D. L. Sanders

The modern management of incisional hernias.

#### Summary points Before the introduction of general anaesthesia by Morton in 1846, incisional hernias were rare. As survival after abdominal surgery became more common so did the incidence of incisional hernias.1 Since then, more than 4000 peer reviewed articles have been published on the topic, many of which have introduced a new or modified surgical technique for prevention and repair. Despite considerable improvements in prosthetics used for hernia surgery, the incidence of incisional hernias and the recurrence rates after repair remain high. Arguably, no other benign disease has seen so little improvement in terms of surgical outcome. #### Sources and selection criteria We searched PubMed from 1970-2012 and Embase and the Cochrane Library from inception using the terms “hernia” and “incisional” (using the Boolean operator AND) and “ventral” (using the Boolean operator OR). The reference lists were also used to identify studies of interest. Both authors independently identified publications for inclusion and differences were resolved by discussion. We gave priority to research published in the past five years and highly regarded older publications. Unlike other abdominal wall hernias, which occur through anatomical points of weakness, incisional hernias occur through a weakness at the site of abdominal wall closure. Why, unlike primary abdominal wall hernias, are the results after repair so poor? Perhaps it is because in the repair of incisional hernias several problems need to be overcome: a multilayered wall structure of different tissue properties in constant motion has to be sutured; positive abdominal …

Prosthetic mesh materials used in hernia surgery

It is estimated that 20 million prosthetic meshes are implanted each year worldwide. It is clear that the evolution of meshes is not yet complete and the ideal mesh is yet to be found. There is a vast array of prosthetics available for hernia repair. This review outlines the properties of available meshes and the evidence to be considered when choosing a prosthetic for hernia repair.

Randomized clinical trial comparing self-gripping mesh with suture fixation of lightweight polypropylene mesh in open inguinal hernia repair

Postoperative pain is an important adverse event following inguinal hernia repair. The aim of this trial was to compare postoperative pain within the first 3 months and 1 year after surgery in patients undergoing open mesh inguinal hernia repair using either a self‐gripping lightweight polyester mesh or a polypropylene lightweight mesh fixed with sutures.

Operation hernia: humanitarian hernia repairs in Ghana

Ghana has a high incidence of inguinal hernias and the healthcare system is unable to deliver an adequate repair rate. This results in morbidity and mortality and has a knock-on effect on the local economy. A project has been set up to try and reduce the burden of these hernias by establishing Africa’s first Hernia Centre. This is supported by structured visits by European surgeons to the centre. In October 2006, a team of four surgeons, two specialist registrars, one hernia nurse specialist, and three nurses was assembled in order to open the Hernia Centre, which will provide a base for the delivery of hernia services in the West of Ghana. A 2-year teaching programme has been formulated, tailored to the needs of local surgeons and nurses, with the aim of developing an integrated team that will initially deliver up to 50 hernia repairs each month. It is planned that the centre will be supported by structured periodic visits from surgeons and nurses based in Plymouth, the European Hernia Society, and any other volunteers wishing to support the link.

From ancient to contemporary times: a concise history of incisional hernia repair

PurposeThis historical review explores the origins of incisional hernia surgery.MethodsResources from each significant historical time period were reviewed, namely ancient times, the Greco-Roman period, the Middle Ages and the dawn of the surgeon anatomist, and the modern era.ResultsAlthough incisional hernias only started to be widely reported in the literature in the early twentieth century, an awareness of the risk of incisional hernia formation dates back to ancient times.ConclusionsSometimes, it is important to look back at the history and evolution of a topic to continue making positive advances in that field.

Nomenclature in Abdominal Wall Hernias: Is It Time for Consensus?

Abdominal wall reconstruction is a rapidly evolving area of surgical interest. Due to the increase in prevalence and size of ventral hernias and the high recurrence rates, the academic community has become motivated to find the best reconstruction techniques. Whilst interrogating the abdominal wall reconstruction literature, we discovered an inconsistency in hernia nomenclature that must be addressed. The terms used to describe the anatomical planes of mesh implantation ‘inlay’, ‘sublay’ and ‘underlay’ are misinterpreted throughout. We describe the misinterpretation of these terms and give evidence of where it exists in the literature. We give three critical arguments of why these misinterpretations hinder advances in abdominal wall reconstruction research. The correct definitions of the anatomical planes, and their respective terms, are described and illustrated. Clearly defined nomenclature is required as academic surgeons strive to improve abdominal wall reconstruction outcomes and lower complication rates.

Ten-Year Personal Experience of Using Low Density Polyethylene (LDPE)Mesh for Inguinal Hernia Repair

Introduction: An innovative frugal technology that has recently been reported with positive short-term clinical outcomes is the use of sterilised mosquito net as an alternative to commercial hernia meshes. However, long-term clinical data supporting the use of this mesh is lacking. Methods: A ten year retrospective analysis of consecutive patients undergoing inguinal hernia repair using Low Density PolyEthylene (LDPE) mesh with 12-18 months follow up. Results: During the study period 713 inguinal hernia repairs were performed using low cost polyethylene mesh in 651 patients. Thirty-two patients were lost to follow up. There were six superficial surgical site infections (0.9%), one seroma (0.1%), two patients who experienced chronic pain (0.3%), and two hematomas (0.3%). There were no recurrences or cases of mesh rejection. Discussion: The results of this retrospective study confirm the long-term safety and effectiveness of the use of LDPE mosquito net mesh for inguinal hernioplasty.

Design and validation of a novel quantitative method for rapid bacterial enumeration using programmed stage movement scanning electron microscopy.

The adhesion of bacteria to surgical implants is the first stage of implant infection. The method for detecting bound bacteria is an important consideration in the study of bacterial adherence and colonisation. Enumeration of bacteria by direct visualisation techniques is labour intensive and time consuming. We have developed and validated a method for enumerating bacteria on porous material surfaces using programmed stage movement scanning electron microscopy and compared cumulative counts after 1-10 stage movements with absolute bacterial counts. We describe this method with three commercially sourced meshes used for abdominal wall hernia repair and with three different inoculums of Staphylococcus epidermidis. The results demonstrate significant correlation to the absolute count after five cumulative counts for all meshes analysed. The mean time saved by the cumulative counting method was 1h and 9 min per mesh. We conclude that advances in scanning electron microscopy and the advent of precise automated stage control have facilitated rapid data acquisition for bacterial counting purposes and that five cumulative counts at 1000× or 2500× magnification are a valid quantitative method for enumerating S. epidermidis bacteria on porous surfaces (with a pore size of up to 1.3 mm).

Opportunities for surgical trainees: project hernia in Ghana

With clinical governance and patient safety as an integral part of clinical practice, the age-old adage ‘see one, do one, teach one’ is, rightly, no longer acceptable. This presents a hurdle to trainee and trainer alike as experiential learning is reduced. In addition, reduced theatre time for trainees and increasing performance pressures for consultants mean that it is difficult for trainees to learn operative surgery in a structured fashion, on regular theatre lists and on a regular basis. These problems are mirrored to a lesser extent in the USA.

Worlds apart: training in rural South Africa.

Background:  Reforms in the delivery of surgical and anaesthetic services in the UK have reduced the opportunity for trainees to acquire ‘hands‐on’ training. These problems are seen in other European countries and in North America.