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Background There is a reasonable body of evidence around oral/dental health and implant infection in orthopaedic and cardiovascular surgery. Another large area of surgical practice associated with a permanent implant is mesh hernia repair. This study aimed to review the evidence around oral/dental health and mesh infection. Methods The research protocol was registered in PROSPERO (CRD42022334530). A systematic review of the literature was undertaken according to the PRISMA 2020 statement. The initial search identified 582 publications. A further four papers were identified from references. After a review by title and abstract, 40 papers were read in full text. Fourteen publications were included in the final review, and a total of 47,486 patients were included. Results There is no published evidence investigating the state of oral hygiene/health and the risk of mesh infection or other infections in hernia surgery. Improvement in oral hygiene/health can reduce surgical site infection and implant infection in colorectal, gastric, liver, orthopaedic and cardiovascular surgery. Poor oral hygiene/health is associated with a large increase in oral bacteria and bacteraemia in everyday activities such as when chewing or brushing teeth. Antibiotic prophylaxis does not appear to be necessary before invasive dental care in patients with an implant. Conclusion Good oral hygiene and oral health is a strong public health message. The effect of poor oral hygiene on mesh infection and other complications of mesh hernia repair is unknown. While research is clearly needed in this area, extrapolating from evidence in other areas of surgery where implants are used, good oral hygiene/health should be encouraged amongst hernia patients both prior to and after their surgery.

Introduction Ventral hernias are common and operations for ventral hernias are some of the most commonly performed procedures in general surgery. These operations are often motivated also by symptoms such as back pain, the bulge growing and abdominal wall pain or inability to exercise. Material and methods We have run a retrospective trial looking at our cohort of patients with large ventral hernias that have successfully completed a prehabilitation programme. We have specifically focused at symptoms of back pain, size of their hernias and other general symptoms like ability to exercise. Results 78 patients have successfully completed the programme and 45 have decided against an operation as the symptoms that have originally motivated them to seek surgical help have diminished. Their abdominal circumference (measured over the hernia) has not increased in any of them. Conclusion Individual physiotherapy can lead to improvement in patient symptoms and can prevent a hernia from getting bigger.

Aim Hernia Basecamp is an online learning platform hosted within the WebSurg website with 205 video lectures. A number of these lectures are selected to create 10 modules of 3 hours each with UEMS CME accreditation. The aim of this study was to review the CME module test results since launch in June 2021. Methods Hernia Basecamp was interrogated in January 2023. Data on the number of CME module tests taken, the pass rate and the country of the examinee were collected. Results The numbers of tests taken, the number of passes, and the pass rate per module as well as the totals is shown in the table. The UK, Switzerland and Germany were the top 3 countries representing 36% of the modules passed. Conclusions The UEMS approved CME accreditation tests generally had a high pass rate. BUT, detailed knowledge of the basics of groin hernia AND published guidelines was poor as reflected in the lower pass rates.

Background There is an increasing number of patients following hernia surgery with implanted mesh reporting symptoms that could indicate autoimmune or allergic reactions to mesh. ‘Allergy’ to metals, various drugs, and chemicals is well recognised. However, hypersensitivity, allergy or autoimmunity caused by surgical mesh has not been proven by a scientific method to date. The aim of this study was twofold: to describe the pathophysiology of autoimmunity and foreign body reaction and to undertake a systematic review of surgical mesh implanted at the time of hernia repair and the subsequent development of autoimmune disease. Methods A systematic review using the PRISMA guidelines was undertaken. Pubmed (Medline), Google Scholar and Cochrane databases were searched for all English-written peer-reviewed articles published between 2000 and 2021. The search was performed using the keywords “hernia”, “mesh”, “autoimmunity”, “ASIA”, “immune response”, “autoimmune response”. Results Seven papers were included in the final analysis—three systematic reviews, three cohort studies and one case report. Much of the current data regarding the association of hernia mesh and autoimmunity relies on retrospective cohort studies and/or case reports with limited availability of cofounding factor data linked to autoimmune disease such as smoking status or indeed a detailed medical history of patients. Three systematic reviews have discussed this topic, each with a slightly different approach and none of them has identified causality between the use of mesh and the subsequent development of autoimmune disease. Conclusion There is little evidence that the use of polypropylene mesh can lead to autoimmunity. A large number of potential triggers of autoimmunity along with the genetic predisposition to autoimmune disease and the commonality of hernia, make a cause and effect difficult to unravel at present. Biomaterials cause foreign body reactions, but a chronic foreign body reaction does not indicate autoimmunity, a common misunderstanding in the literature.

Background Abdominal wall hernia repair is one of the most commonly performed surgical procedures worldwide, yet despite this, there remains a lack of high-quality evidence to support best management. The aim of the study was to use a modified Delphi process to determine future research priorities in this field. Methods Stakeholders were invited by email, using British Hernia Society membership details or Twitter, to submit individual research questions via an online survey. In addition, questions obtained from a patient focus group (PFG) were collated to form Phase I. Two rounds of prioritization by stakeholders (phases II and III) were then completed to determine a final list of research questions. All questions were analyzed on an anonymized basis. Results A total of 266 questions, 19 from the PFG, were submitted by 113 stakeholders in Phase I. Of these, 64 questions were taken forward for prioritization in Phase II, which was completed by 107 stakeholders. Following Phase II analysis, 97 stakeholders prioritized 36 questions in Phase III. This resulted in a final list of 14 research questions, 3 of which were from the PFG. Stakeholders included patients and healthcare professionals (consultant surgeons, trainee surgeons and other multidisciplinary members) from over 27 countries during the 3 phases. Conclusion The study has identified 14 key research priorities pertaining to abdominal wall hernia surgery. Uniquely, these priorities have been determined from participation by both healthcare professionals and patients. These priorities should now be addressed by well-designed, high-quality international collaborative research.

Background There is a reasonable evidence around oral/dental health and implant infection in orthopaedic and cardiovascular surgery. Mesh hernia repair is another area of surgical practice associated with a permanent implant. The aim of this SR was to review the evidence around oral/dental health and mesh infection. Mehods The study was registered at Prospero. A systematic review of the literature was undertaken according to the PRISMA2020 statement. The initial search identified 520 publications. After a review by title and abstract, 40 papers were read in full text. A further 4 papers were identified from references and searching.15 publications were included in the final review. Results There is no published evidence investigating the state of oral hygiene/health and the risk of mesh infection. Improvement in oral hygiene/health can reduce surgical site infection and implant infection in colorectal, gastric, liver, orthopaedic and cardiovascular surgery. Poor oral hygiene/health is associated with a large increase in oral bacteria and bacteraemia on everyday activities such as when chewing or brushing teeth. Antibiotic prophylaxis does not appear to be necessary before invasive dental care in patients with an implant. Conclusion Good oral hygiene and oral health is a strong public health message. The effect of poor oral hygiene on mesh infection and other complications of mesh hernia repair is unknown. While research is clearly needed in this area, extrapolating from evidence in other areas of surgery where implants are used, good oral hygiene/health should be encouraged amongst hernia patients both prior and after their surgery.

Background There is an increasing number of patients following hernia surgery with implanted mesh reporting symptoms that could indicate autoimmune or allergic reactions. ‘Allergy’ to metals, drugs, and chemicals is well recognised. However, allergy or autoimmunity caused by mesh has not been proven by a scientific method to date. The aim of this study was twofold: to describe the pathophysiology of autoimmunity and foreign body reaction and to undertake a systematic review of mesh implanted at the time of hernia repair and the subsequent development of autoimmune disease. Methods A systematic review using the PRISMA guidelines was undertaken. Pubmed, Google Scholar, and Cochrane databases were searched for English-written articles published between 2000 and 2021. The search was performed using keywords “hernia”, “mesh”, “autoimmunity”, “ASIA”, “immune response”, “autoimmune response” Results Seven papers, were included in the final analysis – three systematic reviews, three cohort studies and one case report. Much of the current data regarding the association of hernia mesh and autoimmunity relies on retrospective cohort studies and/or case reports with limited availability of cofounding factor data linked to autoimmune disease. Three systematic reviews have discussed this topic, each with different approach and none of them has identified causality between the use of mesh and development of autoimmune disease. Conclusion There is evidence that certain biomaterials can lead to immune dysregulation and induce autoimmunity. However, this has never been proven with synthetic hernia mesh. The bias in trials are high. And scientific studies have not been undertaken mesh-related autoimmunity.

Background Primary and incisional ventral hernia trials collect unstandardized inconsistent data, limiting data interpretation and comparison. This study aimed to create two minimum data sets for primary and incisional ventral hernia interventional trials to standardize data collection and improve trial comparison. To support these data sets, standardized patient-reported outcome measures and trial methodology criteria were created. Methods To construct these data sets, nominal group technique methodology was employed, involving 15 internationally recognized abdominal wall surgeons and two patient representatives. Initially a maximum data set was created from previous systematic and panellist reviews. Thereafter, three stages of voting took place: stage 1, selection of the number of variables for data set inclusion; stage 2, selection of variables to be included; and stage 3, selection of variable definitions and detection methods. A steering committee interpreted and analysed the data. Results The maximum data set contained 245 variables. The three stages of voting commenced in October 2019 and had been completed by July 2020. The final primary ventral hernia data set included 32 variables, the incisional ventral hernia data set included 40 variables, the patient-reported outcome measures tool contained 25 questions, and 40 methodological criteria were chosen. The best known variable definitions were selected for accurate variable description. CT was selected as the optimal preoperative descriptor of hernia morphology. Standardized follow-up at 30 days, 1 year, and 5 years was selected. Conclusion These minimum data sets, patient-reported outcome measures, and methodological criteria have allowed creation of a manual for investigators aiming to undertake primary ventral hernia or incisional ventral hernia interventional trials. Adopting these data sets will improve trial methods and comparisons.

Background An acute inguinal hernia remains a common emergency surgical condition worldwide. While emergency surgery has a major role to play in treatment of acute hernias, not all patients are fit for emergency surgery, nor are facilities for such surgery always available. Taxis is the manual reduction of incarcerated tissues from the hernia sack to its natural compartment, and can help delay the need for surgery from days to months. The aim of this study was to prepare a safe algorithm for performing manual reduction of incarcerated inguinal hernias in adults. Methods Medline, Scopus, Ovid and Embase were searched for papers related to emergency inguinal hernias and manual reduction. In addition, the British National Formulary and Safe Sedation Practice for Healthcare Procedures: Standards and Guidance were reviewed. Results A safe technique of manual reduction of an acute inguinal hernia, called GPS (Gentle, Prepared and Safe) Taxis, is described. It should be performed within 24 h from the onset of a painful irreducible lump in groin, and when concomitant symptoms and signs of bowel strangulation are absent. Conscious sedation guidelines should be followed. The most popular drug combination is of intravenous morphine and short-acting benzodiazepine, both titrated carefully for optimal and safe effect. The dose of drugs must be individualised, and the smallest effective dosage should be used to avoid oversedation. Following successful taxis, the patient should undergo a short period of observation. Urgent surgery can be undertaken during the same admission or up to several weeks later. Conclusions Taxis is a benign/non-invasive method for patients with an acute, non-strangulated inguinal hernias. It likely reduces the risk and complications of anaesthesia and surgery in the emergency settings. GPS Taxis should be considered as first line treatment in the majority of patients presenting with an acute inguinal hernia when existing bowel infarction is unlikely. Supplementary Information The online version contains supplementary material available at 10.1007/s10029-021-02429-1.

BackgroundVentral hernia repair is one of the most commonly performed surgical procedures worldwide. To reduce the risk of complications, pre- and intra-operative strategies have received increasing focus in recent years. To assess possible preventive surgical strategies, this European Hernia Society endorsed project was launched. The aim of this review was to evaluate the current literature focusing on pre- and intra-operative strategies for surgical site occurrences (SSO) and specifically surgical site infection (SSI) in ventral hernia repair.MethodsA systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Databases used were Pubmed and Web of Science. Original retrospective or prospective human adult studies describing at least one intra-operative intervention to reduce SSO after ventral hernia repair were considered eligible.ResultsFrom a total of 4775 results, a total of 18 papers were considered suitable after full text reading. Prehospital chlorhexidine gluconate (CHG) scrub appears to increase the risk of SSO in patients undergoing ventral hernia repair, while there is no association between any type of surgical hat worn and the incidence of postoperative wound events. Intraoperative measures as prophylactic negative pressure therapy, surgical drain placement and the use of quilt sutures seem beneficial for decreasing the incidence of SSO and/or SSI. No positive effect has been shown for antibiotic soaking of a synthetic mesh, nor for the use of fibrin sealants.ConclusionThis review identified a limited amount of literature describing specific preventive measures and techniques during ventral hernia repair. An advantage of prophylactic negative pressure therapy in prevention of SSI was observed, but different tools to decrease SSIs and SSOs continuously further need our full attention to improve patient outcomes and to lower overall costs.

Ventral hernia repair is one of the most commonly performed surgical procedures worldwide. To reduce the risk of complications, patient prehabilitation has received increasing focus in recent years. To assess prehabilitation measures, this European Hernia Society endorsed project was launched. The aim of this systematic review was to evaluate the current literature on patient prehabilitation prior to ventral hernia repair.The strategies examined were optimization of renal disease, obesity, nutrition, physical exercise, COPD, diabetes and smoking cessation. For each topic, a separate literature search was conducted, allowing for seven different sub-reviews.A limited amount of well-conducted research studies evaluating prehabilitation prior to ventral hernia surgery was found. The primary findings showed that smoking cessation and weight loss for obese patients led to reduced risks of complications after abdominal wall reconstruction.Prehabilitation prior to ventral hernia repair may be widely used; however, the literature supporting its use is limited. Future studies evaluating the impact of prehabilitation before ventral hernia surgery are warranted.

Surgical mesh is widely used not only to treat but also to prevent incisional hernia formation. Despite much effort by material engineers, the 'ideal' mesh mechanically, biologically and surgically easy to use remains elusive. Advances in tissue engineering and nanomedicine have allowed new concepts to be tested with promising results in both small and large animals. Abandoning the concept of a pre-formed mesh completely for a 'pour in liquid mesh' has never been tested before.Thirty rabbits underwent midline laparotomy with closure using an absorbable suture and small stitch small bites technique. In addition, their abdominal wall closure was reinforced by a liquid nanofibrous scaffold composed of a fibrin sealant and nanofibres of poly-ε-caprolactone with or without hyaluronic acid or the sealant alone, poured in as an 'onlay' over the closed abdominal wall. The animals were killed at 6 weeks and their abdominal wall was subjected to histological and biomechanical evaluations.All the animals survived the study period with no major complication. Histological evaluation showed an eosinophilic infiltration in all groups and foreign body reaction more pronounced in the groups with nanofibres. Biomechanical testing demonstrated that groups treated with nanofibres developed a scar with higher tensile yield strength.The use of nanofibres in a liquid form applied to the closed abdominal wall is easy to use and improves the biomechanical properties of healing fascia at 6 weeks after midline laparotomy in a rabbit model.

Background: An acute inguinal hernia remains a common emergency surgical condition worldwide. While emergency surgery has a major role to play in treatment of acute hernias, not all patients are fit for emergency surgery, nor are facilities for such surgery always available. Taxis is the manual reduction of incarcerated tissues from the hernia sack to its natural compartment, and can help delay the need for surgery for days to months. The aim of this study was to prepare a safe algorithm for performing manual reduction of incarcerated inguinal hernias in adults. Methods: Medline, Scopus, Ovid and Embase were searched for papers related to emergency inguinal hernias. In addition, the British National Formulary and Safe Sedation Practice for Healthcare Procedures: Standards and Guidance were reviewed. Results: A safe technique of manual reduction of an acute inguinal hernia, called GPS (Gentle, Prepared and Safe) Taxis, is described. It should be performed within 24h from the onset of a painful irreducible lump in groin, and when concomitant symptoms and signs of bowel strangulation are absent. Conscious sedation guidelines should be followed. The most popular drug combination is of intravenous morphine and short acting benzodiazepine, both titrated carefully for optimal and safe effect. The dose of drugs must be individualised, and the smallest effective dosage should be used to avoid oversedation. Following successful taxis, the patient can be safely discharged after a short period of observation to return form more planned urgent surgery. Conclusions: Taxis is a feasible and safe method for patients with an incarcerated inguinal hernias. It likely reduces the risk and complications of anaesthesia and surgery in the emergency settings. GPS Taxis should be considered as first line treatment in the majority of patients presenting with an acute inguinal hernia when existing bowel infarction is unlikely.

Background Acute IH is a common surgical presentation. Despite new guidelines being published recently, a number of important questions remained unanswered including the role of taxis, as initial non-operative management. This is particularly relevant now due to the possibility of a lack of immediate surgical care as a result of COVID-19. The aim of this review is to assess the role of taxis in the management of emergency inguinal hernias. Methods A review of the literature was undertaken. Available literature published until March 2019 was obtained and reviewed. 32,021 papers were identified, only 9 were of sufficient value to be used. Results There was a large discrepancy in the terminology of incarcerated/strangulated used. Taxis can be safely attempted early after the onset of symptoms and is effective in about 70% of patients. The possibility of reduction en-mass should be kept in mind. Definitive surgery to repair the hernia can be delayed by weeks until such time as surgery can be safely arranged. Conclusions The use of taxis in emergency inguinal hernia is a useful first line of treatment in areas or situations where surgical care is not immediately available, including the COVID-19 pandemic. Emergency surgery remains the mainstay of management in the strangulated hernia setting.

Background Umbilical and epigastric hernia repairs are frequently performed surgical procedures with an expected low complication rate. Nevertheless, the optimal method of repair with best short- and long-term outcomes remains debatable. The aim was to develop guidelines for the treatment of umbilical and epigastric hernias. Methods The guideline group consisted of surgeons from Europe and North America including members from the European Hernia Society and the Americas Hernia Society. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, the Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists, and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were used. A systematic literature search was done on 1 May 2018, and updated on 1 February 2019. Results Literature reporting specifically on umbilical and epigastric hernias was limited in quantity and quality, resulting in a majority of the recommendations being graded as weak, based on low-quality evidence. The main recommendation was to use mesh for repair of umbilical and epigastric hernias to reduce the recurrence rate. Most umbilical and epigastric hernias may be repaired by an open approach with a preperitoneal flat mesh. A laparoscopic approach may be considered if the hernia defect is large, or if the patient has an increased risk of wound morbidity. Conclusion This is the first European and American guideline on the treatment of umbilical and epigastric hernias. It is recommended that symptomatic umbilical and epigastric hernias are repaired by an open approach with a preperitoneal flat mesh.

Barbora East,1,2 Martin Plencner,3,4 Martin Kralovic,1,3,5 Michala Rampichova,3 Vera Sovkova,1,3,5 Karolina Vocetkova,1,3,5 Martin Otahal,6,7 Zbynek Tonar,8,9 Yaroslav Kolinko,8,9 Evzen Amler,1,3,5 Jiri Hoch1,10 1Second Medical Faculty, Charles University in Prague, Prague, Czech Republic; 2Third Department of Surgery, Motol Faculty Hospital, First Medical Faculty, Charles University in Prague, Prague, Czech Republic; 3Institute of Experimental Medicine, The Czech Academy of Sciences, Prague, Czech Republic; 4The Czech Academy of Sciences, Institute of Physiology, Prague, Czech Republic; 5University Centre of Energy Efficient Buildings, Czech Technical University in Prague, Bustehrad, Czech Republic; 6Department of Anatomy and Biomechanics, Faculty of Physical Education, Charles University in Prague, Prague, Czech Republic; 7Department of Natural Sciences, Faculty of Biomedical Engineering, Czech Technical University in Prague, Kladno, Czech Republic; 8Department of Histology and Embryology, 9Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic; 10Surgery Department, Motol Faculty Hospital, Second Medical Faculty, Charles University in Prague, Prague, Czech Republic Purpose: Incisional hernia repair is an unsuccessful field of surgery, with long-term recurrence rates reaching up to 50% regardless of technique or mesh material used. Various implants and their positioning within the abdominal wall pose numerous long-term complications that are difficult to treat due to their permanent nature and the chronic foreign body reaction they trigger. Materials mimicking the 3D structure of the extracellular matrix promote cell adhesion, proliferation, migration, and differentiation. Some electrospun nanofibrous scaffolds provide a topography of a natural extracellular matrix and are cost effective to manufacture.Materials and methods: A composite scaffold that was assembled out of a standard polypropylene hernia mesh and poly-ε-caprolactone (PCL) nanofibers was tested in a large animal model (minipig), and the final scar tissue was subjected to histological and biomechanical testing to verify our in vitro results published previously.Results: We have demonstrated that a layer of PCL nanofibers leads to tissue overgrowth and the formation of a thick fibrous plate around the implant. Collagen maturation is accelerated, and the final scar is more flexible and elastic than under a standard polypropylene mesh with less pronounced shrinkage observed. However, the samples with the composite scaffold were less resistant to distracting forces than when a standard mesh was used. We believe that the adverse effects could be caused due to the material assembly, as they do not comply with our previous results.Conclusion: We believe that PCL nanofibers on their own can cause enough fibroplasia to be used as a separate material without the polypropylene base, thus avoiding potential adverse effects caused by any added substances. Keywords: nanofibers, hernia, mesh, PCL, minipig, biomechanical, large animal

Incisional hernia is a frequent complication of midline laparotomy and enterostomal creation and is associated with high morbidity, decreased quality of life, and high costs. The International Symposium on Incisional Hernia Prevention was held October 19 –20, 2017, at the InterContinental Hotel in San Francisco, CA, hosted by the Department of Surgery, University of California, San Francisco. One hundred and three attendees included general and plastic surgeons from 9 countries, including principal participants for several of the seminal studies in the field. Over the course of the 2-day meeting, there were 38 oral presentations, 3 keynote lectures, and 2 panel discussions. The Symposium was a combination of new information but also a comprehensive review of the existing data so as to assess the current state of the field and to set the stage for future research. Further, the Symposium sought to increase awareness and thus emphasize the importance of preventing the formation of incisional and enterostomal hernias. pre-print 443 KB

Objectives Army body composition standards are based upon validated criteria; however, certain field-expedient methodologies (e.g., weight-for-height, body mass index [BMI]) may disqualify individuals from service who may otherwise excel on physical performance and military-relevant tasks. The purpose was to assess soldier physical performance and military-specific task/fitness performance stratified by BMI. Design Cross-sectional observational study. Methods Male (n = 275) and female (n = 46) soldiers performed a wide-array of physical fitness tests and military-specific tasks, including the Army physical fitness test (APFT). Within-sex performance data were analyzed by BMI tertile stratification or by Army Body Composition Program (ABCP) weight-for-height (calculated BMI) screening standards using ANOVA/Tukey post-hoc or independent t-tests, respectively. Results BMI stratification (higher vs. lower BMI) was associated with significant improvements in muscular strength and power, but also with decrements in speed/agility in male and female soldiers. Within the military specific tasks, a higher BMI was associated with an increased APFT 2-Mile Run time; however, performance on a 1600-m Loaded March or a Warrior Task and Battle Drill obstacle course was not related to BMI in either sex. Male and Female soldiers who did not meet ABCP screening standards demonstrated a slower 2-Mile Run time; however, not meeting the ABCP BMI standard only affected a minimal number (∼6%) of soldiers’ ability to pass the APFT. Conclusions Military body composition standards require a careful balance between physical performance, health, and military readiness. Allowances should be considered where tradeoffs exist between body composition classifications and performance on physical tasks with high military relevance.

Incisional hernia is the most common complication following abdominal surgery. While mesh repair is common, none of the current meshes mimic the physiology of the abdominal wall. This study compares suture only repair with polypropylene mesh and a prototype of a novel implant (poly-epsilon-caprolactone nanofibers) and their influence on the physiology of an abdominal wall in an animal model. 27 Chinchilla rabbits were divided into six groups based on the type of the implant. Midline abdominal incision was repaired using one of the compared materials with suture alone serving as the control. 6 weeks post-surgery animals were killed and their explanted abdominal wall subjected to biomechanical testing. Both—hysteresis and maximum strength curves showed high elasticity and strength in groups where the novel implant was used. Polypropylene mesh proved as stiff and fragile compared to other groups. Poly-epsilon-caprolactone nanofiber scaffold is able to improve the dynamic properties of healing fascia with no loss of maximum tensile strength when compared to polypropylene mesh in an animal model.