The cutaneous nerves encountered during laparoscopic repair of inguinal hernia: new anatomical findings for the surgeon

Suturing Versus Adhesion for Mesh Fixation in Ventral Hernia Repair and Abdominal Wall Reconstruction: A Systematic Review and Network Meta-Analysis

Abdominal wall reconstruction (AWR) is a surgical procedure performed to address various conditions such as hernias, incisional hernias, and complex abdominal wall defects. Mesh fixation plays a crucial role in providing mechanical reinforcement to the weakened abdominal wall during AWR. Traditionally, suturing has been the preferred method for mesh fixation; however, adhesion techniques using tissue adhesives or glues have gained attention as an alternative approach. This systematic review aims to compare suturing and adhesion techniques for mesh fixation in AWR and assess their effectiveness in preventing hernia recurrence. A comprehensive literature search was conducted across relevant databases, including PubMed, MEDLINE, Embase, and the Cochrane Library. Studies that fulfilled the predetermined eligibility criteria were included. The primary outcome measure of interest was hernia recurrence rates. Secondary outcomes included mesh-related complications, surgical site infections, patient-reported outcomes, and functional outcomes. A risk of bias assessment was performed for the included studies, and data were synthesized qualitatively. Overall, the results of the included studies suggest that atraumatic mesh fixation with glue may have the potential to reduce chronic groin pain (CGP). However, there were significant variations in patient selection criteria, glue administration techniques, and hernia repair methods among the trials, which limited the ability to draw definitive conclusions. Additionally, the definitions of CGP and measurement scales for postoperative pain varied across studies, making it challenging to compare outcomes. The limitations of the review include the small sample sizes in some trials, relatively short follow-up durations, and the lack of standardized criteria for assessing variables such as foreign body sensation and groin compliance. Furthermore, the economic implications of using glue fixation compared to traditional suture fixation need to be considered.

Standardization and learning curve in laparoscopic hernia repair: experience of a high-volume center

PURPOSE

Groin hernias are a common condition that can be treated with various surgical techniques, including open surgery and laparoscopic approaches. Laparoscopic surgery has several advantages but its use is limited due to the complexity of the posterior inguinal region and the need for advanced laparoscopic skills. This paper presents a standardized and systematic approach to trans-abdominal pre-peritoneal (TAPP) groin hernioplasty, which is useful for training young surgeons.

METHODS

The paper provides a detailed, step-by-step description of the TAPP based on evidence from literature, anatomical knowledge, and the authors' experience spanning over 30 years. The sample includes 487 hernia repair procedures, with 319 surgeries performed by experienced surgeons and 168 surgeries performed by young surgeons in training. The authors performed a descriptive analysis of their data to provide an overview of the volume of laparoscopic hernioplasty performed.

RESULTS

The analysis of the data shows a low complication rate of 0.41% (2/487) and a low recurrence rate of 0.41% (2/487). The median duration of the surgery was 55 min, while the median operation time for surgeons in training was 93 min, specifically 83 min for unilateral hernia and 115 min for bilateral hernia.

CONCLUSIONS

The TAPP procedure appears, to date, comparable to the open inguinal approach in terms of recurrence, postoperative pain and speed of postoperative recovery. In this paper, the authors challenge the belief that TAPP is not suitable for surgeons in training. They advocate for a training pathway that involves gradually building surgical skills and expertise. This approach requires approximately 100 procedures to achieve proficiency.

Anatomical peculiarities of dissection in the transabdominal preperitoneal procedure for inguinal hernias

Inguinal hernia, a common surgical pathology, has substantial medical, social, and economic implications. Over time, various repair techniques have been explored to optimize outcomes, considering multiple postoperative factors beyond recurrence risk. This article aims to define anatomical and technical aspects impacting the immediate and late postoperative evolution of patients with inguinal hernia. Precise knowledge of anatomical structures and standardized surgical gestures result in the reduction of intraoperative and postoperative complications. Throughout history, the alloplastic procedure has demonstrated superiority over the anatomical approach, reinforcing the potential for ongoing advancements. Correct performance according to well-defined principles improves patients' quality of life after inguinal hernia surgery. These principles encompass the exact knowledge of anatomy, dissection steps, dissection limits, the sequence of dissection, and the prosthetic materials used. We describe our approach, with the laparoscopic method representing over 90% of cases at our clinic, indicating the shift towards minimally invasive techniques and emphasizing adherence to rigorous principles to achieve low perioperative complications.

Diagnosis and Treatment of Inguinal Hernias after Surgical Treatment of Prostate Cancer, Current State of the Problem

(1) Purpose: To compare and evaluate the immediate and long-term results of the use of various hernioplasties for the treatment of inguinal hernias after surgical treatment of prostate cancer; to determine the possibility of performing transabdominal preperitoneal (TAPP) hernioplasty and total extraperitoneal (eTEP) hernioplasty in patients with inguinal hernia during surgical treatment of prostate cancer. (2) Method: This study is a clinical analytical prospective study, without the use of randomization. The study included 220 patients with inguinal hernia, who were randomly divided into two groups (group A (n = 100) and group B (n = 120)). Patients in group A received eTEP, and those in group B received TAPP. The end points of the study were the results associated with the operation itself and the prognosis of the disease in the two groups. (3) Results: Group A: five patients had a scrotal hematoma, in 10 cases nosocomial pneumonia or infectious complications from the postoperative wound. The overall rate of early postoperative complications was 15%. In group B, the following postoperative complications were reported: one case of intestinal injury, six cases of acute urinary retention, eight cases of scrotal hematoma and 12 cases of nosocomial pneumonia or infectious complications from the postoperative wound were admitted. The overall incidence of early postoperative complications was 22.5%. There was no statistically significant difference in the incidence of postoperative complications between the two groups (χ2 (3) = 2.54, p > 0.05). (4) Conclusion: During the analysis of the obtained results, no statistically significant difference was found in the duration of hospitalization, the volume of blood loss, the severity of pain syndrome, postoperative complication incidence and recurrence incidence (p > 0.05); however, the comparison groups differed in the duration of the operation: the operation time in group A was much longer compared to group B (p < 0.05).

The transition from open to laparoscopic surgery for bilateral inguinal hernia repair: how we did it

PURPOSE

To describe the transition process from open repair (OR) to laparoscopic repair (LR) of bilateral inguinal hernia in a small basic general hospital METHODS: We describe the technical details and training strategy used to facilitate the transition to systematic LR of bilateral inguinal hernia. We conducted a retrospective analysis of prospectively collected data from all patients undergoing bilateral inguinal hernia repair between January 2017 and December 2020. We analysed the evolution of LR and compared the surgical outcomes: complications, acute pain (24 h), chronic pain (> 3 months), and recurrence (1 year) of the patients operated on by OR and LR.

RESULTS

We performed 132 bilateral inguinal hernia repairs, 55 (41.7%) ORs, and 77 (58.3%) LRs. A significant difference was observed in the choice of LR over time (2017: 9%, 2018: 32%, 2019: 75%, 2020: 91%, p < 0.001). The mean operative time was shorter in the OR group than in the LR group (56 min vs. 108 min, p < 0.001). However, the operative time of the LR decreased over the years. No significant differences were observed in complications or recurrence. LR was associated with lower acute postoperative pain at 24 h (2.2 vs. 3.1 points, p = 0.021) and lower chronic groin pain than OR (1.3% vs. 12.7%, p = 0.009).

CONCLUSION

A structured and systematized training process made the transition from OR to LR of bilateral inguinal hernias feasible and safe in a small basic general hospital. This transition did not increase complications or recurrence. Additionally, LR was associated with a decrease in postoperative pain and chronic groin pain.

Robotic hernia surgery I. English version : Robotic inguinal hernia repair (r‑TAPP). Video report and results of a series of 302 hernia operations

The treatment of inguinal hernias with open and minimally invasive procedures has reached a high standard in terms of outcome over the past 30 years. However, there is still need for further improvement, mainly in terms of reduction of postoperative seroma, chronic pain, and recurrence. This video article presents the endoscopic anatomy of the groin with regard to robotic transabdominal preperitoneal patch plasty (r‑TAPP) and illustrates the surgical steps of r‑TAPP with respective video sequences. The results of a cohort study of 302 consecutive hernias operated by r‑TAPP are presented and discussed in light of the added value of the robotic technique, including advantages for surgical training. r‑TAPP is the natural evolution of conventional TAPP and has the potential to become a new standard as equipment availability increases and material costs decrease. Future studies will also have to refine the multifaceted added value of r‑TAPP with new parameters.

[Robotic hernia surgery : Part I: Robotic inguinal hernia repair (r‑TAPP). Video report and results of a series of 302 hernia operations]

The treatment of inguinal hernias with open and minimally invasive procedures has reached a high standard in terms of outcome over the past 30 years. However, there is still need for further improvement, mainly in terms of reduction of postoperative seroma, chronic pain, and recurrence. This video article presents the endoscopic anatomy of the groin with regard to robotic transabdominal preperitoneal patch plasty (r‑TAPP) and illustrates the surgical steps of r‑TAPP with respective video sequences. The results of a cohort study of 302 consecutive hernias operated by r‑TAPP are presented and discussed in light of the added value of the robotic technique, including advantages for surgical training. r‑TAPP is the natural evolution of conventional TAPP and has the potential to become a new standard as equipment availability increases and material costs decrease. Future studies will also have to refine the multifaceted added value of r‑TAPP with new parameters.

Fascinating history of groin hernias: Comprehensive recognition of anatomy, classic considerations for herniorrhaphy, and current controversies in hernioplasty

Groin hernias include indirect inguinal, direct inguinal, femoral, obturator, and supravesical hernias. Here, we summarize historical turning points, anatomical recognition and surgical repairs. Groin hernias have a fascinating history in the fields of anatomy and surgery. The concept of tension-free repair is generally accepted among clinicians. Surgical repair with mesh is categorized as hernioplasty, while classic repair without mesh is considered herniorrhaphy. Although various surgical approaches have been developed, the surgical technique should be carefully chosen for each patient. Regarding as interesting history, crucial anatomy and important surgeries in the field of groin hernia, we here summarized them in detail, respectively. Points of debate are also reviewed; important points are shown using illustrations and schemas. We hope this systematic review is surgical guide for general surgeons including residents. Both a skillful technique and anatomical knowledge are indispensable for successful hernia surgery in the groin.

Crucial anatomy and technical cues for laparoscopic transabdominal preperitoneal repair: Advanced manipulation for groin hernias in adults

Groin hernias include indirect inguinal, direct inguinal, and femoral hernias. Obturator and supravesical hernias appear very close to the groin. High-quality repairs are required for groin hernias. The concept of "tension-free repair" is generally accepted, and surgical repairs with mesh are categorized as "hernioplasties". Surgeons should have good knowledge of the relevant anatomy. Physicians generally focus on the preperitoneal space, myopectineal orifice, topographic nerves, and regional vessels. Currently, laparoscopic surgery has therapeutic potential in the surgical setting for hernioplasty, with laparoscopic transabdominal preperitoneal (TAPP) repair appearing to be a powerful tool for use in adult hernia patients. TAPP offers the advantages of accurate diagnoses, repair of bilateral and recurrent hernias, less postoperative pain, early recovery allowing work and activities, tension-free repair of the preperitoneal (posterior) space, ability to cover obturator hernias, and avoidance of potential injury to the spermatic cord. The disadvantages of TAPP are the need for general anesthesia, adhering to a learning curve, higher cost, unexpected complications related to abdominal organs, adhesion to the mesh, unexpected injuries to vessels, prolonged operative time, and as-yet-unknown long-term outcomes. Both technical skill and anatomical familiarity are important for safe, reliable surgery. With increasing awareness of the importance of anatomy during TAPP repair, we address the skills and pitfalls during laparoscopic TAPP repair in adult patients using illustrations and schemas. We also address debatable points on this subject.

Primary unilateral not complicated inguinal hernia: our choice of TAPP, why, results and review of literature

BACKGROUND

Currently, three different techniques are favored for repair of an inguinal hernia: (1) The suture repair described by Shouldice. (2) An open mesh repair according to Lichtenstein. (3) Laparo-endoscopic techniques TAPP and TEP. The aim of the presented paper was to describe the ranking of the Transabdominal Preperitoneal Patch Plasty (TAPP) in comparison to the other techniques for inguinal hernia repair.

METHODS

The manuscript is based on the experiences gained in more than 15,000 TAPPs and numerous own studies as well. The technique of TAPP is described in detail and also the results which can be achieved with special reference to primary unilateral inguinal hernias in male patients. Moreover, a systematic review of the literature is done for the comparison with the other techniques.

RESULTS

According to own experiences, 98% of all patients with an inguinal hernia admitted for surgery to Marienhospital Stuttgart could be operated on using the TAPP technique. The recurrence rate and the rate of severe chronic pain in this setting were below 1%. Due to the limited quality of most of the published studies an evidence-based comparison which is the best of the currently most recommended techniques is questionable. Therefore, when comparing TAPP with TEP, no definite conclusion about superiority of one technique over the other is possible. Both techniques are safe and effective if properly performed. The guidelines recommend that the surgeon should use the technique he had learned best and is familiar with. The comparison between TAPP and the Shouldice repair shows less pain and a higher effectivity after TAPP. The recurrence rate after Lichtenstein repair and after TAPP is similar, but pain and recovery time are significantly less after TAPP.

CONCLUSION

Analyzing the own abundant experiences and the reports in the literature, the TAPP technique has the potential to become the standard operative technique for repair of inguinal hernias in future. However, due to the low level of evidence of most of the studies definite conclusions are difficult to draw at this point of time.

Essentials of surgical anatomy and technique in TAPP repair of inguinal hernia

Laparoscopic hernia repair has opened a new era in hernia surgery shifting paradigms from anterior to posterior approaches. This has exposed surgeons to new anatomical perspectives, technical challenges and clinical implications all of which preventing the technique from becoming ubiquitous despite numerous advantages, limited contraindications and low recurrence rates. In order to address the difficult learning curve of the laparoscopic transabdominal preperitoneal hernia repair this paper presents the experience and points of view from a tertiary surgical department on the systematization of anatomical concepts pertinent to the TAPP repair technique, a decalogue of suggestions related to the surgical technique and a short reminder of the most common complications and how to avoid them. Revising the anatomy essentials and proposing a decalogue of the surgical technique and a memento on the most common complications will provide young surgeons with a scaffold of basic knowledge on TAPP hernia repair.

Retroperitoneal anatomy of the iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous nerve: consequences for prevention and treatment of chronic inguinodynia

PURPOSE

Chronic inguinodynia is one of the most frequent complications after groin herniorrhaphy. We investigated the retroperitoneal anatomy of the iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous nerve to prevent direct nerve injury during hernia repairs and to find the most advantageous approach for posterior triple neurectomy.

METHODS

We dissected the inguinal nerves in 30 human anatomic specimens bilaterally. The distances from each nerve and their entry points in the abdominal wall were measured in relation to the posterior superior iliac spine, anterior superior iliac spine, and the midpoint between the two iliac spines on the iliac crest. We evaluated our findings by creating high-resolution summation images.

RESULTS

The courses of the iliohypogastric and ilioinguinal nerve are most consistent on the anterior surface of the quadratus lumborum muscle. The genitofemoral nerve always runs on the psoas muscle. The entry points of the nerves in the abdominal wall are located as follows: the iliohypogastric nerve is above the iliac crest and lateral from the anterior superior iliac spine, the ilioinguinal nerve is with great variability, either above or below the iliac crest and lateral from the anterior superior iliac spine, the genital branch is around the internal inguinal ring, the femoral branch is either cranial or caudal to the iliopubic tract, and the lateral femoral cutaneous nerve is either medial or lateral to the anterior superior iliac spine.

CONCLUSION

Nerve injury during inguinal hernia repairs can be avoided by taking the topographic anatomy of the inguinal nerves into consideration. The most advantageous plane to look for the iliohypogastric and ilioinguinal nerve during posterior neurectomy is on the anterior surface of the quadratus lumborum muscle. For the surgical treatment of severe chronic inguinodynia, especially after posterior open or endoscopic mesh repair (TAPP/TEP), the retroperitoneoscopic or open retroperitoneal approach for posterior triple neurectomy can be considered.

Tacks-free transabdominal preperitoneal (TAPP) inguinal hernioplasty, using an anatomic 3-dimensional lightweight mesh with peritoneal suturing: pain and recurrence outcomes-initial experience

BACKGROUND

The emphasis for research in inguinal hernia repair has shifted from hernia recurrence to groin pain, which is considered the most important factor for poor quality of life.

AIM

: To evaluate hernia recurrences and pain at trocar site and at inguinal hernia site, in patients who underwent tacks-free transabdominal preperitoneal inguinal hernia repair, using a lightweight nonfixed 3-dimensional mesh with peritoneal suturing.

MATERIALS AND METHODS

Between 2009 and 2011, 32 patients (2 female) with mean age 51 years underwent hernia repair. The mean follow-up period was 12.4 months.

RESULTS

The mean operative time was 84 minutes. There was minimal blood loss. No bowel or urinary bladder injury had occurred. Mean hospital stay was 1 day. One patient developed seroma 4 months postoperatively. There were no conversions to open repair, no hernia recurrence, and no deaths. The mean value of pain at trocar site and inguinal hernia site 12 hours postoperatively was 1.469 and 0.875, respectively. The pain was more intense bearing a peak at 12 hours postoperatively at the trocar site, compared with the inguinal site.

CONCLUSIONS

It is demonstrated with this technique that there are no recurrences and the chronic pain is negligible. These findings call for confirmatory randomized trials in larger series with longer follow-up.

Neurophysiological characterization of persistent pain after laparoscopic inguinal hernia repair

PURPOSE

About 2-5% of patients undergoing laparoscopic inguinal repair experience persistent pain influencing everyday activities. However, compared with persistent pain after open repair, the combined clinical and neurophysiological characteristics have not been described in detail. Thus, the aim of the study was to describe and classify patients with severe persistent pain after laparoscopic herniorrhaphy.

METHODS

Eleven patients with severe persistent pain following laparoscopic inguinal herniorrhaphy were assessed in detail by their medical history, questionnaires (impairments of daily activities, pain description, psychological parameters, socio-economic status), physical examination, sensory mapping, and quantitative sensory testing.

RESULTS

The median time since operation was 2 years (range 1-14 years). Ten patients experienced pain in the inguinal region and five patients had pain outside the inguinal region. Based upon the clinical pain pattern and the detailed quantitative sensory testing, the patients could be separated into three different entities, suggesting different pathogenic mechanisms leading to the persistent pain state. Four patients experienced dysejaculation. Six patients were unemployed or retired due to the postherniorrhaphy pain.

CONCLUSIONS

These results suggest that patients with severe persistent pain after laparoscopic inguinal herniorrhaphy belong to distinctive subgroups with indicators of either neuropathic, inflammatory, or mechanical irritation from the mesh, or a combination of these symptoms. The findings of a number of pain localizations outside the inguinal region demarcate it from persistent pain following open groin hernia repair. A classification based on a larger study group is required in order to define mechanism-based treatment strategies.

Ultrasound-guided supra-inguinal fascia iliaca block: a cadaveric evaluation of a novel approach

Existing descriptions of ultrasound-guided fascia iliaca block focus on injection of local anaesthetic inferior to the inguinal ligament, relying on supra-inguinal spread to block the lateral femoral cutaneous nerve in the iliac fossa. In this study, we explored injectate spread and nerve involvement in a cadaveric dye-injection model, using a supra-inguinal ultrasound-guided technique that places local anaesthetic directly into the iliac fossa. Bilateral injections of 20 ml 0.25% aniline blue dye were made in six unembalmed cadavers. The femoral nerve was stained by the dye in all twelve injections. The lateral femoral cutaneous nerve was stained bilaterally in five cadavers, but the nerve was absent on both sides in the sixth cadaver. The ilio-inguinal nerve passed into the iliac fossa over the iliacus muscle in eight of the hemi-pelvi and was stained in seven of these occasions. We have performed more than 150 blocks in patients using this approach without complications. Injection using this technique in cadavers leads to extensive fluid spread throughout the iliac fossa. In patients this approach may allow a lower volume block of the femoral nerve and lateral femoral cutaneous nerve while still injecting at a distance from the femoral nerve.

Improved analgesia with the ilioinguinal block compared to the transversus abdominis plane block after pediatric inguinal surgery: a prospective randomized trial

BACKGROUND

Ultrasound-guided transversus abdominis plane (TAP) block has shown promise for analgesia after pediatric inguinal surgery. This prospective, randomized study tested the hypothesis that the TAP block would provide comparable analgesia after pediatric inguinal surgery compared with a conventional ultrasound-guided ilioinguinal block.

METHODS

After induction of general anesthesia, infants and children presenting for elective inguinal surgery were randomly assigned to receive an ultrasound-guided TAP block (needle cephalad of the iliac crest at the anterior axillary line) (n = 20) or ilioinguinal block (needle immediately anteromedial to the anterior superior iliac spine) (n = 21). Supplemental analgesia consisted of as-required intraoperative fentanyl, regular acetaminophen, as-required ibuprofen, and rescue morphine. Patients were assessed in the recovery room, the day-stay unit (30 min to 2 h after surgery) and at 24 h for age appropriate numerical pain score, analgesic consumption, and parental satisfaction.

RESULTS

In the day-stay unit, pain was more frequent (76% vs 45%, P = 0.040), and ibuprofen use was higher (62% vs 30%, P = 0.037) in the TAP group. Recovery room pain, morphine consumption and postdischarge ibuprofen use, comfort and satisfaction scores were similar between groups. Ultrasound image quality was poorer, and needle time under the skin was longer (median [interquartile range] 81 [66-120] vs 46 [40-51], P < 0.001) for the ilioinguinal group.

CONCLUSIONS

Following pediatric inguinal surgery, ilioinguinal block provides more effective analgesia than the TAP block.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Anatomical variations of the lumbar plexus: a descriptive anatomy study with proposed clinical implications

This study used dissection of 34 lumbar plexes to look at the prevalence of anatomical variations in the lumbar plexus and the six peripheral branches from the origin at the ventral roots of (T12) L1-L4 to the exit from the pelvic cavity. Prevalence of anatomical variation in the individual nerves ranged from 8.8-47.1% with a mean prevalence of 20.1%. Anatomical variations included absence of the iliohypogastric nerve, an early split of the genitofemoral nerve into genital and femoral branches, an aberrant segmental origin for the lateral femoral cutaneous nerve, bifurcation of the lateral femoral nerve prior to exiting the pelvic cavity, bifurcation of the femoral nerve into two to three slips separated by psoas major muscle fibers, the presence of a single anterior femoral cutaneous nerve rather than the normal presentation of two separate anterior femoral cutaneous branches, and the presence of an accessory obturator nerve. Comparison with relevant research literature showed a wide variation in reported prevalence of the anatomical variations noted in this study. Clinical implications and directions for future research are proposed.

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.

Laparoscopic transabdominal preperitoneal (TAPP) hernia repair: surgical phases and complications

BACKGROUND

This study aimed to determine the nature of complications after transabdominal preperitoneal (TAPP) hernia repair, and to evaluate possible links to intraoperative factors in an effort to reduce the incidence of complications.

METHODS

The TAPP procedures for inguinal/femoral hernias performed between 1992 and 2004 at a single center were analyzed retrospectively. Complications were categorized according to severity and stage of the surgical procedure at which they occurred. Individual surgeon performances were examined to determine whether the rates of complications were related to surgeon experience.

RESULTS

A total of 1,973 TAPP procedures were reviewed, and 81% of the patients completed 5 years of follow-up evaluation. The 74 complications (3.7%) reported were categorized as follows: 33 major (1.7%) versus 41 minor (2.0%), 66 hernia-related (3.4%) versus 8 laparoscopy-related (0.5%) complications, and 12 recurrences (0.6%). Risk factors for complications included inguinoscrotal hernia (p < or = 0.001), dissection/reduction of the sac (p = 0.02), and surgeon experience (< 50 TAPP procedures; odds ratio, 7.1; 95% confidence interval, 4.2-11.9).

CONCLUSIONS

Accuracy in dissection/reduction of the sac improves the outcome of TAPP hernia repair. This effect is related to the experience of the surgeon. Experience performing more than 75 procedures is required for optimal results.

Anatomical landmarks for the lumbar plexus on the posterior abdominal wall

OBJECT

Reports describing surgical landmarks with which to identify the branches of the lumbar plexus found on the posterior abdominal wall are lacking in the English-language literature.

METHODS

The authors examined 22 sides from six female and five male cadavers. Measurements were made between the branches of the lumbar plexus and various bone landmarks such as the midline vertebral bodies, supracristal plane--a horizontal line connecting the superior-most aspect of the left and right iliac crests approximating the LA-5 vertebrae--and anterior superior iliac spine (ASIS). The mean distances from the midline and as they emerged through or lateral to the psoas major muscle to the subcostal, iliohypogastric, ilioinguinal, lateral femoral cutaneous, genitofemoral, and femoral nerves, were 5.5, 6, 6.5, 6, 4.5, and 4.5 cm, respectively. At a vertical line through the midpoint between the ASIS and the midline, the subcostal, iliohypogastric, and ilioinguinal nerves were superior to the supracristal plane at mean distances of 8, 4, and 5 cm, respectively. Inferior to the supracristal plane and in a vertical line through a midpoint between the ASIS and the midline, the lateral femoral and femoral nerves were found to have mean distances of 5 and 5.5 cm, respectively. The obturator nerve had a mean distance of 3 cm lateral to the midline. Additionally, the lateral femoral cutaneous nerve had a mean distance of 1.5 cm inferomedial to the ASIS.

CONCLUSIONS

A good working knowledge of the locations and anatomy of the nerves of the lumbar plexus on the posterior abdominal wall is necessary for the surgeon who operates in this region. The measurements provided herein will aid the surgeon who wishes to expose or avoid these nerves, thus precluding injury.

Central and peripheral motor conduction to cremasteric muscle

The few electrophysiologic studies of the cremasteric muscle (CM) have mainly been restricted to the cremaster reflex with no reference to central and peripheral nerve conduction to the muscle, probably for technical reasons.Twenty-six normal adult male volunteers were studied by transcranial magnetic cortical stimulation (TMS) and stimulation of thoracolumbar roots. The genitofemoral nerve (GFN) was stimulated electrically at the anterior superior iliac spine and a needle electrode was inserted into the CM for conduction studies. The motor latency to the CM from the cortical TMS ranged from 20 to 33 ms among the subjects (25.8 +/- 2.9 ms, mean +/- SD). Magnetic stimulation of the lumbar roots produced a motor response of the CM within 9.6 +/- 1.9 ms (range, 6-15). The central motor conduction time to the CM was 16.5 +/- 2.8 ms (range, 10-21). Stimulation of the GFN produced a compound muscle action potential with a mean value of 6.4 +/- 1.8 (range, 4-10) ms in 23 of the 26 cases. Thus, central motor nerve fibers to the CM motor neurons exist, and there may be a representation area for the CM in the cerebral cortex. The GFN motor conduction time to the CM may have clinical utility, such as in the evaluation of the groin pain due to surgical procedures in the lower abdomen.

Electrophysiological evaluation of the genitofemoral nerve in patients with inguinal hernia

Groin pain in the lower abdomen but including the ilioinguinal region is frequent after inguinal hernia operations, but the integrity of the nerves in this region, including the genitofemoral nerve (GFN), has not been investigated. We studied GFN motor conduction time to the cremasteric muscle (CM), the CM electromyogram (EMG), and the CM reflex in 30 patients with unilateral inguinal hernia who underwent herniorrhaphy and in 26 similar patients who had no surgical intervention. Among the 30 patients undergoing herniorrhaphy, 14 (47%) showed motor involvement of the GFN, whereas 6 of the 26 (23%) patients not treated surgically had involvement of the GFN. These findings indicate that subclinical motor involvement of the GFN can be demonstrated by electrophysiological methods and is common after inguinal herniorrhaphy. Based on patient complaints, the herniated mass may also be responsible for motor involvement of the GFN in some patients before surgery.

Inguinodynia after two inguinal herniorrhaphy methods

The aim of this study was to compare the rate and characteristics of postoperative neuralgia after 2 methods of inguinal hernia repairs. Between July 1997 and December 2000, 400 inguinal hernia repairs were performed and followed up in a prospective trial about postoperative nerve irritations: 200 patients with laparoscopic transabdominal hernioplasty (TAPP group), and 200 patients with tension-free hernia repair using Lichtenstein's technique (LICH group). We applied a clinic protocol of data about pain location, neuralgia characteristics, and period of time until the patient was completely pain free. The global rate of nerve irritation in the study was 7.6% (30 cases); in the TAPP group, it was 5.5% (n = 11) and in the LICH group, it was 9.5% (n = 19) (P = .03). The genitofemoral nerve was affected with particularly high frequency (4.3% in the global series); although in laparoscopic repair, the lateral cutaneous nerve of the thigh (LFC) was most damaged (3.3% in TAPP group). We observed more persistent symptoms in LICH group, while in TAPP group the most of cases was transitory (P = .08). There were no significant differences in pain characteristics according to clinical type of hernia. The TAPP method causes less rate of postoperative inguinal neuralgia than Lichtenstein repair, emphasizing more persistent discomfort in anterior approach than laparoscopic repair.

Nerve injury after laparoscopic varicocelectomy

PURPOSE

Laparoscopic varicocelectomy is a minimally invasive option for varicoceles in children. Occasional reports of nerve injury after inguinal laparoscopic procedures have been published. There is anatomical variation in the sensory innervation of the anterior thigh and variable branching patterns of the nerves involved. We report a retrospective analysis of our patients, focusing on the incidence of sensory changes on the ipsilateral anterior thigh after laparoscopic varicocelectomy.

MATERIALS AND METHODS

The medical records of all patients who underwent laparoscopic varicocelectomy at 1 institution performed by 2 of us (YR and DV) from 1997 to 2002 were retrospectively reviewed. Demographics, outcomes and any postoperative sensory complications were obtained by chart review and telephone interview.

RESULTS

A total of 58 patients underwent laparoscopic varicocelectomy during this 5-year analysis and 51 with a total of 62 varicoceles were available for review. Three patients (4.8%) experienced transient numbness of the ipsilateral anterior thigh, which resolved or improved in an average of 8.0 months (range 6 to 9). Symptoms were not always noticed immediately postoperatively (range 0 to 10 days). In affected patients the sensory distribution was usually consistent with injury to the genitofemoral nerve.

CONCLUSIONS

Laparoscopic varicocelectomy is a minimally invasive procedure that still has the potential for complications. Cautery or harmonic dissection of the peritoneum overlying the spermatic cord and excessive traction on the tissues surrounding the cord should be avoided intraoperatively. Patients and surgeons should be aware of the possibility of nerve injury and the resultant sensory deficit.

Prevalence and severity of chronic groin pain after endoscopic totally extraperitoneal inguinal hernioplasty

BACKGROUND

Chronic groin pain after open inguinal hernia repair is a common long-term morbidity, but its incidence after endoscopic totally extraperitoneal inguinal hernioplasty (TEP) has not been studied in detail. The objective of this study was to evaluate the prevalence and severity of chronic groin pain after TEP.

METHODS

Between June 1999 and September 2001, 313 consecutive patients who underwent TEP at our institution were recruited. To evaluate the incidence and severity of chronic pain, a cross-sectional telephone survey using a standardized questionnaire was conducted by a research assistant. Clinical data between the chronic pain group and the pain-free group were compared to identify any clinical factors that had a significant association with the subsequent development of chronic groin pain.

RESULTS

The prevalence of chronic groin pain was 9.2% ( n = 24). The severity of the pain was mild ( n = 18), moderate ( n = 5), or severe ( n = 1). In more than half of the patients, the groin pain occurred less often than once a month and its duration did not exceed 1 min. Only one patient reported an impairment of functional activities as a result of the pain. Multivariate analyses identified a significant association between a high postoperative pain score on coughing on postoperative day 6 and the subsequent development of groin pain.

CONCLUSIONS

The prevalence of chronic groin pain in patients after TEP was low. The pain was mostly mild and transient without associated sensory symptoms. The occurrence of pain had a negligible impact on daily activities.