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176
S. Grant and B. Ramshaw
surface modifications have been performed. For example,
Whelove et al. [33] used chemical modifications to covalently attached gold nanoparticles to PET mesh in order to
improve tissue integration. The study demonstrated enhanced
cellularity, reduced reactive oxygen species, and reduced
bacteria adhesion to PET mesh. In addition, Grant et al. [34]
successfully chemically modified polypropylene mesh with
AuNPs and achieved similar improved results.
Besides chemically modifying the surface of existing hernia mesh materials, new coating and composite materials are
in development. For example, monofilament polyester 3D
mesh with an absorbable layer of oxidized collagen and chitosan on its peritoneal side has been developed [35]. This
new coated mesh may be able to improve clinical outcome
by lowering the development of seromas and minimizing
pro-inflammatory cytokine response. Research has also
shown that coating mesh with polyethylenimine (PEI) can
also improve the material characteristics of implants [36].
Polypropylene, polyester, and ePTFE have all been coated
with PEI and have indicated promising results.
Another modification to attempt to improve biocompatibility is to change the manufacturing process of the mesh.
Most meshes are woven, but one type of mesh is made from
randomly oriented microfibers of polypropylene (Aspide
Medical, France). The random orientation is theoretically
more biocompatible compared with a mechanical weave;
however the polypropylene is still at risk of oxidation from
the foreign body response. This particular mesh product is
further described in Chap. 10.
The development of drug-eluting mesh or cell-coated
mesh is being investigated as potential new hernia mesh
materials. Vermet et al. [37] developed a resorbable knitted
mesh material composed of poly-l-lactic acid functionalized
with a cyclodextrin polymer (polyCD) and activation with
ciprofloxacin with cyclodextrin. The purpose was to achieve
long-term, local release of the antibiotic while preserving the
biocompatibility of the mesh. Another technique is cell coating. The purpose of utilizing cell-coated mesh would be to
isolate the implanted mesh from the immune system and thus
prevent adsorbing proteins and inflammatory cells from contacting the implant. A study performed by Majumder et al.
[38] investigated cell-coated mesh. Fibroblast cells and mesenchymal stem cells (MSCs) were coated onto three different commercial mesh: Parietex (polyester, Medtronic), TIGR
(copolymer composite resorbable, Novus Scientific), and
Strattice (non-crosslinked collagen, biologic mesh, LifeCell.)
Results of this study were mixed with the cell-coated synthetic mesh demonstrating a positive effect on integration in
the onlay position. Additional studies are needed in order to
determine if cell-coated mesh will improve clinical
outcomes.
Choosing the “Best” Mesh
While polypropylene, PET, and PTFE make up the majority
of current hernia mesh materials, there are over 80 different
types of hernia mesh available [1]. Given that the properties
of the mesh can vary considerably, choosing the best mesh
for a particular patient population and/or procedure can be
confusing. Thus, it is not surprising that investigators have
performed controlled prospective and retrospective case
studies in order to formulate different algorithms and suggestions of mesh usage [39]. In addition, ventral hernia
experts have tried to achieve a consensus on the best practices to manage ventral hernias. Unfortunately, the lack of
high-quality data led to lack of consensus in mesh type, component separation technique, and management of complex
patients [40].
Since not all hernias are alike and they can differ significantly in size and complexity, the choice of mesh should be
based on risk of adhesions, risk of infections, surgeon familiarity, cost, and patient characteristics. In particular, patient
characteristics such as BMI, diabetes, tobacco use, second
surgeries, previous hernias, etc. need to be considered.
Studies that take into account patient demographics need to
be performed in order to fully characterize patient-material
effects and eventually be utilized to develop algorithms that
match the “best mesh” for a particular patient population.
Because of the complexity of this issue and the biologic variability in people, traditional reductionist scientific tools, like
prospective, randomized, controlled trials will not be adequate to produce these algorithms that will better match
patient subpopulations to appropriate mesh choices. A published peer-reviewed international guideline for ventral/incisional hernia management recommends that tools from
systems and data science will be required for this effort.
Tools from this scientific paradigm include continuous quality improvement and nonlinear analytics [41]. From a material’s point of view, the “best mesh” would be one where the
engineering properties of the mesh match the engineering
properties of the abdominal wall. Table 8.2 summarizes
some of the engineered mesh material factors that may influence tissue response.
Future of Hernia Mesh Materials
With over 80 different surgical meshes available for hernia
repair, surgeons are left with the impossible task of choosing
the “best” mesh for their patients. While research in this area
will continue as investigators search for the ideal mesh, it is
unlikely that a “summum bonum” mesh will ever be determined due to the complex nature of human systems.
8 Progress in Synthetic Prosthetic Mesh for Ventral Hernia Repair
177
Table 8.2 Mesh-tissue response
Mesh physical characteristics Noted tissue responses
Interstices greater than
75 μm
Interstices less than 10 μm Leads to rigid scar plate formation
Interstices less than
1.00 mm
Density (heavyweight vs
lightweight)
Tensile strengths of
synthetic mesh
Strains at physiological
loads
Coating or composite type
of coating
Filament diameter (smaller
diameter filaments have
more compliance,
flexibility)
Isotropic or anisotropic
behavior of mesh (based on
weave)
Pore design (hexagonal
pores, square pores, etc)
Allows passage of macrophages,
fibroblasts, blood vessels; reduces
risk of infection
due to granuloma bridging; restricts
passages of macrophages that may
lead to infection
Leads to rigid scar plate formation
A more severe foreign body reaction
(FBR) is noted with heavyweight
mesh
Almost all mesh are overengineered, causing compliance
mismatch between the mesh and
tissue that can result in enhanced
FBR
Mesh with less strain than tissue can
result in enhanced FBR
Initial FBR is reduced, adhesions
reduced, but long-term performance
needs to be characterized
Less FBR with smaller diameter
filaments but too small of filaments
may lead to breakage
Tissue response of different mesh
designs has yet to be investigated
Tissue response of different mesh
designs has yet to be investigated
Implementing continuous quality improvement (CQI) could
alleviate the uncertainty in mesh selection by using adaptive
processes and outcome measures to determine mesh-patient
population matches. But until such systems are in practice,
surgeons will have to rely on their own clinical experiences
in choosing the best mesh for their patients.
References
1. Brueing K, Butler CE, Ferzoco S, Franz M, Hultman CS, Kilbridge
JF, Rosen M, Silverman RP, Vargo D. Incisional ventral hernias:
review of the literature and recommendations regarding the grading
and technique of repair. Surgery. 2010;148(3):544–58.
2. Bendavid R. Recurrences: the fault of the surgeon. In: Schumpelick
V, Nyhus LM, editors. Meshes: benefits and risks. New York:
Springer; 2004. p. 55.
3. Arroyo A, Garcia P, Perez F, Andreu J, Candela F, Calpena
R. Randomized clinical trial comparing suture and mesh repair of
umbilical hernia in adults. Br J Surg. 2001;88:1321–3.
4. Kummerow K, Huang LC, Faqih A, Phillips SE, Baucom RB,
Pierce RA, Holzman MD, Sharp KW, Poulose BK. Hidden morbidity of ventral hernia repair with mesh: as concerning as common
bile duct injury? J Am Coll Surg. 2017;224:35–42.
5. Tentes A, Xanthoulis AI, Mirelis CG, et al. Nuttall technique:
a method for subumbilical incisional hernia repair revised.
Langenbeck’s Arch Surg. 2008;393:191–4.
6. Hadad I, Small W, Dumanian GA. Repair of massive ventral hernias with the separation of parts technique: reversal of the lost
domain. Am Surg. 2009;75:301–6.
7. Lanier ST, Fligor JE, Miller KR, Dumanian GA. Reliable complex
abdominal wall hernia repairs with a narrow, well-fixed retrorectus polypropylene mesh: a review of over 100 consecutive cases.
Surgery. 2016;160(6):1508–16.
8. Shankaran V, Weber DJ, Reed RL, Luchette FA. A review
of available prosthetics for ventral hernia repair. Ann Surg.
2011;253(1):16–26.
9. Alkhoury F, Helton S, Ippolito RJ. Cost and clinical outcomes of
laparoscopic ventral hernia repair using intraperitoneal nonheavyweight polypropylene mesh. Surg Laparosc Endosc Percutan Tech.
2011;21(2):82–5.
10. Sailes FC, Walls J, Guelig D, Mirzabeigi M, Long WD, Crawford
A, Moore JH, Copit SE, Tuma GA, Fox J. Synthetic and biological
mesh in component separations: a 10-year single institution review.
Ann Plast Surg. 2010;64(5):696–8.
11. Van’t RM, Vrijland WW, Lange JF, Hop WC, Jeekel J, Bonjer
HJ. Mesh repair of incisional hernia: comparison of laparoscopic
and open repair. Eur J Surg. 2002;168(12):684–9.
12. Yavuz N, Ipek T, As A, Kapan M, Eyuboglu E, Erguney
S. Laparoscopic repair of ventral and incisional hernias: our
experience in 150 patients. J Laparoendosc Adv Surg Tech A.
2005;6:601–5.
13. Patel PP, Love ME, Ewing JA, Warren JA, Cobb WS, Carbonell
AM. Risks of subsequent abdominal operations after laparoscopic
ventral hernia repair. Surg Endosc. 2017;31:823–8.
14. Nardi M Jr, Millo P, Brachet Contul R, Lorusso R, Usai A, Grivon
M, Persico F, Ponte E, Bocchia P, Razzi S. Laparoscopic ventral hernia repair with composite mesh: analysis of risk factors
for recurrence in 185 patients with 5 years follow-up. Int J Surg.
2017;40:38–44.
15. Mercoli H, Tzedakis S, D’Urso A, Nedelcu M, Memeo R, Meyer
N, Vix M, Perretta S, Mutter D. Postoperative complications as an
independent risk factor for recurrence after laparoscopic ventral
hernia repair: a prospective study of 417 patients with long-term
follow-up. Surg Endosc. 2017;31:1469–77.
16. Cozad M, Ramshaw BR, Grant DN, Bachman SL, Grant DA, Grant
SA. Materials characterization of explanted polypropylene, polyethylene terephthalate, and expanded polytetrafluoroethylene composites: spectral and thermal analysis. J Biomed Mater Res B Appl
Biomater. 2010;49B:455–62.
17. Costello CR, Bachman SL, Ramshaw BR, Grant SA. Materials
characterization of explanted heavyweight polypropylene hernia
meshes. J Biomed Mater Res B Appl Biomater. 2007;83B:44–9.
18. Smith SE, Cozad MJ, Grant DA, Ramshaw B, Grant SA. Materials
characterization of explanted polypropylene hernia mesh: patient
factor correlation. J Biomater Appl. 2016;30(7):1026–35.
19. Gonzalez R, et al. Relationship between tissue ingrowth and mesh
contraction. World J Surg. 2005;29(8):1038–43.
20. Pierce RA, Perrone JM, Nimeri A, Sexton JA, Walcutt J, Frisella
MM, Matthews BD. 120-day comparative analysis of adhesion
grade and quantity, mesh contraction, and tissue response to a novel
omega-3 fatty acid bioabsorbable barrier macroporous mesh after
intraperitoneal placement. Surg Innov. 2009;16:46–54.
21. Schmidbauer S, Ladurner R, Hallfeldt KK, Mussack T. Heavyweight versus low-weight polypropylene meshes for open sublay
mesh repair of incisional hernia. Eur J Med Res. 2005;10(6):247–53.
22. Brown CN, Finch JG. Which mesh for hernia repair? Ann R Coll
Surg Engl. 2010;92:272–8.
178
S. Grant and B. Ramshaw
23. Weyhe D, Schmitz I, Belyaev O, Grabs R, Müller K-M, Uhl W,
Zumtobel V. Experimental comparison of monofile light and heavy
polypropylene meshes: less weight does not mean less biological
response. World J Surg. 2006;30(8):1586–91.
24. Gemma Pascual G, Rodrıguez M, Gomez-Giln V, Garcıa-Honduvilla
N, Bujan J, Bello JM. Early tissue incorporation and collagen deposition in lightweight polypropylene meshes: bioassay in an experimental model of ventral hernia. Surgery. 2008;144(3):427–35.
25. Groene SA, Prasad T, Lincourt AE, Augenstein VA, Sing R,
Heniford BT. Prospective, multi-institutional surgical and qualityof- life outcomes comparison of heavyweight, midweight, and
lightweight mesh in open ventral hernia repair. Am J Surg.
2016;212:1054–62.
26. Burger JWA, Halm JA, Wijsmuller AR, Raa ST, Jeekel J. Evaluation
of new prosthetic meshes for ventral hernia repair. Surg Endosc.
2006;20(8):1320–5.
27. Scheidback H, Tamme C, Tannapfel A, Lippert H, Kockerling F. In
vivo studies comparing the biocompatibility of various polypropylene meshes and their handling properties during endoscopic total
extraperitoneal (TEP) patchplasty: an experimental study in pigs.
Surg Endosc. 2004;18(2):211–20.
28. Sehreinemacher MHF, Emans PJ, Gijbels MJJ, Greve JWM,
Beets GL, Bouvy ND. Degradation of mesh coatings and intraperitoneal adhesion formation in an experimental model. Br J Surg.
2009;96(3):305–13.
29. Kong CY, Lai LL, Khoo AYY, Rahman NA, Chin KF. Inflammatory
reaction to fish oil coated polypropylene mesh used for laparoscopic
incisional hernia repair: a case report. BMC Surg. 2016;16(1):123.
30. Poppas JJ, Sung CM, Magro J, Chen J, Toyohara JP, Ramshaw BJ,
Felsen D. Hydrogel coated mesh decreases tissue reaction resulting from polypropylene mesh implant: implication in hernia repair.
Hernia. 2016;20(4):623–32.
31. Rivolo P, Nisticò R, Barone F, Giulia Faga M, Duraccio D,
Martorana S, Ricciardi S, Magnacca G. Study of the adhesive properties versus stability/aging of hernia repair meshes after deposition
of RF activated plasma polymerized acrylic acid coating. Mater Sci
Eng C. 2016;65:287–94.
32. Nicolo E, Cahalan L, Johnson G, Gartner M, Cahalan P, Fill BJ,
Hussain A, Speakman JW. Surface treated polymeric synthetic hernia mesh prosthesis, surface treated sutures and staples and meth-
ods of manufacturing the same. Original Assignee: Ension, Inc. US
20130110137 A1. Apr 2 2007.
33. Whelove OE, Cozad MJ, Lee B-D, Sengupta S, Bachman SL,
Ramshaw BJ, Grant SA. Development and in vitro studies of
a polyethylene terephthalate-gold nanoparticle scaffold for
improved biocompatibility. J Biomed Mater Res B Appl Biomater.
2011;99B(1):142–9.
34. Grant DN, Benson J, Cozad MJ, Whelove OE, Bachman SL,
Ramshaw BJ, Grant DA, Grant SA. Conjugation of gold nanoparticles to polypropylene mesh for enhanced biocompatibility. J Mater
Sci Mater Med. 2011;22(12):2803–12.
35. Pascual G, Sotomayor S, Rodriguez M, Bayon Y, Bellon
JM. Tissue integration and inflammatory reaction in full-thickness
abdominal wall repair using an innovative composite mesh. Hernia.
2016;20:607–22.
36. Scheuerlein H, Erdmann J, Rauchfuss F, Dittmar Y, Jandt K, Jandt
KD, Settmacher U, Zankovych S. Preparation and in-vitro analysis
of a polyethylenimine coating on hernia meshes. Zentralbl Chir.
2015;140(2):170–8.
37. Vermet G, Degoutin S, Chai F, Maton M, Flores C, Neut C, Danjou
PE, Martel B, Blanchemain N. Cyclodextrin modified PLLA parietal reinforcement implant with prolonged antibacterial activity.
Acta Biomater. 2017;53:222–32.
38. Majumder A, Gao Y, Sadava EE, Anderson JM, Novitsky Y. Cellcoating affects tissue integration of synthetic and biologic meshes:
comparative analysis of the onlay and underlay mesh positioning in
rats. Surg Endosc. 2016;30:4445–53.
39. Eriksen JR, Gogenur I, Rosenberg J. Choice of mesh for laparoscopic ventral hernia repair. Hernia. 2007;11:481–92.
40. Liang MK, Holihan JL, Itani K, Alawadi ZM, Gonzalez JR,
Askenasy EP, Ballecer C, Chong HS, Goldblatt MI, Greenberg JA,
Harvin JA, Keith JN, Martindale RG, Orenstein S, Richmond B,
Roth JS, Szotek P, Towfigh S, Tsuda S, Vaziri K, Berger DH. Ventral
hernia management: expert consensus guided by systematic review.
Ann Surg. 2017;265(1):80–9.
41. Bittner R, Bingener-Casey J, Dietz U, et al. Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias
(International Endohernia Society) (IEHS)-part 1. Surg Endosc.
2014;28:2–29. https://doi.org/10.1007/s00464-013-3170-6.
Logistics and Specialised Hernia Units
Giampiero Campanelli, Piero Giovanni Bruni,
Francesca Lombardo, Andrea Morlacchi,
and Marta Cavalli
9
Introduction
Inguinal hernia repair is one of the most common operations
done by general surgeons in practice today [1].
In the early 1990s, the surgical approach to inguinal hernias underwent a major transformation from pure tissue
repairs to the widespread use of meshes tension-free mesh
repairs and, since that, we have witnessed a more and more
increasing interest in this issue, both from surgical society
and manufacturing companies.
Today abdominal wall surgery is considered as a high
specialised discipline that requires deep knowledge, great
professionalism and intellectual dedication: these features
are essential to obtain better outcome.
Hence, centres dedicated exclusively to this type of surgeons (the so-called hernia centre) appeared spontaneously,
first in the USA and, in the last years, also in Europe.
Routinely and daily hernia surgery is not enough to be
tagged like hernia centre.
A Specialised Hernia Unit is a multidisciplinary programme
providing state-of-the-art care for all types of hernias, from the
most common to the most complex and technically challenging, from the simple primary hernia to multi-recurrent hernia or
mesh-related complication (such as infection or post-operative
chronic pain), from the small ventral hernia to the swiss cheese
with real loss of substance incisional hernia, from the pubic
inguinal pain syndrome (the so-called sportsman hernia) to the
floppy abdomen postpartum.
General surgeon, plastic and reconstructive surgeon,
osteopath and physiotherapist, nutritionist, radiologist, anaesthesiologists and pain therapist: these are essential part of the
unit and collaborate to gain better result in each single patient.
G. Campanelli (*) • P.G. Bruni
F. Lombardo • A. Morlacchi • M. Cavalli
Istituto Clinico Sant’Ambrogio, Day & Week Surgery Unit,
Milano Hernia Center - MHec, University of Insubria, Center of
Research on the Pathology and High Specialization on the
Abdominal Wall and Hernia Surgery, Milan, Italy
e-mail: giampiero.campanelli@grupposandonato.it
Surgeon should be confident in all kinds of approach [2]
(open and laparoscopic, both for inguinal and ventral hernia,
in anterior and posterior approach), in the use of further surgical step in abdominal wall reconstruction, like, for example, in the different possibilities of component separation or
TAR (transversus abdominis release) when necessary and in
the use of all surgical implants (synthetic, composite or biological) and their fixation.
A minimum number of about 300 procedures per year
should be required because research [2, 3, 5] has demonstrated that hernia surgeons performing a high volume of
procedures obtain better outcomes for their patients, such as
in other specialist procedures.
Scientific and researching activities (like active attendance to congresses, publications in peer reviewed journals,
operative positions in scientific committee and/or society,
direction of basic and clinical researches) are aimed to refine
surgical technique, improve mesh materials and enhance
clinical outcomes.
These features all together make a centre a Specialised
Hernia Unit.
The need for a credible certification process for hernia
centre is well pointed out by Kockerling et al. [4], and hernia
societies and/or non-profit organisations that are interested
in assuring the best possible quality of hernia surgery are
called upon to define clear requirements and certification
processes for hernia centre. The first steps in that direction
have been taken with the Certified COEHS (Centre of
Excellence in Hernia Surgery) programme of the Surgical
Review Corporation and the Certified Hernia Centre programme of the German Hernia Society (DHG) and the
German Society of General and Visceral Surgery.
Several procedures listed before can be performed as outpatient, and inguinal hernia repair is certainly among the
procedures that contribute to the worldwide development
and diffusion of ambulatory surgery practice in the last
25 years.
In ambulatory surgery (called also as day surgery or outpatient service), as the name implies, the patient is sent home
© Springer International Publishing AG, part of Springer Nature 2018
K.A. LeBlanc et al. (eds.), Management of Abdominal Hernias, https://doi.org/10.1007/978-3-319-63251-3_9
179
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G. Campanelli et al.
the same day of the surgical treatment, with no overnight
stay [5]. Day surgery arose from the need to reduce healthcare costs while maintaining quality of treatment. Early discharge is also appreciated by patients. Among other things,
these procedures require the same technically sophisticated
facilities as when done on an inpatient basis, rigorous preoperative selection procedures and post-operative follow-up of
some hours.
Modern day surgery is not simply a shortened hospital
stay or an architectural model. Rather, it is a complex, multifaceted concept involving institutional, organisational, medical, economic and qualitative consideration.
Day surgery can be performed in:
– Freestanding on campus: department with free manage-
ment and administration engaged in a hospital site, with
own operating theatre, division and staff.
– Freestanding off campus: department located out of a
hospital site, with free management and administration,
with own operating theatre, division and staff, but with a
formal agreement with a hospital in case of complication
or emergency
– Division: integrated unit in a hospital, multidisciplinary
or monodisciplinary. Operating room is shared with other
divisions according as agreed turns.
– Beds: beds in a general surgery department, dedicated to
day surgery. Operating room is shared with other division
according as agreed turns [6].
Best option for a hernia centre is a freestanding department on campus.
Day surgery rather than inpatient surgery must be regarded
as the standard for all elective surgery: it should be considered the principal option and no longer an alternative form of
treatment [7].
In a self-contained day unit, the day surgery patient is the
centre of attention and receives more personalised care [8].
Day surgery procedure must be performed by highly qualified professionals, with considerable experience in traditional
inpatient surgery, to reduce the number of complications and/
or unplanned readmission and to achieve greater efficiency.
A daily hospitalisation avoids problems that may arise
from prolonged stay, like exposure to infection [9, 10] or
variation in the usual drug therapy (e.g. diabetic inpatients
are often unnecessary switched from their oral drugs to insulin or drug doses may be missed, delayed or duplicated by
hospital staff) [11].
Day surgery is not associated with complication rates
higher than those encountered following inpatient surgery.
Readmission rates [12, 13] and contacts with the primary
and community healthcare teams [14] are no greater than for
the same procedures undertaken as an inpatient. There is less
post-operative pain and a reduction in the risk of thromboembolism associated with early ambulation [15], and it is
less stressful for patient. Patients’ satisfaction rates following day surgery are high [16].
Because the risk of last minute cancellation is minimal in
dedicated day surgery facilities, hospital can manage elective
surgery more efficiently. This allows more accurate scheduling than for inpatient work and makes more effective use of
staff and facilities alike [17].
Day surgery is cost-effective compared with inpatient surgery as hospitalisation time is reduced, night and weekend
staffing is not required, the hotel element of treatment is
removed and capital facilities and staff are used more intensively and effectively [18].
However, not all patients can be treated on a day surgery
basis: it is not the operation that is ambulatory, it is the
patient. It is of paramount importance that all patients are
carefully selected, taking social, medical (comorbidity) and
surgical criteria into account.
As early as 1955, the advantages of inguinal hernia repair
as day surgery were already described in the literature [19],
and nowadays they are confirmed in several studies, many
retrospective [20–24] and some randomised [25–30].
EHS guidelines for inguinal hernia repair [31] report day surgery as safe, effective and in addition cheaper for every patient.
In a large American cohort study [32], the cost of inguinal
hernia repair in a clinic setting was found to be 56% higher
than those for day surgery. Also in Germany, this procedure
is generating less costs [33].
In addition to these few randomised studies, there are a
multitude of cohort studies concerning patients successfully
operated on as day surgery, under general, regional or local
anaesthetics, and with both classical operation techniques as
well as open tension-free repairs and endoscopic techniques.
A large study conducted in Denmark noted the hospital readmission rate of 0.8% [33, 34].
Although a tension-free repair under local anaesthetic
seems to be the most suitable operation, the published series
showed that other surgical and anaesthesiologic techniques
can also be effectively used as day surgery. Only the extensive open preperitoneal approach (Stoppa technique) has not
been described in the context of day surgery [31].
On a worldwide basis, there is a clear increase in the
percentage of inguinal hernia repairs in ambulatory surgery
[35, 36].
There is a considerable variation between different countries, which cannot be clarified solely by the degree of
acceptability of day surgery among patients and surgeons
but, to a significant extent, is also determined by healthcare
financing system. In the last year (2000–2004), 35% of
inguinal hernia operation carried out in the Netherlands and
33% in Spain were done on a day surgery basis; there is
9 Logistics and Specialised Hernia Units
181
room for this number to be increased. In the Swedish
National Registry, 75% of inguinal hernia repair are performed in day care [37]. In 2013 in Italy, 50% of inguinal
hernia repair in adult were done in day surgery [38].
In literature there is no high evidence about abdominal
wall hernia in ambulatory surgery rather than inguinal hernia, but some successful personal experience for umbilical,
epigastric or incisional hernia repair in outpatient setting are
reported [39–41].
Patient Pathway in a Hernia Centre
First Access in Hospital
Surgeon, during the first examination in the consulting room,
requires more test (e.g. ecotomogrophy or CT) if necessary,
makes a diagnosis and, if necessary, gives a surgical indication. In this case, he makes the first choice about the kind of
recovery (ambulatory surgery or ordinary hospitalisation)
according to social, medical and surgical criteria.
Social Criteria
Patient should prove the availability of a person to accompany him at home and remain with him for the first night.
The patient should be contactable by telephone and reside
(home or hotel) within 60 min or 1 h by car from the hospital.
Patient should be able to understand the operation and its
requirements, comply with advice given by the physician
and have acceptable personal hygiene and a suitable
lodging.
Medical Criteria
Anaesthetic risk categories ASA I-II or ASA III for stable
comorbidities unaffected by the surgical procedures are suitable for ambulatory surgery. Advanced age, diabetes, asthma,
obesity (up to BMI <35 kg/m2), sleep apnoea (if postoperative opioids not programmed) and epilepsy are not
exclusion criteria. Remember that selection of patient should
be based on their overall physiological status.
Surgical Criteria
Procedure suitable for ambulatory surgery has the following
characteristics:
– Post-operative care might be specific, but is neither inva-
sive nor prolonged, and will not lead to unexpected
admission to hospital.
– The risk of severe pre- and post-operative blood loss is
low.
– The duration of the procedure is less than 90 min.
– Post-operative pain is easily controlled [42].
Almost all primary inguinal or femoral hernia repairs with
normal size or small recurrences approachable with open or
laparoscopic technique can be performed in outpatient setting.
Patients complaing huge, old, unreducible hernia should
have the option to be able to an extended recovery
(overnight).
Little epigastric or umbilical hernia suitable for a primary
repair or for a small mesh repair can be performed in ambulatory surgery. Pubic inguinal pain syndrome treatments are
feasible for day surgery setting.
All ventral defects requiring large mesh repair must be
hospitalised for a short stay or longer.
Preoperative Screening and Selection
Advanced assessment provides a valuable opportunity to
have more knowledge about whole health condition of
patient, correct abnormalities and drugs therapy.
The patient during a day hospital admission is submitted
to the following evaluations:
– Blood test.
– ECG.
– Chest X-rays (according to the hospital policy, usually
required adult older than 40 years old or smokers or
patients with lung disease history).
– Interview with the surgeon for a complete clinic history,
for review the examination results and for obtaining
informed consent for day surgery and for the
procedure.
– Interview with the anaesthetist.
– The patient will be supplied with a written booklet with
information about preparation at home, surgery and post-
operative care.
At the end of day hospital, surgeon and anaesthetist
decide if the patient is suitable to surgery and to the kind of
recovery proposed (ambulatory surgery or ordinary hospitalisation). Otherwise the patient can be switched to a different kind of hospitalisation.
The patient will be advised by hospital secretariat by
phone about the day of the surgery.
According to the hospital policy, preoperative screening
can be organised and accomplished the same day of
surgery.
Day of Surgery
At the hernia centre, patient is normally admitted to the hospital the same day of the surgery. The nurse and surgical
182
G. Campanelli et al.
team receive the patient and check his preparation (drug
therapy, shaving, fast) and mark the correct side of the
hernia.
Operating Theatre
According to the European Hernia Society guidelines, in
clinic settings with low rates of wound infection, there is no
indication for the routine use of antibiotic prophylaxis in
elective open groin hernia repair in low-risk patients. In elective incisional or large ventral hernia, requiring a large mesh
repair, the antibiotic prophylaxis starts in the operating theatre and goes on at least until the removal of drains.
Antithrombotic prophylaxis is given if the patient had risk
factors for thrombosis.
Antiemetic medication is given if indicated.
Drains are not usually used in patients undergoing normal
size groin hernia repair and small ventral hernia repair.
Drains are always placed in open retromuscolar ventral hernia repair.
Nasogastric tube is normally placed during surgery
requiring the opening of the abdominal cavity (large ventral
hernia repair or incisional hernia repair).
At the end of the surgery, a waterproof dressing is placed
and patients are supported wearing stretchable post- operative
underwear (groin hernia) or strip (ventral hernia).
Post-operative Time and Discharge
After a period of observation in the recovery room, the
patient is transferred to his bed in the ward.
In case of outpatient, a small meal is served. Adequate
post-operative analgesia is mandatory for successful day surgery and is ensured using multimodal opioid-sparing techniques shown to improve recovery and outcomes after short
admissions.
Before discharge, patient is assessed for vital signs, pain,
nausea, vomiting, dizziness, bleeding, walking and dressing,
using the modified postanesthesia discharge scoring system
(PADSS) (Table 9.1) [43]. A minimum PADSS score of 9
was required for discharge. If the patient scores below 9, he
or she is moved to a normal ward and the admission is no
longer in day centre regime.
Voiding seems not to be a requirement before discharge
from DS as it could delay the discharge of 5–10% of patients
who have no risk factors of urinary retention after ambulatory surgery.
But hernia surgery is considered, like anorectal surgery,
old age, male sex, spinal anaesthesia, risk factor for postoperative urinary retention. So, we usually prefer to wait for
spontaneous voiding before discharge.
Table 9.1 Postanesthesia discharge scoring system (PADS) for determining home-readiness
Score
Vital signs
Vital signs must be stable and consistent with age and
preoperative baseline
Blood pressure and pulse within 20% of preoperative
baseline
Blood pressure and pulse 20–40% of preoperative baseline 1
Blood pressure and pulse w > 40% of preoperative
baseline0
Activity level
Patient must be able to ambulate at pre-op level
Steady gait, no dizziness, or meets pre-op level 2
Requires assistance 1
Unable to ambulate 0
Nausea and vomiting
Patient should have minimal nausea and vomiting before
discharge
Minimal: successfully treated with os medication 2
Moderate: successfully treated with intramuscular
medication
Severe: continues after repeated treatment 0
Pain
Patient should have minimal or no pain before discharge
The level of pain that the patient has should be acceptable
to the patient
Pain should be controllable by oral analgesics
The location, type and intensity of pain should be consistent
with anticipated post-op discomfort
Acceptability
Yes 2
No 1
Surgical bleeding
Post-operative bleeding should be consistent with expected
blood loss for the procedure
Minimal: does not require dressing change 2
Moderate: up to two dressing changes required 1
Severe: more than three dressing changes required 0
2
0
1
Of course, patient must accept discharge in readiness and
he is required to be accompanied by a responsible, physically able adult who can bring him at home and care for him
overnight. Patients and their care must understand the
planned procedure and post-operative care.
In case of complex surgical procedure not suitable for
outpatient, fasting is continued until the following morning;
in the first day the patient has usually a liquid diet and in the
second a light diet.
In the first day, patient is supported to mobilisation, and a
breathing physiotherapy programme starts.
Early discharge for a patient traveling long distance is
extremely challenging. Often, a simple visit to the office for a
wound check or drain removal may require several hours of
car ride or take a plane. Likewise, discharging a patient to a
9 Logistics and Specialised Hernia Units
183
local hotel for a short period can result in significant cost for
the patient. For these reasons, care coordination with local
physicians and visiting nursing facilities is very important [5].
Patients confirmed for discharge receive a standard discharge report also specifying the date and time of next check up, phone number in case of emergency and a booklet with
post-operative instructions.
All discharged patients receive a phone call in the morning after the surgery, to check for any problems.
Follow-Up
The patient comes back to the hospital for a clinical check
some days after surgery, as described in the discharge letter.
Periodic follow-up by phone is organised for long-term
results.
Acknowledgement This is an updated version of the chapter authored
by Giampiero Campanelli, Marta Cavalli, Valentina Bertocchi and
Cristina Sfeclan. Valentina Bertocchi and Cristina Sfeclan have not participated in the revision of this chapter for the 5th edition.
References
1. Kingsnorth A, LeBlanc K. Hernias: inguinal and incisional. Lancet.
2003;362(9395):1561–71.
2. Jacob D, Hackl J, Bittner R, Kraft B, Köckerling F. Perioperative
outcome of unilateral versus bilateral inguinal hernia repairs in
TAPP technique: analysis of 15,176 cases from the herniamed registry. Surg Endosc. 2015;29:3733–40.
3. Gilbert AI, Graham MF, Young J, Patel BG, Shaw K. Closer to an
ideal solution for inguinal hernia repair: comparison between general surgeons and hernia specialists. Hernia. 2006;10:162–8.
4. Köckerling F, Berger D, Jost JO. What is a certified hernia center?
The example of the German Hernia Society and German Society of
General and Visceral Surgery. Front Surg. 2014;1:26.
5. Opening Statement of founding members of the International
Association for Ambulatory Surgery. (IAAS) in 1995.
6. Celli G, Campanelli G, Corbellini L, de Stefano B, Fortino A,
Francucci M, Mastrobuono I, Torre M. Modelli organizzativi e
sedi di svolgimento. Commisssione di studio sulla day-surgery e
la chirurgica ambulatoriale istituita con decreto Ministeriale del
12 settembre 2000 Ministero della Sanità and 2001 pp. 21–23.
Proposta per l’organizzazione, lo sviluppo e la regolamentazione
della attività chirurgiche a ciclo diurno.
7. NHS Modernisation Agency. The 10 high impact changes for ser-
vice improvement and delivery. London: Department of Health
Puplications; 2004.
8. Davis JE. The major ambulatory surgical center and how it is devel-
oped. Surg Clin North Am. 1987;67:671–92.
9. Baxter B. Day case surgery. Clarke P, Jones J, editors. Brigden’s
operating department practice. Edinburgh. Churchill Livingstone;
1998. pp. 24–31.
10. Cole BOI, Hislop WS. A grading system in day surgery: effective
utilisation of theatre time. J R Coll Surg Edinb. 1998;43:87–8.
11. Sorabjee JS. Day care surgery—the physicians viewpoint. Bombay
Hosp J. 2003;45:2.
12. Handerson J, Goldacre MJ, Griffith M, et al. Day case surgery:
geographical variation, trends and readmission rates. J Epidemiol
Community Health. 1989;43:302–5.
13. Cahill CJ, Tillin T, Jarrtt PEM. Wide variations in day case practice
and outcomes in Southern England—a comparative audit in 15 hospitals. Abstracts of the 1st International Congress on ambulatory
surgery. Brusseil, Belgium; 1995.
14. Lewis C, Bryson J. Does day case surgery generate extra workload
for primary and community health service staff? Ann R Coll Surg
Engl. 1998;80:200.
15. Australian Day Surgery Council. Day surgery in Australia. Revised
edition. Melbourne: Royal Australasian College of Surgeons; 2004.
First published; 1981.
16. Commission Authorities. Measuring quality: the patients view of
day surgery. London: HMSO; 1991.
17. Department of Health. Day surgery: operational guide. Waiting,
booking and choice. London: Department of Health Publications;
2002.
18. Jarrett PEM, Staniszewski A. The development of ambulatory surgery and future challenges. In: Lemos P, Jarrett P, Philip B, editors.
Day surgery: development and practice. London: First International
Edition; 2006. p. 24–6.
19. Farquharson EL. Early ambulation with special reference to herniorrhaphy as an outpatient procedure. Lancet. 1955;269:517–9.
20. Goulbourne IA, Ruckley CV. Operations for hernia and varicose
veins in a day-bed unit. Br Med J. 1979;2:712–4.
21. Michelsen M, Walter F. Comparison of outpatient and inpatient
operations for inguinal hernia (1971 to 1978). Zentralbl Chir.
1982;107:94–102.
22. Dhumale R, Tisdale J, Banwell N. Over a thousand ambulatory
hernia repairs in a primary care setting. Ann R Coll Surg Engl.
2010;92:127–30.
23. Acevedo A, León J. Ambulatory hernia surgery under local anesthesia is feasible and safe in obese patients. Hernia. 2010;14(1):57–62.
24. Kurzer M, Kark A, Hussain ST. Day-case inguinal hernia repair in
the elderly: a surgical priority. Hernia. 2009;13(2):131–6.
25. Pineault R, Contandriopoulos AP, Valois M, Bastian ML, Lance
JM. Randomized clinical trial of one-day surgery. Patient satisfaction, clinical outcomes, and costs. Med Care. 1985;23(2):171–82.
26. Prescott RJ, Cutherbertson C, Fenwick N, Garraway WM, Ruckley
CV. Economic aspect of day care after operations for hernia or varicose vein. J Epidemiol Community Health. 1978;32:222–5.
27. Ruckley CV, Cuthbertson C, Fenwick N, Prescott RJ, Garraway
WM. Day care after operations for hernia or varicose veins: a controlled trial. Br J Surg. 1978;65:456–9.
28. Ramyl VM, Ognonna BC, Iya D. Patient acceptance of outpatient treatment for inguinal hernia in Jos Nigeria. Cent Afr J Med.
1999;45:244–6.
29. Ramyil VM, Iya D, Ogbonna BC, Dakum NK. Safety of daycare
hernia repair in Jos Nigeria. East Afr Med J. 2000;77(6):326–8.
30. Mattila K, Vironen J, Eklund A, Kontinen VK, Hynynen
M. Randomized clinical trial comparing ambulatory and inpatient
care after inguinal hernia repair in patients aged 65 years or older.
Am J Surg. 2011;201(2):179–85.
31. Miserez M, Peeters E, Aufenacker T, Bouillot JL, Campanelli
G, Conze J, Fortelny R, Heikkinen T, Jorgensen LN, Kukleta
J, Morales-Conde S, Nordin P, Schumpelick V, Smedberg S,
Smietanski S, Weber G, Simons MP. Update with level 1 studies of
the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2014;18:151–63.
32. Mitchell JB, Harrow B. Costs and outcomes of inpatient versus outpatient hernia repair. Health Policy. 1994;28:143–52.
33. Weyhe D, Winnemoller C, Hellwig A, Meurer K, Plugge H, Kasoly
K, Laubenthal H, Bauer KH, Uhl W. (Section sign) 115 b SGB V
threans outpatient treatment for inguinal hernia. Analysis of outcome and economics. Chirurg. 2006;77:844–55.
184
G. Campanelli et al.
34. Engbaek J, Bartholdy J, Hjortsø NC. Return hospital visits and
morbidity within 60 days after day surgery: a retrospective study
of 18736 day surgical procedures. Acta Anaesthesiol Scand.
2006;50:911–9.
35. Jarrett PE. Day care surgery. Eur J Anaesthesiol Suppl.
2001;23:32–5.
36. De Lathouwer C, Poullier JP. How much ambulatory surgery in the
World in 1996–1997 and trends? Ambul Surg. 2000;8:191–210.
37. Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli
G, Conze J, de Lange D, Fortelny R, Heikkinen T, Kingsnorth A,
Kukleta J, Morales Conde S, Nordin P, Schumpelick V, Smedberg
S, Smietanski M, Weber G, Miserez M. European hernia society
guidelines on the treatment of inguinal hernia in adult patients.
Hernia. 2009;13:343–403.
38. Databank of Ministero della Salute, http://www.sanita.it. Healthcare
Department of Italy.
39. Moreno-Egea A, Cartagena J, Vicente JP, Carrillo A, Aguayo
JL. Laparoscopic incisional hernia repair as a day surgery proce-
dure: audit of 127 consecutive cases in a university hospital. Surg
Laparosc Endosc Percutan Tech. 2008;18(3):267–71.
40. Donati M, Gandolfo L, Privitera A, Brancato G, Donati A. Day
hospital for incisional hernia repair: selection criteria. Acta Chir
Belg. 2008;108(2):198–202.
41. Engledow AH, Sengupta N, Akhras F, Tutton M, Warren SJ. Day
case laparoscopic incisional hernia repair is feasible, acceptable
and cost effective. Surg Endosc. 2007;21(1):84–6.
42. De Jong D, Rinkel RNPM, Marin J, van Kesteren PJM, Rangel R,
Imhof S, Henry Y, Baart JA, de Gast A, Ekkelkamp S, van der Horst
CMAM, de la Rosette JJMCH, Laguna Pes MP. Day surgery procedures. In: Lemos P, Jarrett P, Philip B, editors. Day surgery development and practice. London: First International Edition; 2006.
p. 91–2.
43. Marshall S, Chung F. Discharge criteria and postdischarge complications. Anesth Analg. 1999;88:508e17.
Outcomes Assessment and Registries
Ferdinand Köckerling, Iris Kyle-Leinhase,
and Filip E. Muysoms
Introduction
What is the outcome of an abdominal wall hernia repair and
how can it be measured?
Outcome of abdominal wall hernia repair is mostly
described by evaluating the recurrence rate related to specific
operation techniques or devices. The recurrence rate of a hernia operation is an important factor, but there are certainly
more outcome parameters to be considered for hernia repair
outcome assessment. The interpretation of outcome after
hernia surgery is complex and influenced by the large number of variables included.
As described by Muysoms [1, 2], the outcome of abdominal wall hernia repair should be assessed in three main
domains: hernia recurrence, operative and postoperative
complications as well as quality of life assessment and
patient-reported outcome measurements (PROMs).
Moreover, as illustrated in the triple P-triangle of abdominal wall hernia repair (Fig. 10.1), the operative outcome will
be influenced by many patient-related variables, characteristics of the prosthesis used and the details of the surgical
procedure.
In this chapter we will focus on two aspects:
10
Fig. 10.1 Triple P-triangle of abdominal wall hernia repair
(1) The outcome parameters which describe the results of a
surgery. Which parameters do we need to assess to fully
describe the results of an abdominal wall surgery? By
means of operative and postoperative complications,
patient-reported outcome measurements (PROMs) and
the recurrence rate.
F. Köckerling (*)
Vivantes Hospital Spandauv,
Neue Bergstrasse 6, 13585 Berlin, Germany
e-mail: ferdinand.koeckerling@vivantes.de
I. Kyle-Leinhase • F.E. Muysoms
Department of Surgery, Maria Middelares Hospital,
Ghent, Belgium
© Springer International Publishing AG, part of Springer Nature 2018
K.A. LeBlanc et al. (eds.), Management of Abdominal Hernias, https://doi.org/10.1007/978-3-319-63251-3_10
(2) How should we evaluate and register these outcome
parameters? Consequently, reporting the outcome of a
hernia operation in case control studies, through large
randomized controlled trials (RCTs) or well-established
hernia databases and registries.
Outcome
Complications
Each hernia operation is paired with a specific risk of either
operative, postoperative or both complications, depending
185