial of non-mesh versus mesh repair of primary inguinal hernia

Prospective studies and meta‐analyses have indicated that non‐mesh repair is inferior to mesh repair based on recurrence rates in inguinal hernia. The only reliable way to evaluate recurrence rates after hernia surgery is by long‐term follow‐up.

An international consensus algorithm for management of chronic postoperative inguinal pain

PurposeTension-free mesh repair of inguinal hernia has led to uniformly low recurrence rates. Morbidity associated with this operation is mainly related to chronic pain. No consensus guidelines exist for the management of this condition. The goal of this study is to design an expert-based algorithm for diagnostic and therapeutic management of chronic inguinal postoperative pain (CPIP).MethodsA group of surgeons considered experts on inguinal hernia surgery was solicited to develop the algorithm. Consensus regarding each step of an algorithm proposed by the authors was sought by means of the Delphi method leading to a revised expert-based algorithm.ResultsWith the input of 28 international experts, an algorithm for a stepwise approach for management of CPIP was created. 26 participants accepted the final algorithm as a consensus model. One participant could not agree with the final concept. One expert did not respond during the final phase.ConclusionThere is a need for guidelines with regard to management of CPIP. This algorithm can serve as a guide with regard to the diagnosis, management, and treatment of these patients and improve clinical outcomes. If an expectative phase of a few months has passed without any amelioration of CPIP, a multidisciplinary approach is indicated and a pain management team should be consulted. Pharmacologic, behavioral, and interventional modalities including nerve blocks are essential. If conservative measures fail and surgery is considered, triple neurectomy, correction for recurrence with or without neurectomy, and meshoma removal if indicated should be performed. Surgeons less experienced with remedial operations for CPIP should not hesitate to refer their patients to dedicated hernia surgeons.

Feasibility study of three-nerve-recognizing Lichtenstein procedure for inguinal hernia

Inguinal nerve identification during open inguinal hernia repair is associated with less chronic postoperative pain. However, most Dutch surgeons do not identify all three inguinal nerves when carrying out this procedure. The aim of this study was to evaluate the feasibility of a nerve‐recognizing Lichtenstein hernia repair and to measure the extra time required for surgery

Optimizing the critical view of safety in laparoscopic cholecystectomy by clipping and transecting the cystic artery before the cystic duct

A. R. Wijsmuller1, M. Leegwater1, L. Tseng2, H. J. Smaal1, G. J. Kleinrensink3,4 and J. F. Lange1,4 1Department of Surgery, Erasmus MC, University Medical Centre, Rotterdam, 2Department of Surgery, Groene Hart Hospital, Gouda, 3Department of Neurosciences, Erasmus MC, University Medical Centre, Rotterdam and 4Lowlands Institute of Surgical and Applied Anatomy, Rotterdam, The Netherlands Correspondence to: Professor J. F. Lange, Department of Surgery, Erasmus MC, University Medical Centre, PO Box 2040, 3000 CA Rotterdam, The Netherlands (e-mail: j.lange@erasmusmc.nl)

Watchful Waiting Versus Surgery of Mildly Symptomatic or Asymptomatic Inguinal Hernia in Men Aged 50 Years and Older: A Randomized Controlled Trial

Objective: To compare if watchful waiting is noninferior to elective repair in men aged 50 years and older with mildly symptomatic or asymptomatic inguinal hernia. Background: The role of watchful waiting in older male patients with mildly symptomatic or asymptomatic inguinal hernia is still not well-established. Methods: In this noninferiority trial, we randomly assigned men aged 50 years and older with mildly symptomatic or asymptomatic inguinal hernia to either elective inguinal hernia repair or watchful waiting. Primary endpoint was the mean difference in a 4-point pain/discomfort score at 24 months of follow-up. Using a 0.20-point difference as a clinically relevant margin, it was hypothesized that watchful waiting was noninferior to elective repair. Secondary endpoints included quality of life, event-free survival, and crossover rates. 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). Conclusions: Our data could not rule out a relevant difference in favor of elective repair with regard to the primary endpoint. Nevertheless, in view of all other findings, we feel that our results justify watchful waiting as a reasonable alternative compared with surgery in men aged 50 years and older.

Uniformity of Chronic Pain Assessment after Inguinal Hernia Repair: A Critical Review of the Literature.

Background: Chronic postoperative inguinal pain (CPIP) is the most common long-term complication of inguinal hernia repair. As such procedures are routinely performed, CPIP can be considered a significant burden to global health care. Therefore, adequate preventative measures relevant to surgical practice are investigated. However, as no gold standard research approach is currently available, study and outcome measures differ between studies. The current review aims to provide a qualitative analysis of the literature to seek out if outcomes of CPIP are valid and comparable, facilitating recommendations on the best approach to preventing CPIP. Methods: A systematic review of recent studies investigating CPIP was performed, comprising studies published in 2007-2015. Study designs were analyzed regarding the CPIP definitions applied, the use of validated instruments, the availability of a baseline score, and the existence of a minimal follow-up of 12 months. Results: Eighty eligible studies were included. In 48 studies, 22 different definitions of CPIP were identified, of which the definition provided by the International Association for the Study of Pain was applied most often. Of the studies included, 53 (66%) used 33 different validated instruments to quantify CPIP. There were 32 studies (40%) that assessed both pain intensity (PI) and quality of life (QOL) with validated tools, 41% and 4% had a validated assessment of only PI or QOL, respectively, and 15% lacked a validated assessment. The visual analog scale and the Short Form 36 (SF36) were most commonly used for measuring PI (73%) and QOL (19%). Assessment of CPIP was unclear in 15% of the studies included. A baseline score was assessed in 45% of the studies, and 75% had a follow-up of at least 12 months. Conclusion: The current literature addressing CPIP after inguinal hernia repair has a variable degree of quality and lacks uniformity in outcome measures. Proper comparison of the study results to provide conclusive recommendations for preventive measures against CPIP therefore remains difficult. These findings reaffirm the need for a uniform and validated assessment with uniform reporting of outcomes to improve the burden that CPIP poses to a significant surgical patient population.

Authors' reply: Optimizing the critical view of safety in laparoscopic cholecystectomy by clipping and transecting the cystic artery before the cystic duct (Br J Surg 2007; 94: 473–474)

Sir We thank Kanhere and Bridgewater for their reaction. However, they probably misunderstood us when they conclude that we propose transection of the cystic artery before obtaining the critical view for safety. The surface area of Calot’s triangle was measured: initially after opening the covering peritoneal sheath and removing all fatty tissue from the triangle. Secondly after releasing the neck of the gallbladder from its fossa (critical view of safety has been obtained), and third after ligation and transection of the cystic artery. Our conclusion therefore applies to transection of the cystic artery before cystic duct only after the critical view has been obtained and with that, the cystic artery and cystic duct have been positively identified. Transection of the cystic artery before transection of the cystic duct, displaying Calot’s triangle significantly, represents a final check with regard to the identity of the presumed cystic duct and furthermore will prevent tearing off the cystic artery. A. R. Wijsmuller, M. Leegwater, L. Tseng, H. J. Smaal, G. J. Kleinrensink and J. F. Lange Department of Surgery, Erasmus MC, University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands DOI: 10.1002/bjs.5937

Authors' reply: Nerve management during open hernia repair (Br J Surg 2007; 94: 17–22)

Sir We thank Kanhere and Bridgewater for their reaction. However, they probably misunderstood us when they conclude that we propose transection of the cystic artery before obtaining the critical view for safety. The surface area of Calot’s triangle was measured: initially after opening the covering peritoneal sheath and removing all fatty tissue from the triangle. Secondly after releasing the neck of the gallbladder from its fossa (critical view of safety has been obtained), and third after ligation and transection of the cystic artery. Our conclusion therefore applies to transection of the cystic artery before cystic duct only after the critical view has been obtained and with that, the cystic artery and cystic duct have been positively identified. Transection of the cystic artery before transection of the cystic duct, displaying Calot’s triangle significantly, represents a final check with regard to the identity of the presumed cystic duct and furthermore will prevent tearing off the cystic artery. A. R. Wijsmuller, M. Leegwater, L. Tseng, H. J. Smaal, G. J. Kleinrensink and J. F. Lange Department of Surgery, Erasmus MC, University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands DOI: 10.1002/bjs.5937