An evidence-based approach for laparoscopic inguinal hernia repair: lessons learned from over 1,000 repairs

The Efficacy and Safety of Parecoxib Multimodal Preemptive Analgesia in Artificial Joint Replacement: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Postoperative pain after artificial joint replacement is intense and remains an unsolved problem. Some studies have shown that parecoxib can provide better analgesia in postoperative multimodal analgesia, however, doubts arise about whether its multimodal preemptive analgesia can reduce postoperative pain.

OBJECTIVES

The purpose of this systematic review and meta-analysis was to evaluate the impact of preoperative injection of parecoxib on postoperative pain in patients undergoing artificial joint replacement.

STUDY DESIGN

Systematic review and meta-analysis.

SETTING

Embase, PubMed, Cochrane Library, CNKI, VIP, Wangfang databases were searched to identify relevant randomized controlled trials. The last search was in May 2022.

METHODS

Randomized controlled trials of efficacy and adverse reactions of intra-operative and postoperative injection of parecoxib in artificial joint replacement were collected. The primary outcome was postoperative visual analog scale scores and the secondary outcomes included cumulative postoperative opioid consumption and incidence of adverse reactions. Using the Cochrane systematic review method to screen the studies, evaluate the quality of the included studies, and extract feature information, RevMan 5.4 software performs a meta-analysis of the corresponding research indicators.

RESULTS

In total, nine studies were involved in the meta-analysis with 667 patients. The trial and control group were given the same dose of parecoxib or placebo at the same time point before and after surgery. The results showed that compared with the control group, the trial group is associated with substantially reduced visual analog scale scores in 24, 48 h at rest (P < 0.05), visual analog scale scores in 24, 48, 72 h at movement (P < 0.05), dose of opioid need in trial group is notably lower than that in control group (P < 0.05), but shows no obvious effect on visual analog scale scores in 72 h at rest, and adverse events (P > 0.05).

LIMITATIONS

The major limitation of this meta-analysis relates to some low-quality studies.

CONCLUSIONS

Our results support parecoxib multimodal preemptive analgesia in reducing postoperative acute pain in hip and knee replacement patients, and reduces cumulative opioid consumption without increasing the risk of adverse drug events. Its multimodal preemptive analgesia is safe and effective in hip and knee replacement.

PROSPERO REGISTRATION

CRD42022379672.

Laparoscopic total extraperitoneal inguinal hernia repair: Retrospective study on prosthetic materials, postoperative management, and quality of life

Laparoscopic inguinal hernia repair is one of the most frequently performed operations. However, the search for the most appropriate prosthetic materials continues to occupy the surgical community. The purpose of this study was to evaluate the postoperative short- and mid-term effects (like duration of stay, number and type of complications, and inguinal pain) of laparoscopic inguinal hernia repair using the total extraperitoneal (TEP) approach. The evaluation encompassed different types of mesh and fixation devices, as well as medications prescribed during hospitalization.This retrospective study was conducted at the General, Laparoendoscopic, Bariatric, and Robotic Surgical Clinic of the Athens Medical Center. Clinical data from 524 patients were evaluated. The answers from an appropriately designed questionnaire completed from each individual were used to obtain information about their postoperative course. The statistical analysis was implemented in SPSS v 23.Analysis revealed that pain sensation on discharge decreased with increasing age (P < .05). No clear relationship was found between surgical clips and pain (P = .292), as well as mesh absorbability and chronic pain (P = .539). The major postoperative complications were annoyance and discomfort (15.9%). The recurrence rate was 1.7%.Postoperative complications following the TEP approach were mostly found to be minor; chronic pain, as an aspect of impaired quality of life, was not experienced in the majority (89.08%). The properties of prosthetic materials used and the type of medications prescribed were not found to exert a significant role in satisfactory postoperative outcomes.

Comparison of peritoneal closure versus non-closure in laparoscopic trans-abdominal preperitoneal inguinal hernia repair with coated mesh

BACKGROUND

Peritoneal closure during laparoscopic trans-abdominal preperitoneal (TAPP) inguinal hernia repair has been the standard of care to prevent bowel obstruction due to adhesions generated by contact with mesh. However, with newer coated meshes, leaving the peritoneal layer open may be safe. While many studies compare methods of peritoneal flap closure, there is a deficit of literature reporting the outcomes of non-closure.

METHODS

A retrospective comparison of peritoneal flap closure versus non-closure during primary laparoscopic TAPP inguinal hernia repair with coated mesh was performed for all patients at Baystate Medical Center meeting inclusion criteria between January 2005 and August 2016. Primary outcome was any procedure-related adverse outcome following repair. Secondary outcomes included operative time, resolution of pre-operative pain and/or gastrointestinal symptoms, and hernia recurrence.

RESULTS

Of 231 patients, 55 (24%) underwent peritoneal flap closure and 176 (76%) underwent non-closure. Demographic, comorbidity, and hernia characteristics were comparable between groups with the exception of obesity (p = 0.01), current smoking status (p = 0.05) and hernia side [p = 0.04 (left), 0.0003 (right)]. Mean operative time was higher in the closure group than non-closure (98.1 ± 37.1 min vs. 76.8 ± 32.9, p < 0.0001). No cases were converted to open. Average follow-up was 21.6 ± 23.8 months. Ninety-three percent of closure patients had documented resolution of pre-operative pain versus 94.0% of non-closure (p = 0.81). The closure group experienced a higher percentage of post-operative complications, though this did not reach significance (5.5 vs. 2.3%; p = 0.36). Compared to the closure group, the non-closure groups experienced similar post-operative pain (3.6 vs. 1.2%; p = 0.24) and recurrence rate (1.8 vs. 4.0%; p = 0.68). There were no bowel obstructions, surgical site infections, unplanned readmissions, or unplanned re-operations.

CONCLUSIONS

Equivalent patient outcomes were seen for both procedure types post-operatively and during follow-up. Operative times were significantly shorter for non-closure patients. Larger study population and longer follow-up is necessary to evaluate true long-term complication rates in flap non-closure.

Tacks, staples, or suture: method of peritoneal closure in laparoscopic transabdominal preperitoneal inguinal hernia repair effects early quality of life

INTRODUCTION

TAPP inguinal hernia repair (IHR) entails the development of a peritoneal flap (PF) in order to reduce the hernia sac and create a preperitoneal space in which to place mesh. Many methods for closure of the PF exist including sutures, tacks, and staples. We hypothesized that patients who had PF closure with suture would have better short-term QOL outcomes.

METHODS AND PROCEDURES

A prospective institutional hernia-specific database was queried for all adult, TAPP IHRs from July 2012 to August 2013. Unilateral and bilateral patients were included and each hernia was analyzed separately. The main outcome of interest was quality of life (QOL) at two- and four-week follow-up, as measured by the Carolinas Comfort Scale.

RESULTS

There were 227 patients who underwent TAPP, with 99 bilateral and 128 unilateral IHR, for a total of 326 IHR. PF closure was performed using tacks in 45.1%, suture in 19.0%, and staples in 35.9%. Patient characteristics were statistically similar between the tack, suture, and staple group. There were 32.9% direct, 46.5% indirect, and 20.6% pantaloon hernias, which were not significantly different when compared by PF closure method. Post-operative complications and length of stay were same for the three groups. There were no hernia recurrences. Post-operative activity limitation at two weeks was significantly better in the suture group when compared to the stapled group (p = 0.005). Additionally, sutured PF closure had less early post-operative pain when compared to the tack group (p = 0.038).

CONCLUSIONS

Following TAPP IHR, suture closure of the PF significantly improves 2-week post-operative movement limitation compared to stapled and tacked PF closure. Continued randomized studies are needed to determine the best surgical hernia repair methods for ideal post-op QOL.

Laparoscopic transabdominal inguinal hernia repair in community hospital settings: a general surgeon's last 10 years experience

Numerous studies have documented the laparoscopic TransAbdominal Pre-Peritoneal (TAPP) approach as an excellent choice for inguinal hernia repair, especially with an experienced surgeon. A cohort population of patients who underwent TAPP laparoscopic surgery for inguinal hernias over the last 10 years, with follow-up, were evaluated, focusing on the feasibility, safety and benefits of this procedure in a community hospital setting.

MATERIALS AND METHODS

A total of 533 patients underwent TAPP for inguinal hernias between January 2003 and March 2013 in two community hospitals in the Northeast of Italy-"Civil Hospital" in Vittorio Veneto (TV) and "Civil Hospital" in Adria (RO).

RESULTS

The total number of hernias treated was 1,000. The overall mean operative time was 43.50 min (±13.2). All but three of the procedures were done on a day surgery basis. There were no conversions to open repair or deaths in our series. We had two cases of small bowel obstruction and eight relapses (0.8 %) in our series. The mean follow-up was 59.4 months (±5.6; range 3-120). No patients reported severe pain at 10 days, 21 patients (3.9 %) reported mild pain at 3-month follow-up. Over 90 % of the patients had a return of physical work capacity within 2 weeks, the remaining within 30 days. All patients were completely satisfied (numerical rating scale 10/10) 3 months after the operation.

CONCLUSIONS

The analysis of the short- and long-term post-operative outcomes of our experience enabled us to conclude that in an appropriate setting, TAPP is feasible, effective, safe and beneficial for patients. It should be incorporated into general surgeons' expertise and selectively used for the management of patients with hernias, as long as adequate training is obtained and appropriate preparation performed.

Clinical considerations, management and treatment of fever of unknown origin caused by urachal cyst: a case report

Introduction

Urachal cysts are rare congenital anomalies that often prompt referral to the paediatric general surgeon because of their associated complications such as infection, abdominal pain and the young age at presentation. In this report we describe a rare case of fever of unknown origin caused by an urachal cyst which was successfully treated with incision and drainage only. Since the first description of urachal anomalies by Cabriolus in 1550, few cases have been reported and, until now, only one case of infected urachal cyst presenting as fever of unknown origin has been described in the literature. Moreover, the spontaneous resolution of an urachal cyst without excision is extremely rare.

Case presentation

We report our experience in the management and treatment of an infected urachal cyst that occurred in a 12-year-old Caucasian girl who presented to our Department of Paediatric Surgery with a 30-day history of evening fever. The urachal cyst was treated only with incision and drainage through a minimally invasive laparoscopic approach.

Conclusions

The incision and drainage of an infected urachal cyst is a simple and safe procedure. It assures a complete recovery and avoids potential surgical complications related to the total excision of the urachal cyst. This report may provide important clues regarding the management of this rare anomaly and we emphasise the importance for paediatricians, who should consider the possibility that a fever of unknown origin can be caused by an urachal cyst, and for surgeons and urologists, because it suggests that conservative treatment of this rare anomaly should be considered when possible.

Laparoscopic versus open inguinal hernia repair

The laparoscopic approach to inguinal hernia surgery is safe and reliable. It has a similar recurrence rate as open tension-free mesh repair. Because the laparoscopic approach has less chronic postoperative pain and numbness, fast return to normal activities, and decreased incidence of wound infection and hematoma, it should be considered an appropriate approach for inguinal hernia surgery. These results can be achieved if a surgeon is proficient in the technique, has a clear understanding of the anatomy, and performs it on a regular basis. This article focuses on questions related to laparoscopic inguinal hernia surgery and provides answers based on published literature.