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Watchful waiting is safe for men with asymptomatic inguinal hernias, but data from randomized trials suggest that most men will ultimately undergo surgery, primarily because of pain. Watchful waiting is not recommended in women, given their higher prevalence of femoral hernias. This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors’ clinical recommendations. A 67-year-old man presents with a bulge in his right groin, which he recently noticed while in the shower. He is easily able to push it back completely, but it reappears intermittently. He says it is not painful and that he has not altered his activity level because of it. Physical examination confirms the presence of a right inguinal hernia. How should . . .

In this large, multicenter, randomized trial comparing laparoscopic mesh and open mesh repair of inguinal hernias, men randomly assigned to laparoscopic repair had a higher rate of recurrence at two years and a higher rate of complications than those assigned to open repair. Subgroup analyses revealed a significantly higher recurrence rate after laparoscopic repair than after open repair of primary hernias (the majority of the hernias studied), but not of recurrent hernias. These results help inform the choice between laparoscopic mesh and open mesh repair of inguinal hernias in men. Surgical repair of inguinal hernias is a common procedure in adult men. However, recurrence of hernias has been reported to occur after repair in 15 percent or more cases, and postoperative pain and disability are frequent. 1 – 5 When traditional surgical methods are used, outcomes after repair of recurrent hernias have been worse than after primary repair. 6 , 7 After the introduction of tension-free surgical repair with the use of prosthetic mesh, recurrence rates were reported to be less than 5 percent, and patients' comfort was reported to be substantially improved over that obtained by the traditional, tension-producing techniques. 8 , 9 Local anesthesia . . .

Background Primary laparoscopic hiatal hernia repair is associated with up to a 42% recurrence rate. This has lead to the use of mesh for crural repair, which has resulted in an improved recurrence rate (0–24%). However, mesh complications have been observed. Methods We compiled two cases, and our senior author contacted other experienced esophageal surgeons who provided 26 additional cases with mesh-related complications. Care was taken to retrieve technical operative details concerning mesh size and shape and implantation technique used. Results Twenty-six patients underwent laparoscopic and two patients open surgery for large hiatal hernia ( n  = 28). Twenty-five patients had a concomitant Nissen fundoplication, two a Toupet fundoplication, and one a Watson fundoplication. Mesh types placed were polypropylene ( n  = 8), polytetrafluoroethylene (PTFE) ( n  = 12), biological mesh ( n  = 7), and dual mesh ( n  = 1). Presenting symptoms associated with mesh complications were dysphagia ( n  = 22), heartburn ( n  = 10), chest pain ( n  = 14), fever ( n  = 1), epigastric pain ( n  = 2), and weight loss ( n  = 4). Main reoperative findings were intraluminal mesh erosion ( n  = 17), esophageal stenosis ( n  = 6), and dense fibrosis ( n  = 5). Six patients required esophagectomy, two patients had partial gastrectomy, and 1 patient had total gastrectomy. Five patients did not require surgery. In this group one patient had mesh removal by endoscopy. There was no immediate postoperative mortality, however one patient has severe gastroparesis and five patients are dependent on tube feeding. Two patients died 3 months postoperatively of unknown cause. There is no apparent relationship between mesh type and configuration with the complications encountered. Conclusion Complications related to synthetic mesh placement at the esophageal hiatus are more common than previously reported. Multicenter prospective studies are needed to determine the best method and type of mesh for implantation.

Incisional hernias (IH) following a laparotomy, on average, occur in 10–20% of patients, however, little is known about its molecular basis. Thus, a better understanding of the molecular mechanisms could lead to the identification of key target(s) to intervene pre-and post-operatively. We examined the current literature describing the molecular mechanisms of IH and overlap these factors with smoking, abdominal aortic aneurysm, obesity, diabetes mellitus, and diverticulitis. The expression levels of collagen I and III, matrix metalloproteinases, and tissue inhibitors of metalloproteases are abnormal in the extracellular matrix (ECM) of IH patients and ECM disorganization has an overlap with these comorbid conditions. Understanding the pathophysiology of IH development and associated risk factors will allow physicians to identify patients that may be at increased risk for IH and to possibly act preemptively to decrease the incidence of IH. •Disorganization of ECM leads to IH.•Alternation of collagen 1 and 3 ratio, MMPs and TIMPs leads to ECM disorganization.•MMPs altered collagens and TIMPs are associated with many comorbid conditions.•These comorbid conditions are associated with higher incidence of IH after laparotomy.•An insight of molecular mechanisms may decrease IH incidence with intervention.

Large complex ventral hernias associated with loss of domain pose several difficulties for surgical repair, as attempts to return the herniated contents to the peritoneal cavity may result in respiratory difficulty or significant intra-abdominal hypertension.1 There are several ways to address the issue of loss of domain, including component separation, bridging with synthetic material, and botulinum toxin use; however, there are cases in which these techniques fail.2 In these situations, surgeons caring for complex abdominal wall hernias should also be prepared to use preoperative progressive pneumoperitoneum (PPP) when necessary. A needle is then placed through the lower portion of the port pocket into the abdominal cavity, just to the right of the falciform ligament, which is followed by the introduction of a guidewire and tear-away introducer. By allowing for preoperative expansion of the peritoneal cavity, patients experience successful reduction of hernia contents with reduced time in the operating room, reduced length of hospital stay, decreased analgesic requirement, and decreased risk for development of respiratory complications whereas avoiding abdominal compartment syndrome.

Development of incisional hernia (IH) is multifactorial but inflammation and abdominal wall ECM (extracellular matrix) disorganization are key pathological events. We investigated if the differential expression of fibroblast biomarkers reflects the cellular milieu and the dysregulated ECM in IH tissues. Expression of fibroblast biomarkers, including connective tissue growth factor, alpha-smooth muscle actin (α-SMA), CD34 (cluster of differentiation 34), cadherin-11 and fibroblast specific protein 1 (FSP1), was examined by histology and immunofluorescence in the hernial-fascial ring/neck tissue (HRT) and hernia sack tissue (HST) harvested from the patients undergoing hernia surgery and compared with normal fascia (FT) and peritoneum (PT) harvested from brain-dead healthy subjects undergoing organ procurement for transplantation. The H&E staining revealed alterations in tissue architecture, fibroblast morphology, and ECM organization in the IH tissues compared to control. The biomarker for undifferentiated fibroblasts, CD34, was significantly higher in HST and decreased in HRT than the respective FT and PT controls. Also, the findings revealed an increased level of CTGF (connective tissue growth factor) with decrease in α-SMA in both HRT and HST compared to the controls. In addition, an increased level of FSP1 (fibroblast specific protein 1) and cadherin-11 in HRT with decreased level in HST were observed relative to the respective controls (FT and PT). Hence, these findings support the heterogeneity of fibroblast population at the laparotomy site that could contribute to the development of IH. Understanding the mechanisms causing the phenotype switch of these fibroblasts would open novel strategies to prevent the development of IH following laparotomy.

Background Laparoscopic adrenalectomy (LA) has become the standard of care for many conditions requiring removal of the adrenal gland. Previous studies on outcomes after LA have had limitations. This report describes the 30-day morbidity and mortality rates after LA and analyzes factors affecting operative time, hospital length of stay (LOS), and postoperative morbidity. Methods Patients undergoing LA in 2007and 2008 were identified from the American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP). Using multivariate analysis of variance (ANOVA) and logistic regression, 52 demographic/comorbidity variables were analyzed to ascertain factors affecting operative time, LOS, and morbidity. Results The mean age of the 988 patients was 53.5 ± 13.7 years, and 60% of the patients were women. The mean body mass index (BMI) of the patients was 31.8 ± 7.9 kg/m 2 . The 30-day morbidity and mortality rates were 6.8% and 0.5%, respectively. The mean and median operative times were 146.7 ± 66.8 min and 134 min, respectively. The mean and median hospital stays were 2.6 ± 3.1 days and 2 days, respectively. Compared with independent status, totally dependent functional status was associated with a 9.5-day increase in LOS ( P  = 0.0006) and an increased risk for postoperative morbidity (odds ratio [OR], 14.7; 95% confidence interval [CI], 2.4–91.9; P  < 0.0001). Peripheral vascular disease (OR, 7.3; 95% CI, 1.7–31.7; P  = 0.008) also was associated with increased 30-day morbidity. Neurologic and respiratory comorbidities were associated with increased LOS ( P  < 0.05). American Society of Anesthesiology (ASA) class 4 patients had a longer operative time than ASA class 1 patients ( P  = 0.002). Conclusions The morbidity and mortality rates after LA are low. Dependent functional status and peripheral vascular disease predispose to postoperative morbidity. Dependent status, higher ASA class, and respiratory and neurologic comorbidities are associated with longer operative time and LOS.

Ventral hernias are a common clinical problem. Immediate repair is recommended for most ventral hernias despite significant recurrence rates. This practice may be related to a lack of understanding of the natural history of ventral hernias. The purpose of this study was to determine the natural history of ventral hernias and to determine if watchful waiting is an acceptable and safe option. Forty-one patients with ventral hernias were enrolled in a longitudinal cohort study of watchful waiting. Primary outcomes were functional impairment resulting from hernia disease as measured by the Activities Assessment Scale (AAS) and changes from baseline to two years in the physical and mental component score of the SF-36 Health Survey. Secondary outcomes included complications such as incarceration. Mixed-effects model for repeated measures and Student's t tests were used to evaluate scale performance. The mean age of enrollees was 64 years, and the mean hernia size was 239 cm 2 . Eleven patients were lost to follow-up, and seven patients died of other causes. All remaining patients were followed for two years. There was one incarceration during the follow-up period. There was no deterioration in the AAS score (baseline vs 24 months = 28 vs 25, P = 0.60). There was deterioration of the physical functioning dimension of the SF-36 (baseline vs 24 months = 40 vs 32, P < 0.01), but the mental functioning dimension was improved (45 vs 51; P = 0.01). Watchful waiting was a safe option for patients in this study with ventral hernias.

We sought to determine perioperative variables predictive of complications or recurrence for patients undergoing surgical repair of inguinal hernias. Using data from the Veterans Affairs trial, regression analyses were utilized to identify perioperative factors significantly associated with complications (overall, short-term and long-term), long-term pain, and to develop a risk model for recurrence. Recurrent and scrotal hernias were predictors for short term and overall complications, regardless of technique. Older age and higher Mental Component Score of the SF-36 were associated with higher risk of long term complications in the open group while prostatism and increased body mass index were the significant predictors in the laparoscopic group. Long-term pain complaints decreased as patient age increased in both groups. Patient and surgeon factors were predictive of recurrence but varied greatly depending on surgical technique. Regardless of technique, scrotal and recurrent hernias were associated with a greater risk of complications and younger patients had more long-term pain. Predictors of recurrence vary based on surgical technique.

The incidence of hernia accident for inguinal hernias in men who are minimally symptomatic is sufficiently low that watchful waiting is an acceptable alternative to routine repair. Our aim was to determine whether a delay in hernia surgery affects short- and long-term outcomes. Patients from a multicenter randomized clinical trial of immediate tension-free repair versus watchful waiting for minimally symptomatic inguinal hernias were studied. Patients (n = 353) underwent tension-free repair and were classified as immediate repair (≤6 months, N = 288) or delayed repair (>6 months, N = 65). Patients were similar at baseline with respect to age, American Society of Anesthesiologists classification, pre-existing conditions, hernia type, and hernia characteristics. Patients undergoing immediate and delayed repair had comparable surgical time, surgical complications, recurrence rates, and satisfaction with outcome. Multivariate analyses found no relation between duration until hernia repair and operative time, incidence of complications, long-term pain, or functional status. Delaying hernia repair in patients who are minimally symptomatic does not have an adverse effect on subsequent operation and on other outcomes.