The effects of hernia repair on testicular function remain uncertain, regardless of the technique used. Studies that analyze testicular volume and flow after hernia repair or hormonal measurements are scarce and show contradictory results. This study aimed to evaluate the impact of bilateral inguinal hernia repair on male fertility in surgical patients in whom the Lichtenstein and laparoscopic transabdominal preperitoneal (TAPP) techniques were used.

A randomized clinical trial comparing open (Lichtenstein) versus laparoscopic (TAPP) hernia repair using polypropylene mesh was performed in 48 adult patients (20 to 60 years old) with primary bilateral inguinal hernia. Patients were evaluated preoperatively and 90 and 180 postoperative (PO) days. Sex hormones (Testosterone, FSH, LH and SHGB) analysis, testicular ultrasonography, semen quality sexual activity changes and quality of life (QoL) were performed. Postoperative pain was evaluated using the visual analog scale (VAS).

Thirty-seven patients with aged of 44 ± 11 years were included, 19 operated on Lichtenstein and 18 operated on TAPP. The surgical time was similar between techniques. The pain was greater in the Lichtenstein group on the 7th PO day. The biochemical and hormonal analyses, testicular ultrasonography (Doppler, testicular volume, and morphological findings) and sperm quality were similar between groups. However, the sperm morphology was better in the Lichtenstein group after 180 days (p < 0.05 vs. preoperative) and two patients who underwent Lichtenstein hernia repair had oligospermia after 180 days. The QoL evaluation showed a significant improvement after surgery in the following domains: physical function, role emotional, bodily pain and general health (p < 0.05). On comparison of Lichtenstein vs. TAPP none of the domains showed statistically significant differences. No patient reported sexual changes.

Bilateral inguinal hernia repair with polypropylene mesh, whether using Lichtenstein or TAPP, does not impair male fertility in terms of long-term outcomes.

Approved by the Ethics Committee for the Analysis of Research Projects (CAPPesq) of the HC/FMUSP, Number 2.974.457, in June 2015, Registered on Plataforma Brasil in October 2015 under Protocol 45535015.4.0000.0068. Registered on Clinicaltrials.gov, NCT05799742. Enrollment of the first subject in January 2016.

Studies on immunological infertility after inguinal hernia correction are few and not very representative. Anti-sperm antibodies have been shown to reduce male fertility. Although the extent of infertility due to anti-sperm antibodies alone is not very clear, data indicates that about 8%-10% of infertile patients have immunological infertility DESIGN: This retrospective study includes all infertile male patients (n = 2258) who underwent mixed antiglobulin reaction tests and urologic examination from 2000 to 2020. Sperm quality (assessed by the number of spermatozoa, their motility, vitality, and normal form) was also evaluated. Among these patients, 191 had previously undergone unilateral or bilateral inguinal hernia surgery repair. The aim of the study is to evaluate if there is a higher incidence of positive mixed antiglobulin reaction test among patients undergoing inguinal hernioplasty compared to the unselected infertile population.

Anti-sperm antibodies would seem to increase in both patients who performed general andrological surgery and groin hernia correction, respectively 3.48 (95% Confidence Interval: 1.70-7.10; p < 0.001) and 2.45 (95% Confidence Interval: 1.01-5.99; p < 0.05) times more than the unselected infertile population.

Mixed antiglobulin reaction test could be useful in patients undergone previous scrotal surgery or hernia correction men, to avoid false unexplained infertility diagnoses and to direct the couple to assisted reproductive technology procedures. Basal evaluation of spermatozoa does not actually consider andrological surgery as an indication to autoimmunity investigation.

Groin hernias include indirect inguinal, direct inguinal, femoral, obturator, and supravesical hernias. Here, we summarize historical turning points, anatomical recognition and surgical repairs. Groin hernias have a fascinating history in the fields of anatomy and surgery. The concept of tension-free repair is generally accepted among clinicians. Surgical repair with mesh is categorized as hernioplasty, while classic repair without mesh is considered herniorrhaphy. Although various surgical approaches have been developed, the surgical technique should be carefully chosen for each patient. Regarding as interesting history, crucial anatomy and important surgeries in the field of groin hernia, we here summarized them in detail, respectively. Points of debate are also reviewed; important points are shown using illustrations and schemas. We hope this systematic review is surgical guide for general surgeons including residents. Both a skillful technique and anatomical knowledge are indispensable for successful hernia surgery in the groin.

Groin hernias include indirect inguinal, direct inguinal, and femoral hernias. Obturator and supravesical hernias appear very close to the groin. High-quality repairs are required for groin hernias. The concept of "tension-free repair" is generally accepted, and surgical repairs with mesh are categorized as "hernioplasties". Surgeons should have good knowledge of the relevant anatomy. Physicians generally focus on the preperitoneal space, myopectineal orifice, topographic nerves, and regional vessels. Currently, laparoscopic surgery has therapeutic potential in the surgical setting for hernioplasty, with laparoscopic transabdominal preperitoneal (TAPP) repair appearing to be a powerful tool for use in adult hernia patients. TAPP offers the advantages of accurate diagnoses, repair of bilateral and recurrent hernias, less postoperative pain, early recovery allowing work and activities, tension-free repair of the preperitoneal (posterior) space, ability to cover obturator hernias, and avoidance of potential injury to the spermatic cord. The disadvantages of TAPP are the need for general anesthesia, adhering to a learning curve, higher cost, unexpected complications related to abdominal organs, adhesion to the mesh, unexpected injuries to vessels, prolonged operative time, and as-yet-unknown long-term outcomes. Both technical skill and anatomical familiarity are important for safe, reliable surgery. With increasing awareness of the importance of anatomy during TAPP repair, we address the skills and pitfalls during laparoscopic TAPP repair in adult patients using illustrations and schemas. We also address debatable points on this subject.

With standardization of laparoscopic technique of groin hernia repair, the focus of surgical outcome has shifted to lesser studied parameters like sexual function and fertility.

This prospective randomized study was conducted in a single surgical unit at a tertiary care hospital. A sample size of 144 was calculated with 72 in each group (Group 1 TEP and Group 2 TAPP). Primary outcomes measured included comparison of sexual function using BMFSI, qualitative semen analysis and ASA levels between patients undergoing TEP or TAPP repair. Semen analysis and ASA was measured pre-operatively and 3 months post-operatively.

A total of 145 patients were randomized into two groups, TAPP (73) and TEP (72) patients. Both the groups were comparable in terms of demographic profile and hernia characteristics with majority of the patients in both the groups having unilateral inguinal hernia (89.0% in TAPP group and 79.2% in TEP group). Both the groups showed statistically significant improvement in overall sexual function score (BMFSI) at 3 months; however, there was no inter group difference. Both the groups were also comparable in terms of ASA and qualitative semen analysis.

Both TEP and TAPP repair are comparable in terms of sexual function and effect on semen analysis. Laparoscopic repair improves the overall sexual functions in patients with groin hernia.

To evaluate the vas deferens and testicles of rats submitted to bilateral inguinotomy and polypropylene (PP) mesh placement.

Sixty Wistar rats were randomized into three groups: Control (inguinotomy only), mesh placement over the vas deferens (Mesh-DD) or under the spermatic funiculus (Mesh-SF). The following analyses were performed: vas deferens morphometry (lumen area and wall thickness), quantification of collagen fibers, spermatogenesis, apoptosis (cleaved caspase-3 and TUNEL) and cellular proliferation (Ki67). Quantitative gene expression (qPCR) for apoptosis and inflammatory cytokines were evaluated by RT-PCR.

In the apoptosis pathway, Mesh-DD showed one upregulated gene (Il10) and three downregulated genes (Fadd, Tnfrsf1b and Xiap). In Mesh-SF, 17 genes were downregulated. In the inflammation pathway (Mesh-DD), one gene was upregulated (Il1r1), and one gene was downregulated (Ccl12). In Mesh-SF, three genes were upregulated (Il1r1, Tnfsf13b and Csf1), and two were downregulated (Ccl12 and Csf2). PP mesh placement preserved spermatogenesis and did not alter the vas deferens or the testicle. In the ductus deferens, there was reduced luminal area (30 days), increased wall thickness (90 days), and increased type III collagen and cell proliferation (30 and 90 days) (p < 0.05). In the testicle, cell proliferation was greater in the Mesh-DD (p < 0.05).

PP mesh, whether or not in direct contact with spermatic funicular structures, induces changes that were not sufficient to cause damage to the evaluated organs.

Our study was conducted to compare self-fixing lightweight polyester mesh (group I) to the standard heavy weight polypropylene mesh (group II) using tension-free Lichtenstein hernioplasty as regard to the effect of mesh implantation and perimesh fibrosis on testicular blood flow. 80 patients with uncomplicated inguinal hernia were divided in two groups. Doppler ultrasonography measured testicular volume, testicular artery velocity preoperative and 3rd month post operative. Blood flow in the testicles was represented by resistive index (RI). No case of testicular atrophy occurred in either group, however, in both groups a significant postoperative decrease in testicular volume (p = 0.001 in group I and p < 0.001 in group II) was accompanied by a significant increase in RI as compared to their pre-operative values (p < 0.001 in group I and p = 0.009 in group II). Comparing the two groups, patients in group I showed higher values of decrease in testicular volume accompanied by more increase in RI values postoperatively compared to group II patients, but these values did not reach a significant value (p = 0.107, p = 0.136). There was a significant increase in the number of post-operative varicocele and hydrocele in group I compared to group II. Mesh implantation has an effect on testicular size and blood flow by decreasing the testicular size and increasing the RI. This effect was more obvious in the parietex progrip. Although there is an indirect relation between RI and the sperm count, testicular blood flow alone is not enough to judge fertility.

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

Endoscopic totally extraperitoneal (TEP) hernia repair with polypropylene mesh has become a well-established technique. However, since the mesh is placed in close contact with the spermatic cord, mesh-induced inflammation may affect its structures, possibly resulting in impaired fertility. The aim of this observational prospective cohort study was to assess fertility after bilateral endoscopic TEP inguinal hernia repair in male patients.

Fifty-seven male patients (22-60 years old) with primary, reducible, bilateral inguinal hernias underwent elective bilateral endoscopic TEP hernia repair with use of polypropylene mesh. The primary outcome was testicular perfusion; secondary outcomes were testicular volume, endocrinological status, and semen quality. All patients were assessed preoperatively and 6 months postoperatively.

Follow-up was completed in 44 patients. No statistically significant differences in measurements of testicular blood flow parameters or testicular volume were found. Postoperative LH levels were significantly higher [preoperative median 4.3 IU/L (IQR 3.4-5.3) versus postoperative median 5.0 IU/L (IQR 3.6-6.5), p = 0.03]. Levels of inhibin B were significantly lower postoperatively [preoperative median 139.0 ng/L (IQR 106.5-183.0) versus postoperative median 27.0 ng/L (IQR 88.3-170.9), p = 0.01]. No significant changes in FSH or testosterone levels were observed. There were no differences in semen quality.

Our data suggest that bilateral endoscopic TEP hernia repair with polypropylene mesh does not impair fertility, as no differences in testicular blood flow, testicular volume, or semen quality were observed. Postoperative levels of LH and inhibin B differed significantly from preoperative measurements, yet no clinical relevance could be ascribed to these findings.

There is very scant literature on the impact of inguinal hernia mesh repair on testicular functions and sexual functions following open and laparoscopic repair. The present randomized study compares TAPP and TEP repairs in terms of testicular functions, sexual functions, quality of life and chronic groin pain.

This study was conducted from April 2012 to October 2014. A total of 160 patients with uncomplicated groin hernia were randomized to either trans-abdominal pre-peritoneal (TAPP) repair or totally extra-peritoneal (TEP) repair. Testicular functions were assessed by measuring testicular volume, testicular hormone levels preoperatively and at 3 months postoperatively. Sexual functions were assessed using BMSFI, and quality of life was assessed using WHO-QOL BREF scale preoperatively and at 3 and 6 months postoperatively. Chronic groin pain was evaluated using the VAS scale at 3 months, 6 months and at 1 year.

The median duration of follow-up was 13 months (range 6-18 months). The mean preoperative pain scores (p value 0.35) as well as the chronic groin pain were similar between TEP and TAPP repairs at 3 months (p value 0.06) and 6 months (p value 0.86). The testicular resistive index and testicular volume did not show any significant change at follow-up of 3 months (p value 0.9) in the study population. No significant difference was observed in testicular resistive index and testicular volume when comparing TEP and TAPP groups at at follow-up of 3 months (p value >0.05). There was a statistically significant improvement in the sexual drive score, erectile function and overall satisfaction over the follow-up period following laparoscopic inguinal hernia repair. However, sexual function improvement was similar in patients undergoing both TEP and TAPP repairs. All the domains of quality of life in the study population showed a significant improvement at a follow-up of 3 and 6 months. Subgroup analysis of all the domains of quality of life in both TAPP and TEP groups showed a similar increment as in the study population (p value <0.001); however, the mean scores of all the domains were comparable between the two subgroups (p value >0.05), preoperatively and 3 and 6 months follow-up.

Laparoscopic groin hernia repair improves the testicular functions, sexual functions and quality of life, but TEP and TAPP repairs are comparable in terms of these long-term outcomes.

In order to know reproduction-related complications due to standing laparoscopic peritoneal flap hernioplasty, histological characteristics of the testicles from five stallions one year after surgery were compared with seven testicles from four healthy stallions. Moreover, the daily sperm output (DSO) was determined before (T0) and one year after surgery (T12). DSO did not show significant differences between T0 and T12. The diameter of the seminiferous tubules was significantly decreased in the samples from the hernioplasty group. The percentage of tubules with full spermatogenesis was smaller in the hernioplasty group, but the difference was not significant. It can be concluded that standing laparoscopic peritoneal flap hernioplasty produced mild histological changes in the testicular parenchyma, epididymis and pampiniform plexus after one year follow-up.

Inguinal hernia repair is one of the most performed surgeries in the world. It is recognized that any surgery of the pelvic floor may represent a risk factor of male infertility.

Retrospective study of patients with azoospermia and a history of adult inguinal hernia repair surgery and referred to our center between January 1990 and January 2011 for infertility.

Among 69 azoospermia patients with history of adult inguinal hernia repair surgery, 60 patients underwent surgical extraction of sperm that was successful in 75% (45/60). Positive extraction rate decreases in the subgroup of patients with risk factors for infertility (61.4%) as well as in the group with bilateral inguinal hernia (67.9%). There was no statistically significant difference in the positive rate of sperm retrieval according to surgical technique or according to the use of polypropylene mesh (P>0.05).

The obstruction of the vas deferens due to an inguinal hernia repair was a potential iatrogenic cause of male infertility that was rare and underestimated. The influence of using a polypropylene mesh was not clearly demonstrated. The management of these patients is based on prevention in order to identify patients with risk factors of infertility in order to propose a presurgery cryopreservation of sperm.

5.

Acquired inguinal herniation is a very common condition in stallions, usually leading to unilateral or bilateral castration to prevent future recurrence. Recently, several surgical techniques such as the standing laparoscopic peritoneal flap hernioplasty (SLPFH) have been developed to avoid herniation recurrence and also preserve the breeding activity of high economic value stallions. However, studies on SLPFH lack more comprehensive and systematic data about reproductive-related adverse effects and outcomes. The aim of this study was to evaluate whether SLPFH of the internal inguinal rings produces changes in the testicular blood flow in a 1-year follow-up. For that purpose, six healthy stallions were used and testicular blood flow was assessed before, 3, 6, and 12 months (T0, T3, T6, and T12) after the procedure. Blood flow was evaluated ultrasonographically, using the pulsed-wave color Doppler mode. Peak systolic velocity, end-diastolic velocity, the time-averaged maximum velocity, and the derived indexes (resistive index) and pulsatility index) of the testicular artery were measured in two localizations: in the spermatic cord and on the caudal epididymal edge of the testicle. On the spermatic cord, the peak systolic velocity of the testicular artery increased significantly at T12. However, on the epididymal edge location of the artery, the pulsatility and resistive indexes were decreased at T12 (P < 0.05). This pattern of blood flow was related to a hyperemic process. Furthermore, SLPFH might have compressed the spermatic cord, causing a slight occlusion of the testicular artery and triggering a compensatory hyperemia to compensate the deficit of blood flow that supplies the testes. The SLPFH of the internal inguinal ring affected the testicular perfusion in stallions in a 1 year follow-up, although there was no effect on sperm production during this time. The spectral Doppler ultrasound is a useful tool to asses the testicular perfusion after reproductive surgical procedure and provides information which anticipates vascular supply compromise of the stallion testicles.

Laparoscopic hernioplasty techniques have been developed in the recent years to avoid the recurrence of inguinal hernias and to spare the testicles for breeding purposes in stallions. However, there have been no previous comprehensive and systematic studies of the reproductive outcomes and prognoses for stallions after inguinal hernioplasty. Therefore, the objective of this study was to assess the possible effects of one of these techniques (standing laparoscopic peritoneal flap hernioplasty) on the sperm production and motility characteristics of six healthy stallions that received this procedure based on 1-year follow-ups. There were no significant differences in the measured sperm variables (assessments based on the DSO, MOT, PMOT, VSL, VCL and VAP) during 1-year follow-ups.

This study aimed to compare the effects of polypropylene (PP), lightweight PP (UP) and expanded polytetrafluorethylene (e-PTFE) hernia mesh on the reproductive function of adult male Sprague-Dawley (SD) rats following open tension-free hernioplasty. Forty adult SD rats were obtained and divided into five groups: A sham-operated (FO) group, an e-PTFE mesh group, a PP mesh group, the UP mesh group and a normal control (NC) group (without any surgical manipulation). Ninety days following open tension-free hernioplasty, hematoxylin and eosin staining and immunhistochemistry were used to observe the pathological changes of the testicular tissue and to compare the expression of hypoxia-inducible factor-1α (HIF‑1α) in the rat testis, respectively. ELISA was used to analyze the serum concentration of antisperm antibodies (AsAbs) and routine semen testing was conducted to measure the percentage of grade a+b sperm from the epididymis. More than 50% of mesh adherence to the spermatic cord was observed in the PP and UP groups, and mild or no adhesion was observed in the NC, FO and e-PTFE groups. In the UP and PP groups, marked congestion of necrotic tissue was observed in the seminiferous tubule cavity, a significant reduction in the percentage of grade a+b sperm and a significant increase in the expression levels of AsAbs and HIF-α. It was concluded that the e-PTFE mesh exhibited a marginal effect on the reproductive function of rats compared with that of the PP and UP mesh and is more suitable for tension-free hernioplasty. The clinical significance of these results requires further elucidation with a multi-centered prospective study.

Open and laparoscopic tension-free techniques of hernia repair using synthetic meshes are a well-accepted practice with an excellent patient comfort and a low recurrence rate. It is well known that, direct contact of the mesh to the vessels in the inguinal canal and perimesh fibrosis may have a negative impact on testicular flow. Whether different operative techniques or mesh materials used have an effect on the integrity of the testicle, the influence of the resulting fibrosis on testicular perfusion, and spermatic cord structures is still unclear. Our objective is to review whether there is an association between inguinal hernia and hernia repair techniques, pitfalls of various manipulations and also specific applications on spermatic cord structures and testicular perfusion in view of the literature. Most of the clinical and experimental studies result support the idea that inguinal mesh application for hernioplasty is still a safe procedure in patients. Testicular blood flow may be influenced during open and laparoscopic inguinal hernia surgery. But, so far, there is no evidence for a significant impairment of cord structures after open or laparoscopic hernia repair using tension free techniques. It is clear that fine surgical dissection and reconstruction, doing respect for anatomy and using proper prosthetic material could be obtain the best results. Whether changes in flow parameters remain in the late postoperative period, and whether they have an impact on complications should be evaluated in further clinical and experimental studies.

This article reviews the incidence, presentation, anatomy, and surgical management of abdominal wall defects found in the pediatric population. Defects such as inguinal hernia and umbilical hernia are common and are encountered frequently by the pediatric surgeon. Recently developed techniques for repairing these hernias are aimed at improving cosmesis and decreasing pain while maintaining acceptably low recurrence rates. Less common conditions such as femoral hernia, Spigelian hernia, epigastric hernia, lumbar hernia, gastroschisis, and omphalocele are also discussed. The surgical treatment of gastroschisis and omphalocele has undergone some advancement with the use of various silos and meshes.

Sportsmen's groin, also called sports hernia and Gilmore groin, is one of the most frequent sports injuries in athletes and may place an athletic career at risk. It presents with acute or chronic groin pain exacerbated with physical activity. So far, there is little consensus regarding pathogenesis, diagnostic criteria, or treatment. There have been various attempts to explain the cause of the groin pain. The assumption is that a circumscribed weakness in the posterior wall of the inguinal canal, which leads to a localized bulge, induces a compression of the genital branch of the genitofemoral nerve, considered responsible for the symptoms.

The authors developed an innovative open suture repair-the Minimal Repair technique-to fit the needs of professional athletes. With this technique, the circumscribed weakness of the posterior wall of the inguinal canal is repaired by an elastic suture; the compression on the nerve is abolished, and the cause of the pain is removed. In contrast with that of common open suture repairs, the defect of the posterior wall is not enlarged, the suture is nearly tension free, and the patient can return to full training and athletic activity within a shorter time. The outcome of patients undergoing operations with the Minimal Repair technique was compared with that of commonly used surgical procedures.

THE FOLLOWING ADVANTAGES OF THE MINIMAL REPAIR TECHNIQUE WERE FOUND: no insertion of prosthetic mesh, no general anesthesia required, less traumatization, and lower risk of severe complications with equal or even faster convalescence. In 2009, a prospective cohort of 129 patients resumed training in 7 days and experienced complete pain relief in an average of 14 days. Professional athletes (67%) returned to full activity in 14 days (median).

The Minimal Repair technique is an effective and safe way to treat sportsmen's groin.

Inguinal hernia repair is a common surgical procedure, and the majority of operations worldwide are performed ad modum Lichtenstein (open tension-free mesh repair). Until now, no suitable surgical training model has been available for this procedure. We propose an experimental surgical training model for Lichtenstein's procedure on the male and female pig.

In the pig, an incision is made 1 cm cranially to the inguinal sulcus where a string of subcutaneous lymph nodes is located and extends toward the pubic tubercle. The spermatic cord is located in a narrow sulcus in the pig, thus complicating the procedure if operation should be done in the inguinal canal. The chain of lymph nodes resembles the human spermatic cord and can be used to perform Lichtenstein's hernia repair.

This experimental surgical model has been tested on two adult male pigs and three adult female pigs, and a total of 55 surgeons have been educated to perform Lichtenstein's hernia repair in these animals.

This new experimental surgical model for training Lichtenstein's hernia repair mimics the human inguinal anatomy enough to make it suitable as a training model. The operation facilitates the training in the positioning and fixation of the mesh and can be performed numerous times on the same pig. It is therefore a useful training method for inexperienced surgeons to obtain experience in aspects of the Lichtenstein procedure.

We investigated whether new absorbable materials can be used in the treatment of inguinal hernia with the same efficacy as the traditionally used polypropylene.

We compared local tissue inflammation and fibrous reaction, postoperative complications (bleeding, wound haematoma, wound infection) and postoperative recovery time (time of mobilisation) in rats (Fischer strain) after implantation of a polypropylene mesh (PPM) (Prolene, Ethicon, Bracknell, UK) or a dual component fibrin mesh (DCFM) (Tachosil, Nycomed, Marlow, UK), between the muscle layer and the fascia transversalis defect. We further compared direct hernia repair methods using Lichtenstein's operation in humans after implantation of either PPM or DCFM for fascia transversalis reinforcement regarding postoperative pain and complications, time needed for patient mobilisation, and recurrence.

The results show that implantation of DCFM in rats resulted in milder inflammatory response and thicker fibrous tissue formation. Patients implanted with DCFM had significantly lower postoperative pain scores on a visual-analogue scale and lower analgesic use. The overall incidence of postoperative complications was significantly reduced with the use of DCFM. The incidence of recurrence after 24-month follow-up was the same in both groups.

This study has shown that DCFM has the same short-term efficacy in hernia treatment as the standard PPM, with a reduction in postoperative pain and analgesic use, and a decrease in overall postoperative complications. In the rat model, DCFM resulted in milder inflammatory response and thicker fibrous plate than the PPM. Further biomechanical testing and longer follow-up is necessary, but initial results are promising.

Sportsmen's groin, also known as sportsman's hernia, sports hernia, (athletic) pubalgia or athletic hernia, especially in professional sportsmen, is a difficult clinical problem, and may place an athlete's career at risk. It presents with acute or chronic inguinal pain exacerbated with physical activity. So far, the diagnostic criteria and treatment modalities are inconsistently described and there is no evidence-based consensus available to guide decision-making.

We developed an innovative open suture repair, called the "Minimal Repair" technique. With this technique, the defect of the posterior wall of the inguinal canal is not enlarged, the suture is nearly tension-free and the patient can, therefore, return to full training and athletic activity within the shortest time.

In September 2008, we started a prospective cohort study to evaluate the outcome of patients undergoing operations under the Minimal Repair technique for sportsmen's groin. Between September 2008 and May 2009, 129 patients were included in the study and were questioned at entry and 4 weeks after the operation. The primary endpoints were time to complete freedom of pain and time to resumption of exercise and sport. Here, we present the results observed 4 weeks after operation under the Minimal Repair technique.

At enrollment, all but three patients reported a significant restriction of physical activities due to severe groin pain (median duration of pain 142 days, interquartile range [IQR] 57-330 days). Four weeks after operation under the Minimal Repair technique, 96.1% had resumed training (median 7 days, IQR 5-14 days). At this time, there was a full return to pre-injury sports activity levels in 75.8% (median 18.5 days, IQR 11.75-28 days). Focusing on the group of professional athletes, 83.7% had returned to unrestricted sports activities (median 14 days, IQR 10-28 days). In this subgroup, the median time to complete pain relief was 14 days (IQR 6-28 days).

The surgical treatment of sportsmen's groin is common practice when non-surgical treatment has failed over a period of 6 weeks or more. However, there is no evidence-based data on the type of treatment. A wide variety of techniques with and without mesh are being performed. So far, laparoscopic repair is believed to enable a faster recovery and return to unrestricted sports activities. Our results, however, show that the outcome after operation under the Minimal Repair technique is very fast, without exposing the patient to possible risks related to mesh insertion or laparoscopic procedures.

The Minimal Repair technique is an effective and safe way to treat sportsmen's groin.

Modern treatment of inguinal hernias includes prosthetic mesh repairs. However, direct contact of the mesh to the vessels in the inguinal canal and perimesh fibrosis may have a negative impact on testicular flow. The aim of this prospective study was to evaluate the effect of mesh implantation/perimesh fibrosis on testicular flow after repair of indirect inguinal hernias (IIHs).

Forty-eight male patients with unilateral IIH were included. Both testicular parenchyma were assessed using gray-scale sonography, and color/spectral Doppler sonography was performed to evaluate testicular arterial impedance, perfusion, and venous flow. Measurements were made bilaterally at the level of the inguinal canal 1 day before and at the end of the 2nd month after the operation.

There was no difference in testicular and echotexture perfusion between the hernia and the control sides pre- and postoperatively. No venous thrombosis was found. In all groups, resistance index and pulsatility index, measured at 4 levels, were highest in the proximal inguinal canal and lowest at the extratesticular-intrascrotal level (p < 0.05). For all Doppler parameters there was no significant difference between the pre- and postoperative measurements on both the hernia and the control sides.

Mesh implantation/perimesh fibrosis does not adversely affect ipsilateral testicular flow. Mesh application is still a safe procedure in male patients in whom testicular function is important.

Results on hernia surgery from numerous centers confirm that tensionless repair with various meshes reduces the complication rates and the frequency of recurrences. Some evidence on incisional hernias suggests, however, that the use of mesh seems to transfer the onset of recurrences by several years. Persistent pain and other discomfort is also an unpleasant complication of otherwise successful surgery in a number of patients. Thus, improved, slowly degrading, mesh materials, with strong connective tissue-inducing action, might be more optimal for hernia surgery. Accumulating evidence also suggests that recurrent hernias appear in patients having inherited weakness of connective tissues. Numerous tissue specific collagens, in addition to the classical fibrillar I-III collagens and numerous substrate specific matrix proteinases, have recently been described in biochemical literature, and their roles as possible causes of tissue weakness are discussed.

Despite convincing advantages offered by meshes, their use in hernia surgery remains controversial because of fears concerning the long-term effects of their implantation. To improve biocompatibility, a large variety of newly developed light meshes has been introduced to the market. This overview of the literature aimed to establish whether absolute material reduction (g per implanted mesh), use of absorbable components, and coating by inert materials are evidence-based ways to improve biocompatibility of meshes.

A review of the current English and German language literature on the outcome of groin und incisional hernia mesh repair was performed. Both basic research and clinical trials were used as sources of data. Meta-analyses and randomized controlled trials were given priority and were referred to whenever possible.

Operative technique was an independent prognostic factor for the clinical outcome. Mesh construction and composition as characterized by pore size and filament structure appeared to be more important determinants of foreign body reaction after implantation than absolute material reduction of 1 g or more per implant. No data exist about an oncogenic effect of alloplastic materials in humans, but disturbed fertility in animal studies remains an issue of concern and should be further investigated.

According to data from current randomized controlled trials and retrospective studies, light meshes seem to have some advantages with respect to postoperative pain and foreign body sensation. However, their use is associated with increased recurrence rates. Light meshes offer no advantages with respect to alleviating severe chronic groin pain. At the same time, experimental data reveal that material composition and mesh structure may significantly affect foreign body reaction.

This study explored the vulnerability of the ductus deferens due to mesh induced inflammation and shrinkage after hernia repair in the rodent model. Two commonly used types of hernioplastic implants (Prolene and Vypro II) were surgically wrapped around the ductus deferentes on both sides in 20 juvenile and 20 adult Sprague-Dawley rats. Twenty male rats underwent sham surgeries as controls. After 3 months, each male was mated with 2-3 adult females, which were subsequently sacrificed and oocytes or embryos were flushed and counted. Histochemical investigations of the implants and the ductus recovered surgically 4 weeks after implantation (one side) and after the fertility test (second side) were conducted. All groups exhibited 1-3 males with decreased or restricted fertility but there was no difference between groups. Histochemical analysis of the implants and the ductus recovered 4 weeks and 4 months after implantation revealed some sperm granulomes due to lesions of the spermatic cord caused by the implant in the Prolene group. There was no inflammatory reaction in the mucosa or blockage of the spermatic cord visible. Both types of hernioplastic implants tested in this investigation do not give an indication of a negative influence on male fertility in juvenile or adult rats.