weekly_question 8/1/2022

[Admin]

A 17 year old boy presents with bilateral inguinal hernias. Discussion about the repair includes both high ligation and repair with polypropylene mesh. Which complication is unique to repair with mesh?

A Recurrence

B Nerve injury

C Infection.

D Fibrosis of the vas.

E Post-operative pain.

[Admin]

correct answer
D Fibrosis of the vas.

Estimates for the lifetime risk of an inguinal hernia in males are variable. Approximately five percent of all males develop some type of hernia during their lifetime. Premature infants are at an increased risk for inguinal hernia with incidence rates of two percent in females and seven to 30% in males although others have suggested an even higher rate. High ligation of the sac at the level of the internal ring has been the standard historically. Because the majority of pediatric hernias are indirect hernia repairs, no floor repair is usually needed. Recurrence rates should be in the range of 1%. Due to high recurrence rates in the adult population, tension-free repairs with mesh were introduced in the early 90’s by Liechtenstein and Amid.

Debate has continued in the adolescent population if the hernia repair should be primarily a pediatric approach (high ligation) or an adult approach (mesh repair). When should a child be treated as an adult? There are no high quality studies to guide the care in this population. Survey studies demonstrate adult surgeons tend to place mesh in adolescence while pediatric surgeons tend to avoid mesh. There are no clear differences in terms of recurrence, nerve injury, and infection in this age group (15-19). There is the theoretic risk of pain with growth of the child, and perhaps mesh should only be used when an individual has reached their full stature. Although postoperative pain is perhaps the most common complication, it can occur with either technique and evidence that the incidence is significantly higher with one or the other approach is lacking.

There are numerous articles in the literature raising concern of mesh causing fibrosis of the vas and leading to infertility. The polypropylene mesh creates a dense fibroblastic inflammatory reaction in the surrounding tissues. Studies in beagles demonstrate narrowing of the vas from a fibroblastic reaction. Although sperm counts were normal at 1 year, this raises concern for long-term effects. Another study has documented decreased sperm motility at 1 year in patients with mesh repairs. There are also case reports and small series demonstrating azoospermia after mesh repair. One review found azoospermia in .03% of patients with mesh repairs, and infertility in 0.8%. While the literature is not definitive on the risk of fibrosis of the vas, this should be discussed with patients who will have bilateral inguinal hernia repairs with mesh.

[Eslam Ghazy]

D

[KAMATARI Didier]

D

[Ismail]

D

[Admin]

correct answer
D Fibrosis of the vas.

Estimates for the lifetime risk of an inguinal hernia in males are variable. Approximately five percent of all males develop some type of hernia during their lifetime. Premature infants are at an increased risk for inguinal hernia with incidence rates of two percent in females and seven to 30% in males although others have suggested an even higher rate. High ligation of the sac at the level of the internal ring has been the standard historically. Because the majority of pediatric hernias are indirect hernia repairs, no floor repair is usually needed. Recurrence rates should be in the range of 1%. Due to high recurrence rates in the adult population, tension-free repairs with mesh were introduced in the early 90’s by Liechtenstein and Amid.

Debate has continued in the adolescent population if the hernia repair should be primarily a pediatric approach (high ligation) or an adult approach (mesh repair). When should a child be treated as an adult? There are no high quality studies to guide the care in this population. Survey studies demonstrate adult surgeons tend to place mesh in adolescence while pediatric surgeons tend to avoid mesh. There are no clear differences in terms of recurrence, nerve injury, and infection in this age group (15-19). There is the theoretic risk of pain with growth of the child, and perhaps mesh should only be used when an individual has reached their full stature. Although postoperative pain is perhaps the most common complication, it can occur with either technique and evidence that the incidence is significantly higher with one or the other approach is lacking.

There are numerous articles in the literature raising concern of mesh causing fibrosis of the vas and leading to infertility. The polypropylene mesh creates a dense fibroblastic inflammatory reaction in the surrounding tissues. Studies in beagles demonstrate narrowing of the vas from a fibroblastic reaction. Although sperm counts were normal at 1 year, this raises concern for long-term effects. Another study has documented decreased sperm motility at 1 year in patients with mesh repairs. There are also case reports and small series demonstrating azoospermia after mesh repair. One review found azoospermia in .03% of patients with mesh repairs, and infertility in 0.8%. While the literature is not definitive on the risk of fibrosis of the vas, this should be discussed with patients who will have bilateral inguinal hernia repairs with mesh.