Table showing number and percentage of patients as per indication for surgery. We experienced six episodes of recurrence 1. All recurrences were detected after 3 months on clinical evaluation at the time of follow up. However, on subsequent corrective surgery, no true hernia was evident in any patient other than a lipoma of the cord. All recurrences were re-operated on by the open technique and required a non-absorbable suture repair of the internal ring only.
Of the patients pain scores are complete for individuals. The following boxplot Figure 1 demonstrates that before surgery the pain scores were widely spread, almost across the whole range in a slightly skewed distribution, median 5, IQR 4—7 , while after surgery there is a distinctive drop with Hence, the overall difference between time-points is statistically significant, showing a reduction in pain after surgery.
Figure 1. A comparison was made between unilateral and bilateral hernias for the with pain scores. Those with a bilateral hernia appeared to have a larger degree of pain pre surgery median [IQR] 6 [4. Testing the change scores to see whether they come from a similar distribution, the p -value of 0. In conclusion the difference in pain between uni and bilateral hernias lies pre-surgery, with a greater change seen in bilateral hernias.
Whether the hernia was uni or bilateral did not affect the pain scores post operatively. Those with a bilateral hernia appear to have a larger degree of pain pre surgery, followed by the left side median [IQR] 6 [4. Testing the change scores using a Kruskal Wallis test to see whether they come from a similar distribution, the p -value 0. The post-hoc test suggests that the change in pain scores is significantly different for those with bilateral vs.
Of the patients have complete pain scores and a defined operation group. Although the different groups have different levels of pain prior to surgery, afterwards all seem to decrease to similar small levels. A Kruskal-Wallis test gives a p -value of 0. Table 3. In linear regression analyses there was no effect shown in terms of laterality of hernia and degree of post-operative pain. The commonest complication noted was a seroma in 12 patients 3.
Other complications included hydrocele of the cord, haematoma formation and testicular discomfort. There were no re-operations within 3 months and no early recurrences as well as any reported deaths or re-hospitalization. Hernia surgery remains a technique driven surgical entity. What constitutes a good repair remains a contentious question and in consequence any particular repair can be recommended by a surgeon with a high volume practice depicting evidence of good outcomes 8 , Recently published groin hernia guidelines promote a safe and evidence guided practice for hernia surgery 8 , In these guidelines, recommendations are made based on mesh type, fixation technique and the method of repair 8 , Mesh fixation is mandated for large medial hernias, M3 as per the EHS classification of groin hernias grade of recommendation A 8 , In the case of other smaller hernias, no-fixation has been deemed both safe and effective 8.
Earlier publications evaluated surgical management options for patients suffering with chronic pain following IHR where various methods of treatment were examined; mesh removal, selective neurectomy, removal of surgical clips as well as the use of diagnostic, and therapeutic analgesics and anesthetic agents. The overall level of evidence included in this review was not of a robust enough standing by being based on largely subjective data and evidence. Therefore, despite the reports of favorable outcomes in individual cases, no clear conclusions can be drawn on what exactly causes CPIP, it is likely that a multitude of factors are responsible Despite this, the rational-minded surgeon can be led to believe that increasing traumatic injury to an area of tissue, particularly containing nerves, poses an increased risk of neuropathic symptoms and may subsequently contribute to CPIP 8.
Three reviews comparing permanent versus non-permanent fixation in TEP repair have depicted advantages of glue-fixation in reducing the incidence of chronic pain 16 , 17 , The use of FS, a composite of fibrinogen and thrombin preparations, is now a well-established and recognized method for mesh-fixation.
For TEP repair, mechanical integrity was first shown in animal experiments 24 and also a reduction in the need for post-operative analgesia was demonstrated in a randomized controlled trial setting 25 as was a quicker return to physical and social activities A systematic review of the use of FS compared to staples in TEP repair concluded that there was no superiority in terms of hernia recurrence and that FS fixation might be the preferable technique based on its associated decreased incidence of CPIP Recent retrospective analyses of case series have shown favorable patient centered outcomes with low incidences of CPIP and recurrence 19 , In the author's experience, currently very few open and laparoscopic surgeons opt for a no-fixation method of mesh placement in day-to-day practice.
Given the aforementioned recommendation that there is still a need to fixate mesh prostheses in some instances, namely a large direct hernia M3 and above 8 , it is likely that it will take some time and considerable evidence for no-fixation to be widely adopted in practice. With the possibility that self-gripping mesh technology may play a role in advancing this movement Recent international guidelines have reviewed 23 RCTs relating to mesh material and clinical outcomes and subsequently state that the evidence supports the contention that mesh characteristics influence clinical outcomes 8.
Key characteristics of a prosthesis that should be commonplace in the rationale for groin hernia repair include; mesh size, mesh material, mesh construct and the size of the pores within the mesh. Contemporary advice from recent international guidelines is states that the use of the weight of an implant as a singular parameter for mesh classification is no longer acceptable 8. This case series reporting the use of the Manchester groin repair had already begun ahead of the publication of the aforementioned guidelines.
These factors make a difference with the larger pore size significantly improving surrounding soft tissue integration 29 , 30 and reducing fibrotic bridging between filaments and the subsequent risk of excessive mesh contraction Any mesh prosthesis used is required to obtain adequate coverage of the hernia defect and so reduce the risk of recurrence.
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The author alludes to the fact that with the increased coverage and subsequent mesh associated strengthening of a wider area, in addition to the added effect of the enhanced collagen deposition as a result of the use of FS, will have contributed to the lower level of hernia recurrence and possibly too the incidence of CPIP.
This study, albeit with not large numbers, provides more evidence for atraumatic mesh-fixation with FS. In addition, it outlines the role of selective application of FS at key areas within the groin. This creates a space for mesh-fixation to the obturator fascia. The results demonstrate that this technique has the potential to be highly efficacious.
A reported low rate of recurrence 1. This case series provides evidence and rationale of a safe and efficacious modification of the established TEP repair. This information supports that a surgeon establishing laparoscopic hernia practice will consider the use of a lightweight, wide-pore mesh of a good size 15 by 12 cm and achieve mesh-fixation with an atraumatic method e. This combination assures a relative low incidence of post-herniorrhaphy pain, both acute and chronic, and a low incidence of hernia recurrence.
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Data from a high volume hernia surgeon; is the high volume nature of practice the real benefactor to the favorable results seen here or is it the technical alterations most likely a combination of the two. The numbers are small but the follow up spans over a long period, but although not all patients were able to provide VAS pain scores.
Ethics approval was sought and advised that this retrospective data analysis is exempt from Ethics and this has been defined in the methodology. JP: Writing of manuscript and data analysis.
AJS: Operating surgeon, data analysis, writing and editing of manuscript. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. BBC News. Lorenz R. Do we really need a renaissance of pure tissue repair? Invited comment to: Desarda's technique versus Lichtenstein technique for the treatment of primary inguinal hernia: a systematic review and meta-analysis of randomized controlled trials.
Emile S, Elfeki H. Hernia —8. Randomized clinical trial of non-mesh versus mesh repair of primary inguinal hernia. Br J Surg. Grant AM.
Open mesh versus non-mesh repair of groin hernia: meta-analysis of randomised trials based on individual patient data [corrected]. Hernia —6. Long-term follow-up of a randomized clinical trial of non-mesh versus mesh repair of primary inguinal hernia. International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery. Hernia — An international consensus algorithm for management of chronic postoperative inguinal pain.
Group H. International guidelines for groin hernia management. Decreasing prevalence of chronic pain after laparoscopic groin hernia repair: a nationwide cross-sectional questionnaire study. Surgery Today — Less chronic pain following mesh fixation using a fibrin sealant in TEP inguinal hernia repair. Hernia —7. Tisseel versus tack staples as mesh fixation in totally extraperitoneal laparoscopic repair of groin hernias: a retrospective analysis. Surg Endoscopy —7. Lau H, Patil NG. Selective non-stapling of mesh during unilateral endoscopic total extraperitoneal inguinal hernioplasty: a case-control study.
Arch Surg. A meta-analysis examining the use of tacker fixation versus no-fixation of mesh in laparoscopic inguinal hernia repair. Int J Surg. A meta-analysis of randomized controlled trials of fixation versus nonfixation of mesh in laparoscopic total extraperitoneal inguinal hernia repair.
Surg Endoscopy — Outcomes of staple fixation of mesh versus nonfixation in laparoscopic total extraperitoneal inguinal repair: a meta-analysis of randomized controlled trials. World J Surg. Postoperative complications occurred in 16 patients in the control Table 5 shows the distribution of complications by severity and type of resection.
The distribution of complications was similar in patients with minor hepatectomies irrespective of treatment. Two patients in both groups who had major hepatectomy developed postoperative liver failure grade IV that required management in the intensive care unit. The number of readmissions was higher in the control group than in the collagen sponge group 8. A multivariate analysis was performed to identify independent covariates that predict postoperative complications. The main finding of the present study is that application of a new carrier-bound collagen sponge to the raw liver surface is useful for decreasing both postoperative drainage volume and blood transfusion requirements and hospital stay.
Use of the collagen sponge is also associated with a significant decrease in moderate to severe postoperative complications requiring surgical and radiological intervention in patients who have major hepatectomy, while it is less effective in those who have minor resections.
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Despite widespread use of topical hemostatic agents in liver surgery, it is surprising how liver surgeons accept without criticism the use of new devices and biological products with an apparent advantage but without evidence-based utility. In the past 5 years, more than articles on the efficacy of topical sealants in liver surgery have been published in the indexed literature. A preliminary trial by Frilling et al 15 comparing the same carrier-bound collagen sponge to argon beamer showed a significant superiority of the sponge in terms of time to intraoperative hemostasis and lower hemoglobin concentration in drainage fluid after the second postoperative day.
Intraoperative time to hemostasis, defined as the time from sealant application to the liver surface to the time when there was no further evidence of bleeding after direct observation for 1 minute, is an endpoint widely used. Focus on parameters such as drainage volume, postoperative blood transfusion, and surgery-related adverse events may be more clinically relevant, and these were the main endpoints used in our study.
A controversial point of this study is the routine use of closed mixed capillary suction drains in patients who had major hepatectomy. Some authors have shown that prophylactic drains are of little value in patients with posthepatectomy both with 17 and without 18 liver disease. In agreement with such views, these drains have not been used in our institution since However, for the purposes of this clinical study, the daily volume drained was considered to be a direct measure of the effectiveness of the collagen sponge tested.