Outcomes of primary and recurrent inguinal hernia repair with prosthetic mesh in a single region over 15 years

Background Sutured inguinal hernia repairs are now uncommon, with evidence suggesting that those augmented with mesh are associated with a lower recurrence rate. We aimed to explore the suggestion that the established use of mesh does indeed lower the rate of operation for recurrence in a single National Health Service region. Method We collected retrospective Office of Population Censuses and Surveys coded data across one region of all primary and recurrent inguinal hernia repairs over 15 years (2004–2019). Electronic records of recurrent repairs were scrutinised to identify year and type of previous primary repair. Results In total, 7,234 repairs were performed during this time, of which 289 (4%) were for symptomatic recurrence. Operations for primary repair increased year on year (111 in 2004 to 402 in 2019). Frequency of operation for recurrent herniation declined with increasing use of mesh (8.8% in 2004 to 3.5% in 2019). The majority of repairs (73%) for recurrence were by an open approach. As opposed to an open mesh repair, a primary laparoscopic repair was associated with an earlier recurrence. Conclusions Inguinal hernia repairs are increasing in frequency but operations for later symptomatic recurrence following an open primary prosthetic mesh repair are not.

Incidence and clinical impact of vertebral endplate changes after limited lumbar microdiscectomy and implantation of a bone-anchored annular closure device

Background An annular closure device (ACD) could potentially prevent recurrent herniation by blocking larger annular defects after limited microdiscectomy (LMD). The purpose of this study was to analyze the incidence of endplate changes (EPC) and outcome after LMD with additional implantation of an ACD to prevent reherniation. Methods This analysis includes data from a) RCT study-arm of patients undergoing LMD with ACD implantation and b) additional patients undergoing ACD implantation at our institution. Clinical findings (VAS, ODI), radiological outcome (reherniation, implant integrity, volume of EPC) and risk factors for EPC were assessed. Results Seventy-two patients (37 men, 47 ± 11.63yo) underwent LMD and ACD implantation between 2013–2016. A total of 71 (99%) patients presented with some degree of EPC during the follow-up period (14.67 ± 4.77 months). In the multivariate regression analysis, localization of the anchor was the only significant predictor of EPC (p = 0.038). The largest EPC measured 4.2 cm3. Reherniation was documented in 17 (24%) patients (symptomatic: n = 10; asymptomatic: n = 7). Six (8.3%) patients with symptomatic reherniation underwent rediscectomy. Implant failure was documented in 19 (26.4%) patients including anchor head breakage (n = 1, 1.3%), dislocation of the whole device (n = 5, 6.9%), and mesh dislocation into the spinal canal (n = 13, 18%). Mesh subsidence within the EPC was documented in 15 (20.8%) patients. Seven (9.7%) patients underwent explantation of the entire, or parts of the device. Conclusion Clinical improvement after LMD and ACD implantation was proven in our study. High incidence and volume of EPC did not correlate with clinical outcome. The ACD might prevent disc reherniation despite implant failure rates. Mechanical friction of the polymer mesh with the endplate is most likely the cause of EPC after ACD.

Incidence and Clinical Impact of Vertebral Endplate Changes after Limited Lumbar Microdiscectomy and Implantation of a Bone-anchored Annular Closure Device

Background: An annular closure device (ACD) could potentially prevent recurrent herniation by blocking larger annular defects after limited microdiscectomy (LMD). The purpose of this study was to analyze the incidence of endplate changes (EPC) and outcome after LMD with additional implantation of an ACD to prevent reherniation. Methods: This analysis includes data from a) RCT study-arm of patients undergoing LMD with ACD implantation and b) additional patients undergoing ACD implantation at our institution. Clinical findings (VAS,ODI), radiological outcome (reherniation, implant integrity, volume of (EPC) and risk factors for EPC were assessed. Results: Seventy-two patients (37men, 47±11.63yo) underwent LMD and ACD implantation between 2013-2016. A total of 71 (99%) patients presented with some degree of EPC during the follow-up period (14.67±4.77months). In the multivariate regression analysis, localization of the anchor was the only significant predictor of EPC (p=0.038). The largest EPC measured 4.2 cm3. Reherniation was documented in 17 (24%) patients (symptomatic: n=10; asymptomatic: n=7). Six (8.3%) patients with symptomatic reherniation underwent rediscectomy. Implant failure was documented in 19 (26.4%) patients including anchor head breakage (n=1, 1.3%), dislocation of the whole device (n=5, 6.9%), and mesh dislocation into the spinal canal (n=13, 18%). Mesh subsidence within the EPC was documented in 15 (20.8%) patients. Seven (9.7%) patients underwent explantation of the entire, or parts of the device.Conclusion: Clinical improvement after LMD and ACD implantation was proven in our study. High incidence and volume of EPC did not correlate with clinical outcome. The ACD might prevent disc reherniation despite implant failure rates. Mechanical friction of the polymer mesh with the endplate is most likely the cause of EPC after ACD.

Incidence and clinical impact of vertebral endplate changes after limited lumbar microdiscectomy and implantation of a bone-anchored annular closure device

Background: An annular closure device (ACD) could potentially prevent recurrent herniation by blocking larger annular defects after limited microdiscectomy (LMD). The purpose of this study was to analyze the incidence of endplate changes (EPC) and outcome after LMD with additional implantation of an ACD to prevent reherniation. Methods: This analysis includes data from a) RCT study-arm of patients undergoing LMD with ACD implantation and b) additional patients undergoing ACD implantation at our institution. Clinical findings (VAS,ODI), radiological outcome (reherniation, implant integrity, volume of (EPC) and risk factors for EPC were assessed. Results: Seventy-two patients (37men, 47±11.63yo) underwent LMD and ACD implantation between 2013-2016. A total of 71 (99%) patients presented with some degree of EPC during the follow-up period (14.67±4.77months). In the multivariate regression analysis, localization of the anchor was the only significant predictor of EPC (p=0.038). The largest EPC measured 4.2 cm3. Reherniation was documented in 17 (24%) patients (symptomatic: n=10; asymptomatic: n=7). Six (8.3%) patients with symptomatic reherniation underwent rediscectomy. Implant failure was documented in 19 (26.4%) patients including anchor head breakage (n=1, 1.3%), dislocation of the whole device (n=5, 6.9%), and mesh dislocation into the spinal canal (n=13, 18%). Mesh subsidence within the EPC was documented in 15 (20.8%) patients. Seven (9.7%) patients underwent explantation of the entire, or parts of the device.Conclusion: Clinical improvement after LMD and ACD implantation was proven in our study. High incidence and volume of EPC did not correlate with clinical outcome. Mechanical friction of the polymer mesh with the endplate is most likely the cause of EPC after ACD.

Retrospective Analysis of Reoperation Rate After Standard Lumbar Discectomy and Microdiscectomy - Single Center Experience

Discectomy is a surgical procedure in the treatment of lumbar disc herniation (LDH) if sciatica or neurological deficits occur and still persist after a course of conservative therapy. Standard discectomy (SD) and microdiscectomy (MD) are still equal in curent clinical practice. Many retrospective and prospective studies have shown that there is no clinically significant difference in the functional outcome after two treatment modalities. The aim of our study was to determine whether there are differences in the incidence of reoperation after performing SD and MD. The research included 545 patients with average period of postoperative follow-up of approximately 5.75 years. Standard discectomy was performed in 393 patients (72.11%), and micro-discectomy in 152 (27.8%) patients. The total number of reoperated patients was 37/545, or 6.78%. In the SD group, the number of reoperated patients was 33/393 (8.39%) and in the MD group 4/152 or 2.63%. Statistically significant difference (p <0.05) was recorded in favor of the MD group. Although it has been proven that both SD and MD give good endpoints of treatment and similar functional recovery, the advantage is given to microdiscectomy due to statistically significantly lower rates of recurrent herniation. This result is attributed to better visualization of neural structures and pathological substrates, as well as their mutual relationship.

Prevalence of Recurrent Herniation Following Percutaneous Endoscopic Lumbar Discectomy: A Meta-Analysis

Background: Percutaneous endoscopic lumbar discectomy (PELD) is a minimally invasive surgery for the treatment of lumbar disc herniation (LDH) with a smaller incision, decreased damage to soft tissues, faster recovery, and fewer postoperative complications. However, the exactly epidemiological prevalence of recurrent herniation after PELD remains unclear. Objectives: To investigate the epidemiological prevalence of recurrent herniation in patients following PELD and to analyze the potentially related risk factors. Study Design: Meta-analysis and systematic review of prospective and retrospective studies. Methods: We conducted a comprehensive search in MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials that mentioned the incidence of recurrent herniation after PELD. The overall prevalence estimate was calculated by an appropriate meta-analysis. Subgroup analysis, sensitivity analysis, and publication bias assessment were also performed in our study, respectively. Results: Our results showed the overall prevalence of recurrent herniation after PELD was 3.6% (95% CI 3.0-4.3%). The prevalence estimates after percutaneous endoscopic interlaminar discectomy (PEID) and percutaneous endoscopic transforaminal discectomy (PETD) were 4.2% and 3.4%, respectively. Individuals with older age (≥ 50 years) and higher BMI (≥ 25) had increased recurrence rates after PELD than those with younger age (4.3% vs. 2.7%) and normal body mass index (BMI) (4.8% vs. 1.5%). The prevalence was significantly higher at upper discs (5.4%) than that at L4-5 (2.7%) and L5-S1 (3.1%) level. The incidence of recurrent herniation at lateral disc was 4.7%, and the recurrence rate of migrated herniation was 3.8%. In most cases, the recurrent herniation occurred within 6 months postoperatively (accounting for 61.7%). Limitations: A majority of the included articles were relatively low quality retrospective studies with significant heterogeneity among them. Furthermore, owing to the paucity of data focused on recurrence, many potentially predictive factors related to subgroup analyses could not be conducted, which might have influenced the accuracy and comprehensiveness of our meta-analysis. Conclusions: PELD is associated with a certain rate of recurrence (3.6%), which usually occurred within 6 months postoperatively. Older age (≥ 50 years), obesity (BMI ≥ 25), upper lumbar disc and central disc herniation might be independent risk factors for recurrence after PELD; however, different surgical approaches (PETD or PEID), lateral discs, migrated discs and foraminoplasty did not affect the incidence. These factors could be useful in preoperative evaluation, appropriate patient selection and informed consent before PELD. Key words: Percutaneous endoscopic lumbar discectomy, prevalence, recurrent herniation, meta-analysis

Safe and sustainable: the extracranial approach toward frontoethmoidal meningoencephalocele repair

OBJECTIVEAlthough rare, frontoethmoidal meningoencephaloceles continue to pose a challenge to neurosurgeons and plastic reconstructive surgeons. Especially when faced with limited infrastructure and resources, establishing reliable and safe surgical techniques is of paramount importance. The authors present a case series in order to evaluate a previously proposed concise approach for meningoencephalocele repair, with a focus on sustainability of internationally driven surgical efforts.METHODSBetween 2001 and 2016, a total of 246 patients with frontoethmoidal meningoencephaloceles were treated using a 1-stage extracranial approach by a single surgeon in the Department of Neurosurgery of the Yangon General Hospital in Yangon, Myanmar, initially assisted by European surgeons. Outcomes and complications were evaluated.RESULTSA total of 246 patients (138 male and 108 female) were treated. Their ages ranged from 75 days to 32 years (median 8 years). The duration of follow-up ranged between 4 weeks and 16 years (median 4 months). Eighteen patients (7.3%) showed signs of increased intracranial pressure postoperatively, and early CSF rhinorrhea was observed in 27 patients (11%), with 5 (2%) of them requiring operative dural repair. In 8 patients, a decompressive lumbar puncture was performed. There were 8 postoperative deaths (3.3%) due to meningitis. In 15 patients (6.1%), recurrent herniation of brain tissue was observed; this herniation led to blindness in 1 case. The remaining patients all showed good to very good aesthetic and functional results.CONCLUSIONSA minimally invasive, purely extracranial approach to frontoethmoidal meningoencephalocele repair may serve well, especially in middle- and low-income countries. This case series points out how the frequently critiqued lack of sustainability in the field of humanitarian surgical missions, as well as the often-cited missing aftercare and dependence on foreign supporters, can be circumvented by meticulous training of local surgeons.