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Resume Introduction L’evaluation du taux de readmissions a 30 jours apres cure de hernie inguinale represente un indicateur de qualite de la prise en charge des patients. L’objectif de notre etude a ete d’evaluer le taux de readmissions dans les 30 jours apres cure de hernie inguinale et d’identifier les facteurs de risque de readmission. Methode Au sein d’un registre national prospectif, les donnees des patients successifs operes d’une cure de hernie inguinale ont ete collectees sur une periode de 2 ans. Le nombre de readmissions, ainsi que leurs causes, ont ainsi ete colligees. Resultats Un total de 5126 patients, âges en moyenne de 61 ans, ont ete operes d’une cure de hernie inguinale. Une procedure ambulatoire a ete realisee chez 4013 (78 %) patients. Cent (2 %) patients ont presente un echec de l’ambulatoire. Trente-trois (0,64 %) patients ont ete readmis dans les 30 jours suivant la chirurgie pour 34 raisons differentes. Le taux de readmissions apres chirurgie ambulatoire etait de 0,5 %. La moitie des patients readmis ont presente une complication severe necessitant une reintervention. En analyse multivariee, la cure de hernie inguinale en urgence (OR 4,899 [1,309–18,327] ; p = 0,01) et la duree operatoire prolongee (OR 1,023 [1,009–1,037] ; p = 0,001) ont ete identifies comme facteurs de risque independants de readmission dans les 30 jours postoperatoires. Conclusion Au sein d’une cohorte nationale prospective, nous avons identifie un taux de readmissions global dans les 30 jours apres cure de hernie inguinale de 0,64 %, apparaissant moindre chez les patients operes en ambulatoire. La moitie des patients readmis ont necessite une reprise chirurgicale. La cure de hernie en urgence et la duree operatoire prolongee apparaissent comme facteurs de risque de readmission.

PMID: 33891224; PURPOSE: To assess the rate of late chronic postoperative inguinal pain (CPIP) after groin hernia repair in patients with different categories of preoperative VRS (Verbal Rating Scale) pain and to make a pragmatic evaluation of the rates of potentially surgery-related CPIP vs. postoperative continuation of preexisting preoperative pain. METHODS: Groin pain of patients operated from 01/11/2011 to 01/04/2014 was assessed preoperatively, postoperatively and at 2-year follow-up using a VRS-4 in 5670 consecutive groin hernia repairs. A PROM (Patient Related Outcomes Measurement) questionnaire studied the impact of CPIP on the patients' daily life. RESULTS: Relevant (moderate or severe VRS) pain was registered preoperatively in 1639 of 5670 (29%) cases vs. 197 of 4704 (4.2%) cases at the 2-year follow-up. Among the latter, 125 (3.7%) cases were found in 3353 cases with no-relevant preoperative pain and 72 (5.3%) in 1351 cases with relevant preoperative pain. Relevant CPIP consisted of 179 (3.8%) cases of moderate pain and 18 (0.4%) cases of severe pain. The rate of severe CPIP was independent of the preoperative VRS-pain category while the rate of moderate CPIP (3.1%, 3.4%, 4.1%, 6.8%) increased in line with the preoperative (none, mild, moderate, and severe) VRS-pain categories. The VRS probably overestimated pain since 71.6% of the relevant CPIP patients assessed their pain as less bothersome than the hernia. CONCLUSION: At the 2-year follow-up, relevant CPIP was registered in 4.2% cases, of which 63.5% were potentially surgery-related (no-relevant preoperative pain) and 36.5% possibly due to the postoperative persistence of preoperative pain. The rate of severe CPIP was constant around 0.4%.

Purpose Data on primary (PH) and incisional hernias (IH) are often pooled, even though several studies have illustrated that these are different entities with worse outcomes for IHs. The aim of this study is to validate previous research comparing PHs and IHs and to examine whether hernia width is an important contributor to the differences between these hernia types. Methods A registry-based, prospective cohort study was performed, utilizing the French Hernia Club database. All patients undergoing PH or IH repair between September 8th 2011 and May 22nd 2019 were included. Baseline, hernia and surgical characteristics, and postoperative outcomes were collected. Outcomes were analyzed per width category (≤ 2 cm, 3–4 cm, 5–10 cm and > 10 cm). Results A total of 9159 patients were included, of whom 4965 (54%) had PH and 4194 (46%) had IH. PHs and IHs differed significantly in 12/15 baseline characteristics, 9/10 hernia and surgical characteristics, and all outcomes. Overall, complications and re-interventions were more common in patients with IH. After correcting for width, the differences between PH and IH were no longer significant, except for medical complications, which were more common after IH repair compared to PH. Conclusion After correcting for hernia width, most outcomes do not significantly differ between PH and IH, indicating that not hernia type, but hernia width is an important factor contributing to the differences between PH and IH.

Onflex™ mesh has replaced Polysoft™ patch on the market, without being clinically evaluated thus far in the transinguinal preperitoneal (TIPP) technique. All consecutive TIPP registered in our registry during the overlap period of availability of both meshes were included and studied with the chronic postoperative inguinal pain (CPIP) as primary endpoint, assessed with a verbal rating scale (VRS), and included in a patient-related outcome measurement (PROM) phone questionnaire. A total of 181 Onflex cases vs 182 Polysoft cases were studied with a 2-year follow-up rate of 92% vs 88%. The overall rate of pain or discomfort was not statistically different in the 2 studied subgroups (16.5% vs 17.6%; p = 0.71), while moderate or severe pain were significantly more frequent in the Polysoft subgroup (5.5% vs 11.6%; p = 0.01). These symptoms did not interfere with the patient daily life in 16% vs 16.5% of cases, and they were self-assessed as more bothersome than the hernia in only 0.5% vs 0.5% of cases, suggesting an overestimation of the pain by the VRS. Patients assessed the result of their hernia repair as excellent or good in 97.8% vs 96.7% and medium or bad in 2.2% vs 3.3% (p = 0.53). The cumulative recurrence rate was 0% vs 2.2%. Two reoperations (one for early and one for late recurrence) were reported in the Polysoft subgroup (1%), none related to the non-absorbable memory ring. These results suggest that TIPP with Onflex provides results at least similar than those with Polysoft.

Background: Incisional hernias can be associated with pain or discomfort. Surgical repair especially mesh reinforcement, may likewise induce pain. The primary objective was to assess the incidence of pain after hernia repair in patients with and without pre-operative pain or discomfort. The secondary objectives were to determine the preferred mesh type, mesh location and surgical technique in minimizing postoperative pain or discomfort. Materials and methods: A registry-based prospective cohort study was performed, including patients undergoing incisional hernia repair between September 2011 and May 2019. Patients with a minimum follow-up of 3–6 months were included. The incidence of hernia related pain and discomfort was recorded perioperatively. Results: A total of 1312 patients were included. Pre-operatively, 1091 (83%) patients reported pain or discomfort. After hernia repair, 961 (73%) patients did not report pain or discomfort (mean follow-up = 11.1 months). Of the pre-operative asymptomatic patients (n = 221), 44 (20%, moderate or severe pain: n = 14, 32%) reported pain or discomfort after mean follow-up of 10.5 months. Of those patients initially reporting pain or discomfort (n = 1091), 307 (28%, moderate or severe pain: n = 80, 26%) still reported pain or discomfort after a mean follow-up of 11.3 months postoperatively. Conclusion: In symptomatic incisional hernia patients, hernia related complaints may be resolved in the majority of cases undergoing surgical repair. In asymptomatic incisional hernia patients, pain or discomfort may be induced in a considerable number of patients due to surgical repair and one should be aware if this postoperative complication.

To assess the rate of late chronic postoperative inguinal pain (CPIP) after groin hernia repair in patients with different categories of preoperative VRS (Verbal Rating Scale) pain and to make a pragmatic evaluation of the rates of potentially surgery-related CPIP vs. postoperative continuation of preexisting preoperative pain.Groin pain of patients operated from 01/11/2011 to 01/04/2014 was assessed preoperatively, postoperatively and at 2-year follow-up using a VRS-4 in 5670 consecutive groin hernia repairs. A PROM (Patient Related Outcomes Measurement) questionnaire studied the impact of CPIP on the patients' daily life.Relevant (moderate or severe VRS) pain was registered preoperatively in 1639 of 5670 (29%) cases vs. 197 of 4704 (4.2%) cases at the 2-year follow-up. Among the latter, 125 (3.7%) cases were found in 3353 cases with no-relevant preoperative pain and 72 (5.3%) in 1351 cases with relevant preoperative pain. Relevant CPIP consisted of 179 (3.8%) cases of moderate pain and 18 (0.4%) cases of severe pain. The rate of severe CPIP was independent of the preoperative VRS-pain category while the rate of moderate CPIP (3.1%, 3.4%, 4.1%, 6.8%) increased in line with the preoperative (none, mild, moderate, and severe) VRS-pain categories. The VRS probably overestimated pain since 71.6% of the relevant CPIP patients assessed their pain as less bothersome than the hernia.At the 2-year follow-up, relevant CPIP was registered in 4.2% cases, of which 63.5% were potentially surgery-related (no-relevant preoperative pain) and 36.5% possibly due to the postoperative persistence of preoperative pain. The rate of severe CPIP was constant around 0.4%.

Summary Introduction The evaluation of the re-admission rate within 30 days of inguinal hernia repair represents a patient management quality indicator. The goal of our study was to evaluate the re-admission rate at 30 days after inguinal hernia repair and identify the risk factors for re-admission. Methods Based on a prospective national registry, patient data were collected during two years. The number of and reasons for re-admissions were compiled. Results A total of 5126 patients, mean age 61 years, underwent inguinal hernia repair. Ambulatory surgery was performed in 4013 (78%) patients. Failed ambulatory surgery was recorded for 100 (2%) patients. Thirty-three (0.64%) patients were re-admitted within 30 days following surgery for 34 various reasons. The re-admission rate after ambulatory surgery was 0.5%. Half of patients re-admitted presented with a severe complication that required re-intervention. In multivariable analysis, emergency hernia repair (OR 4.899 [1.309-18.327]; P = 0.01) and prolonged duration of operation (OR 1.023 [1.009-1.037]; P = 0.001) were identified as independent risk factors for re-admission within 30 days after surgery. Conclusion Within this prospective national cohort, the overall re-admission rate after inguinal hernia repair was 0.64%, slightly less among the patients undergoing ambulatory surgery. Half of re-admitted patients required surgical re-operation. Emergency hernia repair and prolonged duration of operation were risk factors for re-admission.

Onflex™ mesh has replaced Polysoft™ patch on the market, without being clinically evaluated thus far in the transinguinal preperitoneal (TIPP) technique.All consecutive TIPP registered in our registry during the overlap period of availability of both meshes were included and studied with the chronic postoperative inguinal pain (CPIP) as primary endpoint, assessed with a verbal rating scale (VRS), and included in a patient-related outcome measurement (PROM) phone questionnaire.A total of 181 Onflex cases vs 182 Polysoft cases were studied with a 2-year follow-up rate of 92% vs 88%. The overall rate of pain or discomfort was not statistically different in the 2 studied subgroups (16.5% vs 17.6%; p = 0.71), while moderate or severe pain were significantly more frequent in the Polysoft subgroup (5.5% vs 11.6%; p = 0.01). These symptoms did not interfere with the patient daily life in 16% vs 16.5% of cases, and they were self-assessed as more bothersome than the hernia in only 0.5% vs 0.5% of cases, suggesting an overestimation of the pain by the VRS. Patients assessed the result of their hernia repair as excellent or good in 97.8% vs 96.7% and medium or bad in 2.2% vs 3.3% (p = 0.53). The cumulative recurrence rate was 0% vs 2.2%. Two reoperations (one for early and one for late recurrence) were reported in the Polysoft subgroup (1%), none related to the non-absorbable memory ring.These results suggest that TIPP with Onflex provides results at least similar than those with Polysoft.

El objetivo principal de la reparacion de las hernias es doble: curacion de la hernia y prevencion de las recidivas. En la ultima decada las intervenciones sin tension han permitido reducir el dolor postoperatorio y la duracion de la incapacidad consiguiente, pero muchos estudios actuales insisten en la elevada incidencia del dolor cronico. La prevencion de esta complicacion a largo plazo sera el motivo principal de preocupacion para los equipos especializados en los proximos anos. La tecnica de Lichtenstein ha arrebatado la consideracion de «patron oro» a la de Shouldice, y despues del «tapon», se han descrito otras dos tecnicas, la de PHS y la de Polysoft.

Introduction The Accreditation and Certification of Hernia Centers and Surgeons (ACCESS) Group of the European Hernia Society (EHS) recognizes that there is a growing need to train specialist abdominal wall surgeons. The most important and relevant argument for this proposal and statement is the growing acceptance of the increasing complexity of abdominal wall surgery due to newer techniques, more challenging cases and the required ‘tailored’ approach to such surgery. There is now also an increasing public awareness with social media, whereby optimal treatment results are demanded by patients. However, to date the complexity of abdominal wall surgery has not been properly or adequately defined in the current literature. Methods A systematic search of the available literature was performed in May 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, with 75 publications identified as relevant. In addition, an analysis of data from the Herniamed Hernia Registry was performed. The percentage of patients with hernia- or patient-related characteristics which unfavorably impacted the outcome of inguinal and incisional hernia repair was also calculated. Results All present guidelines for abdominal wall surgery recommend the utilization of a ‘tailored’ approach. This relies on the prerequisite that any surgical technique used has already been mastered, as well as the recognized learning curves for each of the several techniques that can be used for both inguinal hernia (Lichtenstein, TEP, TAPP, Shouldice) and incisional hernia repairs (laparoscopic IPOM, open sublay, open IPOM, open onlay, open or endoscopic component separation technique). Other hernia- and patient-related characteristics that have recognized complexity include emergency surgery, obesity, recurrent hernias, bilateral inguinal hernias, groin hernia in women, scrotal hernias, large defects, high ASA scores, > 80 years of age, increased medical risk factors and previous lower abdominal surgery. The proportion of patients with at least one of these characteristics in the Herniamed Hernia Registry in the case of both inguinal and incisional hernia is noted to be relatively high at around 70%. In general surgery training approximately 50–100 hernia repairs on average are performed by each trainee, with around only 25 laparo-endoscopic procedures. Conclusion A tailored approach is now employed and seen more so in hernia surgery and this fact is referred to and highlighted in the contemporaneous hernia guidelines published to date. In addition, with the increasing complexity of abdominal wall surgery, the number of procedures actually performed by trainees is no longer considered adequate to overcome any recognized learning curve. Therefore, to supplement general surgery training young surgeons should be offered a clinical fellowship to obtain an additional qualification as an abdominal wall surgeon and thus improve their clinical and operative experience under supervision in this field. Practicing general surgeons with a special interest in hernia surgery can undertake intensive further training in this area by participating in clinical work shadowing in hernia centers, workshops and congresses.

A case–control study was performed to compare laparoscopic ventral hernia repair (LVHR) using the Ventralight ST™ lightweight surgical mesh with LVHR using other types of mesh. Adult patients undergoing intraperitoneal implantation of Ventralight ST™ during LVHR (Ventralight ST™ group; VG) over a 2-year period (2011–2013) were identified from the prospective French Hernia-Club registry. Patients undergoing elective LVHR using other types of intraperitoneal mesh in the first semester of 2013 formed the control group (CG). Patient, hernia and surgical characteristics, and postoperative outcomes after 8 days, 1 month, and 1 year were compared between the two groups. The VG comprised 90 LVHRs in 85 patients, and the CG 86 LVHRs in 81 patients. Patient, hernia and surgical characteristics were similar between the two groups, apart from the method of mesh fixation and the number of procedures involving fascial closure. A low rate of minor complications was observed in both groups at 1 month [4.4 % (VG) and 2.3 % (CG)], and the level of postoperative pain was similar in the two groups at Day 8 and 1 month. After 1 year, no complications, recurrences or cases of chronic pain had occurred in either group, and Quality-of-Life outcomes were similar. Patients rated their procedure as excellent or good in 96 % (VG) and 92 % (CG) of cases. Ventralight ST™ mesh is effective and well tolerated in LVHR, producing very low complication and recurrence rates in the short and medium term. The results are comparable to those achieved with other types of mesh.

The originally published article: The surname and given name of authors, M. Pawlak and A.C. de Beaux has been incorrectly published.

IF 2.417; International audience; BackgroundLong-term patient’s satisfaction after groin hernia repair is rarely studied in the literature. The aim of this study was to compare the four main techniques of inguinal hernia repair in terms of patient‘s satisfaction and quality of life at the 2-year follow-up in a prospective registry.MethodsFrom September 2011 to March 2014, consecutive patients underwent groin hernia repair and were prospectively included in the Club Hernie registry, which also consisted of expert surgeons in parietal repair. The data on patient demographics, clinical presentation, initial workup, operative technique, postoperative course, clinical follow-up, and quality of life at 2 years (2Y-FU) were recorded.ResultsOverall, 5670 patients were included in the study: 1092 undergoing Lichtenstein’s technique, 1259 for trans-inguinal preperitoneal technique (TIPP), 1414 for totally extraperitoneal approach (TEP) and 1905 for transabdominal preperitoneal approach (TAPP). The patients undergoing Lichtenstein’s technique were significantly older, with more inguinoscrotal hernias and co-morbidities than those undergoing other techniques. A total of 83% patients had a complete 2Y-FU. The patient’s satisfaction at 2Y-FU was similar between the different techniques. In the univariate and multivariate analyses, pain on postoperative day 1 was the only independent prognostic factor of the patient’s satisfaction at 2Y-FU.ConclusionIn this large series, no statistical differences were found between the four studied techniques regarding the 2Y-Fu results and patients’ satisfaction. Provided the technique has been done properly (expert surgeon) the results and the patients’ satisfaction are fair and equivalent among the four studied techniques. In a multivariate analysis, the only factor predictive of bad late results was severe pain at D1.

Introduction: The aim of the international CORE project was to explore the databases of the existing hernia registries and compare them in content and outcome variables. Methods: The CORE project was initiated with representatives from all established hernia registries (Danish Hernia Database, Swedish Hernia Registry, Herniamed, EuraHS, Club Hernie, EVEREG, AHSQC) in March 2015 in Berlin. The following categories were used to compare the registries: initiation and funding, data collection and use for certification of hernia centers, patient data and data protection, operative data, registration of complications and follow-up data. Results: The Danish Hernia Database is the only one to qualify as a genuine national registry where participation is compulsory for entry of all procedures by all surgeons performing a hernia operation. All other registries have to be considered as voluntary and completeness of data depends upon the participating hospitals and surgeons. Only the Danish Hernia Database and the Swedish Hernia Registry are publicly funded. All other registries are reliant on financial support from the medical technology industry. As an incentive for voluntary participation in a hernia registry, hospitals or surgeons are issued a certificate confirming that they are taking part in a quality assurance study for hernia surgery. Due to data protection and privacy regulations, most registries are obliged or have chosen to enter their patient data anonymously or coded. The Danish Hernia Database and Swedish Hernia Registry utilize a national personal patient code. In the Herniamed Registry, patient data are saved in a coded and anonymous format after obtaining the patient’s informed consent. Conclusion: Despite the differences in the way data are collected for each of the listed hernia registries, the data are indispensable in clinical research.

Introduction: Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery. Methods: An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group’s first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as “strong” (recommendations) or “weak” (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term “should” refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. Results and summary: The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with “watchful waiting” since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon’s expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10–12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation “Hernia Center”. From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients. Conclusions: The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

Little is known about both incidence of chronic pain and quality of life (QoL) after the transinguinal preperitoneal (TIPP) technique using a totally extraperitoneal, parietalized, memory ring patch. Among 622 (428 unilateral and 194 bilateral) hernia repairs (HR) in 525 patients, 92 % had a postoperative clinical control. Thereafter, two sets of postal self-assessed questionnaires were sent. A total of 531 HR were studied with a mean follow-up of 17 ± 8 months. Only one recurrence was detected. In 151 (28.4 %) HR the patients alleged various symptoms, but in only 10 (1.9 %) HR they considered their discomfort more bothersome than the hernia they had before, and in just 2 (0.4 %) HR they judged their result as bad (one patch removal for sepsis and one for hematoma). Only mild pain (including no painful discomfort such as a foreign body sensation) or moderate pain was frequent. Pain was self-graded as severe in four cases. None of them reported any regular consumption of antalgics. None of them judged their result as bad. Dysesthesia (numbness 19, paresthesia 20) mentioned in 39 HR (7 %), associated with pain in 16 HR, was said to be more bothersome than the hernia treated in just 3 HR (0.6 %). The results of the entire series were self-assessed as good or excellent in 97 % of the HR. In our TIPP series, both the incidence of recurrences (0.2 %) and that of severe chronic pain (≤0.7 %) were very low, as well as patients’ QoL was excellent. In our experience, the postoperative course was as painless as that of laparoscopic TEP we had been performing previously, but TIPP appeared more suited to day-case surgery.

Resume En chirurgie propre (Altemeier I), la presence d’une prothese n’augmente pas l’incidence des infections. Les infections de prothese sont plus frequentes et plus graves en ventral qu’en inguinal. L’ablation de la prothese regle le probleme infectieux mais pose d’autres problemes tout aussi epineux, incitant : (i) a explorer les traitements conservateurs, finalement souvent realisables, et (ii) au strict respect des mesures preventives.

Resume Introduction Le traitement du pseudomyxome peritoneal (PMP) et des mucoceles appendiculaires (MA) a radicalement evolue. Dans le but d’evaluer l’apport de l’imagerie preoperatoire a la strategie therapeutique et au choix de la voie d’abord, les dossiers de tous les patients traites pour PMP ou MA dans les quatre etablissements d’un meme bassin de vie du 1er janvier 1996 au 31 decembre 2008 ont ete relus par un chirurgien et un radiologue, different du radiologue initial. Malades et methodes Vingt-sept patients, (20 H/7 F) de 63 ± 13 ans, ont ete inclus. Onze patients avaient une MA non rompue, sept patients avaient un PMP synchrone (lesion appendiculaire maligne deux fois sur sept), six patients avaient un PMP metachrone, (carcinose peritoneale mucineuse cinq fois, adenomucinose peritoneale diffuse une fois), trois patients avaient une MA rompue sans PMP. L’incidence des tumeurs mucosecretantes observees (27 cas en 12 ans sur un bassin de vie de 500 000 habitants) correspondait a environ cinq cas par an et par million d’habitants. Les tableaux cliniques aigus (7/27) etaient significativement plus frequents dans les formes malignes (5/7) (p Resultats et discussion La sensibilite globale de la tomodensitometrie (TDM) sur l’ensemble des criteres etudies etait de 93 %. La valeur predictive de rupture de MA de la visualisation de calcifications epaisses etait de 100 %. A contrario, la visualisation d’une MA sous tension, a parois et cloisons fines ne s’accompagnait jamais d’une rupture appendiculaire. La valeur predictive de PMP des images de festonnement (scalloping) etait de 100 %. La precision diagnostique de la lecture initiale etait de 25/27 pour l’imagerie prise dans son ensemble et de 25/25 pour la TDM. La visualisation sur l’imagerie preoperatoire de la taille exacte des MA intactes ou des elements diagnostiques de rupture de MA et de PMP ont aide 25 fois sur 27 au choix d’une voie d’abord adaptee.

A systematic review of literature led us to take note that little was known about the costs of incisional ventral hernia repair (IVHR). Therefore we wanted to assess the actual costs of IVHR. The total costs are the sum of direct (hospital costs) and indirect (sick leave) costs. The direct costs were retrieved from a multi-centric cost analysis done among a large panel of 51 French public hospitals, involving 3239 IVHR. One hundred and thirty-two unitary expenditure items were thoroughly evaluated by the accountants of a specialized public agency (ATIH) dedicated to investigate the costs of the French Health Care system. The indirect costs (costs of the post-operative inability to work and loss of profit due to the disruption in the ongoing work) were estimated from the data the Hernia Club registry, involving 790 patients, and over a large panel of different Collective Agreements. The mean total cost for an IVHR in France in 2011 was estimated to be 6451€, ranging from 4731€ for unemployed patients to 10,107€ for employed patients whose indirect costs (5376€) were slightly higher than the direct costs. Reducing the incidence of incisional hernia after abdominal surgery with 5 % for instance by implementation of the European Hernia Society Guidelines on closure of abdominal wall incisions, or maybe even by use of prophylactic mesh augmentation in high risk patients could result in a national cost savings of 4 million Euros.

The material and the surgical technique used to close an abdominal wall incision are important determinants of the risk of developing an incisional hernia. Optimising closure of abdominal wall incisions holds a potential to prevent patients suffering from incisional hernias and for important costs savings in health care. The European Hernia Society formed a Guidelines Development Group to provide guidelines for all surgical specialists who perform abdominal incisions in adult patients on the materials and methods used to close the abdominal wall. The guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach and methodological guidance was taken from Scottish Intercollegiate Guidelines Network (SIGN). The literature search included publications up to April 2014. The guidelines were written using the AGREE II instrument. An update of these guidelines is planned for 2017. For many of the Key Questions that were studied no high quality data was detected. Therefore, some strong recommendations could be made but, for many Key Questions only weak recommendations or no recommendation could be made due to lack of sufficient evidence. To decrease the incidence of incisional hernias it is strongly recommended to utilise a non-midline approach to a laparotomy whenever possible. For elective midline incisions, it is strongly recommended to perform a continuous suturing technique and to avoid the use of rapidly absorbable sutures. It is suggested using a slowly absorbable monofilament suture in a single layer aponeurotic closure technique without separate closure of the peritoneum. A small bites technique with a suture to wound length (SL/WL) ratio at least 4/1 is the current recommended method of fascial closure. Currently, no recommendations can be given on the optimal technique to close emergency laparotomy incisions. Prophylactic mesh augmentation appears effective and safe and can be suggested in high-risk patients, like aortic aneurysm surgery and obese patients. For laparoscopic surgery, it is suggested using the smallest trocar size adequate for the procedure and closure of the fascial defect if trocars larger or equal to 10 mm are used. For single incision laparoscopic surgery, we suggest meticulous closure of the fascial incision to avoid an increased risk of incisional hernias.

Resume But de l'etude. – Etude critique du taux brut de mortalite postoperatoire en tant qu'indicateur de qualite des soins. Materiel et methodes. – Les suites operatoires de 11 756 patients consecutifs, operes du 1er janvier 1987 au 31 decembre 2002 d'une intervention de chirurgie generale, ont ete recueillies prospectivement. Resultats. – Soixante-treize patients (0,60 %) d'un âge median de 77 ans sont decedes. La mortalite etait nulle chez les 5046 operes de moins de 40 ans. Trois mille deux cent soixante-cinq patients (28 %) ont ete operes en urgence. La mortalite des 3952 operes d'une intervention digestive etait de 1,00 % (40/3952 patients) et de 3,56 % (17/478 patients) en cas d'intervention en urgence hors appendicites non suppurees. Les operes pour cancer representaient 8 % des operes (968/11 756 patients) mais 49 % des deces postoperatoires. Dans cette serie le taux brut de mortalite postoperatoire varie du simple au double selon que l'on comptabilise (73 deces) ou pas (34 deces) les interventions de confort chez des patients en phase terminale et les interventions de la derniere chance, en urgence, chez des patients en etat de mort imminente. Six cent-vingt patients (5,3 %) ont eu au moins une complication notamment chirurgicale chez 166 patients et parietale chez 258 patients. Conclusion. – Cette etude montre qu'une demarche rigoureuse d'autoevaluation est realisable sur le tres long terme. Elle confirme que le taux brut de mortalite n'est pas un critere pertinent pour evaluer l'efficience d'une equipe chirurgicale, suggere que le concept de deces evites est un reflet plus fidele et plus valorisant du travail medical, permet de proposer un indice de mortalite abaissee par une gestion efficiente des complications postoperatoires (IMAGE). « IMAGE » = (nombre de complications–nombre de deces)/nombre de complications, prenant en compte le taux de complications n'aboutissant pas a un deces.

Resume Les diverticules geants du grele et du colon sont rares. Quatre cas, traites l’an passe dans notre etablissement, sont rapportes et compares aux cas publies. Leurs caracteres semiologiques communs et ceux qui les differencient des autres images pseudo kystiques de l’abdomen sont etudies. Les circonstances de decouverte de ces diverticules geants sont pour l’essentiel superposables a celles de la maladie diverticulaire commune. Y penser et disposer d’une tomodensitometrie abdominale de qualite sont les cles du diagnostic. Deux types de diverticules geants ont ete decrits : les diverticules geants acquis, les plus frequents, de structure comparable aux diverticules communs et les diverticules congenitaux qui comportent dans leur paroi une couche musculaire et des plexus myenteriques et qui s’apparentent aux duplications digestives. Leur traitement est chirurgical et repose, notamment pour les diverticules geants acquis du colon sigmoide, sur l’exerese colorectale faite pour la maladie diverticulaire commune.

The aim of our retrospective study was to quantify the incidence of chronic pain and cutaneous sensory changes among various anterior and posterior hernia repairs and then to compare laparoscopic with open techniques. A detailed questionnaire was sent in January 1998 to patients operated on from 1992 to 1996. Patients had to record their current parietal status and assess the result from their personal point of view. The replies were recorded without any medical adjustment. Of 545 patients treated for 617 groin hernias, 490 were followed for 1 to 5 years (median 3 years, 2 months). One hundred and ten patients (23%) experienced symptoms persisting for more than one year, including 50 cases of cutaneous sensory changes and 71 cases of pain. Twenty-four patients (5%) assessed their discomfort as more troublesome than the hernia they had before, overriding the benefits of a solid repair. There was no statistical difference concerning the incidence of chronic pain between the nonprosthetic and prosthetic (“tension-free”) subgroups or between the open and laparoscopic subgroups. Forty-five of 50 cutaneous sensory changes occurred after the inguinal approach. The incidence of such changes was 10 times lower in the laparoscopic than in the open subgroup (p

Pharmaco-bezoar apres duodenopancreatectomie cephalique, association Cholestyramine + antisecretoires : situation a risque en chirurgie pancreatique ? J.-F. Gillion, M.-C. Julles, J.-P. Deyme, J.-M. Chollet, M. Lagneau, D. Sirieix Les auteurs rapportent une observation de pharmaco-bezoar de cholestyramine apres duodenopancreatectomie cephalique. Les occlusions par bezoars de cholestyramine sont rares chez l’adulte mais ce risque merite d’etre connu car la chirurgie pancreatique pourrait constituer une situation a risque en raison de la frequence de la prescription successive ou concomitante de cholestyramine, d’inhibiteurs de la pompe a protons et d’octreotide.

The literature dealing with abdominal wall surgery is often flawed due to lack of adherence to accepted reporting standards and statistical methodology.The EuraHS Working Group (European Registry of Abdominal Wall Hernias) organised a consensus meeting of surgical experts and researchers with an interest in abdominal wall surgery, including a statistician, the editors of the journal Hernia and scientists experienced in meta-analysis. Detailed discussions took place to identify the basic ground rules necessary to improve the quality of research reports related to abdominal wall reconstruction.A list of recommendations was formulated including more general issues on the scientific methodology and statistical approach. Standards and statements are available, each depending on the type of study that is being reported: the CONSORT statement for the Randomised Controlled Trials, the TREND statement for non randomised interventional studies, the STROBE statement for observational studies, the STARLITE statement for literature searches, the MOOSE statement for metaanalyses of observational studies and the PRISMA statement for systematic reviews and meta-analyses. A number of recommendations were made, including the use of previously published standard definitions and classifications relating to hernia variables and treatment; the use of the validated Clavien-Dindo classification to report complications in hernia surgery; the use of "time-to-event analysis" to report data on "freedom-of-recurrence" rather than the use of recurrence rates, because it is more sensitive and accounts for the patients that are lost to follow-up compared with other reporting methods.A set of recommendations for reporting outcome results of abdominal wall surgery was formulated as guidance for researchers. It is anticipated that the use of these recommendations will increase the quality and meaning of abdominal wall surgery research.

In clean surgery (Altemeier Class I), the incidence of infections is not increased by the placement of prosthetic material. Prosthetic mesh infections occur more frequently and are more serious in ventral incisional repair than in inguinal hernia repair. While removal of the mesh resolves the infectious problem, it creates other problems that are equally difficult. This underscores the need to: explore other conservative hernia treatment options; in the end, these are often feasible; respect and implement strict measures to prevent infection.

The treatment of pseudomyxoma peritonei (PMPs) and appendiceal mucocele (AM) has changed radically. To assess the contribution of preoperative imaging to the treatment strategy and choice of approach, a surgeon and a radiologist different from the initial radiologist examined the files of all patients treated for PMP or AM in four facilities in one district from January 1, 1996, through December 31, 2008.The study included 27 patients (20 men and seven women, mean age: 63+/-13 years). Eleven patients had an intact AM, seven synchronous PMP (malignant appendiceal lesion in two of seven), six metachronous PMP (five with peritoneal mucinous carcinomatosis and one with diffuse peritoneal adenomucinosis) and three a ruptured AM but not PMP. The incidence of mucin-secreting tumors observed (27 cases in 12 years in a region of 500 000 inhabitants) corresponds to a prevalence of approximately five cases per year per million inhabitants. Acute clinical pictures (7/27) were significantly more frequent for the malignant forms (5/7) (p0,02).The overall sensitivity of computed tomography (CT) for all the criteria studied was 93%. The predictive value for AM rupture of visualization of thick calcifications was 100%. On the other hand, rupture never occurred when the CT showed an AM under pressure, with thin walls and septa. The predictive value for PMP of "scalloping" was 100%. The diagnostic accuracy of the initial reading was 25/27 for the imaging overall and 25/25 for the CT. Preoperative visualization of the exact size of the intact AM or of diagnostic information about ruptured AM and PMP helped to select an appropriate approach in 25 of 27 cases.

The authors describe a case of pharmaco-bezoar consisting of ingested cholestyramine which occurred post pancreaticoduodenectomy. Intestinal obstruction by a cholestyramine bezoar is a rare occurrence but is worthy of note in the post-pancreatectomy setting where there is often concomitant use of cholestyramine, proton pump inhibitors, and octreotide.

Are physicians and their relatives at risk of postoperative complications when they are scheduled for surgery? With the aim to answer this question, a case control study was performed from a cohort of 11,756 patients scheduled for surgery from 01/01/1987 to 12/31/2002. Fourty seven patients were physicians and 122 were a close relative to a physician. The percentage of physicians in the current series is comparable to that in the general urban population in France. Each of these patients was matched with 5 patients as controls regarding sex, age, diagnosis, procedure, and date of surgery.No statistically significant difference was observed between the 47 physicians and their 235 controls in the occurence of postoperative complications: 6% vs 6% (Odds ratio (OR)=1,07; CI(95%): 0,28-3,74), unplanned return to the operative room: 2% vs 2% (OR=1,00; CI: 0,11-8,8), and postoperative mortality: 0% vs 0,5% (p=0,07). No stastistically significant difference was observed between the 122 close relatives to a physician and their 610 controls in the occurence of postoperative complications: 6% vs 6% (OR=1,00; CI: 0,43-2,3), unplanned return to the operative room: 2% vs 3% (OR=0,55; CI: 0,18-3,4), and postoperative mortality: 1% vs 0,5% (OR=1,67; CI: 0,13-12,12).this study does not confirm the widespread opinion that postoperative course would be worse in physicians as patients and in their close relatives. Their recovery is not different from that to other patients if they are treated as well as other patients.

Giant diverticula of the small intestine and colon are rare. Four cases treated at our institution in the last year are reported and compared to published cases; specific features and those which differentiate them from abdominal pseudocysts are described. They most commonly present a clinical tableau similar to commonplace diverticular disease. Awareness of this unusual condition and a good CT study are the keys to diagnosis. Giant diverticula may be acquired or congenital. The acquired type is simply a more spectacular version of commonplace diverticulosis while the congenital type, having a muscular wall and myenteric plexus, is more akin to intestinal duplications. Treatment is surgical and, in the case of sigmoid giant diverticula, usually requires a colon resection similar to that required for sigmoid diverticulitis.

Evaluation of the crude postoperative mortality rate as a relevant criterion of the efficiency of a surgical team.[corrected] We studied prospectively the postoperative course of 11,756 consecutive patients who underwent a general surgery procedure between January 1(st) 1987 and December 31 2002.Seventy-three of patients died (0.60 percent). The median age at the time of death was 77 years old. None of the 5046 patients under 40 years old died. The operations were emergent in 3,265 patients (28 percent). The mortality rate of the 3,952 digestive surgery patients was 1.00 percent (40/3,952 patients). Among them, the mortality rate increased to 3.56 percent (17/478 patients) in case of an emergency procedure excluding procedures for non-suppurative appendicitis. Although only 8 percent of the patients were operated for a cancer (968/11,756 patients), they accounted for 49 percent of the postoperative deaths. In this cohort, the crude mortality rate varied by twice as much as were taken in account (73 deaths) or not (34 deaths) the palliative procedures in terminal phase patients, and the last-chance procedures in patients in imminent-death condition. Six hundred and twenty patients (5.3 percent) experienced at least one postoperative complication, surgical in 166 patients, and parietal in 258 patients.This study shows that a long-term rigorous self-assessment is feasible. It confirms that the crude mortality rate is not a relevant criterion to evaluate the efficiency of a surgical team, suggests that an "avoided death" concept is more representative of medical team work and more rewarding for them and allows us to propose an index taking in account the rate of postoperative complications not followed by death.

The role of post-operative adhesions in chronic abdominal pain remains controversial. The aim of this study was to assess the value of laparoscopic treatment of adhesions for chronic post-operative abdominal pain in 32 patients. Over a period of 8 years, 32 patients (25 women and 7 men) with a mean age of 41.5 years (18-69) were hospitalized for chronic abdominal pain of more than 6 months duration, without an obvious underlying neoplasm or psychiatric disorder. They had all undergone at least one previous abdominal operation (mean, 1.9; range, 1-5), with a mean follow-up of 28 months (6-82). The mean duration of the pain was 18 months (6-65) and in 24 of the 32 cases it was mainly hypogastric. Other than the presence of a scar, the clinical examination was completely normal. Prior to hospitalization, 163 different laboratory tests, 162 radiological investigations, including 13 CT scans and 3 MRIs, and 25 endoscopies had been performed. A pneumoperitoneum was made by "open laparoscopy" in 23 cases and with Verres needle in 9 cases. Eight patients (25%) did not have any adhesions, but 6 of them were found to have a gynecological problem (endometriosis). In this group, the laparoscopy lasted 34 minutes (15-45) and the mean hospital stay was 48 hours. In 24 cases, adhesions were found and selected. This was thought to be complete in 22 cases (91.6%). There was a strict correlation between the adhesions and the scar in 85% of cases. In 5 cases, the adhesions were associated with another intervention. There were no conversions. The mean duration of surgery and hospitalization was respectively 56 minutes (32-120) and 3.2 days. There was no mortality and the morbidity rate was 4.1% (1 monopolar injury). The average follow-up was 26.7 months: 22 of the 24 patients who had freeing of adhesions were evaluated after at least 6 months of follow-up. In 10 cases, the pain had completely resolved (45%), in 6 it had decreased (27%) and in 6 cases it was unchanged or had even worsened (1 case of endometriosis). Laparoscopic exploration for chronic post-operative abdominal pain, after an extensive work-up performed after a suitably long delay post-surgery, can be used to detect and treat adhesions in 3/4 cases. In the absence of another lesion, the pain is lessened in 72% cases. However, if there is another lesion, laparoscopic treatment of adhesions is less effective with respect to the pain, but it nevertheless can identify an.

Two hundred and four groin hernias in 173 patients were laparoscopicaly treated using an intraperitoneal ePTFE patch and prospectively studied. Two patients died for diseases unrelated to their hernia nor their hernioplasty. Eight patients were lost to follow up (5.2%), 163 were followed up for at least 1 year, without recurrence at their last examination, and 155 were followed up for at least 2 years. This study concerns these 155 patients accounting for 184 hernioplasties. Twelve recurrences (6.5%) were found in 11 patients, 10 of 12 occurred within the first year after operation. After each surgeon's 20th hernioplasty the recurrence rate was 3 of 113 hernioplasties (2.6%) (p0.05). Late local pain around the patch and its staples was found in 12 patients, slight in 10 cases, mild in 1 case and serious in 1 case. Local hypoesthesia of the upper internal part of the thigh was found in one patient. Not any testicular atrophy, nor intraperitoneal complications were observed. This study suggests that: 1) the 2-year recurrence rate of intraperitoneal ePTFE hernioplasties is not very different, after the learning phase, from those of many other procedures; 2) their expensive price lead to use these techniques only when other efficient procedures are not feasible, for example in the challenged treatment of recurrent hernia after failure of a preperitoneal prosthetic hernioplasty.

From April 1993 to December 1994, 14 failures of classic prosthetic herniorraphies in 13 patients (13 men) were treated by a laparoscopic intraperitoneal onlay mesh technique (IPOM) using an ePTFE patch. The mean age of these patients was 55.69 +/- 13.11 years (28 to 70). The mean operating time was 72.5 +/- 24 mn (40 to 120). The technique could not be performed in one case. The mean postoperative pain at D1, evaluated by a visual analog scale graduated from 0 to 10 was 2.36 (2 to 3). The mean hospital stay was 1.64 days (1 to 3). One inguinal hematoma occurred and resolved after a short incision. The mean time to return to work or normal activity was 12.14 +/- 7.25 days (3 to 30). All patients were reviewed. The mean follow-up was 13.37 +/- 2.87 months (6 to 25). No testicular atrophy was observed. One recurrence occurred at M6 treated at M9 by an open procedure. Our study suggests that this technique, avoiding extensive preperitoneal dissection, thus decreasing vascular and genital risks, would be useful in the treatment of failures of prosthetic herniorraphies.

Spaw's (original and modified) was technique evaluated in a prospective, multicentre study: from november 1992 to september 1993, 162 intraperitoneal laparoscopic herniorraphies were carried out in 135 patients for recurrent hernias or for hernias associated with a high risk of recurrence. Three needed an open procedure. Three early complications (2 periprosthetic hematomas, 1 microscopic bladder injury) were treated by another laparoscopy; a bowel loop retained in a trocar orifice was reintegrated under local anesthesia; dysesthesias of the lateral cutaneous nerve of the thigh in 1 patient and nonspecific parietal pain in 2 patients resolved within three weeks. Three seromas resolved after only one percutaneous aspiration. The mean post operative pain, evaluated by a visual analogic scale graduated from 1 to 10 was 1.8 (0 to 6) at D1, 05 (0 to 2) at D2 and the mean duration of analgesic requirments was 1.7 (0 to 15) days. The mean hospital stay was 2 (1 to 17) days for unilateral herniorraphies and the mean time to return to work or normal activity was 10 (2 to 44) days, even in heavy workers (35 patients). All patients were reviewed. The mean follow-up was 4 (1 to 10) months. Two complications needed further laparoscopic treatment: 1 recurrence at the internal edge of the patch, easily restapled with a stronger stapler, 1 bowel adhesion between patch and bladder revealed by pain without obstruction. The recurrence rate was 0.6% (1/162). The conversion rate was 2% (3/162) and the overall morbidity was 7.5% (12/162), decreasing respectively to 0 and 4% after the learning curve. This study confirms that Spaw's technique and its variant are feasible, and allows us to continue this study, and suggest these techniques would be useful in the treatment of some recurrent inguinal hernias.

From January 1987 to December 1991, 112 ePTFE patches were inserted in properitoneal sites in 75 patients by median (61 patients) or inguinal (14 patients) approach to cure inguinal hernias. The hernia was direct or combined in 60 patients, bilateral in 37 patients and recurrent in 37 patients. These 75 patients accounted for 19.7% of the 380 patients treated for hernia during the same period. Complications occurred in 5 patients, 3 of whom needed a second operation: 2 periprosthetic seromas, 2 femoral nerve irritations and one periprosthetic infection which resolved after treatment without patch removal. No patch was removed. Ninety three percent of the patients had an uneventful postoperative recovery. All patients were followed (range: 4 months-5 years) for an average of 28 months; 88% for one year or more. There were 3 recurrences which healed after reoperation. No late infection of sinus occurred. One patient complained of severe pain without any attributable cause. One patient had femoral hypoesthesia, 7 others suffered slight intermittent pain without any local complication. Discomfort in these 8 cases was very mild. Sixty-eight patients (91%) rated the result of their surgery as good or excellent. This clinical study confirms the biomechanical properties of ePTFE and demonstrates that, in comparison with mesh of equal strength, the infection rate and its severity would be decreased with ePTFE soft tissue patch.