Laparoscopic transperitoneal procedure for routine repair of groin hernia

Female gender is a risk factor for pain, discomfort, and fatigue after laparoscopic groin hernia repair

PURPOSE

Female gender is a risk factor for early pain after several specific surgical procedures but has not been studied in detail after laparoscopic groin hernia repair. The aim of this study was to compare early postoperative pain, discomfort, fatigue, and nausea and vomiting between genders undergoing laparoscopic groin hernia repair.

METHODS

Prospective consecutive enrollment of women and age-matched (± 1 year) and uni-/bilateral hernia-matched male patients undergoing elective transabdominal preperitoneal hernia repair (TAPP). Patients in the two groups received a similar anesthetic, surgical, and analgesic treatment protocol.

RESULTS

Between August 2009 and August 2010, 25 women and 25 men undergoing elective TAPP were prospectively included in the analysis (n = 50) with no significant difference between groups in psychological status regarding anxiety, depression, and catastrophizing. On day 0, women had significantly more pain during rest (p = 0.015) and coughing (p = 0.012), discomfort (p = 0.001), and fatigue (0.020) compared with men. Additionally, cumulative overall postoperative pain during coughing, discomfort, and fatigue on day 0-3 was significantly higher in women compared with men (all p values < 0.05). Women required significantly more opioids (p = 0.015) and had a significantly higher incidence of vomiting on days 0 and 1 (p = 0.002).

CONCLUSIONS

Women experienced more pain, discomfort, and fatigue compared with men after laparoscopic groin hernia repair.

TRIAL REGISTRATION

Registration number NCT00962338 ( www.clinicaltrials.gov ).

Early pain after laparoscopic inguinal hernia repair. A qualitative systematic review

BACKGROUND

Early post-operative pain after laparoscopic groin hernia repair may, as in other laparoscopic operations, have its own individual pain pattern and patient-related predictors of early pain. The purpose of this review was to characterise pain within the first post-operative week after transabdominal pre-peritoneal repair (TAPP) and total extraperitoneal repair (TEP), and to identify patient-related predictors of early pain.

METHODS

A qualitative systematic review was conducted. Pubmed, Embase, CINAHL, and the Cochrane database were searched for studies on early pain (first week) after TAPP or TEP.

RESULTS

We included 71 eligible studies with 14,023 patients. Post-operative pain is most severe on day 0 and mainly on a level of 13-58 mm on a visual analogue scale and decreases to low levels on day 3. There seems to be no difference in pain intensity and duration when TEP and TAPP are compared. Deep abdominal pain (i.e. groin pain/visceral pain) dominates over superficial pain (i.e. somatic pain) and shoulder pain (i.e. referred pain) after TAPP. Predictors of early pain are young age and pre-operative high pain response to experimental heat stimulation. Furthermore, evidence supported early pain intensity as a predictive risk factor of chronic pain after laparoscopic groin hernia repair.

CONCLUSION

Early pain within the first week after TAPP and TEP is most severe on the first post-operative day, and the pain pattern is dominated by deep abdominal pain. Early post-operative pain is most intense in younger patients and can be predicted by pre-operative high pain response to experimental heat stimulation.

[Training of residents in abdominal wall surgery in Spain]

The training of residents in abdominal wall surgery is a fundamental aspect of surgical training, representing globally 20% of its activity. In this paper, we analyze the current state of resident training in this kind of surgery in Spain, taking into account the broad spectrum it covers: general services, specific functional units, ambulatory surgery programs. To do this, based on the specifications of the specialty program, specific data were used from several different sources of direct information and a review of the results obtained by residents in hernia surgery. In general, our residents agree with their training and the recorded results are in line with objectives outlined in the program. However, it would be important to structure their teaching schedules, a rotation period in any specific unit and their involvement in outpatient surgery programs.

TAPP - Stuttgart technique and result of a large single center series

Laparoscopic hernioplasty is assessed as a difficult operation. Operative technique determines the frequency of complications, the time of recovery and the rate of recurrences. A proper technique is absolutely necessary to achieve results that are superior to open hernia surgery.

Pain characteristics after laparoscopic inguinal hernia repair

BACKGROUND

Previous studies have shown different pain characteristics in different types of laparoscopic operations, but pain pattern has not been studied in detail after laparoscopic inguinal hernia repair. To optimise preoperative patient information and postoperative analgesic treatment the present study investigated postoperative pain in terms of time course, pain intensity and individual pain components during the first 4 days after transabdominal preperitoneal hernia repair (TAPP).

METHODS

The study was a single-centre prospective trial including 50 consecutive male patients with primary or recurrent inguinal and/or femoral hernia undergoing elective repair. Several pain components (visceral pain, incisional pain and shoulder pain) were studied as well as pain at the three different trocar incisions. Pain was recorded before operation and on a daily basis during the first four postoperative days using a visual analogue and a verbal rating scale. We used 1 × 12 and 2 × 5 mm trocars for TAPP.

RESULTS

A total of 46 patients were available for analyses (age median 58 years, range 27-69 years). Visceral pain dominated significantly compared with incisional pain (P < 0.01), which again dominated over shoulder pain intensity and incidence (P < 0.01). Pain intensity did not significantly differ between different trocar incisions (5 and 12 mm) (P > 0.05). The overall pain intensity (a conglomerate of the different pain components) was most intense 3 h after TAPP and declined to preoperative levels on day 3 (P > 0.5).

CONCLUSION

Pain was most intense 3 h after the operation and declined to low levels within the first 3 days. Visceral pain was by far the dominating pain component compared with incisional and shoulder pain.

Lightweight mesh and noninvasive fixation: an effective concept for prevention of chronic pain with laparoscopic hernia repair (TAPP)

BACKGROUND

This prospective study aimed to evaluate the impact of transabdominal preperitoneal patch plasty (TAPP) with implantation of a lightweight mesh (<50 g/m²) fixed by fibrin glue on the occurrence of chronic pain and sexual dysfunction in hernia patients.

METHODS

Patients were examined before TAPP, early and late postoperatively. The primary end point of the study was pain-related functional impairment 6 months after the operation as assessed by the validated assessment scale (AAS). For the first time, patients without any pain before surgery were compared with patients experiencing preoperative pain. Furthermore, the patients were asked about the frequency and extent of impairment in their sexual activities. A secondary end point was chronic pain in relation to the type of mesh fixation (glue vs clip).

RESULTS

The study criteria was met by 276 patients. The dropout rate after 6 months was 2.9%. Mesh fixation was performed with glue for 212 patients and with clip for 64 patients. Chronic pain with significant impairment of daily activities was experienced by 42% of patients before the operation, which decreased to 8.3% after TAPP. The mean level of impairment, assessed by AAS, decreased from 11.2 preoperatively to 2 postoperatively (p < 0.001). The clip patients had more pain on days 4 and 7 postoperatively (p < 0.05) but not later. A majority of the patients (78%) experiencing pain before the operation were pain free 6 months after TAPP. New pain was seen in 7.4% of the patients but was only mild (numeric analog scale [NAS], 1-3; 78% of patients) or moderate (NAS, 4-6; 11% of patients). The only patient with severe pain (NAS, 8) had a clip fixation. Frequency of sexual dysfunction decreased after TAPP (p < 0.05).

CONCLUSION

The TAPP procedure with implantation of a lightweight mesh fixed by glue is a highly effective option for preventing chronic pain in inguinal hernia repair. Fibrin fixation seems superior to clip fixation during the early postoperative period. However, for confirmation of results, a randomized study is recommended.

Inguinal-scrotal hernias in young patients: is laparoscopic repair a possible answer? Preliminary results of a single-institution experience with a transabdominal preperitoneal approach

OBJECTIVES

The laparoscopic trans-abdominal preperitoneal (TAPP) approach to inguinal hernia repair is well documented as an excellent choice in numerous studies, especially when conducted by an experienced surgeon. Its full list of specific indications is still under debate. Generally, the repair of scrotal hernias demands a higher level of experience on the part of the surgeon, irrespective of the applied surgical technique. In this report, we evaluate our preliminary experience of TAPP laparoscopic repair for inguinoscrotal hernias in young patients in a Community Hospital setting, focusing on the feasibility of the technique and the incidence of complications.

MATERIALS AND METHODS

Between January 2008 and January 2009 a total of ten consecutive young patients at the "Civil Hospital" in Vittorio Veneto (TV), underwent TAPP laparoscopic repair of bilateral inguinoscrotal hernias.

RESULTS

The overall mean operative time was 65 (+/-15) min. All procedures were performed on a day surgery basis. There were no conversions to open repair, no mortality/morbidity or relapsing hernias. The mean follow-up was 14 (+/-2) months. No patients reported severe pain at 10 days, There were no reports of night pain at 30 days. All patients had a return to physical-work capacity within 14 days. All patients were completely satisfied at the 3-month follow up.

CONCLUSIONS

Analysis of the short-term post-operative outcomes of our experience enabled us to conclude that, in the proper setting, TAPP can be performed for inguinoscrotal hernia repair with an efficiency comparable to that of normal inguinal hernia repair.

Vypro II mesh for inguinal hernia repair: a meta analysis of randomized controlled trials

OBJECTIVE

The aim of this meta-analysis was to compare the effectiveness of Vypro II mesh and polypropylene mesh after inguinal hernia repair.

SUMMARY BACKGROUND DATA

The use of prosthetic meshes has become increasingly popular in inguinal hernia surgery. Previous randomized controlled trials (RCTs) showed the relative merits and risks between Vypro II mesh and standard polypropylene mesh. A meta-analysis was needed to estimate the real effectiveness.

METHODS

PubMed, the Cochrane library, EMBASE, SCI and Chinese Biomedical Literature Databases were used to search the published clinical randomized controlled trials about Vypro II mesh. Two independent reviewers assessed the trials for eligibility and quality, all the related data matching our standards were abstracted for Meta-analysis by RevMan 5.0.1. The evaluation criteria included recurrence, pain, urinary tract infection, seroma, the feeling of a foreign body, and testicular atrophy.

RESULT

A total of 2027 patients of 10 RCTs were included. Compared with polypropylene Mesh, Vypro II Mesh had no significant difference in recurrence (OR=1.53, 95% CI 0.73-3.19), pain (OR=0.87, 95% CI 0.55-1.37), urinary tract infection (OR=0.71, 95% CI 0.14-3.63), seroma (OR=0.80, 95% CI 0.26-2.48), and testicular atrophy (OR=1.94, 95% CI 0.58-6.49), but the feeling of a foreign body was significantly lower (OR=0.58, 95% CI 0.42-0.80).

CONCLUSION

Current evidence suggests that there is no significant difference between Vypro II and polypropylene mesh in short-term effectiveness. However, use of Vypro II mesh was associated with reduced feeling of a foreign body. Further high-quality, long follow-up period RCTs should be carried out to provide more reliable evidence.

Inguinal hernia repair in a community hospital setting--have attitudes changed because of laparoscopy? A review of a general surgeon's experience over the last 5 years

OBJECTIVES

The laparoscopic transabdominal preperitoneal (TAPP) approach for inguinal hernia repair is well documented in numerous studies as an excellent choice when performed by an experienced surgeon. In this report we wish to evaluate our experience of TAPP laparoscopic inguinal repair performed in a Community Hospital over the last 5 years, focusing on the feasibility of the technique and the incidence of complications when performed by general surgeons in this setting. We also wish to report and discuss how our attitudes concerning inguinal hernia repair have changed since we adopted the laparoscopic approach.

MATERIALS AND METHODS

Between January 2003 and January 2008 a total of 193 patients, at "Civil Hospital" in Vittorio Veneto (TV), underwent TAPP laparoscopic inguinal hernia repair. The total hernias repaired were 362.

RESULTS

The overall mean operative time was 45.58 min. (+/-15.2 min). All the procedures were performed in day surgery. There were no conversions to open repair or deaths in our series. We had 2 cases of small bowel occlusion and 5 relapsing hernias (1.3%), which we preferred to treat with an anterior approach. The mean follow-up was 30.4 (+/-5.6; range: 1 to 60 mo) months. No patients reported severe pain at 10 days, 7.2% (14 cases) reported mild pain at 3 months. There were no reports of night pain at 30 days. Approximately 90% of the patients had a return to physical-work capacity within 7 days, the remainder within 14 days. All patients were completely satisfied at 3 months.

CONCLUSIONS

The analysis of the short-term postoperative outcomes of our experience enabled us to conclude that in the proper setting TAPP is feasible, effective, safe, and beneficial for patients and should be a routine part of any surgical practice providing adequate training has been undertaken and proper preparation observed.

European Hernia Society guidelines on the treatment of inguinal hernia in adult patients

The European Hernia Society (EHS) is proud to present the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. They have been developed by a Working Group consisting of expert surgeons with representatives of 14 country members of the EHS. They are evidence-based and, when necessary, a consensus was reached among all members. The Guidelines have been reviewed by a Steering Committee. Before finalisation, feedback from different national hernia societies was obtained. The Appraisal of Guidelines for REsearch and Evaluation (AGREE) instrument was used by the Cochrane Association to validate the Guidelines. The Guidelines can be used to adjust local protocols, for training purposes and quality control. They will be revised in 2012 in order to keep them updated. In between revisions, it is the intention of the Working Group to provide every year, during the EHS annual congress, a short update of new high-level evidence (randomised controlled trials [RCTs] and meta-analyses). Developing guidelines leads to questions that remain to be answered by specific research. Therefore, we provide recommendations for further research that can be performed to raise the level of evidence concerning certain aspects of inguinal hernia treatment. In addition, a short summary, specifically for the general practitioner, is given. In order to increase the practical use of the Guidelines by consultants and residents, more details on the most important surgical techniques, local infiltration anaesthesia and a patient information sheet is provided. The most important challenge now will be the implementation of the Guidelines in daily surgical practice. This remains an important task for the EHS. The establishment of an EHS school for teaching inguinal hernia repair surgical techniques, including tips and tricks from experts to overcome the learning curve (especially in endoscopic repair), will be the next step. Working together on this project was a great learning experience, and it was worthwhile and fun. Cultural differences between members were easily overcome by educating each other, respecting different views and always coming back to the principles of evidence-based medicine. The members of the Working Group would like to thank the EHS board for their support and especially Ethicon for sponsoring the many meetings that were needed to finalise such an ambitious project.

Comparison of a new self-gripping mesh with other fixation methods for laparoscopic hernia repair in a rat model

BACKGROUND

Microhooks are small structures on the surface of the Progrip (PG; Sofradim Corp) mesh to ensure its anchorage in tissue. Additional fixation is not required. The aim of this animal study was to compare the strength of incorporation, foreign body reaction, and changes in material after implantation of this novel mesh with the current fixation alternatives, namely the hernia stapler (HS) and fibrin glue (FG).

STUDY DESIGN

Forty Sprague-Dawley rats were used in this two-phase, prospective randomized study. Polypropylene meshes (Parietene light; Sofradim Corp) were positioned bilaterally on the abdominal muscle. The randomized mesh fixation groups were named HS, FG, PG, and UM (unfixed mesh). Half of the rats in each group were sacrificed and analyzed 5 days after implantation, and the second half were sacrificed and analyzed after 2 months. Measured parameters were strength of incorporation, foreign-body reaction to, and potential degradation of, mesh and fixation systems.

RESULTS

After 5 days, strength of incorporation was substantially higher for PG (3.2 N/cm(2)) and HS (2.7 N/cm(2)) compared with FG (0.9 N/cm(2)) or UM (1.5 N/cm(2)). After 2 months, PG had a much greater strength of incorporation (14.8 N/cm(2)) compared with all other groups (HS 11.7 N/cm(2); FG 11.4 N/cm(2); UM 8.7 N/cm(2)). Inflammatory reactions were considerably more severe after 5 days than after 2 months. No significant differences in foreign-body reactions were found between groups. At neither time point were signs of degradation detected by scanning electron microscopy.

CONCLUSIONS

PG demonstrated a substantially stronger strength of incorporation in muscle tissue compared with other fixation systems and is an economic alternative to HS or FG. Laparoscopic mesh placement of PG requires some practice because of the microhooks. Clinical studies will have to be performed before the value of this mesh can be established for laparoscopic application.

Transabdominal preperitoneal laparoscopic approach for the treatment of sportsman's hernia

BACKGROUND

Groin pain in athletes presents a diagnostic and therapeutic challenge, particularly in distinguishing between those that will respond to nonoperative management and those that require surgery. Repair of sportsman's hernia, using the Modified Bassini darn or tension-free Lictenstein mesh technique, have been well described. The aim of this study was to assess the role of laparoscopy in the management of these hernias.

PATIENTS AND METHODS

Seventeen consecutive male patients (median age, 27 years), presenting with symptoms and signs of sportsman's hernia to a district general hospital were reviewed. Five patients presented with unilateral groin pain, whereas 12 had bilateral symptoms. All patients underwent a diagnostic laparoscopy, followed by transabdominal preperitoneal polypropelene mesh (15 x 10 cm) repair. All patients except 1 were discharged within 24 hours of surgery, and their rehabilitation was supervised by a single physiotherapist. All patients were assessed postoperatively by the authors and at a median follow-up of 23 weeks.

RESULTS

The laparoscopy confirmed posterior wall weakness in all patients with bilateral symptoms and in 4 of 5 patients with unilateral groin pain. Following repair, no surgical morbidity occurred and the median return to sporting activities was 42 days. All but 1 patient returned to the level of sport reached prior to injury, and mild pain was experienced in 5 groins, which did not interfere with either normal daily or sports activity.

CONCLUSION

The transabdominal preperitoneal laparoscopic approach is safe and feasible in the diagnosis and treatment of Sportsman's hernia, enabling a full return to sports activities.

Sixty-month follow-up after endoscopic inguinal hernia repair with three types of mesh: a prospective randomized trial

BACKGROUND

This prospective, clinical, randomized, double-blind study was intended to investigate the impact of the structure and the amount of polypropylene (PP) mesh used in laparoscopic transabdominal preperitoneal hernioplastic (TAPP) on physical function and life quality.

METHODS

180 male patients with primary inguinal hernia undergoing TAPP were randomized for using a heavyweight (108 g/m(2)), double-filament PP mesh (Prolene, 10 x 15 cm, group A, n = 60), a multifilament, heavyweight variant (116 g/m(2)) of PP mesh (Serapren, 10 x 15 cm, group B, n = 60), or a composite mesh (polyglactin and PP) (Vypro II, 10 x 15 cm, group C, n = 60). We compared in terms of complications (seromas, recurrence rate) and life quality (pain development, physical function). The development of life quality was documented according to the SF-36 Health Survey. The follow-up period was 60 months.

RESULTS

The recurrence rate (2.2% overall) during 60-month follow-up was not significantly different between the groups. Convalescence in group A was slower than in groups B and C: mean-term values of the visual scales for pain development were significantly (p < 0.05) higher, incapacity for work was 8.2 days longer, and urological adverse effects were stronger. The mean-term development of life quality was significantly lower in group A up to 12th week postoperatively. There were no significant differences between groups B and C. Beyond the 12th postinterventional week the differences diminished.

CONCLUSIONS

The composite mesh does not provide an advantage concerning physical function or pain development in comparison to the multifilament, heavyweight, pure polypropylene mesh. Independently of which mesh was implanted 5% of patients are still suffering from discomfort after 5 years.

Inguinal hernia repair

In excess of 100,000 inguinal hernia repairs are performed in the UK each year (Devlin & Kingsnorth 1998). It is the most commonly performed general surgical procedure and is routinely undertaken in patients receiving local anaesthesia in the day case setting. The Royal College of Surgeons has recommended that > 50% inguinal hernias are undertaken on day cases, although at present this figure is only 30% (RCSE 1993). This article defines hernias and describes the aetiology and surgical treatment of inguinal and femoral hernia. The differences between the traditional and laparoscopic repair of hernias are explored as well as the use of materials such as polypropylene mesh to enhance the repair. The need for thromboprophylaxis and antibiotic therapy are outlined together with patient discharge advice.

Experience of laparoscopic hernia repair in a laparoscopically oriented unit of a large community hospital

We describe a consecutive series of 258 laparoscopic inguinal hernia repairs in 189 patients from January 1997 to December 2004. Early results, complications, and follow-up were collected prospectively. Patients were followed in the outpatient clinic and contacted by phone at the time of this review. Three trocars were employed. The polypropylene mesh was inserted through the periumbilical trocar and fixed in the properitoneal space using titanium clips. There were no conversions and the mean operative time was 88 minutes (including bilateral cases). We had no major intraoperative accidents, and only 12 minor postoperative complications (4 urinary retentions, 6 seromas, and 2 cases of prolonged pain). Walking, hospital discharge, and return to activities were prompt, with a mean hospital stay of 1.7 days, and an average time of absence from work of 16 days. There have been 11 (4%) documented recurrences during long-term follow-up (mean, 62 months). The technique appears safe and efficacious even in a community hospital with a large laparoscopic experience.

Consolidated five-year experience with laparoscopic inguinal hernia repair

INTRODUCTION

After the introduction of laparoscopic hernia repair to the National Health Service (NHS), we studied the benefits and practicality of carrying out this specialised hernia repair technique in a District General NHS hospital.

METHODS

Patients with groin hernia were stratified into groups for day-surgery or inpatient care based on Trust guidelines. Patients underwent laparoscopic trans-abdominal pre-peritoneal (TAPP) inguinal hernia repair by a single consultant surgeon. Patients were followed-up in the clinic. All data were collected prospectively on a structured proforma. Postal questionnaire was sent to 100 randomly selected patients who had surgery more than two years ago and responses were evaluated.

RESULTS

A total of 830 hernias were operated upon in 572 patients, aged between 16 and 89 years. Three hundred and twelve patients had the operation as a day-case procedure, and the remaining 260 were treated as inpatients. Incidental hernias were discovered in 19.1% of patients, and were treated simultaneously.

CONCLUSION

The laparoscopic tension-free TAPP method of hernia repair, as done here, is cost-effective and efficacious. Most patients can be treated as day-cases. A low recurrence rate (0.36%) with low morbidity makes it an attractive method for routine treatment of groin hernias in the NHS.

The extended learning curve for laparoscopic fundoplication: a cohort analysis of 400 consecutive cases

Many studies have looked at the learning curve associated with laparoscopic Nissen fundoplication (LNF) in a given institution. This study looks at the learning curve of a single surgeon with a large cohort of patients over a 10-year period. Prospective data were collected on 400 patients undergoing laparoscopic fundoplication for over 10 years. The patients were grouped consecutively into cohorts of 50 patients. The operating time, the length of postoperative hospital stay, the conversion rate to open operation, the postoperative dilatation rate, and the reoperation rate were analyzed. Results showed that the mean length of operative time decreased from 143 min in the first 50 patients to 86 min in the last 50 patients. The mean postoperative length of hospital stay decreased from 3.7 days initially to 1.2 days latterly. There was a 14% conversion to open operation rate in the first cohort compared with a 2% rate in the last cohort. Fourteen percent of patients required reoperation in the first cohort and 6% in the last cohort. Sixteen percent required postoperative dilatation in the first cohort. None of the last 150 patients required dilatation. In conclusion, laparoscopic fundoplication is a safe and effective operation for patients with gastroesophageal reflux disease. New techniques and better instrumentation were introduced in the early era of LNF. The learning curve, however, continues well beyond the first 20 patients.

Recurrent inguinal hernia: randomized multicenter trial comparing laparoscopic and Lichtenstein repair

BACKGROUND

The optimal treatment for recurrent inguinal hernia is of concern due to the high frequency of recurrence.

METHODS

This randomized multicenter study compared the short- and long-term results for recurrent inguinal hernia repair by either the laparoscopic transabdominal preperitoneal patch (TAPP) procedure or the Lichtenstein technique.

RESULTS

A total of 147 patients underwent surgery (73 TAPP and 74 Lichtenstein). The operating time was 65 min (range, 23-165 min) for the TAPP group and 64 min (range, 25-135 min) for the Lichtenstein group. Patients who underwent TAPP reported significantly less postoperative pain and shorter sick leave (8 vs 16 days). The recurrence rate 5 years after surgery was 19% for the TAPP group and 18% for the Lichtenstein group.

CONCLUSION

The short-term advantage for patients who undergo the laparoscopic technique is less postoperative pain and shorter sick leave. In the long term, no differences were observed in the chronic pain or recurrence rate.

Laparoscopic vs conventional tension free inguinal herniorrhaphy: 2005 Society of American Gastrointestinal Endoscopic Surgeons (SAGES) annual meeting debate

This report summarizes the 2005 Society of American Gastrointestinal and Endoscopic Surgeons' inguinal herniorrhaphy debate. Most inguinal herniorrhaphies in the United States are performed using one of several prosthesis-based, tension-free (TFR) procedures. Approximately 15% of the procedures used are laparoscopic inguinal herniorrhaphies (LIH). Technical ease, lower cost, and local anesthesia are the major advantages attributed to TFR, whereas superior cosmesis, less perioperative pain, and a faster return to normal activity is attributed to LIH. The overall cost-benefit ratio, incidence of chronic pain syndromes, and relevance of a recent major trial could not be entirely settled in this debate. The importance of adequate training for surgeons undertaking LIH cannot be overemphasized. Experienced surgeons displaying equivalent results for LIH and TFR are justified in offering LIH to patients with primary unilateral inguinal hernias.

Comparison of biomaterials: three meshes and TAPP for inguinal hernia

BACKGROUND

In laparoscopic hernia repair the use of biocompatible materials is necessary. A prospective, double-blind study was projected to compare three different meshes.

METHODS

Ninety male patients with primary inguinal hernia undergoing transabdominal preperitoneal (TAPP) implant procedures were included. Three different types of mesh were tested: a monofile, heavy-weight, rigid mesh (group A), a smooth, heavy-weight variant of polypropylene (group B), and a polyglactin/polypropylene compound mesh (group C). Complications, pain development, inability to work, physical conditions, testicular volume, and blood circulation were documented.

RESULTS

Convalescence in group A was slower than in groups B and C: Postoperative values of visual scales for pain development were higher, inability to work was 7.3 days longer, urologic effects were more severe, activities of everyday life were more reduced, and data of the German SF-36 Health Survey Test showed a significant reduction of physical condition (p < 0.05).

CONCLUSION

The compound mesh did not create more comfort for the patients than the smooth variant of the heavy-weight polypropylene mesh.

Laparoscopic Inguinal Hernia Repair

As a consequence of the development of laparoscopic cholecystectomy in the late 1980s, diagnostic and therapeutic laparoscopy has now become an integral part of the average general surgeon's practice. Many conventional operations have been successfully adapted for the laparoscopic approach. A laparoscopic operation is unquestionably the surgical procedure of choice for gastroesophageal reflux disease and removal of the gallbladder, spleen, or adrenal gland unless specific contraindications are present. However, the value of laparoscopic techniques for other operations remains controversial within the surgical community. Laparoscopic inguinal herniorrhaphy (LIH) is a case in point. Frequent reanalysis of the controversial procedures such as laparoscopic herniorrhaphy is especially important because videoscopic operations remain in their developmental stages and thus continue to evolve. With this in mind, the purpose of this review was to examine the current state of the art of laparoscopic inguinal herniorrhaphy in relationship to its conventional counterparts.

Dynamic Self-Regulating Prosthesis (Protesi Autoregolantesi Dinamica): The Long-Term Results in the Treatment of Primary Inguinal Hernias

The dynamic self-regulating prosthesis (protesi autoregolantesi dinamica, PAD) is a double-layered prosthesi, in use since 1992 in inguinal hernia repair. In 1999, we published the short-term results on 500 patients and herein we report the long-term follow-up. Five hundred eighty-five PAD procedures were performed on 500 adult male, unselected patients. Hernias were unilateral in 415 patients, were bilateral in 85 patients, were direct in 197 patients (33.7%), were indirect in 269 patients (46.0%), and were combined in 119 patients (20.3%). Four hundred sixty-four patients were alive at the follow-up period of minimum 5 years, whereas 36 died (7.2%) of causes unrelated to the hernia. No information was available on 73 patients (14.6%). Therefore, the follow-up was consisted of 391 patients (78.2%) with 469 hernias. The recurrence and testicular atrophy rates were nil. Three patients (0.77%) presented chronic pain and 18 (4.6%) suffered persistent discomfort or paresthesia. A hydrocoele was observed in one patient (0.2%). The long-term data confirm the efficacy of the dynamic self-regulating posthesis hernioplasty. We propose it as a standard of care in all cases of primary inguinal hernia in adult males, retaining it as a definitive and comfortable solution.

Is there a risk of infertility after inguinal mesh repair? Experimental studies in the pig and the rabbit

The implantation of a non-absorbable polypropylene mesh during hernia repair causes chronic foreign body reaction involving the surrounding tissue. In case of inguinal hernia repair using mesh techniques, the spermatic cord is potentially affected by this chronic inflammatory tissue remodeling. This effect has been investigated using standardized animal models (pig and rabbit). Fifteen adult male pigs underwent transinguinal preperitoneal implantation of a polypropylene mesh. The contralateral side with a Shouldice repair served as control. After 7, 14, 21, 28, and 35 days, three animals were sacrificed. The spermatic cords were resected and analyzed histologically. In a second experiment Lichtenstein repair using the same polypropylene mesh and Shouldice repair on the contralateral side was done in eight chinchilla rabbits. Three animals served as controls. Three months after operation, the analysis included testicular size, testicular temperature, and testicular and spermatic cord perfusion. We added histological evaluation of the foreign body reaction and the spermatogenesis using the Johnsen score. In the pig, we observed a certain foreign body reaction with diffuse infiltrating inflammatory cells after mesh implantation. Venous thrombosis of the spermatic veins occurred in five of 15 cases. One animal presented focal fibrinoid necrosis of the deferent duct wall. The side of Shouldice repair showed only minor postoperative changes. In the rabbit, we also observed a typical foreign body reaction at the interface between mesh and surrounding tissue, which was not detectable after Shouldice repair. The mesh repair led to a decrease of arterial perfusion, testicular temperature, and the rate of seminiferus tubules with regular spermatogenesis classified as Johnsen 10 (Lichtenstein: 48.1%, Shouldice: 63.8%, controls: 65.8%). Testicular volume increased about 10% after each operation. The implantation of a polypropylene mesh in the inguinal region induces major response of the structures of the spermatic cord. This may have an influence also on spermatogenesis. Due to this a strict indication for implantation of a prosthetic mesh during inguinal hernia repair is recommended.

Prospective nationwide analysis of laparoscopic versus Lichtenstein repair of inguinal hernia

BACKGROUND

According to a Cochrane review, laparoscopic inguinal hernia repair compares favourably with open mesh repair, but few data exist from surgical practice outside departments with a special interest in hernia surgery. This study compared nationwide reoperation rates after laparoscopic and Lichtenstein repair, adjusting for factors predisposing to recurrence.

METHODS

Some 3606 consecutive laparoscopic repairs were compared with 39 537 Lichtenstein repairs that were prospectively recorded in a nationwide registry between 1998 and 2003. Patients were subgrouped according to type of hernia: primary or recurrent and unilateral or bilateral. Overall reoperation rates and 95 per cent confidence intervals were calculated. Long-term reoperation rates were estimated using the Kaplan-Meier method.

RESULTS

The overall reoperation rates after laparoscopic and Lichtenstein repair of unilateral primary indirect hernia (0 versus 1.0 per cent), primary direct hernia (1.1 versus 3.1 per cent), unilateral recurrent hernia (4.6 versus 4.8 per cent) and bilateral recurrent hernia (2.6 versus 7.6 per cent) did not differ. However, laparoscopic repair of a bilateral primary hernia was associated with a higher reoperation rate than Lichtenstein repair (4.8 versus 3.0 per cent) (P = 0.017).

CONCLUSION

Laparoscopic repair compared favourably with Lichtenstein repair for primary indirect and direct hernias, and unilateral and bilateral recurrent hernias, but was inferior for primary bilateral hernias.

Early Experience with Laparoscopic Inguinal Hernia Repair in a District General National Health Services Hospital

The introduction of laparoscopic hernia repair into the National Health Services (NHS) gave us an opportunity to study the feasibility and practicality of carrying out this modern hernia repair technique in a district general NHS hospital. The laparoscopic tension-free transabdominal preperitoneal (TAPP) method of hernia repair, as we do it, is cost-effective and efficacious. Most patients can be treated as day cases. We discovered incidental hernias in 18.8% of patients, which were treated simultaneously. A low recurrence rate (0.17%) with low morbidity makes it an attractive method for routine treatment of groin hernias in the NHS.

Laparoscopic totally extraperitoneal mesh repair for femoral hernia

BACKGROUND

The role of laparoscopic repair for femoral hernia has not been clearly defined, although the advantages of this technique for repair of inguinal hernia are well recognized.

AIM

The aim of this study was to assess the outcome of laparoscopic total extraperitoneal (TEP) repair of femoral hernia.

METHODS

Case records of patients who had laparoscopic TEP repair of femoral hernia between 1994 and 2002 were reviewed retrospectively. Patients' demographic details, presentation, operative details, and follow-up information were gathered from the clinical records. Postoperative complications, chronic pain, and recurrence of the hernia were assessed.

RESULTS

Fifteen patients, 10 males and 5 females, with a mean age of 55 years (range, 33-84 years) underwent laparoscopic TEP femoral hernia repair. Fourteen patients (93.3%) had a primary femoral hernia, and one had a recurrent femoral hernia. In 9 (60%) patients the hernia was irreducible but not obstructed. There were no postoperative complications or chronic pain. One patient (7%) with a small (11 x 6 cm) mesh developed an inguinal recurrence.

CONCLUSION

Laparoscopic TEP repair is a suitable technique for repair of femoral hernia, including irreducible but not obstructed femoral hernias.

Comparison of endoscopic techniques vs Shouldice and other open nonmesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials

BACKGROUND

We performed a scientific evaluation of the efficacy of different surgical techniques for inginual hernia repair and supported our findings by conducting a systematic review of randomized studies comparing endoscopic with open nonmesh suture techniques.

METHODS

After an extensive search of the literature, a total of 27 studies (41 publications) with evidence level lb were identified. These studies randomly compared endoscopic with open nonmesh suturing techniques. The quality of data sufficed to enable a quantitative meta-analysis of various parameters using the original software of the Cochrane Collaboration. Due to its superiority in comparison to other open nonmesh suturing techniques, the Shouldice repair technique was analyzed separately.

RESULTS

The systematic comparison of endoscopic techniques with the Shouldice repair showed that these techniques had significant advantages in terms of the following parameters: total morbidity, hematoma, nerve injury, and pain-associated parameters such as time to return to work, and chronic groin pain. The Shouldice operation has the advantages of a shorter operating time and a lower incidence of wound seroma. There was no difference regarding the incidence of major complications, wound infection, testicular atrophy, or hernia recurrence. Open non-Shouldice suturing techniques are associated with higher recurrence rates and more wound infections than endoscopic operations.

CONCLUSION

In comparison to open nonmesh suture repair techniques, endoscopic repair techniques have significant advantages in terms of pain-associated parameters. For the revaluation of long-term complications such as hernia recurrence and chronic groin pain, further clinical examination of the existing study collectives is needed.

Laparoscopic hernia repair?TAPP or/and TEP?

BACKGROUND

Of various endoscopic hernia repair procedures, TAPP and TEP have been selected for routine use.

METHODS

Results from Medline research were analysed.

RESULTS

There is a similar risk for postoperative morbidity for both techniques. The recurrence rate in large single-centre series is between 0% and 3.4%. There were numerous indications for both procedures, whereby a transperitoneal TAPP can also be applied in cases of previous preperitoneal operations.

CONCLUSION

Randomised trials comparing both methods of hernia repair are lacking. Seven non-randomised studies showed no differences in recurrence rate and morbidity. In general the learning curve for is shorter in favour of TAPP repair.