The aim of this study was to compare postoperative complications and long-term clinical efficacy of electrospun composite biomaterial and porcine small intestine submucosa (SIS) patch in open inguinal herniorrhaphy. A prospective, randomized, single-blind, controlled, multicenter study was used to select 172 patients with inguinal hernia who met the inclusion criteria in 3 hospitals. All participants were randomly assigned (1:1) and treated by open inguinal herniorrhaphy. The experimental group used electrospun composite biomaterial patch and the control group used SIS patch. Complications were assessed by ultrasonic volume auto-scan (UVAS) at 6, 33 and 72 months after operation. The results showed that 53 cases were found to be positive by UVAS, including 20 cases of encapsulated effusion (12.74%), 11 cases of soft tissue edema (6.40%), 4 cases of recurrence (3.01%), 2 cases of testicular ischemic atrophy (1.50%), 7 cases of testicular hydrocele (5.26%), 6 cases of varicocele (4.51%), 2 cases of spermatic cord cyst (1.27%) and 1 case of epididymal head cyst (0.64%). At 33-month follow-up, 2 cases recurred in the control group (2/79, 2.53%) while none in the experimental group (0/78) (the 95% CI difference in effective rates between the two groups was -0.93% to 6.00%, within the preset non-degradation range of Δ10%). At 72-month follow-up, there were 4 cases of recurrence in the control group (4/59, 6.78%), while none in the experimental group (0/60) (the lower limit of 95% CI difference in effective rates between the two groups was 0.27% > 0). The main clinical efficacy of the experimental group was better than that of the control group. There was no statistical difference in the secondary efficacy between the two groups. The postoperative safety evaluation effect of the two groups was the same. Long-term follow-up with UVAS after operation showed that the main clinical efficacy of electrospun composite biomaterial applied in this procedure was superior to that of SIS patch, and there was no significant difference in the secondary efficacy between the two biological patches.

This article provided an overview of the basic concepts and historical development of hernias. The introduction of the concept of “tension-free hernioplasty” marked a milestone in hernia surgery, while the establishment of the concept of “abdominal domain” has propelled its development. This article introduced the introduction and promotion of hernia repair techniques in China, with a focus on discussing the stages of development for Chinese hernia surgical repair techniques including open surgery, laparoscopic surgery, robotic surgery, as well as the application and development of minimally invasive techniques. It emphasized that surgical methods should be selected based on the classification of abdominal wall hernia and the 3R(repair, reconstruction, restoration) principle for abdominal wall reconstruction. Additionally, this article explored advancements in materials science and the promotion of day surgery models.

Definition and Evolution of Day Surgery Day surgery, also known as ambulatory surgery, was initially proposed by the British pediatrician James H. Nicoll in the early twentieth century. It refers to a surgical model where "patients undergo admission, surgery, and discharge within 1 day, excluding outpatient surgeries performed in clinics or hospitals." In brief, it condenses traditional surgeries requiring multiple days of hospitalization into a 24-h period. The most widely accepted international definition was established by the International Association for Ambulatory Surgery (IAAS) in 1995, which proposed that "Patients undergo surgery or procedures and are discharged on the same day, excluding those performed in clinics or outpatient settings." In addition, patients requiring overnight admission are referred to as "day surgery–delayed recovery patients." In 2013, the China Ambulatory Surgery Alliance (CASA) officially joined IAAS, indicating a more distinct concept and a new phase for the development of day surgery in China. In 2015, CASA introduced the Chinese definition of day surgery: "Day surgery refers to surgeries or procedures completed between admission and discharge within 1 day (24 h)." In addition, two supplemental agreements were clarified: Firstly, day surgery refers to planned surgical procedures for patients and operations, excluding outpatient surgeries; Secondly, concerning patients with delayed hospitalization for day surgery, it pertains to special cases where hospitalization is postponed due to the patient's medical condition, with a maximum stay shorter than 48 h.[1] In 2022, the National Health and Family Planning Commission of the People's Republic of China issued the "Interim Quality Management of Day Medical Care in Medical Institutions," defining day medical care as a service model providing a complete inpatient process within 24 h while ensuring medical quality and safety. The guidelines propose basic requirements for organizational development, system standards, and process management, and specify the supervisory responsibilities of health administrative departments in day medical care quality management. In recent years, China has further integrated its day surgery practices with international standards, and the concept of "same-day surgery" has been widely accepted: Optimizing and reengineering the service process of daytime surgery, changing the traditional overnight mode of daytime surgery in China, and integrating the individualized enhanced recovery after surgery (ERAS) principles. It shortens the previous 1-day hospitalization for day surgery to the same-day admission, surgery, and discharge. Development and Current Situation of Inguinal Hernia Day Surgery Both adult and pediatric inguinal hernias are common diseases worldwide. In 1955, Dr. Farquharson from the Edinburgh Hospital reported successful cases of adult hernia repair using the day surgery model in "The Lancet" journal. In the 1980s, Wuhan Children's Hospital implemented high ligation of hernia sac for pediatric hernias, initiating early explorations of day surgery. At the end of the twentieth century, Beijing Chaoyang Hospital performed tension-free inguinal hernia repair, aiming to alleviate the difficulty of hospitalization. It began to explore inguinal hernia day surgery and gradually began to set up day operating rooms, day observation beds, and day wards. Currently, the number of inguinal hernia day surgery performed annually nationwide ranks second among all day surgery categories (second only to cataract surgery), conducting day surgery for inguinal hernia repair has significant socioeconomic value. Day surgery for adult inguinal hernias mainly involves laparoscopic inguinal hernia repair (LIHR) and open inguinal hernia repair. For pediatric inguinal hernias, day surgery mainly includes laparoscopic and open hernia sac high ligation. Day surgery has the advantages of shortening the average length of hospitalization, reducing medical costs, and accelerating patient rehabilitation, which can effectively improve the utilization rate of medical resources, improve patient satisfaction, and alleviate the contradiction between medical supply and demand.[2] The operation of inguinal hernia repair in the way of day surgery has put forward higher requirements for operation, anesthesia, and perioperative management. However, at present, there is still a lack of standards, unified, and suitable for the conditions of our country, which is not conducive to the effect evaluation, quality control, and further promotion of day surgery. Given the increasing prevalence of day surgery for inguinal hernia repair in China, experts in hernia and abdominal wall surgery in China have formulated Chinese expert guidelines on the standardized procedures and standards of inguinal hernia day surgery by combining the literature and the actual situation in China, aiming to provide a better reference and basis for the establishment of the standardized procedures of inguinal hernia day surgery. Facility construction of inguinal hernia day surgery. Facility Construction of Inguinal Hernia Day Surgery Different from independent day surgery center abroad, in our country day surgery center is mainly affiliated with large medical institutions. Necessary medical resources including a special day operating room, postanesthesia care unit, medical bed, equipment and facilities, medical staff, etc., should exist in these medical institutions to ensure efficient development of day surgery. Hospitals can construct or reconstruct day surgery facilities according to actual conditions, providing convenient, fast, efficient, and safe medical service and environment. Inguinal hernia day surgery facilities should include a comprehensive service area (reception desk, admission, and discharge management, and operation waiting area), a day surgery area (independent day operating room or relatively fixed operating room), and a day surgery ward.[3] Demands of patients, surgeons, and other staff should be fully considered during design.[4] The Organization Management of Inguinal Hernia Day Surgery Organization structure and team building for day surgery management Hospitals should establish a day surgery quality management committee under the medical quality management committee and develop work responsibilities. The committee periodically organizes meetings of various members under the hospital's authorization to study major management decisions related to day surgery and coordinate the cooperation of relevant departments.[5] The main responsibilities include (1) patient assessment system, follow-up system, medical staff training system, disinfection and isolation system, etc.; (2) establishing a selection mechanism for day surgery patients, diseases, and technologies in the institution, as well as a review and authorization management mechanism for medical staff, and organizing its implementation; (3) organizing the monitoring, early warning, analysis, feedback, and evaluation of day surgery quality in the institution, publishing relevant information on day surgery quality in the institution on a regular basis; and (4) formulating plans and organizing the implementation of continuous quality improvement plans for day surgery in the institution. The day surgery team is the foundation for conducting day surgery. It consists of a multidisciplinary and multisectoral team of medical staff, including anesthesiologists, surgical specialists, day ward physicians, nursing staff, and day surgery managers. The functions of the doctors are divided into outpatient, ward management, surgery, anesthesia, etc.; the nursing positions include appointment scheduling, health education, ward management, operating room collaboration, and postoperative follow-up.[5-7] The management team needs to develop rules for the operation of day surgery, pay attention to the operation status of day surgery at any time, identify problems, and coordinate timely handling. The head of the day surgery center and the head nurse are responsible for daily management.[7] Accreditation system Patients undergoing inguinal hernia day surgery have a short hospital stay, a fast turnover rate, and streamlined procedures. While improving operational efficiency, it is bound to increase medical risks. The establishment of an admission system is an important guarantee for reducing the risks of day surgery. The admission system for inguinal hernia day surgery should include the surgical procedure admission, patient admission, and surgeon admission. Operation type access For inguinal hernia day surgery, it is recommended to choose the surgical procedures that have minimal interference with the physiological functions of the body, low surgical risk, short operation time, low expected blood loss, few postoperative complications, mild postoperative pain, low incidence of nausea and vomiting, and discharge within 24 h after surgery.[7] The approval of the hospital's day surgery management committee is required before the operation can be carried out. The access and selection of inguinal hernia day surgery procedures are described in the "Surgical Procedure" section. Patient access Refer to the "Patient Selection Criteria" section. Surgeon access The surgeons who carry out day surgery must be approved and authorized by the hospital's day surgery management committee to perform day surgery at the corresponding level. Continuous technical ability reevaluation and reauthorization of surgeons are implemented, and dynamic management of surgeon qualifications is implemented. Surgeon access standards: (1) possessing a high-level attending physician or above title; (2) proficient in the corresponding surgical techniques of hernia surgery, with rich experience,[8] able to handle related complications and various emergency situations; (3) possessing good doctor–patient communication skills; and (4) abiding by the day surgery management system. Operation process and management The operation process and management of inguinal hernia day surgery include steps such as outpatient surgery, anesthesia outpatient, surgical appointment, preoperative education, admission for surgery, postoperative observation, discharge, and postoperative follow-up.[5-7] The operation process of inguinal hernia day surgery can be roughly divided into two modes: (1) patients complete preoperative examination and anesthesia evaluation in the surgical outpatient department, and then make a reservation for hospitalization in the day surgery center on the day of the surgical appointment. After completing the surgery and observation, they are discharged within the same day or within 24 h; and (2) patients go to the surgical outpatient department for consultation and then make a reservation for hospitalization in the day surgery center. Preoperative examination and anesthesia evaluation are completed on the day of admission, and surgery is scheduled for the next day. After surgery observation, patients are discharged within the same day (within 24 h). Each day surgery center can choose a suitable operation mode based on its own conditions and situation, and both modes belong to the operation process of inguinal hernia day surgery. During the operation process of inguinal hernia day surgery, it requires support and cooperation from multiple departments within the hospital, with team members coming from multiple disciplines and departments. Therefore, it is necessary to establish relevant work systems and job responsibilities for each position, and regularly organize relevant personnel to study and improve communication channels between different positions. Problems found during practical work should be communicated and resolved promptly.[7] Operation mode The management of day surgery shows differentiated and diversified characteristics. Currently, the main management modes in China are centralized management and centralized treatment (centralized mode), as well as centralized management and decentralized treatment (integrated mode). The previous decentralized management and decentralized treatment mode is not recommended due to its lack of unified management and quality control. The centralized management and centralized treatment (centralized mode) refers to setting up a day surgery center with independent wards and operating rooms, where patients from multiple departments are collected and managed in an integrated manner, including concentrated admission, concentrated surgery arrangement, and concentrated follow-up. The centralized management and decentralized treatment (integrated mode) refer to each department arranging a certain number of beds as day surgery beds, sharing the hospital's operating rooms. During the hospitalization period, patient management is completed by the ward medical staff, while the day surgery appointment scheduling and follow-up are uniformly completed by the day surgery management department. Both modes have their advantages and disadvantages. The centralized mode facilitates unified management and homogenization of quality control, while the integrated mode can maximize the utilization of limited bed and operating room resources. The choice can be based on the hospital's organizational structure and actual operating conditions. Operation status analysis, benefit evaluation, performance management, and patient satisfaction survey Analyze the operation volume, efficiency of medical resource utilization, and medical cost of day surgery to understand its operational status, further evaluate its social and health economic benefits, and timely detect and address issues in the operation process. During the operation of day surgery, an incentive mechanism can be established based on the actual operation situation of the hospital to promote the development of day surgery. Medical institutions should mobilize medical staff to actively carry out day surgery, and take the quality management of day surgery in departments and medical staff as the basis for doctors' regular assessment, promotion, and other work. Patient satisfaction surveys can promote the improvement of day surgery operation processes. Generally, third-party agencies are entrusted to carry out the survey. To reduce interference factors, it is recommended to survey satisfaction after discharge, preferably 1 month after discharge. The survey content includes satisfaction with medical process, satisfaction with treatment effect, satisfaction with the service attitude of medical staff, satisfaction with doctor–patient communication and discharge guidance, etc.[5,7] The Implementation of Day Surgery for Inguinal Hernia Patient selection criteria When selecting patients, apart from meeting the surgical indications, one must also consider the surgical indications, such as the absence of fever, no inguinal region infection, American Society of Anesthesiologists (ASA) class ≤ II, etc.[8] Additionally, patients should adhere to the requirements of the day surgery operating procedures. The patients classified as ASA III or above can also undergo day surgery, as long as their comorbidities are stable and have undergone a rigorous evaluation and preparation by an anesthesiologist. Age alone should not be the sole determinant of eligibility for day surgery. Instead, it should be assessed comprehensively considering the type of surgery, the patient's overall condition, anesthesia methods, the severity of comorbidities, and the control of comorbidities. However, this should be clearly specified in the clinical pathway documented by the medical department.[7,9] The indications for day surgery for inguinal hernia include simple inguinal hernias, including unilateral and bilateral indirect hernias, direct hernias, femoral hernias, and uncomplicated recurrent inguinal hernias. Contraindications include incarcerated hernias, strangulated hernias, and cases where anesthesia assessment deems day surgery inappropriate.[9] Additionally, adult supervision at home is required for patients after discharge.[7,9] Selection of surgery method The tension-free hernia repair using repair materials, which is recommended for adult patients with inguinal hernia, can be categorized into two types: open inguinal hernia repair and LIHR.[10,11] Open inguinal hernia repair includes tension-free repair techniques such as the flat mesh repair method, plug and patch technique, and preperitoneal space repair method.[12] Currently, synthetic hernia repair materials are widely applied in clinical practice such as polypropylene, polyester, and polytetrafluoroethylene.[13,14] Additionally, decellularized extracellular matrix biological patches and synthetic absorbable materials, as a category of absorbable and degradable materials, have become increasingly prevalent in clinical applications of inguinal hernia repair surgery.[15-19] Biological patches have comparable recurrence rates with synthetic patches in terms of both short- and long-term recurrence rates, and they are considered as an alternative in potentially contaminated fields.[20,21] Of course, absorbable and degradable patch repairs are mainly performed for young adults who are concerned about foreign body sensations and infertility. On the other hand, the cost of biological meshes has been decreasing in China over last a few years. The surgical methods for pediatric inguinal hernia mainly include laparoscopic surgery and open surgery with high ligation of the hernia sac. Each surgical method has its specific indications. Experienced specialists can follow the principle of "individualized treatment" to select the appropriate surgical method and hernia repair materials based on the patient's specific condition.[22] The preoperative examination The preoperative examination items for inguinal hernia day surgery are the same as those for traditional inpatient surgery. According to the requirements of anesthesia assessment, all preoperative examinations should be completed before the scheduled surgery date (the specific time limit may vary according to the requirements of the anesthesiologist, but should not exceed 1 month at most), to timely complete the preadmission assessment, ensuring the accuracy and timeliness of the examination results.[8] If any abnormalities or changes in the patient's condition are found during the examination, further targeted examinations or reexaminations should be arranged for related assessment of the condition changes. Preoperative anesthesia assessment For patients with inguinal hernia who require day surgery, a formal preoperative anesthesia assessment is necessary to ensure patient safety and avoid surgical delays or cancelations due to inadequate evaluation and preparation. It is encouraged to establish a preanesthesia assessment clinic (PAC) while alleviating the patient's anxiety toward surgical anesthesia.[22] Please refer to the "Expert Consensus on Anesthesia for Day Surgery" developed by the Chinese Society of Anesthesiology for details of the assessment.[8] Venous thromboembolism (VTE) and bleeding risk assessment Clinicians should assess the risk of VTE and bleeding in patients with high incidence of VTE in patients with daytime surgery for inguinal hernia, and consider whether and how VTE prevention is needed based on the assessment results. For patients who take antithrombotic drugs for a long period of time and require surgical procedures, clinicians and anesthesiologists should evaluate the patient and decide on a perioperative medication regimen based on the assessment results.[23] For the content of the assessment, please refer to the "Chinese Guidelines on Perioperative Thrombosis Prevention and Management in General Surgery" developed by the Chinese Society of Surgery of the Chinese Medical Association.[24] Scheduling of surgical appointments Surgical appointment scheduling is a key link in the control of resource allocation in the operating room: (1) checking patient information and examination results to ensure that the patient meets the admission requirements for day surgery; (2) familiarizing with the physician's surgical plan; (3) knowing the functional arrangements of the operating room to guarantee the effective use of surgical resources; (4) initiating priority scheduling for day surgery; (5) accurate information entry; and (6) carefully conducting audits to ensure that the surgical schedule is accurate.[7] Prehospitalization education Health education can reduce the psychological stress response of surgery to patients, shorten the hospitalization time of surgical patients, save costs, and reduce patient anxiety and postoperative pain. The contents include (1) surgery and anesthesia mode, possible complications and solutions; (2) drug withdrawal plan for patients taking medication, such as discontinuation of rifampicin and anticoagulant or alternative treatment, smoking patients to quit smoking 2 weeks before surgery; (3) informing patients of the program of fasting and abstaining from eating and drinking[8]; and (4) informing the time of admission, the place of hospitalization, the time of surgery, the preparation of medical paperwork and information, the patient's own preparations, and the accompaniment of family members. Educational methods included graphic materials, oral presentations, video education, etc. The principle was to use methods that were easy for patients to accept and had a good effect. Preoperative reassessment After admission to the hospital, preoperative reassessment is required to determine whether the patient meets the criteria for day surgery, and cases that do not meet the criteria for day surgery are eliminated and transferred to the appropriate specialty ward for further treatment according to their condition. Reassessment is jointly initiated by the surgeon and anesthesiologist, and is an important step in reducing the risk of day surgery and ensuring that patients are eligible for day surgery for inguinal hernia. Preoperative reassessment and patient selection in the outpatient clinic are two separate processes, which should serve to validate and complement each other. Surgery and operating room management At the end of the operation, the surgeon and anesthesiologist should again judge whether the criteria for day surgery are met according to the specific conditions of the patients' operation; If any accident occurs during the operation, it should be handled in time, and transferred to a specialist ward (if necessary, it can be transferred to the intensive care unit) to continue observation, and should not pursue the day surgery while neglecting the safety of the operation;[25] the surgical operation should be performed based on the principles of minimally invasive surgery and precise surgical concepts, to reduce surgical trauma. All personnel involved in the daytime surgery process should be familiar with the operation standard of daytime surgery, and the items needed in the operation process should be fully prepared before the operation. Anesthesia Open inguinal hernia repair can be performed under local anesthesia.[26] Local anesthesia primarily includes methods such as local nerve block anesthesia, local regional block anesthesia, and surface infiltration anesthesia. Local nerve block anesthesia targets the iliohypogastric nerve, ilioinguinal nerve, and genitofemoral nerve in the inguinal region. This also encompasses high-level nerve block anesthesia guided by ultrasound for the above nerves. Intensive local anesthesia, intravenous general anesthesia, or intralesional anesthesia is required for complex open inguinal hernia repair or when local anesthesia proves ineffective. General anesthesia is required for LIHR. The specific anesthesia method required can be tailored by an anesthesiologist based on the individual patient's condition. Management of postoperative complications Pain management: Postoperative pain is a major factor in delayed discharge, and effective analgesia can facilitate recovery.[27] If the postoperative visual analog scale (VAS) pain score exceeds three points, intervention is necessary. Long-acting analgesic anesthetics such as ropivacaine and bupivacaine with lidocaine can be used in open inguinal hernia repair to implement nerve block anesthesia, which can effectively extend postoperative analgesia and provide a better pain experience for patients. Pain management, primarily through oral and local analgesia, is the mainstay, with a recent emphasis on the combined use of nonopioid and opioid medications to reduce opioid consumption. Nonsteroidal anti-inflammatory drugs are recommended as foundational medications in the United States and several European countries. If not contraindicated, non-opioid medications are preferred, and selective cyclooxygenase-2 inhibitors in tablet form are recommended as continuous oral analgesics.[28] For inguinal hernia day surgery, due to minimal trauma and lower pain intensity, the above analgesics typically yield satisfactory results, and patient-controlled analgesia is generally not required. Prevention of postoperative nausea and vomiting (PONV): PONV are the second leading factor in prolonging hospitalization for day surgery patients.[29] Severe PONV can affect feeding, wound healing, and delay postoperative discharge. Factors influencing PONV are diverse. For patients at moderate risk of PONV, one or two intervention measures should be adopted for prevention. For high-risk patients, a combination of therapy (≥2 intervention measures) and/or multimodal therapy is needed for prevention. Postoperative care Day surgery for inguinal hernia has relatively fast recovery, allowing patients to quickly return to normal life after surgery. While postoperative care is generally less challenging, attention should still be given to the following: (1) closely observe changes in the patient's condition and provide effective management; (2) after the patient regains consciousness, encourage a comfortable position and early oral intake; (3) motivate early ambulation, guiding patients through a gradual postoperative activity progression; (4) educate patients to understand pain, learn the VAS scoring method, and intervene when the VAS score exceeds three according the medical advice; and (5) train and educate family members to improve the self-care skills of patients and their families.[30] Postoperative contingency plan The postoperative emergency plan for day surgery is designed to urgently deal with emergencies that occur during the patient's hospitalization and ensure the patient's medical safety. Medical institutions should establish daytime medical emergency plans, improve the mechanism of consultation and referral, clarify the mechanism of daytime medical rescue resource allocation and emergency deployment, and ensure that the rescue equipment and medicines of each daytime medical unit are available at any time. Institutions also need to strengthen emergency drills to ensure that the daytime medical emergency plans can be implemented smoothly. Postoperative patients with emergencies need to be handled according to this plan: (1) notify the attending surgeon or assistant to inspect the patient, evaluate the condition, and dispose of the patient accordingly; (2) if the patient's condition does not allow for discharge within 24 h postoperatively, the attending surgeon should arrange for the patient to be transferred to a specialized ward for further observation and treatment; and (3) report to the person in charge of the day surgery center to coordinate the treatment at.[6,7] Discharge criteria and predischarge assessment Discharge criteria: (1) the patient's vital signs were stable, conscious, and clearly cognizant; (2) pain was tolerated or controlled by oral medication; (3) there were no abdominal symptoms or signs, fever, nausea, or vomiting; (4) normal walking with medical advice for discharge; and (5) the patient and family members were prepared for discharge and were accompanied by an adult family member for discharge. The assessment was performed 2 to 3 h before the decision to discharge the patient. For assessment at discharge, patients can be evaluated by the postanesthesia discharge score (PADS) to assess whether they meet the criteria for discharge, and they can be discharged when they meet the PADS criteria. Discharge required the fulfillment of two aspects: (1) a PADS score of ≥9; and (2) an adult with mobility, accompanied by a healthy adult family member. Oral analgesics were routinely carried out at discharge, and relevant precautions and contact information were communicated. The condition of patients undergoing day surgery should be reassessed before discharge, and patients with unstable conditions should be kept in the hospital for a longer period of observation. Day surgery should set up the necessary exit mechanism, for the diagnosis and treatment process found to be unsuitable for the daytime ward process the case should be withdrawn from the daytime surgery process, and arranged to enter the specialized wards for further diagnosis and treatment. Discharge rehabilitation guidance and follow-up of discharged patients Medical and nursing care jointly formulate the items and contents of postdischarge rehabilitation guidance; professional nurses record the condition of discharged patients and provide rehabilitation guidance. The guidance includes postdischarge diet, activities, medication, reporting of abnormalities, and a reminder of follow-up consultations, etc. The integrated community linkage service is adopted to publicize the knowledge related to rehabilitation activities through multichannels. Patients should be informed in writing of the need for outpatient review after discharge and observation of postoperative recovery; if sudden symptoms occur after discharge, contact the Day Surgery Center or go to the emer

PURPOSE:Incisional hernia is a common postoperative complication; however, few transcriptomic studies have been conducted on it. In this study, we used second-generation high-throughput sequencing to explore the pathogenesis and potential therapeutic targets of incisional hernias. METHODS:Superficial fasciae were collected from 15 patients without hernia and 21 patients with an incisional hernia. High-throughput sequencing of the fascia was performed to generate an expression matrix. We analyzed the matrix to identify differentially expressed genes (DEGs) and performed gene ontology and enrichment analyses of these DEGs. Additionally, an external dataset was utilized to identify key DEGs. RESULTS:We identified 1,823 DEGs closely associated with extracellular matrix (ECM) imbalance, bacterial inflammatory response, and fibrillar collagen trimerization. TNNT3, CMAY5, ATP1B4, ASB5, CILP, SIX4, FBN1 and FNDC5 were identified as key DEGs at the intersection of the two expression matrices. Moreover, non-alcoholic fatty liver disease-related, TNF, and IL-17 signaling pathways were identified as key enrichment pathways. CONCLUSIONS:We identified eight key DEGs and three pathways associated with incisional hernias. Our findings offer new insights into the pathogenesis of incisional hernias and highlight potential targets for their prevention and treatment.

目的 探讨湿化高流量鼻导管吸氧(HFNC)与传统鼻导管吸氧治疗老年复杂腹壁疝术后低氧血症的临床疗效.方法 采用回顾性队列研究方法.收集2021年1月至2022年6月复旦大学附属华东医院收治的80例老年复杂腹壁疝术后低氧血症患者的临床资料;男44例,女36例,年龄为(74±7)岁;80例患者中,40例术后采用HFNC,设为HFNC组;40例术后采用传统鼻导管吸氧,设为传统组.观察指标:(1)术后血气指标情况.(2)术后并发症情况.正态分布的计量资料以(x)±s表示,组间比较采用独立样本t检验;偏态分布的计量资料以M(Q1,Q3)表示,组间比较采用秩和检验.计数资料以绝对数或百分比表示,组间比较采用x2检验或Fisher确切概率法.重复测量数据采用重复测量方差分析.结果 (1)术后血气指标情况.HFNC组和传统组患者术前、术后12h、术后24h、术后3d动脉血氧分压分别 为(13.5±2.3)kPa、(13.4±3.2)kPa、(13.8±2.3)kPa、(13.7±2.0)kPa和(12.7±2.1)kPa、(12.9±2.4)kPa、(12.3±2.5)kPa、(13.9±2.1)kPa,动脉血二氧化碳分压分别为(5.6±0.7)kPa、(5.0±0.6)kPa、(4.7±0.6)kPa、(4.9±0.6)kPa 和(5.6±0.6)kPa、(4.4±0.8)kPa、(5.0±4.8)kPa、(5.1±1.1)kPa,指脉血氧饱和度分别为 97.8％±2.2％、98.1％±2.1％、98.9％±1.8％、99.2％±2.0％和 97.8％±3.1％、97.8％±2.1％、99.0％±1.5％、98.8％±2.0％,氧合指数分别为 259±28、300±45、352±46、353±57 和 262±29、297±54、304±63、345±53,两组患者动脉血氧分压组间效应比较,差异有统计学意义(F组间=4.09,P＜0.05),时间效应、交互效应比较,差异均无统计学意义(F时间=2.37.F交互=1.71,P＞0.05);动脉血二氧化碳分压时间效应、交互效应比较,差异均有统计学意义(F时=7.23,F交 互=13.21,P＜0.05),组间效应比较,差异无统计学意义(F组间=1.02,P＞0.05);指脉血氧饱和度时间效应比较,差异有统计学意义(F时间=5.54,P＜0.05),组间效应、交互效应比较,差异均无统计学意义(F组间=1.78,F交互=0.46,P＞0.05);氧合指数组间效应、时间效应、交互效应比较,差异均有统计学意义(F组间=8.21,F时=42.07,F交互=3.49,P＜0.05).(2)术后并发症情况.HFNC组和传统组患者术后重症监护室时间、肺部感染分别为3(3,3)d,3例和6(5,7)d,10例,两组患者上述指标比较,差异均有统计学意义(Z=27.50,x2=4.50,P＜0.05);术后发生肺不张、行气管插管分别为0、1例和4、7例,两组患者上述指标比较,差异均无统计学意义(P＞0.05).两组患者均无死亡病例.结论 HFNC在改善老年患者复杂腹壁疝术后动脉血氧分压和氧合指数方面较常规鼻导管吸氧有优势.

A fabric hydrogel composite hernia mesh with biomechanical and mesh–tissue interface dual compliance is designed for scarless abdominal wall reconstruction. The mesh is composed of a polyester knitted fabric and chitosan–polyacrylamide hydrogel complex. The mechanical properties of the composite mesh are adjusted to resemble the human abdominal wall by alkali treatment of chitosan to achieve good biomechanical compliance. An adhesion group is introduced into the composite mesh that forms covalent bonds with tissue, eliminating the need for suturing, reducing stress concentration at the fixation site, achieving mesh‐tissue interface compliance, and improving the simplicity of the operation. Covalent bonds and hydrogen bonds make the mesh have strong adhesion (70.1 ± 3.2 kPa) and repeatable (four times) robust adhesiveness. In vivo experiments using a rabbit abdominal wall defect model demonstrate quick adhesiveness and excellent functional reconstruction. Biomechanical and mesh–tissue interface dual compliance allow the tissue to regenerate an intact abdominal wall structure. The adhesive fabric hydrogel composite hernia mesh offers significant clinical values for repairing abdominal wall defects and provides design ideas for repairing other load‐bearing soft tissues.

Purpose: Abdominal incisional hernia is one of the most common complications after surgery. The preoperative evaluation of the area of abdominal wall defect and the hernia sac volume(HCV) is very important for the selection of patch size and incisional herniorrhaphy. Meanwhile the overlap range of reinforcement repair is controversial. This study aimed to explore the value of ultrasonic volume autoscan(UVAS) in the diagnosis, classification and treatment of incisional hernia.Methods: Both the width and the area of abdominal wall defect and HCV were measured by UVAS in 50 cases with incisional hernias. In 32 of these cases, the measurements of HCV were compared with those of CT. Classification of incisional hernia based on ultrasonic images were compared with operative diagnosis.Results: The measurements of HCV by UVAS and CT 3D reconstruction had good consistency, of which the mean ratio was 1.0084. According to the location and width of abdominal wall defect, UVAS, which showed good accuracy rate (90%, 96%), reached a good agreement in the classification of incisional hernias with operative diagnoses (Kappa = 0.85, Confidence Interval [0.718,0.996]; Kappa = 0.95, Confidence Interval [0.887,0.999]). The patch area should be at least two times as large as the defect area. Conclusions: UVAS is an accurate alternative to measure the abdominal wall defect and HCV and classify the incisional hernia, with additional benefits of no radiation exposure and instant bedside interpretation. The use of UVAS is conducive to preoperative assessment of the risk of hernia recurrence and abdominal compartment syndrome.(c) 2023 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).

我国对于疝病的认知可追溯到数百年前,经过一代又一代外科医师的不断努力,我国在指南和共识的制定、规范化培训制度的建立、疝病随访系统的建立,以及疝病诊疗质量控制等方面取得了长足的进步.中国目前已在疝病诊疗领域走在了世界的前列,但同时也应该看到在一些复杂疝病方面还需要创新性的开拓,如在腹壁重建技术革新、修复材料科学的发展等方面仍需要进一步努力.如何实现腹壁结构和功能的完整性的统一,材料科学应该是一个突破口.当然我们也应该清醒认识到自身的不足,如疝病专科化、基层外科医生技术水平良莠不齐等短板都亟待进一步解决.另外,如何有效结合机器人手术技术的推广、人工智能、4G网络等信息化技术,都将成为未来造福我国广大疝病患者需要进一步努力发展的方向.

背景与目的:闭孔疝是临床较为罕见的腹外疝,老年女性由于盆底松弛等特点,易罹患此病.由于闭孔疝的疝环狭小缺乏弹性,患者多因嵌顿造成的急腹症就诊,一般在肠梗阻手术时发现.彻底缝闭半坚硬的疝环有一定困难,故疝易复发,再手术率高,使用修补材料可有效降低复发率.本文中笔者通过回顾收治的闭孔疝病例,分析总结闭孔疝的疾病特点及临床诊治方面经验体会,以期为该病的临床诊治提供参考. 方法:回顾性总结2019年6月-2021年6月复旦大学附属华东医院和郑州大学附属郑州中心医院胃肠、疝和腹壁外科收治的10例闭孔疝患者的相关临床资料. 结果:10例患者均为女性,年龄48～86岁,中位年龄(70.7±11.8)岁.所有患者术前接受腹盆腔CT扫描检查,发现2例左侧闭孔疝,8例右侧闭孔疝.术中证实嵌顿疝内容物中肠管8例,大网膜1例,腹膜外脂肪1例.全组病例中未有无张力修补的绝对禁忌患者,结合腹腔污染情况,2例使用生物补片,其余8例患者使用聚丙烯补片.6例完全在腔镜下完成,1例在腔镜下疝修补完成后观察肠管活力恢复欠佳中转开腹行肠切除,1例腔镜探查后中转开腹行肠切除及疝修补,2例患者腔镜不耐受直接行开腹探查并无张力修补术.手术时间50～120min,平均75.5 min.术后1例患者死于围术期内科疾病合并症,其余患者顺利出院,住院时间3～28d.术后6、12、18个月随访,均无复发及补片相关感染. 结论:闭孔疝发病率低,起病隐匿容易发生嵌顿.腹盆腔CT扫描对此病诊断有较高价值.使用补片修补并恰当地固定有助于降低复发率.腹腔污染的情况下使用合成补片一期修补具有可行性,污染较重时生物补片更具优势.修补区域严重感染,应放弃使用补片修补.

Objective: To investigate the factors influencing small intestinal ischemia in elderly patients with incarcerated hernia. Methods: The clinical data of 105 elderly patients admitted for surgical procedures of incarcerated hernia at Department of General Surgery, Huadong Hospital between January 2014 and December 2021 were retrospectively analyzed. There were 60 males and 45 females, aged (86.1±4.3) years (range: 80 to 96 years). They were divided into normal group (n=55) and ischemic group (n=50) according to intraoperative intestinal canal condition. The t test, χ2 test and Fisher's exact probability method were used for the univariate analysis of the factors that influence intestinal ischemia in patients, and Logistic regression was used for multifactorial analysis. Results: In all patients, 18 patients (17.1%) had irreversible intestinal ischemia with bowel resection. Six patients died within 30 days, 3 cases from severe abdominal infection, 2 cases from postoperative exacerbation of underlying cardiac disease, and 1 case from respiratory failure due to severe pulmonary infection. The results of the univariate analysis showed that there were differences in gender, history of intussusception, duration of previous hernia, white blood cell count, neutrophil percentage, C-reactive protein, type of incarcerated hernia, and preoperative intestinal obstruction between the two groups (all P<0.05). The Logistic regression results showed that the short time to the previous hernia (OR=0.892, 95%CI 0.872 to 0.962, P=0.003), high C-reactive protein (OR=1.022, 95%CI 1.007 to 1.037, P=0.003), non-indirect incarcerated hernia (OR=10.571, 95%CI 3.711 to 30.114, P<0.01) and preoperative intestinal obstruction (OR=6.438, 95%CI 1.762 to 23.522, P=0.005) were independent risk factors for the development of intestinal ischemia in elderly patients with incarcerated hernia. Conclusions: The short duration of the previous hernia, the high values of C-reactive proteins, the non-indirect incarcerated hernia, and the preoperative bowel obstruction are influencing factors for bowel ischemia in elderly patients with incarcerated hernia. A timely operation is necessary to reduce the incidence of intestinal necrosis and improve the prognosis.

The Da Vinci surgical robotic system has revolutionized the field of robotic surgery and has become one of the most ubiquitous and recognized systems in the robotic surgery era. The rapid rise in China’s economy will provide crucial support for the promotion and application of robotic surgical systems in the country’s surgical field. At present, approximately 1.2 million inguinal hernia repairs are performed annually in China. However, many of these surgeries are performed via traditional open repair or laparoscopy methods. Using the purported benefits of robotic surgery system to benefit hernia patients should become a future direction for Chinese hernia surgeons.

目的 探讨复合生物补片在腹股沟疝修补术中的远期临床价值.方法 采用前瞻性随机对照非劣效性研究方法.选取2014年7月至2015年2月复旦大学附属华东医院等3家医学中心收治的172例成人腹股沟疝患者的临床资料,按照随机数字表法将患者分为两组.患者均行腹股沟后壁加强+补片重建修补术,术中使用静电纺复合生物补片设为试验组,使用进口猪小肠黏膜下层补片设为对照组.观察指标:(1)入组患者分组情况.(2)研究终点.正态分布的计量资料以(x)±s表示,组间比较采用独立样本t检验.计数资料以绝对数或百分比表示,组间比较采用x2检验或Fisher确切概率法.等级资料比较采用非参数秩和检验.以术后6年疝复发率作为有效性评价依据,使用Cochran-Mantel-Haenszel检验进行组间比较.非劣效性检验采用间隔法进行,若两组疝复发率差值的95％可信区间下限＞-10％,则认为试验组非劣于对照组;若下限＞0,则认为试验组优于对照组.结果 (1)入组患者分组情况.筛选出符合研究条件的成人腹股沟疝患者172例;均为男性;年龄为(61±2)岁.172例患者随机分配至试验组和对照组各86例.随访6年,试验组和对照组分别有20例和19例患者失访.(2)研究终点.①主要研究终点:术后6年,试验组66例患者无复发,对照组67例患者中4例疝复发.非劣效检验结果显示:两组患者疝复发率差值的95％可信区间为0.27％～14.41％,下限0.27％＞-10％,且同时＞0.②次要研究终点:试验组和对照组术后6个月、术后6年静息或咳嗽状态简单疼痛评分量表评分比较,差异均无统计学意义(P＞0.05).术后6个月随访,试验组和对照组患者中分别有2例和5例发生并发症,两组比较,差异无统计学意义(x2=1.38,P＞0.05).术后6年随访,两组患者均未发生并发症.结论 复合生物补片应用于腹股沟疝修补术安全、可行,远期疝复发率低,临床疗效良好.

Objectives:To investigate the clinical value of a novel non-crosslinked biological mesh in laparoscopic inguinal hernia repair.Methods:The prospective randomized controlled study was conducted. The clinical data of 50 adult patients with unilateral inguinal hernia who were admitted to 3 medical centers, including Ruijin Hospital of Shanghai Jiaotong University School of Medicine et al, from September 2019 to March 2020 were selected. Based on random number table, patients were divided into two groups. Patients using the novel non-crosslinked biological mesh in repair surgery were divided into the experiment group and patients using the lightweight, micro-porous, partially absorbable synthetic mesh in repair surgery were divided into the control group. Observation indicators: (1) grouping situations of the enrolled patients; (2) endpoint of the study. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test. Measurement data with skewed distribution were represented as M(range), and comparison between groups was conducted using the non-parameter rank sum test. Count data were described as absolute numbers and (or) persentages, and comparison between groups was conducted using the chi-square test or Fisher exact probability. Comparison of ordinal data was conducted using the non-parameter rank sum test. Repeated measurement data were analyzed using the repeated ANOVA. Taking the recurrence rate of hernia as the basis of efficacy evaluation, according to the intention-to-treat analysis, the confidence interval method (Newcombe Wilson method) was used to conduct non-inferiority statistical analysis of the recurrence rate of hernia between the experiment group and the control group. If the upper limit of 95% confidence interval of the difference of recurrence rate of hernia between the experiment group and the control group is less than 10%, the experiment group is considered to be non-inferior to the control group. Results:(1) Grouping situations of the enrolled patients. A total of 50 adult patients with inguinal hernia were selected for eligibility. There were 44 males and 6 females, aged (60±15)years. All 50 patients were randomly divided into to the experiment group and the control group with 25 cases each. One patient in the control group was not followed up at postoperative month 2, and the rest of 49 patients completed all expected follow-up. No patient in the two groups fell off or were removed. (2) Endpoint of the study. ① The primary endpoint of study. The recurrence rate of hernia was 0 in the experiment group, versus 4%(1/25) in the control group, respectively, showing no significant difference between the two groups ( P>0.05). Results of non-inferiority statistical analysis showed that the 95% confidence interval of the difference of recurrence rate of hernia between the two groups was -19.54% to 9.72%, with the upper limit as 9.72%, which was less than 10%. ② The secondary endpoint of study. There were 2 patients in the control group occurred seroma at postoperative day 14, and none of the rest of patient in the two groups occurred seroma during the follow-up, showing no significant difference in the occurrence of seroma between the two groups ( P>0.05). There was 1 patient in the control group feeling discomfort or foreign body sensation in groin area at postoperative month 2, and none of the rest of patient in the two groups feeling discomfort or foreign body sensation in groin area during the follow-up, showing no significant difference in the feeling discomfort or foreign body sensation in groin area between the two groups ( P>0.05). There was no patient occurred surgical site infection in the experiment group, and there was 1 patient in the control group occurred postoperative skin infection, which had no relationship with mesh. There was no patient in both two groups occurred fever, anaphylaxis and patch related serious adverse reaction during the follow-up. The resting visual analogue scale score, active visual analogue scale score of patients at postoperative 2 days and postoperative 18 months were 0.44±1.00, 1.28±1.46 and 0, 0 in the experiment group, versus 0.40±0.76, 1.28±1.14 and 0.24±1.20, 0.44±1.29 in the control group, respectively. There was a significant difference in the time effect of postoperative active visual analogue scale score of patients between the two groups ( Ftime=10.19, P<0.05). The thickness of the novel non-crosslinked biological mesh before implantation was 0.5?0.7 mm. Two months after operation, results of B-ultrasonic examination in groin area of 10 patients from the experiment group showed a strong echo area at the patch implant area with a thickness as 2 mm. Conclusion:Application of novel non-crosslinked biological mesh in laparoscopic inguinal hernia repair is safe and effective.

目的 总结上海市开展外科住院医师规范化培训10年的实践与经验,为今后进一步提高外科住院医师规培化培训质量提供理论依据.方法 统计2010-2021年上海市32家外科住院医师规范化培训基地的基本情况、外科床位数、带教师资人数、研究生导师人数,招录及出站人数、性别、年龄、学历背景、培训年限,结业综合考合格率、申请课题及发表论文情况、就业情况等信息.结果 上海市共有32家外科专业基地,以三级甲等综合性医院为主,目前累计招录了住培医师4597名,已结业3162名,绝大多数外科住培医师达到培训要求并通过考核结业.上海市外科住院医师规范化培训工作在建立健全制度建设,开展教学活动,推广信息化管理,师资培训与督导检查,临床科研培养等方面取得了满意的成效.同时现阶段工作中仍有不足之处,包括规范教学活动、加强医学人文及思政教育、落实外科培训细则、待遇保障等方面.结论 外科住院医师规范化培训已成为培养高水平外科医学人才的重要途径,后续住院医师规范化培训重点应进一步加强各外科基地培训效果的同质化、标准化、规范化,注重内涵建设和质量建设.

Polypropylene (PP) mesh has been one of the most frequently selected materials for abdominal wall hernia (AWH) repair in the past decades. However, the repair effectiveness is often compromised by the high incidence of adverse events. Improvements are highly desirable to reduce unwanted visceral adhesion and increase tissue integration. Herein, we developed a PP-based composite mesh combined with alginate-assistant nanofiber membrane (NFM) by assembling a large-pore lightweight PP mesh, a NFM barrier consisting of poly (lactic-coglycolic acid) (PLGA) and polycaprolactone (PCL), and an alginate hydrogel (AH). In vitro studies revealed that the resulting meshes had excellent structural stability, mechanical properties, and biocompatibility. The NFM barriers were firmly attached to the PP substrates, with AH effectively eliminating the delamination without unwanted damage to the nanofiber barrier. In vivo experiments showed that incorporating AH-assistant NFM into PP prostheses could prevent visceral adhesion in an effective manner and promote mesh integration into surrounding tissues from the abdominal wall. These results prove a novel facile and successful strategy to endow prosthetic meshes with superior anti-adhesion capability and tissue compatibility for repairing AWH.

针对疝修补合成补片植入后带来的多种并发症问题,明确了并发症的诱发因素为病原菌带来的污染和补片本体材料导致的异物反应.以临床常用的经编补片为研究对象,将目前应对疝修补术后并发症的手段分为经编结构调控和表面修饰改性.根据应对场景(有菌性炎症和无菌性炎症)和使用场合(腹腔内和腹腔外)的不同,对表面修饰改性进行了分类阐述.列举了近年来相关研究及临床商用补片取得的成果进展,并将表面改性补片归纳为抗菌型、防粘连型、抗炎型,通过分别概述其相应的作用机制及并发症应对效果,分析了当前3种不同类型表面改性补片存在的问题,并指出具有高附加功能的经编补片将是未来的发展方向.

目的 分析造口旁疝不同修补术式的有效性和安全性.方法 回顾性分析2006年1月至2021年1月复旦大学附属华东医院普外科收治的403例造口旁疝病人的临床资料及随访结果,对不同手术方式的临床结局进行分析.结果 所有入组病人均接受手术治疗,年龄(67.1±4.7)岁,BMI为27.5±3.1.手术时间57～620(127.1±30.2)min,术后住院时间为4～61(6.2±2.3)d.术后近期并发症包括手术部位感染(SSI)42例,血清肿或血肿19例,不全性肠梗阻19例,造口并发症7例,肠管损伤2例.另有死亡2例,皆因高龄嵌顿疝急诊手术后出现多器官功能衰竭而死亡.中位随访时间36个月,复发55例(13.6％),造口相关并发症14例,不全性肠梗阻22例,迟发性补片感染7例,慢性疼痛11例.不同术式比较,复发率从高到低依次为:缝合修补(29.4％)、Keyhole手术(15.3％)、Sugarbaker手术(3.2％),Sandwich手术和造口移位无复发;Sugarbaker手术后肠梗阻发生率最高(19.4％).不同手术入路比较,开放手术后SSI(18.1％)和肠梗阻(6.4％)发生率均为最高,杂交手术病人造口相关并发症发生率最高(7.5％).结论 治疗造口旁疝的不同手术方法中,Keyhole手术在补片修补手术中复发率最高,Sugarbaker和Sandwich手术复发率相对较低,但须注意预防术后肠梗阻的发生.造口旁疝总体疗效仍有待提高,术式及材料仍需不断发展,腹腔镜修补手术疗效与传统开放手术相近,将占据更重要的治疗地位.

Complex systems science (CSS) is an evaluation system that integrates the overall system and draws multilateral conclusions in the form of dynamic and reasonable interpreta-tion. Evaluation of modern hernia and abdominal wall surgery by CSS includes the application of artificial intelligence, data analysis and other methods. It implements the value oriented clinical quality improvement principle in the overall treatment cycle through the measurement of value, combined cost, quality evaluation and patient perspective. Finally, CSS will realize the sustainable development of hernia and abdominal wall surgical diagnosis and treatment system of medical care system.

随着我国生活和物质条件的极大改善,肥胖症合并疝与腹壁外科疾病越来越多见.而肥胖症及合并的代谢性疾病具有特殊性,由肥胖引起的机体一系列病理生理改变会显著影响疝与腹壁外科疾病的治疗效果.笔者认为:准确判断肥胖症及合并代谢性疾病的状态与严重程度并进行有效控制是确定手术时机与制订手术规划的重要前提,对于肥胖症患者采取各种减重措施行术前减重是其治疗的基本原则,对不同疝与腹壁外科疾病患者采用同期或分期针对性个体化手术方案是其治疗成功的保障.