The Shouldice technique: a canon in hernia repair

Controversy exists on the merits of the various approaches to inguinal repair. Evolution of the classic open repair has culminated in the Shouldice repair. Challenges from newcomers, namely, tension-free repair and laparoscopy, are being examined. These two techniques have a number of disadvantages: the presence of foreign bodies (prostheses) and their implication in cases of infection; the cost of prosthetic material, which is no longer negligible (particularly with expanded polytetrafluoroethylene); and problems of safety in that the laparoscopic approach is no longer a dependable asset except in the hands of a highly specialized and dextrous operator. Still, complications occur with laparoscopic repair that should not be associated with a surgical procedure that is considered benign, safe and cost-effective. Surgeons must recognize the pertinent facts and decide according to their conscience which method of repair to use.

Total costs of laparoscopic and lichtenstein inguinal hernia repairs: a randomized prospective study

In a prospective, randomized study, laparoscopic (n = 20) and Lichtenstein (n = 18) inguinal hernia repairs were compared in relation to operative time, operative costs, hospital stay, postoperative pain, return to work, patient satisfaction, complications, and total costs. All the operations were performed with the patient under general anesthesia. The median operative times in the laparoscopic and Lichtenstein groups were 71.5 (range, 43-140) and 45 (16-83) min, respectively (p < 0.001). Postoperative pain and use of analgesics was less in the laparoscopic group. The median time to return to work was 14 (8-26) days in the laparoscopic group and 19 (5-40) days in the Lichtenstein group. More complications occurred in the Lichtenstein group. The median of the operative costs, in U.S. dollars, was $1,395 and $878, respectively, and the median total costs (including community expenses resulting from lost workdays) were $4,796 in the laparoscopic and $5,320 in the Lichtenstein groups.

[Extraperitoneal, "tension free" inguinal hernia repair with local anesthesia--a contribution to effectiveness and economy]

In this present randomized controlled study, two groups, each consisting of 45 patients, underwent tension-free inguinal hernia repair under general versus local anesthesia. Patients in the local anesthesia group described their pain during mobilisation by using the VAS and were found to have a significant pain level decrease from the first to the fifth postoperative day. In conclusion, it could be shown that tension-free hernia repair under local anesthesia is superior to tension-free hernia repair during general anesthesia concerning perception of pain and pain management.

Laparoscopic inguinal hernia repair: is the enthusiasm justified?

One surgeon repaired 72 inguinal hernias in 61 patients by a transabdominal preperitoneal laparoscopic placement of prosthetic mesh. There were 58 male and 3 female patients; the mean age was 47.9 years. Thirty-six unilateral inguinal hernias (either direct or indirect), 11 bilateral inguinal hernias, 12 recurrent inguinal hernias, and 2 unilateral pantaloon inguinal hernias were repaired. There were no operative mortalities. The mean follow-up was 21 months, with a range of 6 to 42 months. Ten hernia recurrences (13.8%) were documented 3 to 24 months postoperatively (mean, 12 months). There were six direct hernia recurrences, two indirect hernia recurrences, and two recurrences of recurrent hernia repairs. Thirteen patients (21.3%) experienced morbidity: seromas in eight, a hematoma in one, an ileus in one, hematuria in one, and neuropathy in two. In our opinion, the significant morbidity and early recurrence rate of a laparoscopic inguinal hernia repair are unacceptable. Enthusiasm for laparoscopic technique to repair inguinal hernias is not justified if similar morbidity and recurrence rates are documented within the surgical community.

["Tension-free" repair of inguinal hernia: laparoscopic (TAPP) versus open (Lichtenstein) repair]

In a prospective study, from June 1992 to February 1994 94 patients with 100 hernias were treated laparoscopically (TAPP) and from March 1993 to November 1994 100 patients with 108 hernias were treated with a Lichtenstein patch. Concerning duration of operation, postoperative outcome, complications and return to work, only minor differences were noted. Because of the more demanding and difficult technique, all TAPP procedures were performed by one surgeon, whereas all 11 surgeons of the department performed the Lichtenstein procedure without any learning curve, which demonstrates the simplicity of the procedure. A higher recurrence rate was found for the TAPP procedure (8 vs 0), however the learning curve has to be considered. The Lichtenstein operation is easy to learn and perform, safe, efficient, cheaper (750 DM) and therefore superior to the TAPP procedure. A planned randomized study was cancelled; laparoscopic hernia repair is no longer carried out in our department.

Cost-effective endoscopic examination of the contralateral inguinal ring

OBJECTIVES

Laparoscopic examination of the contralateral inguinal ring has recently been advocated to exclude contralateral hernia in young children. We report a modification using nondisposable cystoscopic equipment, which is quick and reliable.

METHODS

Either an 8 or 10 F soft straight catheter or a cystoscope sheath is passed through the open hernia sac. Air is insufflated into the abdomen with a syringe. Once the pneumoperitoneum is completed, a 4-mm cystoscope lens (110 degrees) is used to inspect the contralateral ring.

RESULTS

Twenty-four children between the ages of 6 weeks and 4 years (median, 6 months) underwent exploration for presumed unilateral inguinal hernia and laparoscopic examination of the contralateral inguinal ring. Thirteen patients (54%) had an open processus vaginalis and underwent contralateral inguinal herniorrhaphy. No false-positive or false-negative results were found, and there were no complications associated with the procedure.

CONCLUSIONS

This method of laparoscopic examination of the contralateral inguinal ring using nondisposable cystoscopic equipment is rapid, safe, reliable, and cost effective in evaluating a contralateral patent processus vaginalis. Laparoscopic examination spares the need for formal surgical exploration in patients with a closed processus vaginalis.

The management of hernia. Considerations in cost effectiveness

Approximately 700,000 herniorrhaphies are performed annually in the United States for primary, recurrent, and bilateral inguinal hernias. This article describes the components of cost regarding the approach and management of groin hernias. The trends toward outpatient procedures, regional anesthetic agents, and early return to work are analyzed. The common types of repair are compared with reference to recurrence and complication rates. The advances and results of laparoscopic hernia are reviewed. In summary, a cost-effective approach for the management of inguinal hernias is presented that could reduce the yearly cost of hernia repair by hundreds of millions of dollars.

[Introduction of quality circles and a quality management system (QMS) in a centralized clinic]

At our hospital, a quality management system was developed according to the DIN EN ISO 9001. Additionally, several quality circles and an external quality control system with three tracer diagnoses were carried out and two studies were performed to detect the internal and external acceptance of the hospital. All strategies induce an increase in the quality of management and of the patients' outcome.

[Cost analysis of inguinal hernia surgery in ambulatory and inpatient management]

In Belgium 27,426 hernia repairs were performed in 1994 but only 1,451 (5.29%) were done on ambulatory basis, whereas in the U.S. over 50% of the yearly 600,000 hernia repairs are one day surgery procedures with interstate variation ranging from 6% to 89%. The mean treatment cost of inguinal hernia repair (doctors fees + hotel cost) was 53,704 BEF for inpatients vs. 30,510 BEF (general anesthesia) and 27,501 BEF (local anesthesia) for outpatients. Rates of complication and recurrence were not significantly different. This difference in total costs for hospital admission are determined by the mean length of stay and by the individual forfeitairy day price according to size of the hospital. Also the use of routine diagnostic procedures (clinical chemistry and medical imaging) - not necessarily essential for treatment - is higher at hospitalization. Even with 50% of all hernia repairs carried out in the one day clinic, total cost savings for treatment will hardly exceed 20% if the mean length of stay of the remaining inpatients will not decrease simultaneously. Supplementary and dramatic cost reductions however are possible by an earlier resumption of professional activities. The mean advised sick leave period of 4 weeks (+/- 2) still depends on irrelevant parameters as tradition, patients' preferences, job characteristics and type of insurance. Total costs for work incapacity add up to 2.5 billion BEF (vs. 1.4 billion BEF for total treatment costs) and can be cut by 50.18% via a mean 2 weeks earlier return to work. Since open primary hernia repair under local anesthesia can be easily carried out on outpatients resuming unrestricted daily activities in less than 1 week, the laparoscopic procedure with general anesthesia, higher treatment cost (endoscopic material) and still debated advantages in convalescence time and long-term outcome is not the gold standard for uncomplicated inguinal hernia.

Randomised controlled trial of laparoscopic versus open repair of inguinal hernia: early results

OBJECTIVE

To establish the safety, short term outcome, and theatre costs of transabdominal laparoscopic repair of inguinal hernia performed as day surgery.

DESIGN

Randomised controlled trial. The control operation was the two layer modified Maloney darn.

SETTING

Teaching hospital and district general hospital.

SUBJECTS

125 men randomised to laparoscopic or open repair of inguinal hernia.

OUTCOME MEASURES

Morbidity, postoperative pain and use of analgesics, quality of life, and theatre costs. Outcome was assessed by questionnaires administered to patients daily for 10 days and at six weeks postoperatively and by outpatient review at six weeks. Return to normal activity was assessed by questionnaire at three months.

RESULTS

One vascular complication (2%) occurred in the group that had open repair. Seven complications (12%) including vessel injury and early recurrence arose in the group that had laparoscopic repair (difference in complication rate 10% (95% confidence interval 4% to 18%; P = 0.02). Pain scores and quality of life assessed by the short form 36 showed a significant benefit to the group that had laparoscopic repair in the early postoperative period. Return to normal activity was not significantly different between the two groups. Total theatre costs were higher in the group that had laparoscopic repair (mean cost for laparoscopic repair 850 pounds (622 pounds to 1078 pounds); mean cost for open repair 268 pounds (245 pounds to 292 pounds)).

CONCLUSIONS

Because of the greater complication rate and higher theatre costs for laparoscopic repair and the patient outcome preferences expressed, the results of larger trials of clinical and cost effectiveness using recurrence as the primary outcome measure should be known before laparoscopic herniorrhaphy is widely adopted.

Laparoscopic versus open inguinal herniorrhaphy: preliminary results of a randomized controlled trial

BACKGROUND

Benefits of laparoscopic herniorrhaphy (LH) over open hernia repair (OH) remain unproved.

METHODS

Interim analysis of a prospective randomized controlled trial compared OH with LH where study outcomes were measured by third-party evaluators through patient interviews.

RESULTS

Both groups were well matched for all baseline parameters, although LH patients anticipated a quicker postoperative recovery than OH (p = 0.014). No significant difference was noted in operating time or surgeon operative satisfaction. The median duration of hospital stay was 1 day in both groups; LH patients made use of significantly less postoperative narcotics than OH (p = 0.02). No difference was observed in the durations of convalescence (LH, 9.6 +/- 7.6 days; OH, 10.9 +/- 7.4 days). Greater improvements in quality of life were exhibited in LH patients than OH patients 1 month after operation (p = 0.035), with one of the two measures used. A greater percentage of LH patients seemed "very satisfied with their operation" (p = 0.07). Complication rates were similar, and a single recurrence, in a patient in the OH group, has been observed after a median follow-up of 14 months.

CONCLUSIONS

Direct cost measurements showed LH to be 40% more expensive than OH in the context of a Canadian-type health care system. To date, benefits in postoperative pain and possibly quality of life have been detected in the LH group.

A prospective cost and outcome comparison of inguinal hernia repairs. Laparoscopic transabdominal preperitoneal versus open tension-free preperitoneal

We previously showed that patients undergoing transabdominal preperitoneal laparoscopic inguinal herniorrhaphy (TAPP) returned to activity twice as fast as open herniorrhaphy without mesh but that TAPP was twice as expensive. However, it was not clear if the immediate postoperative benefits offered by TAPP resulted from smaller incisions and less tissue dissection or from the requisite tension-free placement of mesh. We have therefore completed a prospective outcome and cost analysis comparing TAPP (n = 59) to open preperitoneal mesh herniorrhaphy (PPO) (n = 40) to determine the differences between the two different surgical techniques. When comparing unilateral repairs, there was no difference in hernia type. PPO patients were older (P < 0.05) and their operations were shorter (P < 0.01). Comparison of outcome parameters of pill days, out-of-house activity, and intial day to full activity revealed no difference. Cost analysis showed that total costs, disposable equipment costs, and operating room time costs were significantly less for PPO (P < 0.01). There were two major complications (3%) and twelve minor complications (20%) in the TAPP group while PPO exhibited no major and five minor complications (12%). Follow-up data revealed one recurrence in the TAPP group. There were no recurrences in the PPO group at only 7 months average follow-up. We conclude that since both procedures had similar outcomes in the immediate postoperative period, the increased cost of TAPP and increased potential for both major and minor complications make it difficult to justify its routine use.

[Unilateral inguinal hernia in infants: costs, risks and benefits of herniography? Results]

AIM

To assess the advantages of systématic herniography in cases of unilateral inguinal hernia in infants.

METHOD

Decision analysis presented in the first part of this article was used. A preliminary retrospective study of 348 cases as well as a literature review were utilized to determine the probabilities required in order to create and run the decision aid algorithm. Gonadic benefit was used as the health indicator.

RESULTS

For males, gonadic benefit procured by the herniography depends on the risk of strangulation in cases of groin hernia and on the frequency of testicular atrophy after inguinal hernioplasty. The evaluation of these two elements largely determines the choice of medical and surgical practices. For a 0.44% risk of post-operative testicular atrophy and a risk of strangulated hernia estimated at 20%, the cost-effectiveness ratio is FF, 199681 to save a testicle. One testicle is saved every 455 herniographies, with 24 possible post-examination complications. For female, herniography provides no gonadic benefit.

DISCUSSION

Decision analysis permits the quantification of results, leading to improved clinical judgement and facilitating the evaluation of medical practice.

[Unilateral inguinal hernia in infants: costs, risks and benefits of herniography? Methodology]

AIM

To assess the validity and the interest to health of systematic herniography in cases of unilateral inguinal hernia in children under two years of age.

METHOD

Decision theory was used to assess the effect of herniography on individual health by estimating gonadic benefit and establishing a benefit-risk ratio, and on collective health by the use of cost-effectiveness analysis.

RESULTS

a decision tree and algorithms were developed.

DISCUSSION

Decision analysis is used in complex medical decision making, clarifying choices and subdividing a problem into several more manageable sub-problems. The threshold approach pinpoints factors requiring more information.

Postoperative course after inguinal herniorrhaphy. A case-controlled comparison of patients receiving workers' compensation vs patients with commercial insurance

OBJECTIVE

To confirm our observation that patients with work-related hernias, when compared with self-employed patients, had longer recovery times and prolonged pain after hernia repairs, we reviewed our recent experience in a series of patients undergoing inguinal hernia repairs.

DESIGN

The study design was matched retrospective case-control. Each patient receiving workers' compensation was age and sex matched with a control patient with commercial insurance whose repair was done during the same year.

SETTING

All inguinal herniorrhaphies were performed at a single clinic by one of seven surgeons.

PATIENTS

Twenty-two consecutive patients receiving workers' compensation and 22 patients with commercial insurance were studied.

MAIN OUTCOME MEASURES

The postoperative courses in 22 consecutive patients with workers' compensation were compared with those in 22 control patients with commercial insurance. The principal factors compared were indications for surgery, type of hernia, surgical repair performed, the duration of postoperative pain, and the number of days off daily work.

RESULTS

The average age in both groups was 46 years. Hernias in the workers' compensation group were more frequently symptomatic. The duration of postoperative pain (mean +/- SE) was 111.0 +/- 42.2 days for patients with workers' compensation and 17.8 +/- 7.9 days for patients with commercial insurance (P < .05). The number of days off work (mean +/- SE) was 33.5 +/- 4.6 days for patients receiving workers' compensation and 12.6 +/- 2.3 days for patients with commercial insurance (P < .001).

CONCLUSIONS

We believe our results confirm the observation that type of insurance coverage influences post-operative recovery time after inguinal herniorrhaphy. Other studies measuring a patient's outcome after surgical procedures such as herniorrhaphy should include type of insurance coverage as a factor that might affect early return to work. Using multivariate analysis, the only variable independently affecting the duration of pain after hernia repair was the type of insurance coverage (P < .005).

A comparison of laparoscopic and open hernia repair as a day surgical procedure

To evaluate the merits of laparoscopic inguinal hernia repair (LHR) compared to conventional open hernia repair (OHR) a randomized study has been conducted. All patients were day surgical cases, of which 44 were randomized to a standardized OHR under local anesthetic (LA) and 42 to an LHR under general anesthesia (GA). Fifteen LHR patients had bilateral repairs. Operative time for OHR was 30.5 min, for unilateral LHR 35 min, and for bilateral LHR 60 min. OHR patients were discharged after a median of 134.5 min, which was significantly shorter than LHR patients, whose median discharge was 225 min (P < 0.01). Pain scores, activity levels, analgesia requirements, and time taken to return to work were not significantly different following surgery in either group (P < 0.05). There have been two recurrent hernias and one small bowel obstruction in the LHR group. We conclude that both repairs can be successfully performed as day surgical procedures. The added cost of LHR at this stage does not warrant its widespread use in unilateral hernia repairs. Which procedure is adopted should be individualized; however, patients with bilateral hernias on presentation can be successfully managed as day cases, obviating the need for hospitalization or two operations.

Laparoscopic or open inguinal herniorrhaphy? A randomized prospective trial

OBJECTIVE

To determine whether transabdominal preperitoneal laparoscopic hernia repair can equal or surpass an established open method at an acceptable cost.

DESIGN

A randomized, prospective comparison with a follow-up of 7 to 18 months (median, 10 months; planned, 5 years).

SETTING

Health maintenance organization hospital.

PATIENTS

One hundred patients between 20 and 70 years of age were randomized. No patient withdrew from the study after randomization.

INTERVENTIONS

Transabdominal preperitoneal laparoscopic and open tension-free repairs using a polypropylene mesh.

MAIN OUTCOME MEASURES

Operative and discharge times, costs, recovery, and morbidity. "Return to work" was supplemented by a performance assessment using a panel of exercises.

RESULTS

Operative and hospitalization times were not significantly different between the two types of repair. Patients with laparoscopic unilateral repairs returned to work faster (9 vs 17 days). At 1 week postoperatively, performance of straight-leg raises correlated well with time to return to work for patients with strenuous jobs. The laparoscopic repair was more expensive than the open approach ($3093 vs $2494).

CONCLUSIONS

Laparoscopic transabdominal preperitoneal hernia repair can be accomplished with operative and hospitalization times and a short-term recurrence rate similar to those of an established open technique. Perioperative exercise testing may be an important adjunct to return to work in the comparison of methods.

A prospective comparison of transabdominal preperitoneal laparoscopic hernia repair versus traditional open hernia repair in a university setting

In this study, laparoscopic transabdominal preperitoneal inguinal hernia repair and traditional open inguinal hernia repair were compared in relation to operative time, hospital stay, pain medication use, recovery time, complications, and costs. Elective hernia repairs, 126 in 106 patients, were prospectively followed from January 1991 through September 1993. Seventy-five procedures were performed by laparoscopy and 51 by traditional open approach. Time off work, pain medication use, surgical complications, and hospital stay were all significantly less (p < 0.001) with the laparoscopic approach. Patients in the laparoscopic group returned to work on average 5.5 weeks earlier than patients who underwent traditional herniorrhaphy. The difference in operative times was not statistically significant; however, the difference in the cost of the operations was. In conclusion, laparoscopic inguinal hernia repair offers significantly decreased postoperative pain, shorter hospital stays, faster return to work, fewer complications, and comparable operative times, but at an increased expense for the cost of laparoscopic instrumentation and technology.

[Ambulatory surgery--a sensible future perspective]

Increasing costs in health system, reduction of bed capacities and lack of nurses force to search for solution. To prove that day surgery may be a kind of solution, a pilot project was analysed during 8 months. This project was fully integrated in normal clinical management. Operated patients (n = 100; hernias, varicosis, proctological and other indications), preoperatively selected by specific criterias, and the family doctors were questioned retrospectively of their experiences. The results were very encouraging. Moreover we stated that day surgery is cost-covering. So day surgery is to consider as an important factor to cost-reduction.

Costs and outcomes of inpatient versus outpatient hernia repair

This study sought to compare treatment costs and outcomes for a large number of Medicare patients undergoing inpatient versus outpatient hernia repair around the country. Medicare physician and hospital claims were obtained for all Medicare enrollees residing in eleven states in 1987 and 1988, in order to take advantage of geographic variation in treatment location. All patients undergoing uncomplicated inguinal hernia repair were identified from the surgeon's bill; the location of surgery was then validated by the facility bill (n = 27,036). Over one-third of all hernia repairs in our sample were performed on an ambulatory basis, but with tremendous variation across states, ranging from 89.9% of cases in Washington in outpatient settings to almost none (6.3%) in Georgia. Treatment costs were 56% higher for hernias repaired on an inpatient basis, $2341 versus $1505 for those performed in outpatient settings. There were no detectable differences between inpatients and outpatients along such outcomes as complication rates, deaths and hernia recurrence, but readmission rates were higher for inpatients. The dramatic differences in costs, along with the apparent absence of adverse outcomes, suggests that Medicare should actively encourage surgeons to perform more hernia repairs on an outpatient basis.

[Bilateral exploration in unilateral inguinal hernia (cost-benefit)]

The authors performed simultaneous inguinal exploration of the right side on 100 girls operated on for the left sided inguinal hernia and hernial sac was found in 73 cases on the right asymptomatic side too. Though the simultaneous bilateral exploration has been proposed by several authors in the case of unilateral inguinal hernia of infants and children, the controversy continues among the pediatric surgeons in this respect at present too. The great number of the hernial sac found on the asymptomatic side according to the authors opinion must be enough to be agreeable with the routine bilateral exploration on girls. There has not been found any publication in the Hungarian literature about this topic.