Incidence of complications following laparoscopic hernioplasty

Development and preliminary validation of a new task-based objective procedure-specific assessment of inguinal hernia repair procedural safety

BACKGROUND

Surgical videos coupled with structured assessments enable surgical training programs to provide independent competency evaluations and align with the American Board of Surgery's entrustable professional activities initiative. Existing assessment instruments for minimally invasive inguinal hernia repair (IHR) have limitations with regards to reliability, validity, and usability. A cross-sectional study of six surgeons using a novel objective, procedure-specific, 8-item competency assessment for minimally invasive inguinal hernia repair (IHR-OPSA) was performed to assess inter-rater reliability using a "safe" vs. "unsafe" scoring rubric.

METHODS

The IHR-OPSA was developed by three expert IHR surgeons, field tested with five IHR surgeons, and revised based upon feedback. The final instrument included: (1) incision/port placement; (2) dissection of peritoneal flap (TAPP) or dissection of peritoneal flap (TEP); (3) exposure; (4) reducing the sac; (5) full dissection of the myopectineal orifice; (6) mesh insertion; (7) mesh fixation; and (8) operation flow. The IHR-OPSA was applied by six expert IHR surgeons to 20 IHR surgical videos selected to include a spectrum of hernia procedures (15 laparoscopic, 5 robotic), anatomy (14 indirect, 5 direct, 1 femoral), and Global Case Difficulty (easy, average, hard). Inter-rater reliability was assessed against Gwet's AC2.

RESULTS

The IHR-OPSA inter-rater reliability was good to excellent, ranging from 0.65 to 0.97 across the eight items. Assessments of robotic procedures had higher reliability with near perfect agreement for 7 of 8 items. In general, assessments of easier cases had higher levels of agreement than harder cases.

CONCLUSIONS

A novel 8-item minimally invasive IHR assessment tool was developed and tested for inter-rater reliability using a "safe" vs. "unsafe" rating system with promising results. To promote instrument validity the IHR-OPSA was designed and evaluated within the context of intended use with iterative engagement with experts and testing of constructs against real-world operative videos.

The effect of mesh fixation on migration and postoperative pain in laparoscopic TEP repair: prospective randomized double-blinded controlled study

PURPOSE

The development of chronic pain is one of the major post-surgery problems after inguinal hernia repair. Although the possibility of chronic pain formation decreases with laparoscopic methods, pain may develop due to the staples used. It is thought that absence of mesh fixation in total extra-peritoneal (TEP) repair does not increase the recurrence rate. This study aims to investigate the absence of mesh fixation in the TEP on the development of postoperative pain, mesh displacement, and recurrence rate.

METHODS

Between December 2019 and December 2020, 100 patients who underwent TEP repair due to unilateral inguinal hernia in the General Surgery Clinic of Hitit University were included in the study. Study was registered at http://Clinicaltrials.gov (NCT05152654). Patients were divided into two groups as repairs in which the mesh was fixed with a tacker and no-fixation (NF) was used. The mesh is marked with radiopaque clips. Patients were compared in terms of postoperative pain, mobilization time, hospital stay, return to work, chronic pain, early-late mesh displacement, and recurrence.

RESULTS

While there was no significant difference between the groups in terms of mesh displacement and recurrence, it was observed that the NF group developed significantly less pain in the early and late postoperative period compared to the other group. The time-dependent reduction rate of postoperative pain was higher in NF group than in other group. In addition, operation time was shorter in the NF group.

CONCLUSION

While the absence of mesh fixation in TEP hernia repair does not increase the recurrence rate, it can be used safely, because it causes less acute and chronic pain.

TRAIL REGISTRATION

Clinicaltrials number: NCT05152654.

Laparoscopic relief of reduction en-masse in an inguinal hernia: A case report

Introduction and importance

Reduction en-masse is an extremely rare condition that usually develops in prolonged hernias. Spontaneous or iatrogenic reduction of this type of hernia may lead to disastrous consequences such as obstruction, gangrene, or peritonitis. According to the reports so far, surgical management is the only choice for this condition.

Presentation of case

In this paper, we report a 48-year-old man who presented with vague abdominal pain and a history of inguinal hernia for years and had reduced his hernia five days earlier. Computed tomography (CT) and ultrasonography confirmed the diagnosis, and the patient was taken to the operating room to relieve the bowel loop utilizing laparoscopy.

Conclusion

Laparoscopic relief could be an effective tool in diagnosis and surgery of reduction en-masse. Transabdominal preperitoneal repair is the best choice due to its capability to explore the intraabdominal organs and its low risk of recurrence.

•

Reduction en-masse of inguinal hernia is a rare entity in which has been reported about 200 cases so far.

•

We reported a 48-year-old case of reduction en-masse hernia who operated by laparoscopy.

•

Laparoscopy can be a strong diagnostic and therapeutic tool in the management of reduction en-masse hernia

•

Transabdominal preperitoneal repair is the best choice due to its capability to explore the abdominal cavity.

Surgical Procedures and Results of Modified Intraperitoneal Onlay Mesh Repair for Inguinal Hernia After Radical Prostatectomy

Background: Although inguinal hernia occurs frequently after radical prostatectomy, transabdominal preperitoneal (TAPP) inguinal hernia repair occasionally poses challenges due to fibrosis of the preperitoneal cavity. In patients with severe intrapelvic fibrosis, we have adopted a modified intraperitoneal onlay mesh (IPOM) technique. The surgical factors were compared between patients who underwent modified IPOM and those who underwent TAPP for inguinal hernia repair. Materials and Methods: In total, 57 patients underwent laparoscopic surgery for inguinal hernias after radical prostatectomy between February 2013 and January 2020. TAPP was successfully completed in 44 patients, whereas 13 patients underwent modified IPOM converted from TAPP. The surgical results were retrospectively compared. Results: The median follow-up duration was 36.0 months (range, 1-84 months). Intraoperative complications, recurrence of hernia, and chronic pain were not observed in both groups. The average duration of surgery in the modified IPOM group was longer than that in the TAPP group (137 versus 107 minutes, P < .05). There was no significant difference in the incidence of the inguinal-related complications such as inguinal pain or inguinal swelling. Conclusions: Postoperative complications including recurrence of hernia after modified IPOM are comparable to those after TAPP hernia repair. Modified IPOM repair is a surgical option for repairing inguinal hernias following radical prostatectomy.

Mesh fixation using novel bio-adhesive coating compared to tack fixation for IPOM hernia repair: in vivo evaluation in a porcine model

BACKGROUND

Mesh fixation in hernia repair is currently based on penetrating sutures or anchors, with proven early and late complications such as pain, adhesions, erosions, and anchor migration. In an attempt to reduce these complications, a bio-adhesive-based self-fixation system was developed. The purpose of this study was to assess the performance and safety of this novel self-adhesive mesh (LifeMesh™) by comparing it with standard tack fixation.

METHODS

A full-thickness abdominal wall defect was created bilaterally in 24 pigs. The defects were measured 14 days later, and laparoscopic intraperitoneal onlay mesh (IPOM) repairs were performed. In each animal, both LifeMesh and a titanium tack-fixed control, either uncoated polypropylene mesh (PP) or composite mesh (Symbotex™), were used. After 28 and 90 days, we performed macroscopic evaluation and analyzed the fixation strength, shrinkage, adhesion scores, and histopathology in all samples.

RESULTS

Measurements at both time points revealed that LifeMesh had fully conformed to the abdominal wall, and that its fixation strength was superior to that of the tack-fixated Symbotex and comparable to that of the tack-fixated PP. Shrinkage in all groups was similar. Adhesion scores with LifeMesh were lower than with PP and comparable with Symbotex at both time points. Histology demonstrated similar tissue responses in LifeMesh and Symbotex. Lack of necrosis, mineralization, or exuberant inflammatory reaction in all three groups pointed to their good progressive integration of the mesh to the abdominal wall. By 28 days the bio-adhesive layer in LifeMesh was substantially degraded, allowing a gradual tissue ingrowth that became the main fixation mode of this mesh to the abdominal wall.

CONCLUSIONS

The excellent incorporation of LifeMesh to the abdominal wall and its superior fixation strength, together with its low adhesion score, suggest that LifeMesh may become a preferred alternative for abdominal wall repair.

Applications of Fibrin Sealant in Surgery

Fibrin sealant has been used with increasing frequency in a variety of surgical field for its unique hemostatic and adhesive abilities. Fibrin sealant mimics the last step of the coagulation cascade and takes place independently of the patient's coagulation status. With rapid advances in minimally invasive surgery, the potential uses for this type of biologic and synthetic material are expanding exponentially. This article reviews the data associated with the application of fibrin sealant in various surgical procedures. From reinforcing gastrointestinal anastomosis to repair perforated duodenal ulcers to mesh fixation in laparoscopic inguinal hernia repair, fibrin sealant is gaining increasing acceptance among surgeons. The applications of fibrin sealant are expanding, and new preparations of fibrin sealant are currently being evaluated.

The learning curve for laparoscopic inguinal hernia repair: a newly qualified surgeon perspective

BACKGROUND

The number of cases required to overcome the learning curve (LC) for laparoscopic extra-peritoneal inguinal hernia repair (TEP) varies widely in the literature. Less is known about the LC for inexperienced surgeons performing this procedure early in their career. The present study describes the technical challenges of TEP repair and the LC from the perspective of a recently qualified general surgeon.

MATERIALS AND METHODS

Retrospective analysis of a single-surgeon experience of TEP repairs performed during the first 2 y of practice from 2011-2013. Patient demographics, hernia details, operative details, and postoperative outcome were all assessed. The CUSUM method was used to analyze the LC for operative time.

RESULTS

There were 149 consecutive patients (mean age, 56 ± 17, 146 males, 24 bilateral, BMI 26 ± 4) followed for a median of 15 (4-26) mo. Direct herniae accounted for 61% of the cohort, and 16% were recurrent open presentations. The major complication and recurrence rate were <2%, and minor complications including urinary retention (15%) were reported. Re-admission rate was 6%. CUSUM analysis suggested an inflection point at 18 cases after which operative times were stabilized.

CONCLUSIONS

For less experienced surgeons, standard surgical training provides for TEP hernia repair with satisfactory major complication, conversion, and recurrence rates. Minor complication rates can still be reduced further with further training and supervision from experienced peers.

Comparison of the Clinical Outcome and Complications in Laparoscopic Hernia Repair of Inguinal Hernia With Mesh Fixation Using Fibrin Glue vs Tacker

Although laparoscopic repair offers a quick and less morbid way of treating hernias, complications like hematoma, seroma, neuralgia, recurrence, mesh infection, hydrocele, etc. are known. The present study was undertaken to compare various clinical outcomes between mesh fixation using fibrin glue and mesh fixation with tacker in a 3-months follow-up. One hundred patients aged 18 to 60 years having inguinal hernia admitted in Poona Hospital and Research Centre, Pune, between October 2012 and November 2014 for laparoscopic hernia surgery and ready to participate in this study were included. All of them underwent laparoscopic repair of hernia by total extra peritoneal (TEP) method following sample surgical protocol in all of them except for method of mesh fixation. Mean time calculated from insertion of the first trocar to beginning of skin suturing was 54.9 min in tacker group and 50.3 min in fibrin glue group with no statistically significant difference between the two. The incidence of urinary retention was significantly higher in tacker (34 %) as compared to fibrin glue (12 %) group. Incidence of hematoma was significantly higher in tacker group in 15-day follow-up, but there was no significant difference in hematoma formation at hernial sites in both groups after 15 days of follow-up. The incidence of neuralgia was significantly higher in the tacker group (24 %) compared with the fibrin glue group (2 %). Significantly, more number of people in the fibrin glue group 68 and 90 %, respectively, returned to work during 15 and 30 days follow-up as compared to the tacker group 46 and 64 %. Fibrin glue can be considered as an alternative to tacker for mesh fixation.

Is laparoscopic treatment of incisional and recurrent hernias associated with an increased risk for complications?

INTRODUCTION

Hernias of the ventral abdominal wall can be treated with an intraperitoneal onlay mesh (IPOM). The aim of this cohort study was to analyze the complications and recurrence rates after laparoscopic ventral hernia repair focusing especially on incisional and recurrent hernias.

METHODS

The study population comprised 149 patients with a hernia of the abdominal wall, which was treated with an IPOM between January 2006 and January 2011.

RESULTS

Fifty-one patients had a primary hernia (group I) and 98 patients had preceding abdominal surgery (group II). In group II 64 patients had an incisional hernia and 34 patients had a recurrent hernia. The median body mass index was 30.3 kg/m(2) (14.8-69.1) without any significance in sub-group comparison. The mean duration of surgery and the length of stay were significantly longer in group II (p < 0.05). The overall rate of minor complications was 18.1%. There were significantly more minor complications in group II (7.8% vs. 23.5%, p = 0.02). Notably, there were also significantly more major complications in group II (14.3% vs. 2.0%; p = 0.02). The recurrence rate was significantly higher in group II (group I: 3.9% vs. group II: 16.3%, p < 0.05). There were no early recurrences in group I, but 5 early recurrences in group II.

CONCLUSION

Laparoscopic treatment of complex hernias as incisional hernias, recurrent hernias and hernias with interenteric and enteroperitoneal adhesions is associated with high rates of minor and major complications. A high level of expertise of the surgeon and the camera-guiding assistant is therefore needed.

Modified laparoscopic intraperitoneal onlay mesh in complicated inguinal hernia surgery

PURPOSE

To analyse the recurrence rate and postoperative complications in inguinal hernia patients where the laparoscopic intraperitoneal onlay mesh technique (IPOM) was used due to preperitoneal fibrosis.

METHODS

Patients who had undergone inguinal herniotomy with the IPOM technique at Horsens Regional Hospital during the calender years of 2004 through 2010 filled out a questionnaire specific for recurrence and postoperative complications and had a clinical examination. Furthermore the medical records and national databases were analysed for reoperations for recurrent hernias.

RESULTS

37 patients (38 hernias) were operated. Two patients had a recurrent hernia (5 %), four patients (11 %) reported chronic pain and six patients (16 %) reported various bowel symptoms after the operation.

CONCLUSIONS

The optimal treatment of these relatively rare and complicated patients is still an issue of debate, but in the light of the present study it seems that the IPOM technique is equal to or has a better profile compared to Lichtenstein in terms of re-recurrence and chronic pain. We believe that the IPOM technique has a place in the treatment of these patients.

Role of orchiectomy in severe testicular pain after inguinal hernia surgery: audit of the Finnish Patient Insurance Centre

PURPOSE

Testicular ischemia and necrosis are uncommon complications after inguinal hernioplasty. Our aim was to evaluate the incidence of severe urological complications related to adult inguinal hernia surgery in Finland with special reference to orchiectomy in relieving intractable chronic testicular pain.

METHODS

All urological complications related to inguinal hernia surgery during 2003-2010 were analysed from the Finnish Patient Insurance Centre. The patients with intractable chronic scrotal or testicular pain that resulted in orchiectomy were re-evaluated after a median follow-up of 7 years (range 2-15 years). The operative factors related to chronic testicular pain and atrophy were analysed using multiple regression analysis.

RESULTS

Altogether 62 urological complications (from 335 litigations) were recorded from 92,000 inguinal hernia operations. The distribution of claimed urological complications consisted of 34 testicular injuries, ten bladder perforations, seven massive scrotal haemorrhage or 11 miscellaneous injuries. Seventeen atrophic testes were left in situ and 17 (six early < 7 days, 11 late > 8 days) orchiectomies were performed due to necrosis or chronic testicular pain syndrome. In the conservative group of moderate scrotal or testicular pain (n = 17), all patients had late pain symptoms (>8 days), but pain was not so severe that orchiectomy was attempted. Using a multivariate analysis, postoperative infections were associated with chronic testicular or scrotal pain and atrophy, but hospital status, surgeon's training level, laparoscopic or open operation, type of hernia or use of mesh did not correlate with testicular injuries. During follow-up, 11/17 (65%) patients with orchiectomy were free of testicular pain.

CONCLUSION

Urological injuries form one-fifth of the major complications after inguinal hernioplasty. Orchiectomy appears to help the majority of patients with severe testicular pain syndrome.

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

In this educational article, we aim to provide a literature review on laparoscopic anatomy of the inguinal region. We share the lessons learnt from the 1,194 laparoscopic hernia operations we have performed in 16 years of experience, trying to provide an anatomical and physiological basis for surgeons. The current study reports a personal experience with a transabdominal preperitoneal (TAPP) hernioplasty procedure. A literature review using the keywords "hernia," "laparoscopic approach," and "hernia repair" was performed using the electronic biomedical database PubMed, Medline Extra, Embase, Biosis, Science Citation Index, Ovid and text books. Between January 1994 and December 2010, a total of 1,194 patients, males and females (average age, 56.7 years), underwent laparoscopic TAPP inguinal hernia repair. Following reduction of the hernia sac and creation of the preperitoneal flap, a polypropylene mesh (10 × 16) and four spiral tacks were placed. TAPP is easy to learn and perform. Through this approach, a much better view from the inguinal anatomy is achieved, and the procedure also offers a brief learning curve. Our patients reported minimal postoperative pain and returned to work after 5-10 days, which is in accordance with the general anesthesia series. During the follow-up period, 10% of seromas, 3% of scrotal hematomas, 1% of hemorrhages, and 3% of recurrent hernias were observed. It should be emphasized that we have not observed abscess formation or acute infection related to the presence of mesh.

Complications in groin hernia surgery and the way out

Complications in endoscopic inguinal hernia surgery are more dangerous and more frequent than those of open surgery, especially in inexperienced hands and hence are best avoided. It is possible to avoid most of these complications if one follows a set of well-defined steps and principles of endoscopic inguinal hernia surgery.

Complications are known to occur at each and every step of hernia surgery. Applying caution while performing each step can save the patient from a lot of morbidity. One starts by applying strict patient selection criteria for endoscopic hernia repair, especially in the initial part of ones learning curve. A thorough knowledge of anatomy goes a long way in avoiding most of the complications seen in hernia repair. This anatomy needs to be relearned from what one is used to, as the approach is totally different from an open hernia repair. And finally, learning and mastering the right technique is an essential prerequisite before one ventures into inguinal hernia repair.

Although there has been an increased incidence of complications reported in endoscopic repair in the earlier series, this can be explained partly by the fact that it was in the early part of the learning curve of most endoscopic surgeons. As the experience grew and the techniques were standardized, the incidences of complications have also reduced and have come to be on par with open hernia surgery. The various complications and precautions to be taken to avoid them will be discussed.

Small bowel obstruction owing to displaced spiral tack after laparoscopic TAPP inguinal hernia repair

Laparoscopic repair of inguinal hernias has become a widely accepted technique owing to its safety, efficacy, and patient satisfaction. Laparoscopic inguinal herniorrhaphies, such as the transabdominal preperitoneal (TAPP) and the totally extraperitoneal approaches, usually employ a method of fixation involving staples, titanium spiral tacks, or sutures to secure the mesh over the myopectineal orifice. The TAPP approach also requires closure of the peritoneal flap to exclude the mesh from the intraabdominal contents. Overall complication rates with TAPP are low, with small bowel obstruction incidence of 0.2% to 0.5%. This is usually attributed to inadequate peritoneal closure, trocar site herniation, or adhesions. We report a case of small bowel obstruction caused by a displaced spiral tack used for the peritoneal closure during TAPP hernia repair.

The role of fibrin glue in decreasing chronic pain in laparoscopic totally extraperitoneal (TEP) inguinal hernia repair: a single surgeon's experience

BACKGROUND

Chronic pain is a disturbing severe complication of mesh inguinal hernia repair. Its risk, incidence, severity and its aetiologies vary widely in the literatures. It is well established that laparoscopic repair has decreased the incidence of chronic pain, but only to a certain degree. The main source of pain with this approach is staple fixation. Different ways of fixation were sought to avoid this problem.

METHODS

A review of the data collected prospectively, the cohort included 233 consecutive patients who underwent totally extraperitoneal (TEP) inguinal hernia repair by a single surgeon who used fibrin glue (Tisseel) to fix the mesh in all cases. Patients were reviewed by the original surgeon at 2 weeks and 6-12 weeks post-operatively, but also at 6 months in the first year of the study, and selectively then after if pain was reported by the patient. Data was reviewed and analysed by the researcher as part of quality assurance.

RESULTS

During the period from February 2005 to September 2008, 233 consecutive patients underwent 309 TEP inguinal hernia repairs. The mean age was 44.9 years. There was no conversion to open surgery. There was no mortality and only one major morbidity. In total, eight patients were complaining of mild intermittent discomfort (2 in the groins and 6 in the testicles) on their second post-operative review, but had no complaint at 6 months following their surgery. Chronic groin pain occurred in only one patient (0.43%).

CONCLUSIONS

The use of fibrin glue is a safe and reliable way of mesh fixation in inguinal hernia repair, with very limited risk of developing chronic pain.

Cyanoacrylate surgical glue as an alternative to suture threads for mesh fixation in hernia repair

BACKGROUND

In recent years, the use of synthetic glues has become an established practice in several areas of surgical treatment. For example, they are used in open and laparoscopic surgery and in digestive tract endoscopy, interventional radiology, and vascular neuroradiology. The experiments in this study were aimed at elucidating that suture-based permanent mesh fixation can be replaced by fixation with N-butyl 2-cyanoacrylate glue (Glubran2) for surgical repair of abdominal wall hernias.

MATERIALS AND METHODS

In 25 Wistar rats, two hernia defects (1.5 cm in diameter) per animal were created bilaterally in the midline of the abdominal wall. The peritoneum was spared. The lesions were left untreated for 10 d to achieve a chronic condition. Then the defects were covered with TiMESH extralight (2 × 2 cm) and fixed by 30 μL of Glubran2 or traditional suture. The time points of sacrifice were 17 and 28 d, 3, 4, and 5 mo. At autopsy, histology and immunohistochemistry were performed to evaluate the inflammatory response and the presence of apoptotic cells respectively.

RESULTS

Mesh fixation was excellent in all samples at each time point. At application sites, the inflammatory reaction was mild with a small number of macrophages and vascularized connective tissue presence around glue and mesh threads. Glue residues were observed in histologic sections at each time point. No presence of apoptotic cells was found.

CONCLUSIONS

This study demonstrated that Glubran2 can effectively replace traditional suture in mesh fixation without affecting tissue healing and determining a physiological inflammatory reaction at the abdominal wall site.

Complications of laparoscopic inguinal herniorrhaphy including one case of atypical mycobacterial infection

BACKGROUND

Although laparoscopic inguinal herniorrhaphy is considered safe, several complications may occur. This study aimed to evaluate the complications observed in 780 laparoscopic inguinal herniorrhaphies at the authors' hospital.

METHODS

All the patients who underwent laparoscopic inguinal herniorrhaphy at the authors' hospital during a period of 11 years were enrolled retrospectively in this study. Patient demographics, operative data, and intra- and postoperative complications were evaluated.

RESULTS

A total of 569 patients underwent 780 laparoscopic inguinal herniorrhaphies. The male-to-female ratio was 8.8 to 1, and the mean age was 54.8 ± 15.7 years. Hernia recurrence was recognized in 14 patients (2.5%). Intra- and postoperative complications were diagnosed in 28 (4.9%) and 35 (6.2%) patients respectively. There was no mortality. The most common intraoperative complication was extensive subcutaneous emphysema. Two patients with extensive subcutaneous emphysema had cardiac arrhythmia. Small bowel perforation and bladder perforation occurred in one patient each. One patient had extensive preperitoneal infection caused by Mycobacterium massiliense, which required mesh removal, tissue debridement, and prolonged antibiotic therapy.

CONCLUSIONS

Although the mortality rate is low, potentially life-threatening complications such as small bowel and bladder perforation may be experienced by patients subjected to laparoscopic herniorrhaphy.

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.

Laparoscopic totally extraperitoneal repair of inguinal hernia: a policy of selective mesh fixation over a 10-year period

INTRODUCTION

The issue of mesh fixation in laparoscopic totally extraperitoneal (TEP) repair of inguinal hernia repairs remains unresolved. The need for fixing the mesh arises from the fear of increasing recurrence rates. However, specific complications have emerged as a result of mesh fixation.

MATERIALS AND METHODS

A retrospective analysis of 822 laparoscopic TEP hernia repairs in 634 patients over a 10-year period in a single surgical unit was performed. A policy of selective mesh fixation was followed and guidelines regarding indications of mesh fixation formulated. Recurrence rates and complications specific to mesh fixation were evaluated.

RESULTS

Mesh was fixed in only 28 of 822 repairs. There were 6 (0.7%) recurrences. No neuropathic or mesh-fixation-related complications were noted in a follow-up period ranging from 10 to 82 months.

CONCLUSIONS

Avoiding routine fixation of the mesh helps in decreasing complications and operative costs with acceptable recurrence rates. However, a policy of selective mesh fixation is advocated, based on specific indications.

Fibrin glue for mesh fixation in laparoscopic transabdominal preperitoneal (TAPP) hernia repair: indications, technique, and outcomes

BACKGROUND

The efficacy and safety of prosthesis fixation were studied by means of fibrin glue (Tissucol, Baxter Healthcare) during laparoscopic transabdominal preperitoneal (TAPP) treatment of inguinal and femoral hernias.

METHODS

Between September 2001 and December 2004, fibrin glue was used for mesh fixation during TAPP.

RESULTS

In this study, 320 hernias were treated for 230 patients (225 men and 5 women) with an average age of 45 years (range, 20-75 years). No perioperative complications were observed. After an average follow-up period of 26 months (range, 1-40 months), the only postoperative complications observed were six seromas (1.8%) and one trocar-site hematoma (0.3%). The mean operating time was 30 min for unilateral hernias and 50 min for bilateral hernias, whether primary or recurrent. Patients usually were discharged the day after surgery and returned to work after 5 days.

CONCLUSIONS

The authors' experience demonstrates that fibrin glue (Tissucol) is an effective method for mesh fixation during TAPP.

Orchiectomy as a result of ischemic orchitis after laparoscopic inguinal hernia repair: case report of a rare complication

Background

Ischemic orchitis is an established complication after open inguinal hernia repair, but ischemic orchitis resulting in orchiectomy after the laparoscopic approach has not been reported.

Case presentation

The patient was a thirty-three year-old man who presented with bilateral direct inguinal hernias, right larger than left. He was a thin, muscular male with a narrow pelvis who underwent bilateral extraperitoneal mesh laparoscopic inguinal hernia repair. The case was complicated by pneumoperitoneum which limited the visibility of the pelvic anatomy; however, the mesh was successfully deployed bilaterally. Cautery was used to resect the direct sac on the right. The patient was discharged the same day and doing well with minimal pain and swelling until the fourth day after surgery. That night he presented with sudden-onset pain and swelling of his right testicle and denied both trauma to the area and any sexual activity. Ultrasound of the testicle revealed no blood flow to the testicle which required exploration and subsequent orchiectomy.

Conclusion

Ischemic orchitis typically presents 2–3 days after inguinal hernia surgery and can progress to infarction. This ischemic injury is likely due to thrombosis of the venous plexus, rather than iatrogenic arterial injury or inappropriate closure of the inguinal canal. Ultrasound/duplex scanning of the postoperative acute scrotum can help differentiate ischemic orchitis from infarction. Unfortunately, testicular torsion cannot be ruled out and scrotal exploration may be necessary. Although ischemic orchitis, atrophy, and orhiectomy are uncommon complications, all patients should be warned of these potential complications and operative consent should include these risks irrespective of the type of hernia or the surgical approach.

Comparing fibrin sealant with staples for mesh fixation in laparoscopic transabdominal hernia repair: a case control-study

BACKGROUND

Laparoscopic hernia repair is not as popular as cholecystectomy. We have performed more than 3,000 laparoscopic herniorrhaphies using the trans-abdominal (TAPP) technique. To prevent recurrences we fix the polypropylene mesh with staples. The use of fibrin glue for graft fixation is a possible alternative.

METHODS

We have performed 3,130 laparoscopic hernia repairs over 14 years. For mesh fixation we used titanium clips and observed a small number of complications. In July 2003 we started using fibrin glue (Tissucol(R)). The purpose of this retrospective longitudinal study was to evaluate if the use of fibrin sealant was as safe and effective as conventional stapling and if there were differences in post-operative pain, complications and recurrences.

RESULTS

From July 2003 to June 2006 we performed 823 laparoscopic herniorrhaphies. Fibrin glue (Tissucol(R)) was used in 88 cases. Two homogeneous groups of 68 patients (83 cases) treated with fibrin glue and 68 patients (87 cases) where the mesh was fixed with staples, were compared. Patients with relevant associated diseases or large inguino-scrotal hernias were excluded. Operative times were longer in the group treated with fibrin glue with a mean of 35 minutes (range 22-65 mins) compared to the group treated with staples (25 minutes, range 14-50 mins). The time of hospital stay was the same (24 hours). Post-operative complications, that were more frequent in the stapled group, included trocar site pain, hematomas, intra-operative bleedings and incisional hernias. No significant difference was observed concerning seromas, chronic pain and recurrence rate.

CONCLUSIONS

Less post-operative pain, and a faster return to usual activities are the main advantages of laparoscopic repair compared to the traditional approach. The use of fibrin sealant reduces in our experience the risk of post- and intra-operative complications such as bleeding and incisional hernia; recurrence rates are similar, but the operative time is longer.

Quantification of pain in laparoscopic transabdominal preperitoneal (TAPP) inguinal hernioplasty identifies marked differences between prosthesis fixation systems

BACKGROUND

Various systems exist for prosthesis fixation in hernia repair. These techniques vary in terms of postoperative complications and pain. This study compares prosthesis fixation techniques employed in laparoscopic transabdominal preperitoneal (TAPP) hernioplasty using a visual analog scale (VAS) to quantify postoperative pain.

METHODS

Patients (n = 600) underwent TAPP inguinal hernia repair in a randomized prospective study. Prostheses were fixed with Protak (Tyco, Norwalk, Conn), (Group A; n = 150), EndoANCHOR (Ethicon Endo-Surgery, Inc., Cincinnati, Ohio) (Group B; n = 150), EMS (Ethicon Endo-Surgery, Inc.) (Group C; n = 150), or Tissucol (Baxter Healthcare, Milan, Italy) (Group D; n = 150). Patients were interviewed up to 1 month post-intervention. Post-operative pain was evaluated on a 0- to 10-point VAS (0 = no pain, 10 = maximum pain). Morbidity, length of stay, return to work and recurrence were also assessed.

RESULTS

Overall, 803 hernias were treated: 397 patients (66.2%) had unilateral hernias and 203 (33.8%) had bilateral hernias. In total, 96 (12%) hernias were recurrences and 707 (88%) were primary. Postoperative pain ranged from VAS1 to VAS2 (mild pain) between 12 hours and 72 hours with Tissucol (Group D), and it was higher in Groups A-C: Maxima ranged from VAS4 (moderate pain) with EMS to VAS7 (severe pain) with Protak at 48-hour follow-up. Significant differences in length of stay occurred, no recurrence or conversion rates were observed among groups, and morbidity was generally lower with Tissucol. Patients in Group D (Tissucol) also returned to work sooner than did Groups A-C (Protak, EndoANCHOR, and EMS).

CONCLUSIONS

We found differences in postoperative pain among different laparoscopic TAPP prosthesis fixation methods. The use of the biocompatible fibrin sealant Tissucol seems to reduce significantly postoperative pain, complications, and resumption to work times compared with other systems.

A calcified foreign body in the bladder after laparoscopic inguinal hernia repair

In this paper, we report an exceedingly rare complication after laparoscopic inguinal hernioplasty. A 57-year-old man was submitted to transurethral resection of the prostate followed by laparoscopic "bikini mesh" hernia repair. One year later, he presented with miccional irritative symptoms. Ultrasonography showed a vesical intraluminal foreign body and computerized tomography revealed a calcified foreign body on the anterior bladder wall. On reoperation, it was noted that there occurred mesh transfixation of the bladder. The lateral segments were removed and the patient recovered uneventfully. This is a, thus far, unpublished complication of this technique.

Open or endoscopic total extraperitoneal inguinal hernia repair? A systematic review

BACKGROUND

Although a large number of surgeons currently perform endoscopic hernia surgery using a total extraperitoneal (TEP) approach, reviews published to date are based mainly on trials that compare laparoscopic transabdominal preperitoneal (TAPP) repair with various types of open inguinal hernia repair.

METHODS

A qualitative analysis of randomized trials comparing TEP with open mesh or sutured repair.

RESULTS

In this review, 4,231 patients were included in 23 trials. In 10 of 15 trials, TEP repair was associated with longer surgery time than open repair. A shorter postoperative hospital stay after TEP repair than after open repair was reported in 6 of 11 trials. In 8 of 9 trials, the time until return to work was significantly shorter after TEP repair. Hospital costs were significantly higher for TEP than for open repair in all four trials that included an economic evaluation. Most trials (n = 14) reported no differences in subsequent recurrence rates between TEP and open repair.

CONCLUSIONS

The findings showed that endoscopic TEP repair is associated with longer surgery time, shorter postoperative hospital stay, earlier return to work, and recurrence rates similar to those for open inguinal hernia repair. The procedure involves greater expenses for hospitals, but appears to be cost effective from a societal perspective. The TEP technique is a serious option for mesh repair of primary hernias.

The suturing concept for laparoscopic mesh fixation in ventral and incisional hernia repair: Mid-term analysis of 400 cases

BACKGROUND

The authors describe a minimally invasive treatment of moderate to large incisional and ventral hernia defects using Parietex composite mesh.

METHODS

All defects are closed laparoscopically or through a minilaparotomy using sutures, and the composite mesh is fixed intraperitonally using transabdominal fixation with nonabsorbable sutures to avoid the use of staple or tack fixation, which has been associated with various complications, including major loop adhesion and mesh migration. The midterm results for 400 patients are presented in terms of efficacy and safety.

RESULTS

During a mean follow-up period of 28 months for 80% of the patients, the median operating time was 74 min and the median hospital stay was 3 days. There were eight seromas (2%), all on large defects. Transient pain was experienced by 10 patients (2.5%), and resolved over time with analgesic treatment. There was one early case of sepsis (0.25%), attributable to secondary breakdown of the bowel wall in a case of recurrent incisional hernia, which led to removal of the mesh. Residual chronic parietal pain was reported for 10 patients (2.5%), 2 of whom were released after excision of neuroma; 3 trocar-site herniations (0.75%); and lipoma formation on the site of the hernia sac in 6 cases (1.5%).

CONCLUSION

Laparoscopic ventral hernia treatment using Parietex composite mesh is an effective and safe procedure. Morbidity and recurrence rates are low, and the 2-year outcomes are promising, with no prosthesis migration or complication related to intraperitoneal positioning of the mesh.

Technical aspects and access devices for preperitoneal and retroperitoneal endoscopic surgery

The main advantages of preperitoneal and retroperitoneal endoscopic surgery over conventional laparoscopy or open surgery are the decreased risk of injury to organs and reduced postoperative adhesion formation. Exact knowledge of anatomy, as well as correct positioning of the patient, is essential for its success. While a blunt dissection technique, using either the fingers or an endoscope under pneumodissection, is preferred for preperitoneal surgery, the introduction of a balloon dissection device directly into the retroperitoneal cavity simplifies this procedure for retroperitoneoscopy. Different general surgical procedures are described for preperitoneal (hernia) and retroperitoneal (adrenalectomy, neurectomy/ sympathectomy) surgery. Urological/gynaecological procedures (kidney, tumor biopsy, lymphadenectomy) are excluded from this review. In recent years, the number of possible preperitoneal and retroperitoneal surgical procedures has increased, mainly as a result of the development of commercially-available balloon trocars and balloon-tipped trocars, which create and maintain a working space.

Colonoscopic removal of inguinal hernia mesh: report of a case and literature review

The transabdominal preperitoneal (TAPP) procedure for laparoscopic inguinal hernia mesh repair is being applied with increasing frequency. This technique has an acceptable recurrence rate (0.4-3.9%), but has varying complication rates (1.3-17.4%).1,2 We report the first case of mesh penetration of the colon following laparoscopic TAPP repair, treated with colonoscopy.

Infekcija u hirurgiji kila

Traditionally, the operation of hernia is considered as a clean operation due to expected, low incidence of infection, on the spot of surgical work (SSI). The incidence of SSI in hernia surgery is more frequent then it is assumed. The important risk factors for SSI are the following: type of hernia (inguinal, incisional), operative approach (open - laparoscopic), usage of the prosthetic material and drainage. Comparing to inguinal hernia repair, incisional hernia repair, is more frequently followed by the infection. The laparoscopic operations are followed with the lower incidence of SSI then in the case of open operation. The usage of the mesh does not increase the incidence of SSI, although the consequences of the mesh infection may be severe. A type I of the prosthesis is more resistant to the infection then prosthesis II and III. The mesh infection (type I) never involves its body but it is present around sutures and bended edges. The mesh infection Type II involves entire prosthesis while in the case of Type III it is present in its peripheral part. In the case of SSI, a prosthesis Type I is possible to be saved, while prosthesis Type II must be removed completely; and the same is for the Type III (the partial removal is rarely suggested). The defect that remained after excision of non-resorptive prosthesis is a long-term and very complicated surgical problem. In regard to the position of the mesh, SSI is more common if the mesh is placed subcutaneously then in the case of sub-aponeurotic peri-muscular, pre-aponeurotic retromuscular or pre-peritoneal mesh placemen. If the infection is present the non-tension techniques using non-resorptive prosthetic implants are not recommended. the presence of drainage and its duration increases the incidence of SSI. It is more common for incisional hernioplasty then for inguinal hernia repair. If there is an indication for drainage it should be as short as possible. The cause of SSI for elective operations are bacteria?s that arrives from the skin, while in the case of opening of various organs dominant bacteria?s originate from them. The superficial infection does not lead to the recurrence, while it is very possible in the case for deep infection. There are no prospective studies that justify the usage of antibiotic prophylaxes in hernia surgery. The antibiotic prophylaxis in hernia surgery. The antibiotic prophylaxis is indicated for the clean operations when placing the implants and when severe complication is expected. The appearance of SSI increases the price of treatment and may lead to the recurrence.

Tension-free mesh repair of umbilical hernia as a day case using local anaesthesia

BACKGROUND

Umbilical hernias are a common surgical problem with a high recurrence rate using conventional suture techniques. This prospective study examined the feasibility of tension-free mesh repair as a day case using local anaesthetic (LA) for all primary umbilical hernias.

METHOD

Fifty-four patients (eight women) were operated on; 49 using LA. Through a periumbilical skin incision the margins of the sac were freed from the edges of the defect, and a space was made in the extraperitoneal plane. In defects <3 cm in diameter, a cone of polypropylene (pp) mesh was inserted and attached with nonabsorbable sutures. In defects >3 cm, a flat piece of pp mesh was inserted into the extraperitoneal space as a sublay. No attempt was made to close the fascial defect.

RESULTS

Postoperative pain was graded as mild ( n=37) and moderate ( n=17). No patient had severe postoperative pain. Seven superficial wound infections responded to oral antibiotics. In no case it was necessary to remove the mesh. There were no other complications. Patients were recalled between 2 and 6 years postopertively-mean follow-up 43 months (28- 67). There were no recurrences.

CONCLUSION

Umbilical hernia repair can be carried out safely and securely under LA with a tension-free mesh technique (cone or a sublay patch) with a low morbidity, negligible recurrence rate, and a high degree of patient satisfaction. It should be the procedure of choice for all such hernias.

The suturing concept for laparoscopic mesh fixation in ventral and incisional hernias: preliminary results

Having found existing techniques for treatment of incisional hernias unsatisfactory, we developed a new laparoscopic approach with a Parietex Composite mesh. This study shows the preliminary results in order to analyze the validity of the concept on efficacy and safety. Three trocars are needed for this procedure. Non-reabsorbable sutures are mandatory for closure of large defects to avoid having to ultimately extrude the mesh. Ten to 12 cardinal stitches are applied on the polyester side of the mesh. The mesh is anchored to the anterior abdominal wall by transabdominal non-reabsorbable sutures without the use of staples or tacks. One hundred twenty patients with ventral and incisional hernias were included in this study. Early and late complications are reported, showing lower rates of morbidity and no mortality. This technique is satisfactory on the technical front, and the results are as good, or better, than in other trials.

Laparoscopic repair for groin hernias

So where do things stand in 2003? Laparoscopic herniorrhaphy appears to result in less postoperative pain (acute and chronic) and in a shorter convalescence and an earlier return to work, compared with the open repair. It can be performed safely and with a low recurrence rate. However, it takes longer to do, is more difficult to learn, and costs more, all reasons why it is not more commonly performed. Currently, laparoscopic herniorrhaphy accounts for 15% to 20% of hernia operations in America and around the world. Who can blame the surgeon in a community practice for opting for the open mesh repair, operating on familiar anatomy, and using familiar techniques? Nevertheless, with efforts to cut costs by eliminating disposable equipment and honing skills to decrease operating time, laparoscopic herniorrhaphy will probably continue to be a contender, especially for the younger patient who wants to return to work quickly and for patients with bilateral and recurrent hernias. It is arguable that surgeons should possess skill in both open and laparoscopic techniques and should know the indications for each--some hernias are best repaired laparoscopically. That said, laparoscopic herniorrhaphy will most likely be performed by those with a special interest and proficiency in the technique. At the least, the laparoscopic revolution and laparoscopic hernia repair have helped elevate the study of hernia anatomy and herniorrhaphy to a position it deserves and this has made us all better hernia surgeons. What was once the stepchild of general surgery now occupies a more prominent and respectable place. With the continuing efforts of dedicated, energetic investigators, we should continue to see advances in the safe and effective repair of this most common of surgical maladies.

Complications of open groin hernia repairs

As large numbers of patients undergo hernioplasty each year the surgical technique should be a simple one. The results obtained by general surgeons using various open, tension-free techniques, irrespective of the anesthetic used, are excellent and appear to approach those of specialists. This can not be said for laparoscopic hernioplasty, which has a well-known learning curve, is more expensive and is not without complications, some of which may be serious or life threatening. Although proper training in laparoscopic techniques is essential, the same applies to open repair with mesh. Surgical residents should be taught open-mesh repairs under local anesthesia before embarking on training in laparoscopic techniques if they show interest in pursuing this approach. Indeed, we may soon be faced with an increasing number of patients who are not fit for a general anesthetic. Not all hernias need be repaired by specialists and visiting centers with experience in the use of different prosthetic devices allows you to draw your own conclusions. Finally, when consulting a patient with an inguinal hernia, primary or recurrent, the surgeon should pose the question "which combination of anesthetic and hernia repair is the safest and best for my patient?" Local anesthesia with appropriate analgesia and sedation is the safest of all techniques and is suitable for most if not all open repairs. Using this approach, any type of open-mesh repair makes the ideal combination and all can be safely carried out on an ambulatory basis. Attention to surgical technique is paramount, and given the number of hernias repaired annually, it is pertinent to recall the words of Wakely, who said "A surgeon can do more for the community by operating on hernia cases, and seeing that his recurrence rate is lower, than he can by operating on cases of malignant disease."

The Lichtenstein repair for groin hernias

The Lichtenstein tension-free mesh repair opened a new era in groin hernia repair. Without the risk of serious morbidity, it is now readily performed using local anesthesia in patients previously considered unsuitable for surgery. Fears of serious complications related to mesh implantation have proved to be without foundation. As a local anesthetic day care technique without the need for complex and expensive instrumentation, overall costs can be kept to a minimum without compromising the safety or the long-term success of the procedure. It is a straightforward technique to learn, with high patient acceptability and an exceedingly low recurrence rate. At present it must be considered the gold standard of groin hernia repair.