Simultaneous repair of bilateral inguinal hernias: a prospective, randomized study of open, tension-free versus laparoscopic approach

Laparoscopic Transabdominal Pre-peritoneal Repair of a Bilateral Inguinal Hernia in a Pediatric Female Patient in Pakistan: A Case Report

Inguinal hernias, although a common occurrence, pose a significant threat to the surgical community on account of their complexity and socioeconomic consequences. Bilateral inguinal hernias, which are a rare subtype of inguinal hernias, in particular, are problematic since there are no existing definitive international guidelines for their repair. It is estimated that between 8% and 30% of inguinal hernia patients have bilateral hernias, but there is still no clarity as to whether a bilateral hernia represents a special type of inguinal hernia or two different hernias in one patient. The transabdominal pre-peritoneal repair (TAPP), totally extra-peritoneal repair (TEP), and Lichtenstein repair techniques are commonly employed depending on the resources and surgical expertise available, but there is a need to conduct large-scale, prospective, randomized-controlled trials to guide the formation of evidence-based guidelines that could be followed globally. Herein, we present the first known case of a bilateral inguinal hernia in a female pediatric patient repaired by the laparoscopic TAPP technique from Pakistan.

Bilateral inguinal hernia repair by laparoscopic totally extraperitoneal (TEP) vs. laparoscopic transabdominal preperitoneal (TAPP)

BACKGROUND

The guidelines recommend laparoscopic repair for bilateral inguinal hernia. However, few studies compare the totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) techniques in bilateral inguinal hernias. This study aimed to compare the outcomes of TEP and TAPP in bilateral inguinal hernia.

METHODS

We conducted a retrospective cohort study of patients operated on for bilateral inguinal hernia by TEP and TAPP repair from 2016 to 2020. Intraoperative complications, operative time, acute postoperative pain, hospital stay, postoperative complications, chronic inguinal pain, and recurrence were compared.

RESULTS

A total of 155 patients were included in the study. TEP was performed in 71 patients (46%) and TAPP in 84 patients (54%). The mean operative time was longer in the TAPP group than in the TEP group (107 min vs. 82 min, p < 0.001). The conversion rate to open surgery was higher in the TEP group than in the TAPP group (8.5% vs. 0%, p = 0.008). The mean hospital stay was longer in the TAPP group than in the TEP group (p < 0.001). We did not observe significant differences in the proportion of postoperative complications (p = 0.672), postoperative pain at 24 h (p = 0.851), chronic groin pain (p = 0.593), and recurrence (p = 0.471). We did not observe an association between the choice of surgical technique (TEP vs. TAPP) with conversion rate, operative time, hospital stay, postoperative complications, chronic inguinal pain, or hernia recurrence when performing a multivariable analysis adjusted for the male sex, age, BMI, ASA, recurrent hernia repair, surgeon, and hernia size > 3cm.

CONCLUSIONS

Bilateral inguinal hernia repair by TEP and TAP presented similar outcomes in our study.

Trends and predictors of laparoscopic bilateral inguinal hernia repair in Spain: a population-based study

BACKGROUND

International guidelines currently recommend laparoscopy for bilateral inguinal hernia repair (BIHR). Our study aims to evaluate the trends and factors associated with the choice of laparoscopy for BIHR in Spain.

METHODS

We performed a retrospective analysis of patients undergoing BIHR between 2016 and 2019. We used the national database of the Spanish Ministry of Health: RAE-CMBD. We performed a univariate and multivariable logistic regression analysis to identify the factors associated with the utilization of laparoscopy. We identified perioperative complications and the factors associated with their occurrence through multivariable logistic regression analysis.

RESULTS

A total of 21,795 BIHRs were performed: 84% by open approach and 16% by laparoscopic approach. Laparoscopic approach increased from 12% in 2016 to 23% in 2019 (p < 0.001). The 40% of hospitals did not use laparoscopy, and only 8% of the hospitals performed more than 50% of their BIHRs by laparoscopy. The utilization rate of laparoscopy was not related to the number of BIHRs performed per year (p = 0.145). The main factor associated with the choice of laparoscopy in multivariable logistic regression analysis was the patient's region of residence (OR 2.04, 95% CI 1.88-2.21). Other factors were age < 65 years (OR 1.65, 95% CI 1.52-1.79) and recurrent inguinal hernia (OR 1.31, 95% CI 1.15-1.49). The type of approach for BIHR was not independently associated with perioperative complications.

CONCLUSIONS

Despite a significant increase in recent years, laparoscopic BIHR in Spain remains low. The main factor associated with the utilization of laparoscopy was the patient's region of residence; this factor seems to be related to the presence of hospitals with a high rate of laparoscopic approaches where the patient lives. The type of approach was not independently associated with perioperative complications. More efforts are needed to increase laparoscopic use in patients with bilateral inguinal hernias.

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.

Laparoscopic bilateral inguinal hernia repair: Should it be the preferred technique?

Inguinal hernias are amongst the most common conditions requiring general surgical intervention. For decades, the preferred approach was the open repair. As laparoscopy became more popular and available and more surgeons became familiarized with this modality, laparoscopic inguinal hernia repair became an alternative. The aim of this study is to assess the effectiveness of laparoscopic inguinal repair, with a focus on bilateral inguinal hernias. Initial reports have shown promising clinical outcomes compared to those of conventional repair of bilateral hernias. However, there are only a few studies concerning laparoscopic repair of bilateral hernias. It is yet to be proven that laparoscopy is the “gold standard” in the treatment of bilateral inguinal hernias. So far, the choice of an inguinal hernia repair technique has been up to each surgeon, depending on their expertise and available resources after taking into consideration each patient’s needs.

Contralateral exploration and repair of occult inguinal hernias during laparoscopic inguinal hernia repair: systematic review and Markov decision process

BACKGROUND

Contralateral clinically occult hernias are frequently noted at the time of laparoscopic unilateral inguinal hernia repair. There is no consensus on the role of contralateral exploration and repair. This systematic review assessed the safety and efficacy of operative repair of occult contralateral inguinal hernias found during unilateral repair.

METHODS

PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception to February 2020. Adults diagnosed with a unilateral inguinal hernia undergoing laparoscopic repair were included. The primary outcome was the incidence of occult contralateral hernias. Summative outcomes of operative and expectant management were reported along with development of a Markov decision process.

RESULTS

Thirteen studies (1 randomized trial, 12 observational cohorts) with 5000 patients were included. The incidence of occult contralateral inguinal hernias was 14.6 (range 7.3-50.1) per cent. Among patients who underwent repair, 10.5 (4.3-17.0) per cent experienced a postoperative complication. Of patients managed expectantly, 29 per cent later required elective repair for symptoms. Mean follow-up was 36 (range 2-218) months. Using a Markov decision process, it was calculated that, for every 1000 patients undergoing unilateral inguinal hernia repair, contralateral exploration would identify 150 patients with an occult hernia. Repair would result in 15 patients developing a postoperative complication and 105 undergoing unnecessary repair. Alternatively, expectant management would result in 45 patients requiring subsequent repair.

CONCLUSION

Contralateral repair is not warranted in patients with occult hernias diagnosed at the time of elective hernia repair. The evidence is largely based on observational studies at high risk of bias.

Laparoscopic versus open mesh repair of bilateral primary inguinal hernia: A three-armed Randomized controlled trial

PURPOSE

The best approach for simultaneous repair of bilateral inguinal hernia is controversial. The aim of this study is to compare the outcomes after laparoscopic versus open mesh repair of bilateral primary inguinal hernia.

METHODS

this prospective study included 180 patients with bilateral primary inguinal hernia; randomized by sealed envelopes into 3 groups; each includes 60 patients. Group I treated by laparoscopic trans-abdominal pre-peritoneal (TAPP) repair using 2 separate meshes, Group II treated by open pre-peritoneal (PP) single mesh repair, while Group III treated by bilateral Lichtenstein repair.

RESULTS

In comparison to open PP and bilateral Lichtenstein repair, Laparoscopic TAPP repair had significantly longer operative time and superior early postoperative outcomes including significantly less postoperative pain, hospital stay, time till return to normal activity and to work. Chronic groin pain and mesh sensation was lower in Laparoscopic TAPP group with significantly higher satisfaction rate compared to open groups. No significant difference between study groups in 3 years recurrence rate.

CONCLUSION

Simultaneous laparoscopic TAPP repair of uncomplicated primary bilateral inguinal hernia has superior early postoperative outcome, less chronic pain and higher patients' satisfaction rate compared to open approaches with similar low recurrence rate.

Return to outdoor walking, car driving, and sexual activity following elective inguinal hernia repair: surgeons' perspective versus patients' reality

PURPOSE

To determine the time to resumption of outdoor walking, car driving, sports, and sexual activity following elective inguinal hernia repair, and to reveal if there are differences between surgeons' recommendations and patients' real return times.

METHODS

A questionnaire including questions about recommendations to hernia patients for times to resume outdoor walking ability without assistance, driving and sexual intercourse after an elective inguinal hernia repair was sent to surgeons. Also, a short questionnaire was sent to patients who had undergone elective inguinal hernia repair to search the exact times for resuming these physical activities.

RESULTS

Surgeons' thoughts and recommendations to their patients varied significantly. The range of recommendations were same day to 20 days for outdoor walking, and same day to 3 months both for driving and sexual intercourse. Patients' actual resumption of postoperative activities were 1-14 days for outdoor walking, 1 day to 3 months for driving, and 1 day to 2 months for sexual intercourse. When the answers from the two questionnaires were compared, it was observed that the mean times for resumption of outdoor walking and sexual intercourse were significantly longer in the patients' lives than recommended by the surgeons. Patients ≥ 60 years were able to walk outside, drive, and participate in sexual activity earlier than the younger patients. Bilateral and recurrent hernia repairs caused slower resumption of different activities in comparison to primary hernias.

CONCLUSIONS

Patients reported that times for resumption of outdoor walking, driving, and sexual activity were significantly longer than those recommended by surgeons. Age, BMI, bilateral repair, and recurrent hernias were found to be factors affecting return time to different activities.

Laparoscopic transabdominal preperitoneal repair versus open mesh plug repair for bilateral primary inguinal hernia

AIM

A few studies comparing laparoscopic and open techniques have reported that open repair with mesh is the optimal operation for unilateral primary hernia. The aim of this study is to compare the outcomes of laparoscopic transabdominal preperitoneal repair (TAPP) versus open mesh plug repair (MP) for bilateral primary inguinal hernia.

METHODS

This was a retrospective study of 107 patients with bilateral primary inguinal hernia between January 2008 and December 2016. Of these patients, 49 underwent TAPP and 58 underwent MP. The surgical outcomes and the long-term outcomes using a questionnaire were compared between TAPP and MP.

RESULTS

In the TAPP group, the operation time was significantly longer (103 vs 91 minutes; P = .019). The postoperative complication rate was not significantly different between the two groups. One patient (1.0%) in the TAPP group and five patients (4.3%) in the MP group suffered recurrence (P = .30). Postoperative groin pain was not significantly different (14% in the TAPP group vs 31% in the MP group; P = .065), but more patients required analgesics in the MP group (4.1% vs 17%; P = .036). The long-term outcomes, according to a questionnaire, were not significantly different between the two groups. The median follow-up period was 22 (range, 0.4-52) months in the TAPP group and 40 (range, 0.5-108) months in the MP group (P < .001).

CONCLUSION

TAPP for bilateral primary inguinal hernia achieved better results than MP relative to postoperative pain and the use of medication for pain relief without increasing the complication and recurrence rates.

Current Concepts of Inguinal Hernia Repair

With more than 20 million patients annually, inguinal hernia repair is one of the most often performed surgical procedures worldwide. The lifetime risk to develop an inguinal hernia is 27-43% for men and 3-6% for women. In spite of all advances, 11% of all patients suffer from a recurrence and 10-12% from chronic pain following primary inguinal hernia repair. By developing evidence-based guidelines and recommendations, the international hernia societies aim to improve the outcome of inguinal hernia repair due to standardization of care. From a total of more than 100 different repair techniques for inguinal and femoral hernias, classified as tissue repair, open mesh repair, and laparo-endoscopic mesh repair, the new International Guidelines of the Hernia-Surge Group only recommend the totally extraperitoneal patch plasty (TEP), transabdominal preperitoneal patch plasty (TAPP), and Lichtenstein techniques. Since a generally accepted technique suitable for all inguinal hernias does not exist, surgeons should provide both an anterior open (Lichtenstein) and a posterior laparo-endoscopic (TEP or TAPP) approach option. The guidelines strongly recommend that surgeons tailor the treatment of inguinal hernias based on expertise, local/national resources, and patient- and hernia-related factors. A tailored approach in inguinal hernia repair should pay heed to the patient- and hernia-related factors, unilateral hernia in men and women, bilateral hernia, recurrent hernia, scrotal hernia, previous pelvic and lower abdominal surgery, severe cardiac or pulmonary comorbidities, and incarcerated hernia.

Perioperative outcome of unilateral versus bilateral inguinal hernia repairs in TAPP technique: analysis of 15,176 cases from the Herniamed Registry

Introduction

Following repair of a unilateral inguinal hernia, there is a risk of 1 % per year of onset of an inguinal hernia on the other side. Comparison of bilateral with unilateral TAPP operation in a high-volume center found that morbidity and reoperation rates were only marginally higher for bilateral TAPP operation. Some authors are calling for prophylactic operation of the contralateral side.

Methods

Between September 2009 and April 2013, data were entered into the Herniamed Registry on 15,176 patients who had undergone TAPP operation. Of these patients, 10,887 had been operated on because of a unilateral (71.7 %) and 4289 because of a bilateral (28.3 %) inguinal hernia.

Results

A significant difference was noted in the rate of postoperative complications occurring within 30 days, which was 4.9 % for bilateral compared with 3.9 % for unilateral inguinal hernia (p = 0.009). The postoperative complications necessitated reoperation in 0.9 % of patients after unilateral and in 1.9 % of patients after bilateral inguinal hernia repair, thus attesting to the significantly higher risk presented by bilateral inguinal hernia repair (p = <0.001).Multivariate analysis confirmed the highly significant influence of bilateral TAPP on increased reoperation rates due to complications (p > 0.0001). The odds ratio was 2.13 (95 % CI 1.58–2.86). Comparison of the results from a high-volume center with those from the Herniamed Registry showed that perioperative complication rates were markedly higher.

Conclusion

Perioperative outcome of bilateral TAPP operation demonstrates significantly worse postoperative complication and reoperation rates compared with unilateral TAPP. Likewise, the results were markedly unfavorable compared with those of a high-volume center. If a bilateral hernia repair should be attempted in those patients with only a unilateral hernia, these data give the surgeon more information on how to better prepare a patient and obtain consent preoperatively.

Common postoperative findings unique to laparoscopic surgery

The interpretation of images obtained in patients who have recently undergone abdominal or pelvic surgery is challenging, in part because procedures that were previously performed with open surgical techniques are increasingly being performed with minimally invasive (laparoscopic) techniques. Thus, it is important to be familiar with the normal approach used for laparoscopic surgeries. The authors describe the indications for various laparoscopic surgical procedures (eg, cholecystectomy, appendectomy, hernia repair) as well as normal postoperative findings. For example, port site hernias are more commonly encountered in patients with trocar sites greater than 10 mm and occur at classic entry sites (eg, the periumbilical region). Similarly, preperitoneal air can be encountered postoperatively, often secondary to trocar dislodgement during difficult entry or positioning. In addition, intraperitoneal placement of mesh during commonly performed ventral or incisional hernia repairs typically leads to postoperative seroma formation. Familiarity with normal findings after commonly performed laparoscopic surgical procedures in the abdomen and pelvis allows accurate diagnosis of common complications and avoidance of diagnostic pitfalls.

Resultados da herniorrafia inguinal bilateral simultânea pela técnica de Lichtenstein

OBJETIVO: analisar os resultados da herniorrafia inguinal bilateral pela técnica de Lichtenstein. MÉTODOS: estudo dos prontuários de 59 pacientes submetidos à herniorrafia inguinal bilateral simultânea, eletiva, no período entre 2003 e 2007. Foram analisados: sexo, idade, peso, tempo operatório, tempo total de internação, classificação de Nyhus, intercorrências no pós-operatório imediato e tardio, e recidiva. Esses dados foram submetidos à análise estatística descritiva. RESULTADOS: dos 59 pacientes, 95% eram homens; e 5%, mulheres. A idade variou de 40 a 60 anos, o peso de 50 a 103 kg, o tempo operatório de 60 a 180 minutos, o tempo de internação de um a seis dias. Trinta pacientes apresentavam hérnias do tipo IIIB; nove, do tipo II; dez, do tipo IIIA; sete, do tipo IV; um, do tipo II à esquerda e tipo IIIB à direita; um, tipo IIIA à direita e IIIB à esquerda; e um, do tipo IIIA à direita e do tipo II à esquerda. No pós-operatório imediato, a dor foi a manifestação mais importante em 30,5% dos casos. Em 94,92% dos casos, não houve complicações tardias. Ocorreram dois casos de inguinodinia e um de dor em queimação local. Observou-se uma recidiva, no 29º mês de pós-operatório. CONCLUSÕES: a herniorrafia inguinal bilateral simultânea pela técnica de Lichtenstein foi segura e eficaz, pois houve baixo índice de complicações, curta permanência hospitalar e, em um período médio de 48 meses de acompanhamento, houve apenas um caso de recidiva.

Which is the best laparoscopic approach for inguinal hernia repair: TEP or TAPP? A systematic review of the literature with a network meta-analysis

BACKGROUND

Totally extraperitoneal (TEP) repair and transabdominal preperitoneal (TAPP) repair are the most used laparoscopic techniques for inguinal hernia treatment. However, many studies have shown that laparoscopic hernia repair compared with open hernia repair (OHR) may offer less pain and shorter convalescence. Few studies compared the clinical efficacy between TEP and TAPP technique. The purpose of this study is to provide a comparison between TEP and TAPP for inguinal hernia repair to show the best approach.

METHODS

We performed an indirect comparison between TEP and TAPP techniques by considering only randomized, controlled trials comparing TEP with OHR and TAPP with OHR in a network meta-analysis. We considered the following outcomes: operative time, postoperative complications, hospital stay, postoperative pain, time to return to work, and recurrences.

RESULTS

The two techniques improved some short outcomes (such as time to return to work) with respect to OHR. In the network meta-analysis, TEP and TAPP were equivalent for operative time, postoperative complications, postoperative pain, time to return to work, and recurrences, whereas TAPP was associated with a slightly longer hospital stay compared with TEP.

CONCLUSIONS

TEP and TAPP improved clinical outcomes compared with OHR, but the network meta-analysis showed that TEP and TAPP efficacy is equivalent. TAPP was associated with a slightly longer hospital stay compared with TEP.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Laparoscopic inguinal hernia repair: gold standard in bilateral hernia repair? Results of more than 2800 patients in comparison to literature

BACKGROUND

Advantages and disadvantages of open and endoscopic hernia surgery are still being discussed. Until now there has been no study that evaluated the advantages and disadvantages of bilateral hernia repair in a large number of patients.

METHODS

Our prospectively collected database was analyzed to compare the results of laparoscopic bilateral with laparoscopic unilateral hernia repair. We then compared these results with the results of a literature review regarding open and laparoscopic bilateral hernia repair.

RESULTS

From April 1993 to December 2007 there were 7240 patients with unilateral primary hernia (PH) and 2880 patients with bilateral hernia (5760 hernias) who underwent laparoscopic transabdominal preperitoneal patch plastic (TAPP). Of the 10,120 patients, 28.5% had bilateral hernias. Adjusted for the number of patients operated on, the mean duration of surgery for unilateral hernia repair was shorter than that for bilateral repair (45 vs. 70 min), but period of disability (14 vs. 14 days) was the same. Adjusted for the number of hernias repaired, morbidity (1.9 vs. 1.4%), reoperation (0.5 vs. 0.43%), and recurrence rate (0.63 vs. 0.42%) were similar for unilateral versus bilateral repair, respectively. The review of the literature shows a significantly shorter time out of work after laparoscopic bilateral repair than after the bilateral open approach.

CONCLUSIONS

Simultaneous laparoscopic repair of bilateral inguinal hernias does not increase the risk for the patient and has an equal length of down time compared with unilateral repair. According to literature, recovery after laparoscopic repair is faster than after open simultaneous repair. Laparoscopic/endoscopic inguinal hernia repair of bilateral hernias should be recommended as the gold standard.

Laparoscopic versus open inguinal hernia repair

Inguinal hernias are common, with a lifetime risk of 27% in men and 3% in women. Inguinal hernia repair is one of the most common operations in general surgery. Despite more than 200 years of experience, the optimal surgical approach to inguinal hernia remains controversial. Surgeons and patients face many decisions when it comes to inguinal hernias: repair or no repair, mesh or no mesh, what kind of mesh, open or laparoscopic, extraperitoneal or transabdominal, and so forth. Inguinal hernia repairs have morbidity and recurrence rates that are not inconsequential. The search for the gold standard of repair continues.

Laparoscopic inguinal hernia repair

The safest and most effective inguinal hernia repair (laparoscopic versus open mesh) is being debated. As the authors point out, the former accounts for the minority of hernia repairs performed in the United States and around the world. The reasons for this are a demonstration in the literature of increased operative times, increased costs, and a longer learning curve. But the laparoscopic approach has clear advantages, including less acute and chronic postoperative pain, shorter convalescence, and earlier return to work. This article describes the transabdominal preperitoneal and totally extraperitoneal techniques, provides indications and contraindications for laparoscopic repair, discusses the advantages and disadvantages of each technique, and provides an overview of the literature comparing tension-free open and laparoscopic inguinal hernia repair.

[Inguinal hernia repair: results of randomized clinical trials and meta-analyses]

This evidence-based review of the literature aims to answer two questions regarding inguinal hernia repair: 1. should a prosthetic patch be used routinely? 2. Which approach is better - laparoscopic or open surgery? After a comprehensive search of electronic databases we retained only meta-analyses (n=14) and/or randomised clinical trials (n=4). Review of this literature suggests with a good level of evidence that prosthetic hernia repair is the gold standard; the laparoscopic approach has very few proven benefits and may involve more serious complications when performed outside expert centers. The role of laparoscopy for the repair of bilateral or recurrent hernias needs better evaluation.

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.

Surgical management of inguinal hernia

The Lichtenstein repair is now the gold standard for open hernia repairs. This repair is easier to learn and easy to implement for the average general surgeon. Open mesh repairs are not the end-all in hernia operations, however, and surgeons must retain the knowledge for open tissue-based procedures. Laparoscopic inguinal hernia repair is a safe alternative to open repair for inguinal hernias but is much more operator dependent. Open mesh repair has a lower recurrence rate when compared with TEP or TAPP repairs for less experienced laparoscopists. Laparoscopic repair has a quicker return to work, is associated with less postoperative pain, and has a better cosmetic result. It is more difficult to learn, however, and hospital costs are higher. Surgeons need to look at their own numbers and experience to decide which approach is better given the clinical situation based on their proficiency with the various techniques.

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

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

Simultaneous repair of bilateral inguinal hernias: a prospective, randomized study of single versus double mesh laparoscopic totally extraperitoneal repair

The aim of this study was to compare the double and the single mesh techniques, both used in the laparoscopic totally extra peritoneal (TEP) repair of bilateral inguinal hernia. Sixty-five patients with bilateral inguinal hernia were enrolled in a prospective, randomized trial comparing the single and the double mesh techniques. The single and the double mesh techniques compared favorably in terms of operating time, long-term morbidity, hospital stay, time for return to work, postoperative quality of life and recurrence rate. However, the cost of a single, large prosthesis was 38% to 40% lower than that of 2 small ones. The laparoscopic TEP repair of bilateral inguinal hernia with a large, single prosthetic mesh is a technically simple and safe procedure, which offers clear cost savings and a potentially shorter operating time over the double mesh repair. It is strongly recommended for the routine, laparoscopic TEP repair of bilateral inguinal hernias.

Laparoscopic Inguinal Hernia Repair

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

Cure chirurgicale des hernies inguinales de l’adulte

Inguinal hernia repair is the most commonly performed surgical procedure. Nearly one out of three men between 20 and 60 years of age will undergo hernia repair. Multiple surgical techniques are available which have comparable clinical outcomes but which differ in their functional results and economic impact. Despite an extensive surgical literature, no consensus exists regarding an optimal technique. This review aims to compare the indications for the three most common techniques: 1) the Shouldice repair, 2) the Lichtenstein repair, and 3) the laparoscopic hernia repair. To begin with, we present the operative principals of each repair along with criteria for evaluation of outcomes. Evidence-based outcomes data are then presented. We then address the choice of a surgical technique for everyday practice based on these factors. Finally, we propose avenues for future clinical research which may improve clinical, functional, and economic results in the repair of inguinal hernia of the adult.

Prospective nationwide analysis of laparoscopic versus Lichtenstein repair of inguinal hernia

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

For the scientific evaluation of the endoscopic and open mesh techniques for the repair of inguinal hernia, meta-analyses of randomized controlled trials (RCT) are necessary. The Lichtenstein repair is one of the most common open mesh techniques and therefore of special interest.

METHODS

After an extensive search of the literature and a quality assessment, a total of 34 RCT comparing endoscopic procedures both transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP)--with various open mesh repairs were deemed to be suitable for a formal meta-analysis of the relevant parameters. These studies included data for 7,223 patients. Trials that used the Lichtenstein repair for the control group (23 of 34 trials) were analyzed-separately.

RESULTS

Significant advantages for the endoscopic procedures compared with the Lichtenstein repair include a lower incidence of wound infection (Peto odds ratio, 0.39; 95% confidence interval, 0.26, 0.61), a reduction in hematoma formation (0.69 [0.54, 0.90]) and nerve injury (0.46 [0.35, 0.61]), an earlier return to normal activities or work (-1.35[-1.72, -0.97]), and fewer incidences of chronic pain syndrome (0.56[0.44, 0.70]). No difference was found in total morbidity or in the incidence of intestinal lesions, urinary bladder lesions, major vascular lesions, urinary retention and testicular problems. Significant advantages for the Lichtenstein repair include in a shorter operating time (5.45[1.18, 9.73]), a lower incidence of seroma formation (1.42[1.13, 1.79]), and fewer hernia recurrences (2.00[1.46, 2.74]). Similar results are seen when endoscopic procedures are compared with other open mesh repairs. However, in this comparison, total morbidity was lower with the endoscopic operations (0.73[0.61, 0.89]). The incidence of seroma formation, chronic pain syndromes, and hernia recurrence was not significantly different.

CONCLUSION

Endoscopic repairs do have advantages interms of local complications and pain-associated parameters. For more detailed evaluation further well-structured trials with improved standardization of hernia type, operative technique, and surgeons' experience are necessary.

Evaluation of quality of life after laparoscopic surgery: evidence-based guidelines of the European Association for Endoscopic Surgery

BACKGROUND

Measuring health-related quality of life (QoL) after surgery is essential for decision making by patients, surgeons, and payers. The aim of this consensus conference was twofold. First, it was to determine for which diseases endoscopic surgery results in better postoperative QoL than open surgery. Second, it was to recommend QoL instruments for clinical research.

METHODS

An expert panel selected 12 conditions in which QoL and endoscopic surgery are important. For each condition, studies comparing endoscopic and open surgery in terms of QoL were identified. The expert panel reached consensus on the relative benefits of endoscopic surgery and recommended generic and disease-specific QoL instruments for use in clinical research.

RESULTS

Randomized trials indicate that QoL improves earlier after endoscopic than open surgery for gastroesophageal reflux disease (GERD), cholecystolithiasis, colorectal cancer, inguinal hernia, obesity (gastric bypass), and uterine disorders that require hysterectomy. For spleen, prostate, malignant kidney, benign colorectal, and benign non-GERD esophageal diseases, evidence from nonrandomized trials supports the use of laparoscopic surgery. However, many studies failed to collect long-term results, used nonvalidated questionnaires, or measured QoL components only incompletely. The following QoL instruments can be recommended: for benign esophageal and gallbladder disease, the GIQLI or the QOLRAD together with SF-36 or the PGWB; for obesity surgery, the IWQOL-Lite with the SF-36; for colorectal cancer, the FACT-C or the EORTC QLQ-C30/CR38; for inguinal and renal surgery, the VAS for pain with the SF-36 (or the EORTC QLQ-C30 in case of malignancy); and after hysterectomy, the SF-36 together with an evaluation of urinary and sexual function.

CONCLUSIONS

Laparoscopic surgery provides better postoperative QoL in many clinical situations. Researchers would improve the quality of future studies by using validated QoL instruments such as those recommended here.

Functional imaging of the human trigeminal system: Opportunities for new insights into pain processing in health and disease

Peripheral inflammation or nerve damage result in changes in nervous system function, and may be a source of chronic pain. A number of animal studies have indicated that central neural plasticity, including sensitization of neurons within the spinal cord and brain, is part of the response to nervous system insult, and can result in the appearance of altered sensation, including pain. It cannot be assumed, however, that data obtained from animal models unambiguously reflects CNS changes that occur in humans. Currently, the only noninvasive approach to determining objective changes in neural processing and responsiveness within the CNS in humans is the use of functional imaging techniques. It is now possible to use functional magnetic resonance imaging (fMRI) to measure CNS activation in the trigeminal ganglion, spinal trigeminal nucleus, the thalamus, and the somatosensory cortex in healthy volunteers, in a surrogate model of hyperalgesia, and in patients with trigeminal pain. By offering a window into the temporal and functional changes that occur in the damaged nervous system in humans, fMRI can provide both insight into the mechanisms of normal and pathological pain and, potentially, an objective method for measuring altered sensation. These advances are likely to contribute greatly to the diagnosis and treatment of clinical pain conditions affecting the trigeminal system (e.g., neuropathic pain, migraine).

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.