Groin Hernia Repair by Laparoscopic Techniques: Current Status and Controversies

Robotic transabdominal preperitoneal repair for recurrent inguinal hernia after Kugel hernioplasty: A case report

INTRODUCTION AND IMPORTANCE

The laparoscopic posterior approach adapts the advantages of Kugel hernioplasty, making it possible to perform it at the new layer even if the inguinal hernia is recurrent following the anterior approach, producing a high level of completion. However, in laparoscopic surgery for recurrent inguinal hernia using posterior approaches, dissecting the extraperitoneal space is difficult. Robotic surgery may enable precise dissection, even if the space is severely adhered. Here, we report a robotic approach after extraperitoneal approach for recurrent inguinal hernia, which developed after Kugel hernioplasty.

CASE PRESENTATION

A 78-year-old Japanese man, who underwent left inguinal hernia repair (Kugel hernioplasty) 2 years ago, presented with recurrent reducible left inguinal swelling. A peritoneal incision was created above the deep inguinal ring to treat the primary right inguinal hernia. The pressure in the left inguinal region revealed a spermatic cord lipoma protruding from the internal inguinal ring as a recurrent inguinal hernia of the abdominal cavity.

CLINICAL DISCUSSION

Robotic transabdominal preperitoneal repair for recurrent inguinal hernia is effective, especially after posterior approach Kugel hernioplasty, in which dissection of the extraperitoneal space is difficult. In the present case, the peritoneal flap was conserved without removing the direct Kugel patch.

CONCLUSION

Kugel hernioplasty, which is a posterior approach, would result in severe extraperitoneal space adhesion. Essentially, a new and previously unused approach is preferable to the previous approach in patients with recurrent inguinal hernias. Robotic approach is effective for recurrent inguinal hernias even if the space was severe adhesion.

LIECHTENSTEIN VERSUS CORREÇÃO DE HÉRNIA LAPAROSCÓPICA TRANSABDOMINAL PRÉ-PERITONEAL (TAPP): UM ESTUDO COMPARATIVO PROSPECTIVO COM FOCO NOS RESULTADOS PÓS-OPERATÓRIOS EM UMA UNIDADE DE CIRURGIA GERAL

Three surgical techniques for inguinal hernia repair are currently validated. Few studies have compared results among Lichtenstein and transabdominal preperitoneal (TAPP) laparoscopic approach obtained at an early step of the learning curve.

Comparison of slit mesh versus nonslit mesh in laparoscopic extraperitoneal hernia repair

Introduction

Endoscopic hernia repair integrates the advantages of tension-free preperitoneal mesh support of the groin with the advantages of minimally invasive surgery procedures.

Aim

To compare outcomes between slit mesh (SM) and nonslit mesh (NSM) placement in laparoscopic totally extraperitoneal (TEP) inguinal hernia repair.

Material and methods

This is a retrospective study of 353 patients who underwent TEP inguinal hernia repair between January 2010 and December 2011. One hundred forty-nine and 154 hernias were operated on in the SM and NSM groups, respectively. Postoperative complications, recurrence, early postoperative pain, and chronic pain levels were evaluated.

Results

In a total of 303 patients, hernia repair was performed as 395 direct and indirect hernias. Nonslit mesh was converted from TEP to transabdominal preperitoneal patch plasty (TAPP) in 4 patients in the group and 6 patients in the slit mesh group. The average operation time of the SM group was significantly higher than that of the NSM group (p < 0.001). In the evaluation of early postoperative pain, VAS levels of the NSM group were statistically significantly lower than those of the SR group in all evaluations (p = 0.001). The pain rate of the SM group after 3 months of chronic pain was significantly higher than that of the NSM group (p = 0.004). There was no difference in recurrence rate, 6^th month chronic pain, wound infection or wound hematoma.

Conclusions

The use of SM and NSM in TEP operations is not different in terms of recurrence and complications. However, the use of NSM gives better results in terms of early postoperative pain and chronic pain.

Surgical technique of laparoscopic hybrid approach for recurrent inguinal hernia: Report a case

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Our hybrid method is not special but the conventional laparoscopic approach adapted each merits both TAPP and TEP.

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Our hybrid method is effective for difficult recurrent inguinal hernias.

Introduction

Currently, laparoscopic surgery (LS) is a widely accepted surgical treatment for inguinal hernias, and it has major advantages, especially for recurrent cases.

Presentation of case

We diagnosed the recurrent inguinal hernia after wound infection and performed the laparosocopic approach. We would like to introduce our method.

<First step: TAPP part> We distinguished between the presence and absence of bilateral inguinal hernia with an intra-abdominal scope using the transabdominal preperitoneal inguinal hernia repair (TAPP) technique, which we call laparoscopic examination. Thus, we can distinguish between the types of inguinal hernias and whether they are bilateral or not.

<Second step: totally extraperitoneal (TEP) part> We dissected the Retzius space on the inside of an epigastric arteriovenous fistula as part of TEP part A, and dissection was performed without a balloon. We separated and dissected the Retzius space. We also performed lateral dissection of the preperitoneal space.

<Third step: TAPP part > We made an incision in the peritoneum at the inner groin ring (hernia sac). We isolated the cord structures (parietalization) using TAPP.

<Final step: TAPP part> We finally checked this operation from the abdominal space (TAPP filed) and determined whether the repair was satisfactorily completed or not.

Discussion

Our hybrid method is not special but the conventional laparoscopic approach adapted each merits both TAPP and TEP.

Conclusion

Our method is effective for difficult recurrent inguinal hernias.

Raising the quality of hernia care: Is there a need?

INTRODUCTION

With a focus on raising the quality of hernia care through creation of educational programs, SAGES formed the Hernia Task Force (HTF). This study used needs assessment survey to target opportunities for improving surgical training and thus patient outcomes and experience.

METHODS

This qualitative study included structured interviews and online surveys of key stakeholders: HTF members, surgeons, nurses, patients, hospital administrators, healthcare payers and medical suppliers. Questions included perceptions of recurrence and complication rates, their etiologies, perceived deficits in current hernia care and the most effective and training modalities.

RESULTS

A total of 841 participants included 665 surgeons, 66 patient care team members, 12 hospital administrators and 14 medical supply providers. Assessment of technical approach revealed that nearly 26 % of surgeons apply the same, limited range of techniques to all patients without evaluation of patient-specific factors. The majority (71 %) of surgeon respondents related hernia recurrence rates nearing 25 % or more. HTF members implicated surgeon factors (deficits in knowledge/technique, etc.) as primary determinants of recurrences, whereas nurses, medical supply providers and hospital administrators implicated patient health factors. Surgeons preferred attending conferences (82 %), reading periodicals/publications (71 %), watching videos (59 %) and communicating with peers (57 %) for learning and skill improvement. Topics of the greatest interest were advanced techniques for hernia repairs (71 %), preoperative and intraoperative decision making (56 %) and patient outcomes (64 %). Eighty-six percent of nurses felt that there was room for improvement in hernia patient safety and teamwork in the OR. Only 24 % believed that the patients had adequate preoperative education.

CONCLUSIONS

Major reported deficits in hernia care include: lack of standardization in training and care, "one size fits all" technical approach and inadequate patient follow-up/outcome measures. There is a need for a comprehensive, flexible and tailored educational program to equip surgeons and their teams to raise the quality of hernia care and bring greater value to their patients.

Single site and conventional totally extraperitoneal techniques for uncomplicated inguinal hernia repair: A comparative study

OBJECTIVE:

To demonstrate the feasibility of endoscopic extraperitoneal single site (EESS) inguinal hernia repair and compare it outcomes with the conventional totally extraperitoneal (TEP) technique.

BACKGROUND:

TEP inguinal hernia repair is a widely accepted alternative to conventional open technique with several perioperative advantages. Transumbilical laparoendoscopic singlesite surgery (LESS) is an emerging approach and has been reported for a number of surgical procedures with superior aesthetic results but other advantages need to be proven.

PATIENTS AND METHODS:

Thirty-eight uncomplicated inguinal hernias were repaired by EESS approach between January 2010 and January 2011. All procedures were performed through a 25 cm infraumbilical incision using the Alexis wound retractor attached to a surgical glove and three trocars. Body mass index, age, operative time, blood loss, complications, conversion rate, analgesia requirement, hospital stay, return to normal activities and patient satisfaction with aesthetic results were analysed and compared with the last 38 matched-pair group of patients who underwent a conventional TEP inguinal hernia repair by the same surgeon.

RESULTS:

All procedures were performed successfully with no conversion. In both unilateral and bilateral EESS inguinal repairs, the mean operative time was longer than conventional TEP (55± 20 vs. 40± 15 min, P = 0.049 and 70± 15 vs. 55± 10 min, P = 0.014). Aesthetic result was superior in the EESS group (2.88± 0.43 vs. 2.79± 0.51, P = 0.042). There was no difference between the two approaches regarding blood loss, complications, hospital stay, time until returns to normal activities and analgesic requirement.

CONCLUSION:

EESS inguinal hernia repair is safe and effective, with superior cosmetic results in the treatment of uncomplicated inguinal hernias. Other advantages of this new technique still need to be proven.

Use of human fibrin glue (Tisseel) versus staples for mesh fixation in laparoscopic transabdominal preperitoneal hernioplasty (TISTA): a randomized controlled trial (NCT01641718)

BACKGROUND

Inguinal hernia repair is one of the most common surgical procedures worldwide. This procedure is increasingly performed with endoscopic techniques (laparoscopy). Many surgeons prefer to cover the hernia gap with a mesh to prevent recurrence. The mesh must be fixed tightly, but without tension. During laparoscopic surgery, the mesh is generally fixed with staples or tissue glue. However, staples often cause pain at the staple sites, and they can cause scarring of the abdominal wall, which can lead to chronic pain. We designed a trial that aims to determine whether mesh fixation with glue might cause less postoperative pain than fixation with staples during a transabdominal preperitoneal patch plastic repair.

METHODS/DESIGN

The TISTA trial is a prospective, randomized, controlled, single-center trial with a two-by-two parallel design. All patients and outcome-assessors will be blinded to treatment allocations. For eligibility, patients must be male, ≥18 years old, and scheduled for laparoscopic repair of a primary inguinal hernia. One group comprises patients with a unilateral inguinal hernia that will be randomized to receive mesh fixation with either tissue glue or staples. The second group comprises patients with bilateral inguinal hernias. They will be randomized to receive mesh fixation with tissue glue either on the right or the left side and with staples on the other side. The primary endpoint will be pain under physical stress, measured at 24 h after surgery. Pain will be rated by the patient based on a numeric rating scale from 0 to 10, where 10 equals the worst pain imaginable. A total of 82 patients will be recruited (58 patients with unilateral inguinal hernias and 24 patients with bilateral hernias). This number is estimated to provide 90% power for detecting a pain reduction of one point on a numeric rating scale, with a standard deviation of one.

DISCUSSION

Patients with bilateral hernias will receive two meshes, one fixed with glue, and the other fixed with staples. This design will eliminate the inter-individual bias inherent in comparing pain measurements between two groups of patients.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01641718.

Slit versus non-slit mesh placement in total extraperitoneal inguinal hernia repair

BACKGROUND

The goal of the present research was to study patients who underwent laparoscopic total extraperitoneal repair using slit and non-slit mesh placement.

METHODS

Patients who underwent laparoscopic inguinal hernia repair in our hospital between 2005 and 2009 were interviewed and examined. Surgery outcome, hernia recurrence, postoperative pain and time to return to normal physical activities, and surgery satisfaction were compared.

RESULTS

During the study period 389 consecutive patients underwent laparoscopic groin hernia repair: 387 by the total extraperitoneal (TEP) approach and 2 by the TAPP approach. Six of the TEP patients were converted to TAPP. Eighty-seven patients in the TEP group had slit mesh placement and 300 had non-slit mesh placement. Mean follow-up was 36 months (range: 6-66 months). At follow-up, 387 patients responded to a request for interview and 277 were examined. The overall recurrence rate was 4.7%, the incidence of constant postoperative pain was 1.3%, the presence of permanent testicular pain was 2.8%, and patient satisfaction with the surgery was 94.5%. A significantly lower recurrence rate was found in the slit mesh group than in the non-slit group (0.6% versus 5.9%; p < 0.003). There was no difference in the length of time until return to normal activities, patient satisfaction, and postoperative pain between the groups. Surgery time and the occurrence of testicular pain were significantly greater in the anatomic group.

CONCLUSIONS

Total extraperitoneal inguinal hernia repair with slit mesh placement is a safe technique with a very low recurrence rate and is superior to non-slit mesh positioning.

Evaluation of nurse-led discharge following laparoscopic surgery

INTRODUCTION

The United Kingdom's Department of Health has identified reducing delays in patient discharge as a key aim for Health Service development. Laparoscopic cholecystectomy and laparoscopic inguinal hernia repair may be safely performed on a short stay basis, but day case rates remain low, with delays in discharge identified as a major contributing factor. Nurse-led discharge has been widely advocated to speed patient discharge across varied specialities, but objective evidence to support its use is lacking. This study aimed to assess the effectiveness of nurse-led discharge following laparoscopic surgery.

METHODS

A retrospective comparison of doctor-led and nurse-led discharge following laparoscopic surgery was performed by analysis of two consecutive 4-month periods, prior to and following the introduction of nurse-led discharge by a laparoscopic nurse specialist. Outcomes assessed included time to discharge, reasons for delayed discharge, hospital readmissions and primary care episodes following discharge.

RESULTS

A total of 128 patients were included in the study, with each discharge group containing 64 patients. Patients in the nurse-led discharge group were significantly more likely to be discharged on the day of surgery than patients in the doctor-led discharge group (17.2% vs. 4.7%; P = 0.023), with a highly significant difference in same day discharge rates noted among patients operated on during morning theatre lists (44.0% vs. 10.7%; P = 0.006). There was no significant difference between the discharge groups in readmission rates or in the number of patients seeking primary care attention following discharge.

CONCLUSIONS

Nurse-led discharge may speed discharge following laparoscopic surgery with no apparent detriment to patient care.

Bilateral inguinal hernia repair: laparoscopic or open approach?

BACKGROUND

The aim of this study was to investigate outcomes in the treatment of bilateral inguinal hernia, comparing the laparoscopic totally extraperitoneal (TEP) and open tension-free mesh repair (LICHT) approaches.

METHODS

We performed a prospective controlled non randomized clinical study in 128 patients with bilateral inguinal hernia over a period of 3 years. LICHT was used in 106 cases (53 patients) while TEP was employed in 150 cases (75 patients). The main outcome measurements were: recurrence rate, operating time, hospital stay and postoperative complications.

RESULTS

There were three recurrences (2.3%): two in the LICHT group (3.8%) and one (1.3%) in the TEP group P = NS. The TEP procedure was faster than LICHT repair (48.8 ± 10.8 vs. 70.4 ± 11.2 min) P < 0.01. Postoperative complications were more frequent in LICHT group (16%) than TEP group (5.3%) P < 0.01. Hospital stay was significantly shorter in the TEP group (0.6 ± 0.8 vs. 1.3 ± 1.2 days) P < 0.001.

CONCLUSIONS

The TEP approach is an effective option for the treatment of bilateral inguinal hernia when performed by experienced surgeons.

Endoscopic total extraperitoneal repair of recurrent inguinal hernia: a 5-year review

PURPOSE

The experience of endoscopic total extraperitoneal (TEP) repair of recurrent inguinal hernia in a major teaching hospital is reviewed.

METHODS

Between 2003 and 2008, 37 consecutive patients underwent 46 TEP repairs for recurrent inguinal hernia. Patient demographics, hernia characteristics, operating time, conversion rate, intraoperative, postoperative complications and recurrence were measured. Twenty-eight patients had unilateral hernia and nine patients had bilateral hernias. The mean age was 59 years old (range 22-88 years).

RESULTS

The mean operation duration was 88 min (range 60-120 min). Bilateral repairs took 38% longer than for unilateral repairs (108 vs 78 min). Three patients (8.1%) had conversion to open surgery. Seroma developed in two patients, which was subsequently resolved. Within 1 year of follow up evaluation, there was 1 recurrence (2.7%). The mean inpatient hospital stay was 1.6 days, and 24.3% of the operations were performed as outpatients.

CONCLUSION

Repair of recurrent hernia using the TEP approach can be achieved with minimum morbidity, good clinical outcomes and acceptable recurrence rates. Endoscopic repair has become the procedure of choice for the treatment of the majority of recurrent inguinal hernias at our institution.

Do various mesh placement techniques affect the outcome in totally extraperitoneal hernia repair? What is the role of the surgeon?

BACKGROUND

Various modifications of mesh placement are currently used in total extraperitoneal (TEP) groin hernia repair. The aim of this study was to compare three different variants of mesh placement with respect to rate of complications and clinical outcome.

METHODS

A series of 397 consecutive patients with a total of 534 preperitoneal groin hernia TEP repairs performed by four surgeons at a single institution between 1999 and 2003 were retrospectively analyzed. The mean follow-up was 19.7 +/- 7.5 months. A single-mesh technique was used in cases of hernial orifice <1.5 cm. Larger hernial defects were closed either in a double-mesh or a modified double-mesh placement technique. The three placement techniques were compared with respect to hospital stay, operative time, early and late complications, return-to-work time, and recurrence rate.

RESULTS

The modified double-mesh technique was associated with the longest hospital stay, the longest operative time, the slowest return to work, and significantly higher rates of early (5.6% vs. 4.6% vs. 2.9%) and late (19.1% vs. 11.3% vs. 7.9%) postoperative complications, when compared to double-and single-mesh placement. Overall recurrence rate was 1.3% after a mean follow-up of 19.7 months. The larger the experience of a surgeon with his preferred technique, the shorter the operative time and hospital stay were.

CONCLUSIONS

Mesh placement techniques appeared to have a direct impact on clinical outcome and hospital stay. The modified double-mesh technique showed the worst postoperative results, independent of the surgeon's experience. Which mesh placement technique is most appropriate for complex hernias remains to be answered by further randomized, controlled trials.

Preperitoneal herniation and bowel obstruction post laparoscopic inguinal hernia repair: case report and review of the literature

Laparoscopic inguinal hernia repairs, both transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP), are associated with peritoneal defects or tears. Nonclosure of the tears can lead to bowel obstruction. I present a case of an early (48 h) bowel obstruction related to a peritoneal defect post TAPP inguinal hernia repair. The literature on peritoneal closure and bowel obstruction related to laparoscopic inguinal hernia repair is reviewed as well as options for repairing defects.

Mesh erosion into caecum following laparoscopic repair of inguinal hernia (TAPP): a case report and literature review

Repair of inguinal hernia is the most commonly performed surgical procedure. Both open and laparoscopic methods are accepted modalities of surgical treatment. Transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) are the two types of laparoscopic repair of the inguineal hernia. The main advantages of laparoscopic repair, as compared to open repair, are a shorter hospital stay and a quicker recovery to normal activities. However, laparoscopic repairs are associated with a higher incidence of visceral and vascular injuries. One particular complication is the migration and erosion of mesh into the adjacent viscera. Although the total numbers of cases are small, compared to the total numbers of inguinal hernia repairs, they are important, as they often presented with a diagnostic dilemma. Most of the mesh migrations reported in the literature involves the urinary bladder. In this paper, we present a case of erosion of mesh into the caecum. The patient (a 66-year-old male) underwent TAPP repair of a right inguinal hernia in 1996 with polypropelene mesh. He also underwent an open appendicectomy in 1980. During the laparoscopic repair, he was found to have multiple intra-abdominal adhesions. He presented with intermittent diarrhea, for which he was investigated, and a benign caecal lesion was found. He was initially managed conservatively. However, his symptoms persisted and he underwent a right hemicolectomy in February 2006 in our hospital. The offending lesion was found to be the prolene mesh having eroded into the caecum.

Treating recurrence after a totally extraperitoneal approach

BACKGROUND

One of today's most highly regarded procedures for treating inguinal hernia is the totally extraperitoneal approach (TEP), but it can on occasion lead to recurrence. This is commonly managed with an open repair, a transabdominal preperitoneal procedure (TAPP), or another TEP. We report here on our years of experience with the latter.

METHODS

The endeavor to a secondary TEP is much the same as to a primary one, but certain differences are encountered as the operation proceeds. For example, many anatomical landmarks found in a first TEP cannot be seen in a second. There can also be a diminished amount of working space, and this occasionally leads to an open conversion.

RESULTS

From September 1991 to September 2005, we repaired 1,526 hernias in 1,156 male patients, using the TEP in every case. Of these, 21 were TEPs after a previous TEP. In 3 cases, the space could not be opened, and they were converted to the open Lichtenstein. One patient had peritoneal tears that led to conversion and another had conversion because of excessive bleeding. There were no complications, no bladder or bowel injuries, no transfusions, no preperitoneal hematomas, and no fatalities. All patients were discharged the same day.

CONCLUSIONS

A secondary TEP, open repair, and TAPP are alternative solutions to the problem of recurrence after TEP. However, any TEP involves a very prolonged learning curve for general surgeons, since they must learn the anatomy as well as the procedure, both at the same time. This is doubly true for the TEP after a previous TEP.

Avoidable mortality across Canada from 1975 to 1999

BACKGROUND

The concept of 'avoidable' mortality (AM) has been proposed as a performance measure of health care systems. In this study we examined mortality in five geographic regions of Canada from 1975 to 1999 for previously defined avoidable disease groups that are amenable to medical care and public health. These trends were compared to mortality from other causes.

METHODS

National and regional age-standardized mortality rates for ages less than 65 years were estimated for avoidable and other causes of death for consecutive periods (1975-1979, 1980-1985, 1985-1989, 1990-1994, and 1995-1999). The proportion of all-cause mortality attributable to avoidable causes was also determined.

RESULTS

From 1975-1979 to 1995-1999, the AM decrease (46.9%) was more pronounced compared to mortality from other causes (24.9%). There were persistent regional AM differences, with consistently lower AM in Ontario and British Columbia compared to the Atlantic, Quebec, and Prairies regions. This trend was not apparent when mortality from other causes was examined. Injuries, ischaemic heart disease, and lung cancer strongly influenced the overall AM trends.

CONCLUSION

The regional differences in mortality for ages less than 65 years was attributable to causes of death amenable to medical care and public health, especially from causes responsive to public health.