Laparoscopic extraperitoneal inguinal hernia repair using a balloon dissection technique

Total extraperitoneal (TEP) mesh repair of inguinal hernia in the developing world: comparison of low-cost indigenous balloon dissection versus direct telescopic dissection: a prospective randomized controlled study

BACKGROUND

Creation of extraperitoneal space during TEP repair requires an expensive commercially available balloon.

PATIENTS AND METHODS

Fifty-six patients suffering from uncomplicated primary unilateral or bilateral groin hernia were randomized into two groups; group 1--indigenous balloon dissection and group 2--direct telescopic dissection.

RESULTS

There were 55 males and 1 female, with an average age of 49 years; 50% of the inguinal hernias were bilateral. Creation of extraperitoneal space was considered as satisfactory in majority of patients (94.6%) with satisfactory anatomical delineation. Peritoneal breach was noticed during dissection in 36 (64.3%) patients. There was one (3.8%) conversion of TEP to TAPP in group 2. Distance between pubic symphysis to umbilicus was an important factor, which affected the easiness of dissection. In patients with this distance <or=14 cm lateral placement of ports was considered for easy use of graspers. The incidence of scrotal edema was significantly higher in group 2 as compared with group 1 (p < 0.01). Patients with indirect inguinal hernias in group 2 presented with a greater number of scrotal edema. Pain score on VAS at 6 h after surgery was significantly higher in group 2 (p < 0.021). Patients with age <65 years, bilateral hernias, and indirect hernias had a correlation with higher pain score at 6 h. Of the patients, 17.9% developed seroma in group 1 versus 64.3% in group 2 (p < 0.001).

CONCLUSION

Anatomical delineation of inguinal area and dissection in the extraperitoneal space in TEP repair was equally satisfactory with both low-cost indigenous balloon (group 1) and telescopic dissection (group 2). Balloon dissection was associated with significantly reduced postoperative pain at 6 h, scrotal edema, and seroma formation. However at 3 months follow-up balloon dissection did not offer significant advantage over direct telescopic dissection in the overall long-term outcome of TEP repairs. If balloon dissection is considered useful for the beginner, low-cost indigenous balloon may be used to avoid higher cost of commercially available balloon dissector with added early advantages.

A randomized controlled trial of laparoscopic extraperitoneal hernia repair as a day surgical procedure

BACKGROUND

A randomized controlled trial was conducted in a day surgery setting comparing a standardized variant of the Shouldice hernioplasty with extraperitoneal laparoscopic herniorrhaphy.

METHODS

The laparoscopic repair was technically challenging, evidenced by conversion from extraperitoneal to transabdominal repairs in 6.25% of patients. It was free from the inherent dangers of intraperitoneal laparoscopy. Surgical morbidity was low and comparable to that for patients randomized to the open repair.

RESULTS

Outcome following laparoscopic extraperitoneal herniorrhaphy varied depending on the parameter measured. It was comparable to the open repair with respect to postoperative activity levels and the number of days required for return to work but inferior to the open repair in terms of operation time and time to hospital discharge. The extraperitoneal approach was superior to the open repair with respect to postoperative pain levels and analgesic requirements. No attempt was made to compare recurrence rates due to the short follow-up period.

CONCLUSIONS

Laparoscopic extraperitoneal herniorrhaphy should not supercede conventional hernia repair until subjected to further trials with the aid of larger study populations and greater technical expertise; the results of long-term recurrence rates are awaited.

Inguinal hernia repair by laparoscopic surgeons: early experience and attitudes

The introduction of laparoscopic inguinal hernia repair (LIHR) has been controversial. A questionnaire was sent to all general surgeons in New Zealand to document the early experience with LIHR and attitudes towards it. Of the 118 replies (response rate 55%), 74 were from laparoscopic surgeons, 26 of whom had performed 564 (201 public, 363 private) LIHR (23 bilateral) until January 1994. Only nine (35%) of these surgeons had assisted an experienced surgeon before performing an LIHR, and only four (15%) were supervised by an experienced surgeon during their first case. The transabdominal preperitoneal technique of LIHR was used by 14 (54%) surgeons, the extraperitoneal technique by eight (31%), and the transabdominal onlay technique by four (15%). There were 29 (5%) recurrences, 17 (3%) neuropathies, seven (1.2%) conversions, four (0.7%) major perforations, and one (0.17%) death. Of the 26 surgeons who performed LIHR, 20 (77%) were concerned about the absence of long-term results, 14 (54%) considered that the optimal technique had not been established, 13 (50%) were concerned about the unique complications associated with LIHR, 11 (42%) were less enthusiastic about performing LIHR than previously, 10 (38%) were doubtful about its advantages, and six (23%) were uncertain about its future and considered that it should only be performed within the context of a controlled trial. This study highlights a number of issues that need to be addressed before the role of LIHR can be determined.