No abstract

Background: Chronic postoperative inguinal pain (CPIP) is the most common long-term complication of inguinal hernia repair. As such procedures are routinely performed, CPIP can be considered a significant burden to global health care. Therefore, adequate preventative measures relevant to surgical practice are investigated. However, as no gold standard research approach is currently available, study and outcome measures differ between studies. The current review aims to provide a qualitative analysis of the literature to seek out if outcomes of CPIP are valid and comparable, facilitating recommendations on the best approach to preventing CPIP. Methods: A systematic review of recent studies investigating CPIP was performed, comprising studies published in 2007-2015. Study designs were analyzed regarding the CPIP definitions applied, the use of validated instruments, the availability of a baseline score, and the existence of a minimal follow-up of 12 months. Results: Eighty eligible studies were included. In 48 studies, 22 different definitions of CPIP were identified, of which the definition provided by the International Association for the Study of Pain was applied most often. Of the studies included, 53 (66%) used 33 different validated instruments to quantify CPIP. There were 32 studies (40%) that assessed both pain intensity (PI) and quality of life (QOL) with validated tools, 41% and 4% had a validated assessment of only PI or QOL, respectively, and 15% lacked a validated assessment. The visual analog scale and the Short Form 36 (SF36) were most commonly used for measuring PI (73%) and QOL (19%). Assessment of CPIP was unclear in 15% of the studies included. A baseline score was assessed in 45% of the studies, and 75% had a follow-up of at least 12 months. Conclusion: The current literature addressing CPIP after inguinal hernia repair has a variable degree of quality and lacks uniformity in outcome measures. Proper comparison of the study results to provide conclusive recommendations for preventive measures against CPIP therefore remains difficult. These findings reaffirm the need for a uniform and validated assessment with uniform reporting of outcomes to improve the burden that CPIP poses to a significant surgical patient population.

Aim Minimally invasive colorectal surgery reduces surgical trauma with better preservation of abdominal wall integrity, but the extraction site is still at risk of incisional hernia (IH). This study aimed to determine pooled incidence of IH for each type of extraction site, and to compare IH rates after midline, non-midline and Pfannenstiel extraction. Methods A systematic review and meta-analysis was conducted using PRISMA guidelines. Single-armed and multiple-armed cohort studies, and randomized controlled trials regarding minimally invasive colorectal surgery were queried from five databases. Outcomes were pooled and compared with random-effects, inverse-variance models. Risk of bias was assessed using the Cochrane ROBINS-I and RoB 2 tools. Results Thirty-six studies were included, totalling 11,788 patients. Pooled extraction site incisional hernia (ESIH) rate was 16.0% for midline (n=4081), 9.3% for umbilical (n=2425), 5.2% for transverse (n=3213), 9.4% for paramedian (n=134) and 2.1% for Pfannenstiel (n=1449). ESIH occurred significantly more with midline extraction in comparison to Pfannenstiel (Odds Ratio (OR) 8.4 [3.5;20.0]). Non-midline extraction (transverse and paramedian) showed a significantly lower OR for IH compared to midline extraction (midline and umbilical). Pfannenstiel extraction resulted in significantly lower OR for ESIH compared to midline (OR 0.12 [0.050;0.30]), transverse (OR 0.25 [0.13;0.50]) and umbilical (OR 0.072 [0.033;0.16]) extraction sites. The risks of surgical site infection and surgical site occurrence were not significantly different in any analyses. Conclusions Specimen extraction through a Pfannenstiel incision is the preferred method in minimally invasive colorectal surgery. In cases where Pfannenstiel extraction is not possible, surgeons should avoid midline specimen extraction.