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BACKGROUND: Recurrence is the most common complication of inguinal herniorrhaphy and its mending carries an unacceptably high recurrence rate. During the development of a hernia clinic we initially repaired recurrent inguinal hernias using the Shouldice technique which requires complicated dissection followed by tissue approximation under tension. The necessary tissue exposure may injure anatomical elements incorporated into the scarred tissues. METHODS AND MATERIALS: We progressively developed a modality that approaches the hernia sac directly, dissecting it centripetally up to the hernia's neck which was then occluded with a pre-formed polypropylene plug (233 patients). This technique, used for defects measuring up to 3 cm in diameter minimizes the dissection of tissues not involved in the repair reducing the chances of injury to nerves, vas deferent ducts, and veins. For defects larger than 3 cm, the posterior inguinal wall was mesh-reinforced utilizing the Rives or Kugel approaches (19 patients). RESULTS: The centripetal technique, used in the repair of 233 recurrent inguinal hernias produced three recurrences in a ten-year follow up. Incidences of infection, testicular ischemia, or disabling neuropathy were not observed. CONCLUSIONS: In our hands the selective use of the centripetal technique produced good and reproducible results.

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Post Mesh Herniorrhaphy Infection [PMHI] occurs between 3 to 4% of inguinal and 8 to 14% of ventral herniorrhaphies producing an unacceptably high morbidity. Before opening a Hernia Clinic, our infection rate was around 5% for "clean" inguinals and 8% for "clean" ventral herniorrhaphies. Starting in 1982 we implemented a stricter operative aseptic protocol plus the per-operative administration of 1 g of intravenous Cefazolin. In addition, wounds were irrigated with a solution containing 80 mgs of Gentamycin Sulphate dissolved in 250 ml of Normal Saline Solution. During a period of 25 years these measures were used in 4300 consecutive "clean "Inguinal and 320 "clean" Ventral herniorrhaphies. Since the implementation of the above-mentioned aseptic and antiseptic steps no further wound infections were encountered. In our hands, the combination of rigorous aseptic operating room routine plus intravenous and topical antibiotics have, up to now, effectively eliminated wound infections in "clean" herniorrhaphy cases.

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Groin pain may be produced by a true hernia, trauma to the groin structures or peripheral nerve, or root compression at various levels. Approximately 4,000 patients underwent inguinal herniorrhaphy (group A). An additional 134 patients complaining of groin pain and exhibiting no evidence of primary or recurrent hernia fell into two categories: 30 patients who had a previous herniorrhaphy (group B) and 104 patients without previous surgery (group C). Group B patients underwent a diagnostic nerve block which, when positive, suggested ilioinguinal nerve compromise at the wound. Those who failed conservative measures underwent nerve division. Group C patients were advised to decrease recreational and occupational activities; if that failed, they underwent lumbosacral spine imaging. There were no neuralgias in group A. Eight group B patients responded to conservative measures; the 22 others required ilioinguinal nerve division which relieved their pain. In group C, 42 patients responded to physical activity restriction plus NSAIDs; the remaining 62 underwent imaging which revealed lumbosacral bone pathology producing root compression and were referred to orthopedists. Lumbosacral spine pathology should be suspected in patients who complain of groin pain in the absence of hernia or previous herniorrhaphy. Recognition of this syndrome may avoid negative exploratory herniorrhaphies.

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The hypothesis that a hernia clinic could improve the results of external abdominal wall herniorrhaphy was tested in a teaching institution. From 1980 to 1988, all patients exhibiting external abdominal wall hernias were treated under protocol and separate from general surgical patients in a hernia clinic directed by a dedicated surgeon. The incidence of recurrence, infection, and testicular ischemia was significantly better than our previous institutional results. The incidence of incarceration/strangulation also fell significantly in patients over 65 years of age. Chart documentation was kept up to date for the duration of the project. Insufficient emphasis by the Clinic Director on the benefits of the proposed protocol and other factors contributing to the eventual clinic closure could be circumvented by better alternative planning. In our institution, the outcome of surgery for external abdominal wall surgery was significantly improved by the creation of a hernia clinic; our results equal those reported by other recognized herniorrhaphists. Barring some developmental obstacles, the concept of a hernia clinic should be advantageous to patients and residents alike.

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The spigelian hernia is a rare kind of abdominal wall defect that has been treated using a variety of techniques. Recently, we encountered 6 patients with spigelian hernias in whom we have used a new modality consisting of the tension-free occlusion of the hernia ring with a preshaped polypropylene umbrella-type plug. The follow-up was more than 1 year without evidence of recurrence. This technique simplifies the repair and has the advantage of producing minimal postoperative pain and disability.

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Because hernias are repaired increasingly with mesh and plugs, surgeons performing these operations should make an extended effort to prevent infection, and, when infections occur, to treat them expeditiously. This article discusses bacterial binding, infection reduction, the patient-doctor relationship during the care of an infected wound, and other related topics.

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Prostheses of expanded polytetrafluoroethylene (e-PTFE) were used to repair 89 abdominal wall defects in which primary closure would produce undue tension on tissue. Over a 52-month period (median follow-up: 24 months), we observed three wound infections, one in a clean wound, and four hernia recurrences. No other complications were noted. Twenty-one e-PTFE grafts were placed directly over intraperitoneal viscera without clinical evidence of adhesions leading to intestinal obstruction. In grafts inspected postoperatively, no apparent evidence of fatigue or fragmentation was observed. Histologic findings concurred with experimental data obtained during animal trials revealing the creation of a new mesothelial lining. These results encourage the use of e-PTFE prostheses for the repair of abdominal wall hernias, particularly when the parietal peritoneum is absent.

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To ascertain if service specialization and procedure standardization would improve the complication rate of inguinal herniorrhaphy, the results of all inguinal herniorrhaphies performed during a 3-year period by board-certified general surgeons who also performed a variety of other procedures common to the field of general surgery, assisted by general surgical residents (group B, 390 patients), were compared in the same institution with the results of inguinal herniorrhaphy when performed during 3 years under protocol by a Hernia Service directed by a senior faculty member assisted by junior surgical residents (group C, 442 patients). Group B patients had essentially no follow-up until they reappeared for care at the Hernia Service, whereas patients in group C achieved an 82% 7-year follow-up. The infection and recurrence rates of group C patients (0.45% and 0.9%, respectively) were significantly better than those of group B patients (5.9% and 4.6%, respectively). These results suggest that in our institution, the concentration of patients with hernias in a hernia service, manned by a specialized surgeon, produced better short- and long-term results than those obtained by general surgeons not dedicated to the field of hernia repair. Further studies will be necessary to confirm these findings.

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Elective abdominal herniorrhaphy carries morbidity and mortality rates of 26 percent and 1.5 percent, respectively, in patients over 65 years of age. These figures climb to 55 percent and 15 percent during emergent surgery. Our purpose was to investigate if standardization of treatment could improve such results. Our program stressed centralization of care in a hernia clinic; early operation of patients at risk of incarceration; optimization of underlying systemic disorders by consultative services; operation under local anesthesia; preoperative, operative, and postoperative protocol; and continuity of care by senior personnel. Over a 4 year period, we have performed 241 abdominal herniorrhaphies in patients over 65 years of age (median age 71.5 years old) who exhibited an 84 percent incidence of significant preoperative systemic disorders. Since the inception of our program, our rate of emergent operation has decreased significantly from 7 percent to 2 percent (chi-square less than or equal to 0.05). Our rate of systemic complications after elective operation was 1.2 percent and 0 after emergent operation. These data are statistically better than those reported in the literature (chi-square less than or equal to 0.05). These results suggest that the creation of a hernia clinic significantly improves the care of herniated patients.

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Recurrent inguinal hernias occur almost exclusively in adult men. The rarity of both direct and recurrent hernias in women is due, among other factors, to the muscularity of an inguinal canal that has not been partially replaced by fibrous tissue to allow the passage of a large spermatic cord. Throughout the body, contractile dynamic muscular tissue resists strains and stresses better than do fascia and ligaments. With regard to the abdominal wall, herniation through this muscular corset is a rare event and herniations nearly always occur through areas in which fibrous tissue has replaced muscle. When the tissues of a recurrent hernia or the type of hernia preclude a satisfactory repair, transposition of a thigh muscle, preferably the gracilis, will provide a dynamic repair that is superior to the introduction of foreign material with all its disadvantages or to the other approaches when local conditions are unsatisfactory. Clinical experience with seven procedures in six patients is presented as a preliminary report.

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The progression of acute haematogenous osteomyelitis into a chronic infection was investigated in a group of ten dogs in which the infection was produced by injection of micropaque barium mixed with Staphylococcus aureus or Salmonella Group C-2 into the tibial nutrient artery. Antibiotics were not used. Twenty four months later the infected limb of the surviving animals exhibited clinical, histological, radiological and microbiological changes which closely resembled those found in chronic haematogenous osteomyelitis (CHO) in humans. We observed spontaneous fractures, skin fistulae, bone sequestration and active bone remodelling. The original infecting bacteria were often replaced by different microorganisms because of skin fistulae or haematogenous contamination. Although the initial mortality was high the surviving animals showed signs of local and systemic symbiosis with the infecting bacteria. In two animals the previously infected and remodelled bone failed to show histological evidence of infection. This model may be useful in the study of a variety of factors affecting the natural history of CHO, particularly those encompassing the immunological response of the host.

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The pathway across tissue spaces of intravenously injected 125I albumin was studied in five dogs before and after the injection of Escherichia coli endotoxin by the use of perforated plastic capsules placed in the subcutaneous tissue. The already negative extracellular space pressure became less so after the endotoxin injection, when albumin was detected shifting from the intravascular space into the extracellular space compartment and then into the intralymphatic space. The injection of endotoxin produced a marked increase in the thoracic duct lymph flow, while, at the same time, erythrocytes entered the lymphatic stream. Results of this study suggest that experimental canine endotoxemia is associated with an increased passage of albumin into the extravascular compartment and explains, in part, the fall in serum levels of this protein during clinical and experimental sepsis.

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The observation that severe clinical bacterial infections are associated with decreases in total serum albumin levels was confirmed in experiments involving dogs and rats. In rodents, the injection of methylprednisolone sodium succinate after the onst of the infection significantly reduced the decrease in the serum albumin values. However, this protective or corrective effect did not occur if the steroid was given prior to the infection. The effect of cortisone may be due to its capacity to stimulate albumin synthesis by the parenchyma of the liver.

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