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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
A Prospective Clinical Study of Mesh Size Required for Open Inguinal Hernia Repair
Correspondence Address :
Dr. Hina Sharma,
22, Hazareshwar Colony, Near Registry Office, Udaipur, Rajasthan, India.
E-mail: drsharmah@gmail.com
Introduction: Inguinal hernia repair by open method is among the most frequently performed surgical procedures. The current standard surgical procedure employed is Lichtenstein’s tension-free mesh repair which requires covering an area defined by anatomic landmarks like Anterior Superior Iliac Spine (ASIS), pubic tubercle, conjoint tendon etc. with a mesh. The distances among these landmarks vary depending upon stature, race and gender of the patients.
Aim: To study whether the commercially available mesh size can be reduced specifically for a subset of Indian population by estimating the actual sizes of mesh applied during inguinal hernia surgery.
Materials and Methods: In this prospective clinical study, 25 patients undergoing open inguinal mesh hernioplasty were studied at a tertiary care centre, Department of General Surgery, Rabindra Nath Tagore Medical College, Udaipur Rajasthan, India, over a period of one year from August 2019 to July 2020. During surgery the standard size commercially available mesh (15×7.5 cm2) was trimmed down according to the dimensions and anatomical landmarks that were assessed during surgery in the usual manner. Since, it is difficult to measure size of applied mesh intraoperatively and because it is often irregular in shape, a novel method was adopted to estimate the mesh size applied. The trimmed out portions of the mesh were weighed using a high precision electronic weighing machine. The ratio of weight of trimmed out portion to total weight of the standard sized mesh was used to derive the area of the mesh applied. Statistical analysis and significance tests were performed using spreadsheet software and student’s t-test, respectively.
Results: Areas of mesh actually applied in the study- mean (85.26±11.04 cm2), mean+2SD (107.34 cm2), most common (75-97.4 cm2) and maximum (102.75 cm2)- all were found to be less than the standard, commercially available size of mesh. No statistically significant difference was found between areas of mesh applied in patients with indirect and direct hernias using unpaired student t-test (p-value=0.1076).
Conclusion: Areas of mesh actually applied in present study were found to be less than the standard, commercially available size of mesh for inguinal hernia repair.
Inguinal canal, Lichtenstein repair, Mesh hernioplasty, Mesh size estimation
Inguinal hernia repair is one of the most common surgical procedures (1). Approximately 75% of all abdominal wall hernias occur in the inguinal region. The dimensions of the inguinal canal vary according to race, stature and gender of the person (1). Open tension-less mesh hernioplasty is the most commonly performed operative procedure for inguinal hernia patients. It is recommended that the mesh is required to cover upto or beyond 2 cm medial to pubic tubercle, 5-6 cm lateral to the Direct Inguinal Ring (DIR) and 3-4 cm above the Hesselbach triangle (2). The size of the mesh is of paramount importance, as a smaller size mesh inadequately covers all the defects and potential hernia sites and, hence, results in recurrence. However, if larger mesh is used then it can lead to restriction of movements, abdominal wall stiffness and paresthesia (2). Therefore, choice of correct size of mesh requires a correct estimation of inguinal canal dimensions in patients taking into consideration region, gender and race.
The two commercially available sizes of the mesh are used (TVM 151, Healthium Medtech Private Limited) for repair of inguinal hernia are 3×3 inches (7.5×7.5 cm) to 3×6 inches (7.5×15 cm). The current standard surgical procedure employed is Lichtenstein’s tension-free mesh repair of the posterior wall inguinal canal, following which recurrences resulting in reoperation is only 25% that of non mesh repairs (3),(4). In this repair, the posterior wall is strengthened by the formation of a fibrous frame over and through the pores of the mesh (2). Size of the mesh to be applied depends upon the area bounded by deep inguinal ring, pubic tubercle, inguinal ligament and lower border of the conjoint tendon in the inguinal canal region. The mesh must cover this area and also extend beyond it (5). The distances among these points vary depending upon gender, race and stature of the patients. Only a few studies concerning the appropriate size of mesh covering adequate anatomic area for open inguinal hernia repair have been reported (6),(7),(8).
One of the factors affecting financial implications of undergoing inguinal hernia repair is the cost of the mesh which in turn depends upon its size. In a relatively poor population cost effectiveness of the material used is of even bigger concern. Almost invariably the commercially available mesh is tailored during inguinal hernia repair, obviously leading to substantial wastage of costly material. However on literature search no studies were found dealing with this specific aspect of inguinal hernia surgery. The size of commercially available mesh has hitherto largely been determined based on anthropometric measurements of western populations. Obviously, a serious effort to determine mesh size appropriate for Indian population is required. Present study made an attempt to achieve the same objective by studying whether the commercially available mesh size can be reduced specifically for a subset of Indian population by estimating the actual sizes of mesh applied during inguinal hernia surgery.
This prospective clinical study was conducted on 25 adult age group patients (15 indirect hernias, 10 direct hernias) undergoing open inguinal mesh hernioplasty in a single unit of Department of General Surgery, Rabindra Nath Tagore Medical College, Udaipur Rajasthan, India, during a one year period between August 2019 to July 2020. Appropriate Institutional Ethical Committee (IEC) approval was taken to conduct the study (IEC/2020/394). Informed consent was obtained from every patient included in the study.
All the patients undergoing open inguinal hernia repair during the study period from a single surgical unit constituted the sample population for the present study.
Inclusion criteria: Patients of either sex who were undertaken for open inguinal hernia surgery under local/regional/general anaesthesia in a single surgery unit were included in the study.
Exclusion criteria: Emergency inguinal hernia repairs e.g., obstructed or strangulated hernia, laparoscopic hernia repairs, repairs for recurrent inguinal hernia and or those following inguinal lymph node dissection were not included in the study. Patients of paediatric age group were not included in the study.
Data collection: Patients undergoing planned surgery for inguinal hernias were recruited for the study after assessing the inclusion/exclusion criteria. A detailed clinical examination was carried out for all patients and the details of the operating procedures were recorded. Standard size commercially available polypropylene mesh of the Healthium Medtech Private Limited company, TVM 151 made of 15×7.5 cm2 size was used in all hernia repairs. Trimming and application of the mesh proceeded as usual, and all these procedures were carried out in the same surgical unit and under direct supervision of single senior surgeon. The trimmed out portions of the mesh were collected and preserved (Table/Fig 1).
Mesh Size
Mesh used in the study was of the same company (Healthium Medtech Private Limited), make and size. The standard size commercially available mesh (15×7.5 cm2) was trimmed down according to the dimensions and anatomical landmarks assessed during surgery in the usual manner. The mesh is often also re-trimmed after taking a few fixation sutures. In order to account for curved, uneven and often multiple trimmings of the mesh which made a direct intraoperative measurement of mesh area impossible, the trimmed out portions of the mesh were preserved. Since, these portions were also curved, uneven and irregular, a novel method was adopted to estimate the mesh size applied. The trimmed out portions of the mesh were weighed using a high precision electronic weighing machine. This weight (w1) was subtracted from total weight of a standard commercially available mesh (w) to arrive at the weight of mesh applied (w2) [i.e., w2=w-w1]. Since, a uniform distribution of weight can be presumed over the whole area of the mesh, the ratio of weight of the mesh applied and weight of the whole mesh (R=[w2/w]) can reasonably be expected to reflect the ratio of area of applied mesh (A1) and its total area (A). Thus, the following equations were used-
Weight of mesh applied (w2) [i.e., w2=w-w1]
Weight of applied mesh (w2)/Total weight of standard mesh (w)=Area of mesh applied (A1)/Area of standard mesh (A)=R
i.e., Area of mesh applied (A1)=Area of standard mesh (A)×R=(15×7.5)×R
The weight of the standard mesh was 1500 mg which was cross checked by weighing whole meshes at different times. After calculating mean and Standard Deviation (SD), maximum area of mesh required in the study population (mean+2SD) was determined.
Statistical Analysis
Standard Spreadsheet software (iOS, numbers) was used for analysis of the data. Statistical significance was evaluated using student’s unpaired t-test and p<0.05 was considered to be significant.
A total of 25 patients undergoing open inguinal hernioplasty were included in the study. Mean age was 52.24±14.31 years (range-19-68 years), most of the patients 12 (48%) were from the age group of 60-69 years followed by 40-49 year and 50-59 year age groups (four patients each), 30-39 year age group (three patients), 10-19 year and 20-29 year age groups (one patient each). All the patients were male. Out of the 25 patients included in the study, 15 patients had indirect hernias while 10 patients had direct hernias. Majority 13 (52%) of patients had risk factors like chronic cough 5 (20%), prostatomegaly 5 (20%), weight lifting 4 (16%) and constipation 1 (4%). Three patients had more than one risk factors. Rest of the patients did not have any risk factors.
Mesh Size
In present study mean weight of the mesh was 1137±147 mg corresponding to an area of 85.26±11.04 cm2. Minimum and maximum weights of mesh used were 570 mg and 1370 mg respectively which corresponded to 42.75 cm2 and 102.75 cm2 (Table/Fig 2). Area of the standard commercially available mesh was 112.5 cm2.
In an overwhelming majority of patients 22 (88%) weight of mesh applied was in the range of 1000-1299 mg which corresponded to an area range of 75-97.4 cm2. In only one patient the weight and area of mesh (1370 mg, 102.75 cm2) exceeded this range. Rest of the two patients had meshes applied with less weight and hence lesser areas (Table/Fig 3).
Maximum area of mesh applied were 102.75 cm2 among patients with direct hernias while among patients with indirect hernias these statistics was 96.75 cm2 (Table/Fig 4). Mean+2SD weight of mesh applied among direct hernias was 1447 mg (1096+351 mg) which corresponded to 108.98 cm2 (82.70+26.28 cm2). These figures for indirect hernias were 1332 mg (1188+144 mg) and 99.91 cm2 (89.10+10.81 cm2) respectively. No statistically significant difference was found between areas of meshes applied in patients with indirect and direct hernias using unpaired student t-test (p-value=0.1076).
Inguinal hernioplasty is one of the most commonly performed elective surgery in the general surgery operating room. Since, most of morphometric studies are essentially cadaveric studies, only a few studies assessing the inguinal hernia patients to determine the mesh size are available in the literature (7),(8),(9).
In a study conducted by Rabe R et al., after considering the morphometric assessment of the inguinal canal anatomy, the ideal mesh size for the population was 9×15 cm2 (135 cm2) to cover all the potential sites of recurrence using European Hernia Society guidelines (8). In another study conducted by Fitzgibbons RJ Jr et al., the optimal mesh size for the majority of patients was determined to be 8.5×14.0 cm2 (119 cm2) measuring dimensions of inguinal floor undergoing herniorrhaphy. These areas were larger than area of commercially available mesh for inguinal hernia repair (112.5 cm2) (9). However, in present study, maximum expected area of mesh applied was 107.34 cm2 (mean+2SD) during open inguinal hernia surgery, regardless of whether the hernia was indirect or 17direct. It is therefore reasonable to accept that mesh area required for Lichtenstein repair in some populations may be different from mesh area deemed to be required based on other population data.
Thus, areas of mesh actually applied in present study- mean (85.26±11.04 cm2), mean+2SD (107.34 cm2), most common (75-97.4 cm2) and maximum (102.75 cm2) all were found to be less than the standard, commercially available size of mesh. Hence, a serious effort must be made to reduce the commercial mesh size for Indian population which will naturally translate into better utilisation of resources and increase affordability. Another suggestion to emerge from this study is that since medial side of the mesh is invariably trimmed in a curved manner, the mesh could be designed in that shape, so that this this wastage is also minimised. On a practical note, it can be recommended that commercially available mesh sizes for inguinal hernia repair should be available in more than two (15×15 cm and 15×7.5 cm) sizes currently available.
Limitation(s)
Present study has addressed the size of the mesh only and authors have not studied its exact financial impact. However, it is intuitive that reduction of mesh size would have financial benefits too.
Areas of mesh actually applied in present study were found to be less than the standard, commercially available size of mesh for inguinal hernia repair. Hence, a serious effort must be made to reduce their size or make available more than just two standard sizes and also possibly to redesign them in order to ensure better utilisation of resources.
The authors acknowledge the co-operation extended by staff of Rabindra Nath Tagore Medical College and MaharanaBhupal Government Hospital, Udaipur in the conduct of this study.
DOI: 10.7860/JCDR/2022/55912.16608
Date of Submission: Feb 25, 2022
Date of Peer Review: Mar 21, 2022
Date of Acceptance: May 11, 2022
Date of Publishing: Jul 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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