Dear Dr Borodach..

Thank you for bringing attention to this guideline document. While going through the document, I could not find the Cruse Visual Criteria. I will be grateful if you can elaborate on this criteria and how it helps in the decision making process.

Regards, raza

Article WSES guidelines for emergency repair of complicated abdomina...

Dear Dr.Sayyed,

The guidelines have drawn the common attention already because something of the kind were really needed.

As for the Cruse criteria, so it was established from the 70s in my country that the visual criteria for a wound contamination called by P.J.Cruse, perhaps incorrectly. That author emphasized and explained following criteria as early as in 1970 (the wound classification itself was introduced by Committee of Trauma and published in Ann Surg 1964 to the best of my knowledge):

1) clean wounds; (an estimated rate of infection was about 3-5%)

2) clean contaminated (7-10%)

3) contaminated (app.15%)

4) dirty wounds (30% or more)

[P.J.E.Cruse / Surgical wound sepsis // CMAJ 1970; 102: 251-258].

The same or close criteria were used in the aformentioned 'Guidelines". However, in my humble opinion, it would deserve some piece of explanation what namely is considered by the WSES Committee under these grades for the incarcerated hernia wound:

the hernial fluide properties (if yes, what and how to interprate)

or/and that one of the sac itself

those of the incarcerated organ(s) (what and how again), etc.?

And moreover, I think that many colleagues would like to learn what fundamental data serving as a base for the recommendations to choose this or that way of interpretation of visual alterations, save the infection rate reports? In other words, is there exist some investigation on the nature of hernial fluide, its biochemical properties (exsudate or transsudate; is it toxic?); is there any correlation between its colour and bacterial count, or not, etc.; histological alterations of hernial sac and neighbour tissues (is there just mononuclear or neutrophilic infiltration, where, when). And so on, and so on...

At last, what properly is known about the incarcerated (or strangulated, if you please to call it this way) hernia traits above that that have been ever known, or known from the early 20th century publications?

Thank Dr Borodach for this explanation...

These are all pertinent questions, I think the answers may have to be found through a well designed prospective study.. what do you think..

regards, raza

I think why not to discuss its putative design here?

Recently an experimental work conducted in our laboratory, and accepted for publication this year, show that the adhesion of polypropylene mesh is not affected when used in animals with induced peritonitis, and in an experimental study, Sebben et al (Acta Cir Bras 2006. 21 (3) :155-160) showed that in mesh implanted in animals with induced peritonitis there was gradual reduction of bacterial contamination on the mesh, which was reduced to 17% of infected meshes 72 hours of its implementation, which would ensure their incorporation into tissues and allowing its use in infected ones.

And not only this work!

Recently, an experimental animal model of the really chronic ventral hernia was developed by AL.Gomes Aramayo et al from Brazil [Abdominal wall healing in incisional hernia using different biomaterials in rabbits // Acta Chirurgica Brasileira 2013; 28(4): 307]. Common mesh models are not more than an acute musculo-fascial defects of the abdominal wall what cannot meet those traits we found in hernia of the human, so that their value for the clinical practice is quite limited as was noticed by DA.DuBay et al [Incisional herniation induces decreased abdominal wall compliance via oblique muscle atrophy and fibrosis // Ann Surg 2007; 245(1): 140-6].

So, I am looking forward the Sebben et al' and further publications on the matter. However, clinical data on the bacterial contamination and histological examination of the strangulated hernia components are highly needed. In my humble opinion, it is the very it that can serve as the theoretical basement in decision making when and why a surgeon should or should not implant the mesh. The remain is just conclusions based upon indirect data or just speculation.

I would agree that till the conclusive studies are available,it is better to avoid a synthetic mesh in strangulated hernias.

Dr.Reddy,

Do (or did) you perform any bacteriological tests in case of strangulated hernias before a wound purulent complication has already occured?

And one more question if you do not mind: How do you manage the obturator hernia which is nearly always strangulated at its first appearence? If not the mesh than what is your way for it to repair?

Dear researchers,

starting from early 90' I employed prosthetic material for hernia surgery. In the beginning self trimmed prosthetic devices from a large piece of Marlex mesh without antibiotics therapy or prophylaxis were used. later I started to use the modern preshaped prosthetic devices, with adoption of the one shot antibiotics prophylaxis. More than 1500 inguinal hernias and 300 incisional hernias I have repared. The incidence of infection was less than 1% and the need for removing prostesis was less than 0.5%. In emergency setting in case of incarcerated hernia the results were the same that in elective surgery. In case of strangled hernia (vascular failure), with or without high contaminated operatory field, antibiotics therapy were done and the incidence of infection was very low, like the incidence of need for prosthetic explant. I used to do almost always prolene based mesh repairs. Problems has become when I started to use biologic meshes, because in dirty fields not crosslinked prosthesis becomes digesting in a few, on the other hands crosslinked material implanted remains in situ for several months/years, causing in some case bowel erosion. So I think that prolene based prosthesis can be safe used even in case of emergency hernia repairs. The laparoscopic technique needs a dicussion apart.

Thank you, Dr.Vasquez,

May I ask the same question:

Do (or did) you or your colleagues perform routinely (or occasionally) any bacteriological tests in case of the strangulated hernia of so called 'hernial water' or from the hernial sac wall, or from the serosal surface of the strangulated bowel loop?

Dear Andrey,

the answer is no. In case of incisional hernia with obstructed or stranguled bowel we take always sampling for bacterial tests. Almost always we don't do this for surgical procedure for inguinal/femoral obstructed hernias. You should ask me why? The answer in quite empiric but I don't remember infection problems in post surgical period about this surgical site. Anyway the microbiologic reports came too late and you must take a decision on site at the moment of the operation. So, a wide spectrum antibiotic therapy starts in operating room, and in postoperatory period we eventually correct the therapy with the microbiologist support.

Dr.Vasquez,

Thank you again for this frank expanation! I am agreed that the microbiologic reports come up too late to be of any use for a given patient so that to make the decision as to place the mesh or not.

On another hand, why not to publish the early and remote results of yours as to the incisional hernia with obstructed or strangulated bowel repaired with the prolene mesh?

To the best of knowledge, the consolidate statistical data existed for now are quite limited and contradictive; the addional figures on this matter are warranted in all the world. Meanwhile and from what this very discussion began, the WSES recommendations claim to NOT use the mesh in case the gangrene of the strangulated loop has occured already. As far as I could understand, you are not agreed with the statement, are you?

Dear Andrey,

in the WSES Congress held in Bergamo in 2013, the consensus conference about hernia surgery in emergency setting suggests to DO NOT use the mesh in case the gangrene of the strangulated loop has occured already (I have cited your words). OK These are the recommendations: level 2, grade C.

2C > weak recommendation, low-quality or very low-quality evidence. I think that the sense of these words is enough clear to not consider this like Holy Bible words!

Keep in mind that when I started to do this kind of surgery, in elective and emergency setting, most of the AA that have typed these rules, were college students. OK, is not a joke. I strongly agree for the open abdomen and VAC therapy in case of peritonitis, with delayed closure when microbiological specimens reveals that the infection has gone. About which kind of closure, pure tissue repair, prosthetic repair, biologic or not, cross-linked or not, there is much pathway to do.

I hope that you may understand my honestly mind.

Sincerely yours,

Giorgio Vasquez

I understand that that recommendation is of the grade C (and not only that one).

I meant why not add a positive information if you possess lots of it, including that of bacteriological data for the incisional strangulated hernia in spare as you have mentioned in a previous comment? Why not publish it in the very WSES Journal, for example, or discuss here?

Dear Professor,

I've not published data on strangulated inguinal hernia because it has never been a problem in my work, but something about femoral hernia treated with preshaped prolene mesh insertion even in case of emergency setting I have done. I'm glad to send you a copy of this publication. About the open abdomen handling i have an interesting presentation in ppt that will make me happy if should be able to looking at.

Sincerely yours,

Giorgio vasquez

Here we came the paper

Here we came the presentation on femoral hernia

Dear Sir,

Thank you very much for the loaded materials! All of them are excellent and deserve being discussed separately, without any doubt. With your kindly permission, I would like to show them to my medical students so that they can enjoy as well.

However, neither article, nor presentations contain bacteriological data.

In Indian scinario we are comfortable not using a prosthetic material in the above circumstances explaining the patient about the possibility of infection and recurrence.Once Biosynthetic meshes are avilable,I will try.

Thank you, Dr.Reddy, for sharing the Indian herniology strategy experience, one of the largest in the world.

However, as far as I could understand your post, you do not use any bacteriological tests in case of the strangulated hernia, do you?

in our practice we donot unless wound is contaminated.But we do put them on prophylactic antibiotics.It may not be scientific but usual practice.

I see