Live book 4

Candidate Shift — Rectus Diastasis & Non-Inguinal Groin Hernias: Treat the Diastasis, Cover the Defect (Addendum Summary, Ch 4)Do not mesh an isolated rectus diastasis, do plicate a wide diastasis when repairing a midline hernia, and repair femoral, obturator and Spigelian hernias promptly with preperitoneal mesh.Practice Shift — Complex Ventral/Incisional Hernia (CDC II–III): Make the Four Decisions Separately (Table 4.1)Decide mesh plane, component separation, fascial closure and mesh material separately in complex ventral repair — no single rigid rule — and in CDC II–III retromuscular repairs with fascial closure, synthetic mesh beats biologic.Practice Shift — Groin Hernia in Women & Bilateral Primary Inguinal Hernias: Cover the Femoral Canal (Table 4.1)Prefer laparo-endoscopic TEP/TAPP covering the whole myopectineal orifice in women and bilateral primary inguinal hernias — never explore a woman's groin open without evaluating the femoral canal.Practice Shift — Primary Umbilical Hernia 1–4 cm: Mesh Reinforcement Favored Over Routine Suture (Table 4.1)Reinforce primary 1–4 cm adult umbilical hernias with flat preperitoneal or retromuscular mesh — and individualize, rather than mandate mesh, under 1 cm, in contaminated fields, or before planned pregnancy.

Codes 55

PED-HRN-COMP-01 — Testicular atrophy after an incarceration episode~30% — Atrophic testis following incarcerated hernia (historical series)PED-HRN-COMP-02 — Testicular atrophy in modern cohorts(a) 1% · (b) 0.3% — Atrophy identified across awaiting-surgery literature / after elective repairPED-HRN-COMP-03 — Ovarian compromise in girls13–22% of girls' hernias · 58–82% of incarcerated girls' hernias · 27% · 0–36% — Ovary as hernia content / torsion-infarction at surgeryPED-HRN-COMP-04 — Wound infection after elective repair1.2% — Post-operative wound infectionPED-HRN-COMP-05 — Peri- and post-operative complications, lap vs openNo significant difference — Any peri-operative / post-operative complicationPED-HRN-CPPV-01 — Contralateral patent processus vaginalis (CPPV) prevalence63.5% · open contralateral exploration · 38.5% · laparoscopic inspection — Open contralateral processus found at exploration / seen at laparoscopyPED-HRN-CPPV-02 — Metachronous contralateral hernia (MCIH) if the other side is left alonePooled 8.4% · 5.76% overall, 12.4% if <6 months, 12.1% if initially left-sided · 5% · NNT 18 — Later hernia on the un-operated sidePED-HRN-PREV-01 — Cumulative incidence, birth→15 yearsBoys 6.62% · Girls 0.74% — Diagnosed inguinal hernia, cumulative incidence over childhoodPED-HRN-PREV-02 — Incidence by prematurityTerm ~1–5% · Preterm up to ~30% · 8–50 per 1,000 live births · 20% · male:female 4–10:1 — Inguinal hernia occurrence in term vs preterm infantsPED-HRN-RISK-01 — Incarceration while awaiting elective repair — overall11.9% — Hernia incarceration (ED presentation) during the wait for booked elective repairPED-HRN-RISK-02 — Effect of waiting time≤14 days wait: 5.2% · ≤35 days wait: ~10.0% · NNT 21 — Incarceration rate by wait duration; repair ≤14 days ≈ halves the riskPED-HRN-RISK-03 — Risk modifiers for incarceration while waitingAge <1 year: OR 2.07 · Female sex: OR 1.75 · ≥1 ED visit while waiting: OR 2.73 · Age <1 y AND wait >14 days: OR 1.92 — Adjusted odds of incarceration during the waitPED-HRN-RISK-04 — Incarceration in preterm infants11% · 39% — Crude incarceration proportionPED-HRN-SUC-01 — Recurrence after repairLaparoscopic 1.1% · Open 1.2% · not significant — Recurrence requiring/identified at follow-up, RCT meta-analysisPED-HRN-THR-01 — Timing threshold — term/older infantsDecision threshold: book repair within ~2 weeks of diagnosis in infants — Repair promptly after diagnosis; ≤14 days in under-2s halves waiting-incarcerationPED-HRN-THR-02 — Timing in preterm infants — early vs after dischargeTrade-off, no single winner · OR 0.43 · OR 5.17 · OR 3.25 · Standing absolutes (adjudicated 2026-11-08): the preterm-timing RCT (n=122) as reported in UpToDate — incarceration 3.5% early vs 12.3% late · postoperative apnea 15.8% vs 4.6% · bronchopulmonary dysplasia 9.6% vs 1.5% · prolonged hospital stay 11% vs 2%. — Incarceration / respiratory complications / recurrence by repair timingPED-HYD-COMP-01 — Harm from waitingrare · not · no evidence that a hydrocele damages the testis — Progression of a hydrocele into a clinical hernia is ; observation does cause incarceration; there is (EAU chapter, explicit statements)PED-HYD-COMP-02 — Harm from repairvery low in expert hands — EAU: risk of testicular damage at hydrocele repair is " " — qualitative only. ASH repairs carry higher complication rates, potentially including testicular loss/atrophy (EAU, qualitative)PED-HYD-DEF-01 — Patent processus vaginalis (PPV) prevalence80–94% of newborns · ~20% of adults — Processus vaginalis still patent on anatomical/operative assessmentPED-HYD-RES-01 — Resolution by age (guideline framing)92% resolve if presenting <1 y · 43% if presenting >3 y — Spontaneous resolution of congenital hydrocelePED-HYD-RES-02 — Resolution by type (cohort framing)<24 months · 93% · 40% · 15% · >24 months · 8.7% · 95% of all resolutions occurred before 16.9 months; 98% by 24 months — Spontaneous resolution by hydrocele type and age at presentationPED-HYD-RES-03 — Acquired (non-communicating) hydrocele in older boys~75% resolve spontaneously · 6–9 months — Spontaneous resolution of acquired hydrocelePED-HYD-THR-01 — Duration of observation — congenitalObserve for at least 12 months · not indicated within the first 12–24 months — before considering surgery; surgery of life for an uncomplicated hydroceleABD-HER-FEM-COMP-01 — Bowel resection at emergency femoral repair22.7% · 5.4% — Bowel resection during emergency repairABD-HER-FEM-COMP-02 — 30-day mortality, emergency vs elective femoral repair in womenEmergency femoral repair 3.8% · Elective femoral repair <0.1% — 30-day mortality by settingABD-HER-FEM-CTX-01 — Missed femoral hernia found at reoperation~40–41.6% — Femoral hernia found at reoperation for recurrence after an anterior repair performed/booked as "inguinal"ABD-HER-FEM-EMERG-01 — Emergency presentation of femoral hernia35.9% · 36–39% · 4.9–5% · women 40.6% · men 28.1% — Repairs performed as emergencies (incarcerated/strangulated presentation)ABD-HER-FEM-PREV-01 — Femoral hernia as a share of groin hernia repairs2–4% of all groin repairs overall · Women: 22.8% · 28.6% · Men: 1.1% — Femoral repairs as a proportion of all groin hernia repairs/proceduresABD-HER-INC-COMP-01 — Seroma after prophylactic mesh (PRIMA)Onlay 34/188 (~18%) · Sublay 13/185 (~7%) · Suture 5/107 (~5%) · not — Clinically detected seroma by armABD-HER-INC-PM-01 — Incisional hernia at 2 years after prophylactic mesh at closureSuture 30% (33/107) · Onlay mesh 13% (25/188) · Sublay mesh 18% (34/185) — CT/US/examination-detected IH at 2 yearsABD-HER-INC-PM-02 — Incisional hernia at 5 years (long-term PRIMA)Suture 53.4% (40.4–64.8) · Onlay 24.7% (12.7–38.8) · Sublay 29.8% (17.9–42.6) · 62% — Radiological-inclusive IH detection (examination + CT/US) at 5 yearsABD-HER-INC-PREV-01 — Incisional hernia after midline laparotomyMA-1: 12.8% · MA-2: 10.1% (95% CI 7–15%) · 15.2% · 9.5% — Clinically/radiologically detected incisional hernia after midline incision, mixed follow-upABD-HER-INC-REC-01 — Recurrence by mesh position, open ventral/incisional repairSublay lowest recurrence: OR 0.218 (0.06–0.47) · 94.2% — Network meta-analysis odds ratios for recurrence (and SSI) vs reference positionABD-HER-INC-RISK-01 — Risk factors for incisional hernia after open midline laparotomyReoperation during admission HR 4.09 (1.92–8.70) · Surgical-site infection HR 2.96 (1.78–4.90) · Liver disease 1.76 · Diabetes 1.63 (1.11–2.41) · Emergency surgery 1.60 · Colon surgery 1.55 · Stoma 1.53 · Previous surgery 1.52 · Smoking 1.40 (1.12–1.74) · Age ≥65 1.28 — Multivariable pooled hazard ratios, MA of 20 cohort studies (n=790,800)ABD-HER-INC-RISK-02 — Obesity (BMI ≥30) as a risk factor — disputedHR 1.34 (0.98–1.85) — NOT statistically significant — Pooled HR for BMI ≥30 vs <30 in the same MA; individual studies used inconsistent cut-offs (≥25 vs ≥30)ABD-HER-INC-SUC-01 — Small-bites vs large-bites fascial closureSmall bites 13% (35/268) vs large bites 21% (57/277) — Incisional hernia at 1 year (clinical ± US)ABD-HER-INC-WW-01 — Emergency repair risk on watchful waiting, incisionalEmergency repair 4% at 5 years · 19% at 5 years — Same cohort definitionABD-HER-ING-COMP-01 — Clinically significant chronic postoperative inguinal pain (CPIP)10–12% — Bothersome moderate pain impacting daily activities, ≥3 months postoperatively, decreasing over time (HerniaSurge definition)ABD-HER-ING-COMP-02 — Debilitating chronic pain0.5–6% — Chronic pain affecting normal daily activities or workABD-HER-ING-COMP-03 — Patient-reported chronic groin pain at 1 year, by sexWomen 18.4% · Men 15.2% · 0.13% — Chronic pain on the Inguinal Pain Questionnaire (IPQ), SHR postal PROM at 1 year; moderate–severe = pain that cannot be ignored / affects daily activitiesABD-HER-ING-CTX-01 — Occult contralateral inguinal hernia13–22% — Asymptomatic contralateral hernia found at laparoscopy during unilateral repairABD-HER-ING-EMERG-01 — Share of groin hernia repairs performed as emergencies, by sexWomen ~17% (Nilsson) / 14.4% (1992–2022 cumulative) · Men 5.1% / 5.3% — Emergency (unplanned, acute) repair as a proportion of all groin repairsABD-HER-ING-EMERG-02 — Bowel resection during emergency inguinal repair5.4% · 22.7% — Small/large bowel resection at emergency repair for incarcerated/strangulated inguinal herniaABD-HER-ING-EMERG-03 — Mortality, elective vs emergency groin repairElective mortality 0.2–0.5% · Emergency mortality 4–5.5% · 5.8% — 30-day / perioperative mortality by settingABD-HER-ING-PREV-01 — Lifetime occurrence of groin herniaMen 27–43% · Women 3–6% — Occurrence of a groin hernia (inguinal or femoral) at any point in lifeABD-HER-ING-REC-01 — Reoperation after repair of a recurrent hernia4.6% at 24 months — Reoperation for re-recurrence within 24 monthsABD-HER-ING-SUC-01 — Recurrence, mesh vs non-meshNon-mesh 4 per 100 → Mesh 2 per 100 — Clinically detected hernia recurrence, RCT follow-up (up to 5 years)ABD-HER-ING-SUC-02 — Reoperation for recurrence (registry proxy)Danish: Lichtenstein 2.4% vs laparoscopic 3.3% · Swedish: 1.7% at 24 months after primary repair — Reoperation for recurrence as a proportion of primary repairs — a proxy: true recurrence is up to ~twice the reoperation rate (HerniaSurge)ABD-HER-ING-WW-01 — Hernia accident rate during watchful waiting1.8 per 1,000 patient-years · 0.2 per 100 person-years · ~0.2% per year — Acute incarceration requiring emergency surgery ("hernia accident") per person-time on WWABD-HER-ING-WW-02 — Crossover from watchful waiting to surgery, time-anchored28.7% at 1 year · 51.5% at 5 years · 70.6% at 10 years — Cumulative proportion of WW patients undergoing repair (overwhelmingly elective, for pain)ABD-HER-PST-PM-01 — Prophylactic mesh vs no mesh at permanent end colostomy formationBenefit side: · 12 RCTs · OR 0.33 (0.18–0.62) · 32% without mesh vs 11% with mesh · strong (2018) · conditional (2023) · Null side: · no difference · not — updated SR/MA of (EHS/ESCP/EAES): PSH , I²=74%, moderate certainty; EHS rapid-guideline GRADE absolutes: long-term PSH , surgery for PSH 5% vs 2%. EHS position moved from to recommendation. STOMAMESH (largest double-blind multicentre RCT, n=232): in clinical (p=0.866) or radiological (p=0.748) PSH at 1 year, confirmed at 3 years; long-term MA + trial sequential analysis (Surgery 2024, 175:441-450) concluded prophylactic mesh does prevent PSH long-termABD-HER-PST-PREV-01 — Parastomal hernia incidence over time>30% by 12 months · >40% by 2 years · ≥50% with longer follow-up — Clinical ± radiological parastomal hernia after stoma formation; end colostomy = highest-risk typeABD-HER-UMB-COMP-01 — Early wound events, mesh vs suture (same RCT)mesh 3% vs suture <1% · 2% vs 1% · mesh 3/146 (2%) vs suture 1/138 (<1%) — Seroma, haematoma, wound infection — trial definitions; no statistically significant difference between armsABD-HER-UMB-SUC-01 — Recurrence at 2 years, mesh vs suture repairActuarial 2-year: mesh 3.6% (1.4–9.4) vs suture 11.4% (6.8–18.9) · NNT 12.8 — Recurrence (clinical ± imaging) — 2-year Kaplan–Meier actuarial estimates; crude rates shown alongsideABD-HER-UMB-WW-01 — Emergency repair risk on watchful waiting, umbilical/epigastricEmergency repair 4% at 5 years · 16% at 5 years — Kaplan–Meier probability of emergency repair after referral, patients managed without initial surgery

Memory 9

MDs don't LIeDirect vs indirect inguinal hernia vs the inferior epigastric vesselsRIPBoundaries of Hesselbach's triangleNAVELFemoral triangle contents, lateral → medial (the NAVY family)SAILFemoral triangle boundariesFLIPBoundaries of the femoral canalMALTWalls of the inguinal canal — "2M, 2A, 2L, 2T"Papers Don't Contribute To A Good Specialist LevelContents of the spermatic cord (phrase device)Rule of 3s (3-3-3-3)Contents of the spermatic cord (numeric rule)ICE tieFascial coverings of the spermatic cord, inside → out