Right Recurrent Femoral Hernia with Left Inguinal Hernia - A Case Report

Femoral hernias are a relatively uncommon type, accounting for only 3% of all hernias. While femoral hernias can occur in both males and females, they occur approximately 10 times as frequently in women than in men because of the wider bone structure of the female pelvis³. Femoral hernias develop in the upper part of the thigh near the groin just below the inguinal ligament, where abdominal contents pass through a naturally occurring weakness called the femoral canal. Femoral hernia have the highest rate of incarceration amongst groin hernia, 5%–20%⁵

O39 ASSOCIATION OF DIFFERENT MESH AND MESH FIXATION COMBINATIONS WITH REOPERATION RISK AFTER LAPAROSCOPIC GROIN HERNIA SURGERY. A SWEDISH HERNIA REGISTRY STUDY OF 25,190 TEP AND TAPP REPAIRS

Aim The HerniaSurge guidelines concerning mesh and fixation options in laparoscopic totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) groin hernia repair are based on studies focusing on either mesh or fixation. We hypothesized that the value of such recommendations is limited by lacking knowledge on how mesh and fixation interact. The present registry-based nationwide cohort study compared different mesh/fixation combinations regarding relative risks for reoperation after TEP and TAPP. Material and Methods All TEP and TAPP with standard polypropylene (StdPPM) or lightweight (LWM) flat meshes, combined with either tacks, fibrin glue, or no fixation, registered in the Swedish Hernia Registry 2005-2017 were included. Endpoint was reoperation due to recurrence as of December 31, 2018. Multivariable Cox regression rendered relative risk differences between the exposures, expressed as hazard ratios (HR) with 95% confidence intervals (CI). Results Of 25 190 repairs, 924 (3.7%) were later reoperated for recurrence. The lowest, mutually equivalent, reoperation risks were associated with StdPPM without fixation (HR 1), StdPPM with metal tacks (HR 0.8, CI 0.4-1.4), StdPPM with fibrin glue (HR 1.1, CI 0.7-1.6), and LWM with fibrin glue (HR 1.2, CI 0.97-1.6). LWM correlated otherwise with increased risk, whether without fixation (HR 2.0, CI 1.6-2.6), or affixed with metal (HR 1.7, CI 1.1-2.7), or absorbable tacks (HR 2.4, CI 1.8-3.1). Conclusions With StdPPM, fixation seems not to improve outcomes, despite being costlier. Thus, for this mesh category, we recommend non-fixation. With LWM, we recommend fibrin glue fixation, which was the only LWM alternative on par with non-affixed StdPPM.

P138 PREPERITONEAL ENDOSCOPIC GROIN HERNIA SURGERY - REASSESSMENT OF TOPOGRAPHIC ANATOMY AS A BASIS FOR STANDARDIZED DESCRIPTION OF SURGICAL STEPS

Aim Fascial groin anatomy remains a conundrum. In particular, a clear anatomical allocation of the correct extraperitoneal dissection planes and spaces in total extraperitoneal endoscopic hernia surgery (TEP) has not yet agreed upon. The differing anatomical concepts are reflected by the variability of surgical approaches, the considerably long learning curves and subsequent complications. Thus, the aim of this study was to reassess the topographic anatomy of the groin region providing a basis to standardize the surgical steps of TEP according to clearly defined anatomical landmarks. Material and Methods Video analysis of intraoperative surgical anatomy of groin hernia patients was correlated with the findings retrieved by macroscopic anatomical studies. The groin region of formalin fixed body donors was subjected to a stepwise dissection exposing the fascial system of the abdominal wall layer-by-layer and via different angles. Selected areas of interest were processed for histological study. Surgically relevant anatomical landmarks were defined and termed according to the most appropriate anatomical nomenclature. Results The essential surgical dissection steps during TEP could be related to specific anatomical landmarks extending within the extraperitoneal space of the ventral and dorsolateral abdominal wall. The definition of fascial structures and interfaces and the identification of structures at risk allowed the identification of correct dissection planes for mesh placement. Conclusions Our study helps to clarify the definition and nomenclature of anatomical key structures required for a standardized description of TEP in a simplified model. The data may contribute to reduce complications and improve surgical teaching and training.

O11 SEX DIFFERENCES, SLEEP DISTURBANCE AND RISK OF PERSISTENT PAIN ASSOCIATED WITH GROIN HERNIA SURGERY: A NATIONWIDE REGISTER-BASED COHORT STUDY

Aim Persistent pain after groin hernia repair is a major health problem. Sleep disturbance is associated with heightened pain sensitivity. The main objective of this study was to examine the role of sleep disturbance in the development and long-term maintenance of chronic postherniorrhaphy inguinal pain (CPIP), with exploration of sex differences. Material and Methods From 2012-2017, a national cohort of patients with prior groin hernia repair (n = 2084; 45.8% females) were assessed for the development of CPIP 12 months after surgery. Patients then underwent long-term (median 5.0 years) follow-up to evaluate the contribution of sex and sleep disturbance on the maintenance of CPIP. Associations between pre- and postoperative sleep problems (assessed at long-term follow-up) and CPIP were tested using logistic regression. Results Females had higher rates of CPIP with negative impact on daily activities 12 months after surgery as compared to males (14.6 vs 9.2%, p<0.0005), and were more likely to have moderate-severe CPIP in the long-term (3.1 vs 1.2%, p=0.003). Preoperative sleep problems predicted development of CPIP 12 months after surgery (adjusted odds ratio (aOR) 1.76 (95%CI 1.26-2.46), p=0.001) and CPIP in the long-term (aOR 2.20 (1.61-3.00), p<0.0001). CPIP was associated with insomnia and depression. Conclusions Sleep disturbance may increase the risk for CPIP, and contribute to maintenance of postsurgical pain. Females are at heightened risk for CPIP as compared to males. Given the robust associations between sleep disturbance and CPIP, interventions which consolidate and promote sleep, especially in females, may improve long-term pain control.

P080 ROUTINE ELECTIVE ILIOHYPOGASTRIC NEURECTOMY IN LICHTENSTEIN INGUINAL HERNIA REPAIR

Aim Chronic postherniorraphy pain occurs in 8-25% of patients undergoing groin hernioplasty with mesh insertion. The most common cause for inguinodynia is neuropathy resulting from nerve damage or entrapment during mesh fixation. With wide mesh insertion there is often a conflict between upper prosthesis margin and an iliohypogastric nerve. The aim of this study is to present a routine elective iliohypogastric neurectomy in Lichtenstein groin hernia repair for prevention of chronic inguinodynia. Material and Methods Between 2018 and 2020, 398 patients were admitted for open inguinal hernia repair. 218 patients underwent a Lichtenstein repair with transection of iliohypogastric nerve before implantation of 10x14 polypropylene mesh (IH group). In the control group of 180 patients all nerves were spared (C group). Follow-up was conducted on 1 POD,1 month, and 1 year after surgery. Results 1 month after a surgery a pain was reported in 24 (11%) patients in IH group (2.9% severe; 8.1% moderate; 89% no pain), and 48 (26.7%) patients in C group (3.9% severe; 22.8% moderate; 73.3% no pain). 1 year after a surgery a persistent pain was reported in 1 (0.4%) patient in IH group, and in 5 (2.8%) patients in C group. An incidence of inguinodynia was significantly lower after iliohypogastric neurectomy (0.5% vs. 2.8%; p < 0.001). Conclusions Routine neurectomy of iliohypogastric nerve appears to be an effective technique in chronic inguinodynia after open mech repair for inguinal hernias. Iliohypogastric nerve resection allows to place a flat synthetic mesh with wide coverage of myopectineal orifice with no need for additional mesh trimming.

P120 ASSOCIATION BETWEEN SERUM ESTRADIOL LEVELS AND MEN WITH GROIN HERNIA : A CASE - CONTROL STUDY

Aim To assess if increased serum levels of estradiol is an independent risk factor for occurrence of groin hernia in men. Material and Methods We performed a hospital based case-control study. Men diagnosed with groin hernia were taken as cases and men who did not have groin hernia but were admitted for other elective surgery were taken as controls. Cases were matched to controls based on age and BMI. Morning fasting blood sample was collected from both cases and controls used to measure serum estradiol levels. Results A total of 46 hernia cases and 91 non-hernia controls were included in the study. The mean age and BMI of both cases and controls were not significantly different. The mean serum estradiol level for cases was 53.5 ±7.11 pg/ml. This value was significantly higher (p < 0.001) than for the control group which was 28.3 ± 3.14 pg/ml. A strong positive association was observed between increasing serum estradiol levels and hernia incidence. Men in 4th (highest) quartile of estradiol levels had a relative risk of 2.27 (95% CI:1.33-3.04) compared to men in 2nd quartile. Men in 1st (lowest) quartile didn’t have any hernia cases. Conclusions The knowledge may allow treatment or prevention with novel nonsurgical approaches. Therapy with aromatase inhibitors might prevent recurrence after hernia repair or even help men avoid surgery in the first place. Prevention of hernia will lead to decrease in morbidity and cost burden due to surgical treatment to a long extent.

P113 SPIN IS PRESENT IN THE MAJORITY OF THE ARTICLES EVALUATING ROBOT-ASSISTED GROIN HERNIA REPAIR: A SYSTEMATIC REVIEW

Aim The number of articles published each year are increasing, resulting in greater competition to get work published. Spin is defined as specific reporting strategies used to distort the readers’ interpretation of results so that they are viewed more favourable. However, prevalence of spin in studies comparing robot-assisted groin hernia repair with traditional methods is unknown. The aim of the study was to determine the frequency and extent of misrepresentation of results, spin, in studies assessing robot-assisted groin hernia repair. Methods This systematic review was reported according to PRISMA guidelines, and a protocol was registered at PROSPERO before data extraction. Database search included PubMed, EMBASE and Cochrane Central. Results Of 35 included studies, spin was present in 57%. Within these, 95% had spin present in the abstract and 80% in the conclusion of the article. There was no association between study size and spin (p > 0.05). However, presence of spin in studies positively minded towards robot-assisted hernia repair was higher (p < 0.001) compared with those against or being neutral in their view of the procedure. Furthermore, being funded by or receiving grants from Intuitive Surgical were associated with a higher prevalence of spin (p < 0.01) compared with those who were not. Conclusion Spin was found to be common in articles reporting on robot-assisted groin hernia repair, and presence of spin was higher in studies funded by or receiving grants from the robot company. This suggests that readers should be cautious when reading similar literature.

O25 MORTALITY AFTER EMERGENCY VERSUS ELECTIVE GROIN HERNIA REPAIR: A SYSTEMATIC REVIEW AND META-ANALYSIS

Aim This systematic review and meta-analysis aimed to investigate 30- and 90-day postoperative mortality in patients undergoing emergency or elective groin hernia repair. Material and Methods This review is reported after the PRISMA 2020 guidelines. A protocol (CRD42021244412) was registered to PROSPERO. Three databases (PubMed, EMBASE, and Cochrane CENTRAL) were searched in April 2021. The identified studies were screened for eligibility and included if they reported 30- and/or 90-day mortality following emergency or elective groin hernia repair. Meta-analyses were conducted when possible, and a subgroup analysis on patients undergoing bowel resection was made. Results We included 37 studies with a total of 30,740 patients receiving emergency repair and 457,253 receiving elective repair. Meta-analyses could not be conducted for the two repair settings separately due to heterogeneity. However, the 30-day mortality ranged from 0.0–1.7% following elective repair and 0.0–11.8% following emergency repair. The risk of 30-day mortality following emergency repair was estimated to be 26-fold higher than after elective repair. A subgroup meta-analysis on bowel resection in emergency repair estimated 30-day mortality to be 7.9%. Conclusions Emergency groin hernia remains a challenging and potentially fatal surgical emergency. This review emphasizes the importance of performing hernia repair in an elective setting to prevent a potential acute presentation with acute surgical intervention. Patients presenting with symptoms of emergency groin hernias should receive particular attention to minimize the high risk of mortality and morbidity following emergency repair.

O17 CHRONIC GROIN PAIN DUE TO OR DESPITE THE HERNIA REPAIR

Aim There is a discrepancy between the high frequency of chronic post-operative pain reported in questionnaire-based studies after groin hernia surgery and the clinical experience of many surgeons in which it is infrequent that patients return after surgery because of chronic post-operative pain. This is supported by the Swedish Hernia Registry, where the proportion of patients who are re-operated for chronic post-operative pain is 0.02-0.03% for open methods and less than 0,01% for laparo-endoscopic methods. The aim of this study is to find the incidence of non-surgical causes of chronic groin pain and other patient-reported outcomes after inguinal hernia surgery. Material and Methods Prospective cohort observation study of patients evaluated for suspected inguinal hernia-related symptoms at a hernia clinic in Sweden during 1 year. Patients completed validated pain forms before surgery and 6 and 12 months after surgery. Patients were assessed preoperatively about the possible causes of groin pain according to a checklist. For this purpose, a questionnaire of inguinal hernia-related symptoms was used. Patients with moderate or severe chronic groin pain after surgery were offered to participate in a clinical examination where the pain was evaluated for probable cause according to a checklist. Results 574 patients were included in the study, of which 372 were operated on and answered the post-operative questionnaires. Preliminary results on surgical and non-surgical causes of chronic groin pain after hernioplasty and other patient-reported outcomes will be presented at Hernia 2021 EHS-AHS Joint Congress. Conclusions Proportion of patients with chronic groin pain related to groin hernia surgery and other non-surgical pathologies will be reported.