Laparoscopic surgery for inguinal hernia repair: systematic review of effectiveness and economic evaluation

Differences in the rates of seroma complications between hernial sac transection and reduction after laparoscopic inguinal hernia repair: systematic review and meta-analysis

Seroma formation is one of the most common postoperative complications after laparoscopic inguinal hernia repair (LIHR). Many techniques to reduce the incidence of seroma formation after LIHR have been described; however, the evidence for performing hernial sac transection (HST) technique is limited. Therefore, this study was conceived to evaluate the effect of HST on LIHR. We conducted a systematic review and meta-analysis of comparative studies according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) 2020. The PubMed, Embase, Springer, and the Cochrane databases were searched for relevant publications up to December 2023. Studies concerning laparoscopic inguinal hernia repair with clearly specified surgical techniques were included. Studies were excluded if they were open procedures or non-inguinal hernia repair. Egger's test and funnel plot analysis was used to assess bias. Outcomes were reported as odds ratio for dichotomous outcomes and as confidence intervals for continuous outcomes. No funding was received for this study. The study protocol was registered in PROSPERO under the number ID: CRD.42,024,530,115. A total of 3,076 patients in 9 studies were included in the analysis (4 RCTs, 4 retrospective cohorts, and 1 prospective cohort). Three, four, and two studies evaluated TEP, TAAP, and both techniques, respectively. The rate of seroma in HST transection was 57% lower than that in the reduction method (p value < 0.01), with low evidence of publication bias (Egger test and funnel plots, coefficient, 0.470; SE, 0.722; p = 0.275). In the subgroup analysis, 3 RCTs reported lower rates of seroma formation in HST (RR, 0.57; 95% CI, -0.24, 1.37), but the difference was not statistically significant. The rate of seroma formation in the HST for the TAPP method was significantly lower than that for the reduction method by approximately 53% (p value = 0.03). Compared with complete sac reduction, HST is associated with a lower seroma rate after LIHR.

Balloon dissection for robotic totally extra-peritoneal (rTEP) inguinal herniorrhaphy: description of a modified technique and report on 97 consecutive patients

PURPOSE

As the use of robotic platforms for inguinal hernia repairs continues to grow, the rTAPP (Robotic Trans-Abdominal Pre-Peritoneal) approach is being performed significantly more often than rTEP (Robotic Totally Extra-Peritoneal) and is predominantly taught to newly trained robotic surgeons. This study's primary objective was to evaluate the feasibility of a proposed modified rTEP technique that incorporates balloon dissection as a primary tool, enabling the horizontal placement of three trocars aligned with the umbilicus. Secondary objectives included evaluation of safety and effectiveness of this technique, and of the learning curve required to reach proficiency.

METHODS

From February 2023 to April 2024, a total of 97 consecutive patients (87 males, 10 females) with an average age of 61 years (range 17-89) and a mean body mass index of 26 kg/m2 (21-37) underwent rTEP for the repair of 122 inguinal and femoral hernias. All procedures were performed by a single surgeon following a standardized protocol detailed in this manuscript. Key metrics and events assessed included conversions to open or laparoscopic approaches, console operating times, postoperative narcotic usage, postoperative complications, serious adverse events, unplanned returns to the operating room within 30 days, and hernia recurrences. Cumulative sum (CUSUM)_sequential analysis was used for determination of the learning curve.

RESULTS

Repaired hernias included 57 indirect (46.7%), 48 direct (39.3%), 4 femoral (3.3%) and 13 mixed (10.7%). There were no conversions to open or laparoscopic surgery, and the average console time was 45 min for unilateral repairs and 68 min for bilateral repairs. 70% of patients elected not to use the narcotic prescribed for postoperative analgesia. There was one serious adverse event (1/97, 1.0%), and one unplanned return to the operating room within 30 days (1/97, 1.0%). Over an average follow-up period of 52 weeks (range 25-87 weeks), there was one recurrence (1/122, 0.8%). In our analysis of the learning curve, we found that proficiency was reached around the 24th non-complex unilateral case.

CONCLUSION

The modified rTEP technique utilizing balloon dissection is feasible, reproducible and time efficient. This study demonstrates its safety and effectiveness. The technique provides superior visualization of the extraperitoneal space, facilitates manipulation of robotic wristed instruments, and ensures proper mesh placement. Early postoperative outcomes suggest that rTEP could play an important role in the surgical management of inguinal and femoral hernias. Further studies are needed to provide data on short and long-term quality of life, and to compare rTEP to rTAPP.

A Systematic Review of Open, Laparoscopic, and Robotic Inguinal Hernia Repair: Management of Inguinal Hernias in the 21st Century

Background: In the 21st century, the management of groin hernias (GHs) has evolved from watchful waiting (WW) to robotic hernia repair (RHR). The present study interrogates the status of robotics in the context of current repairs and provides one author's perspectives. Methods: A systematic review was undertaken using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines for studies comparing open (OHR) to robotic hernia repair (RHR); RHR to laparoscopic hernia repair (LHR); or OHR vs. LHR vs. RHR. The historical context was extracted from previous reviews. Results: Fifty-four studies were included in the analysis. Three techniques have withstood the test of time: OHR (tissue and mesh repairs), laparo-endoscopic (TEP and TAPP), and RHR. The literature indicates that RHR is safe and effective for the management of groin hernias. Operative times and costs remain a concern when using this technique. While the number of overall complications with RHR is similar to OHR, in a minority of cases, complications are more consequential with the robotic platform. Conclusions: RHR has emerged as an unequivocally powerful technique for the management of GHs. OHR remains the technique of choice for local/regional anesthesia, posterior recurrences, and in centers that lack other platforms. In low- and middle-income countries, OHR is the most utilized technique. Centers of excellence should offer all techniques of repair including WW.

Prospective randomized study comparing mesh displacement in enhanced-view totally extraperitoneal versus totally extraperitoneal laparoscopic inguinal hernia repair without mesh fixation

PURPOSE

In laparoscopic inguinal hernia repair, it is thought that the mesh can be displaced more in the enhanced-view totally extraperitoneal (eTEP) technique. The aim of this study was to compare eTEP and totally extraperitoneal (TEP) techniques without mesh fixation in terms of mesh displacement and hernia recurrence.

METHODS

Between December 2022 and April 2023, 60 consecutive patients with unilateral inguinal hernia were randomized into two groups; eTEP group (n = 30) and TEP group (n = 30). There was without mesh fixation in both groups. Study was registered at http://Clinicaltrials.gov (NCT06070142). The mesh was marked with three radiopaque clips. Pelvic radiographs were performed to evaluate the displacement of the mesh. The primary outcome of this study was mesh displacement. In addition, this is the first study in the literature to compare eTEP and TEP techniques in terms of mesh displacement without fixation in laparoscopic inguinal hernia.

RESULTS

There was no significant difference between the groups in terms of mesh displacement, recurrence, postoperative VAS scores, length of hospital stay, hematoma, and seroma formation. The operation time was higher in the eTEP group and was statistically significant.

CONCLUSION

Without mesh fixation, the eTEP technique does not increase the risk of mesh displacement and recurrence. The eTEP technique can be safely applied without mesh fixation in laparoscopic inguinal hernia repairs.

TRIAL REGISTRATION

ClinicalTrials number: NCT06070142.

Laparoscopic totally extraperitoneal hernia repair in patients with a history of previous abdominopelvic surgery

A retrospective cohort study of patients undergoing laparoscopic inguinal hernia repair compared short- and long-term outcomes between individuals with or without history of previous abdominopelvic surgery, aiming to determine the feasibility of totally extraperitoneal (TEP) repair within this population. All patients who underwent elective TEP inguinal hernia repair by one consultant surgeon across three London hospitals from January 2017 to May 2023 were retrospectively analysed to assess perioperative outcomes. Two hundred sixty-two patients were identified, of whom two hundred forty-three (93%) underwent laparoscopic TEP repair. The most frequent complications were haematoma (6.2%) and seroma (4.1%). Recurrence occurred in four cases (1.6% of operations, 1.1% of hernias). One hundred eighty-four patients (76%) underwent day-case surgery. There were no mesh infections or explanations, vascular or visceral injuries, port-site hernias, damage to testicle, or persisting numbness. There were no requirements for blood transfusion, returns to theatre, or readmissions within 30 days. There was one conversion to open and one death within 60 days of surgery. Eighty-three (34%) had a history of previous AP surgery. There was no significant difference in perioperative outcomes between the AP and non-AP arms. This finding carried true for subgroup analysis of 44 patients whose AP surgical history did not include previous inguinal hernia repair and for those undergoing repair of recurrent hernia. In expert hands, laparoscopic TEP repair is associated with excellent outcomes and low rates of long-term complications, and thus should be considered as standard for patients regardless of a history of AP surgery.

Suture versus tacks in minimally invasive transabdominal preperitoneal inguinal repair: a meta-analysis of randomized controlled trials

INTRODUCTION

There is uncertainty regarding the method of mesh fixation and peritoneal closure during transabdominal preperitoneal (TAPP) repair for inguinal hernias, with no definitive guidelines to guide surgeon choice.

METHODS

MEDLINE, Cochrane, Central Register of Clinical Trials, and Web of Science were searched for RCTs published until November 2023. Risk ratios (RRs) and mean differences (MD) with 95% confidence intervals (CIs) were pooled with a random-effects model. Statistical significance was defined as p < 0.05. Heterogeneity was assessed using the Cochran Q test and I2 statistics, with p values inferior to 0.10 and I2 > 25% considered significant. Statistical analyses were conducted using Review Manager version 5.4 and RStudio version 4.1.2 (R Foundation for Statistical Computing).

RESULTS

Eight randomized controlled trials (RCTs) were included, comprising 624 patients, of whom 309 (49.5%) patients were submitted to TAPP with the use of tacks, and 315 (50.5%) received suture fixation. The use of tacker fixation was associated with a significant increase in postoperative pain at 24 h (MD 0.79 [VAS score]; 95% CI 0.38 to 1.19; p < 0.0002; I2 = 87%) and one week (MD 0.42 [VAS score]; 95% CI 0.05 to 0.79; p < 0.03, I2 = 84%). The use of tacks was associated with shorter operative time (MD-25.80 [min]; 95% - 34.31- - 17.28; P < 0.00001; I2 = 94%). No significant differences were found in overall complications, chronic pain, seromas, hematomas, and urinary retention rates.

CONCLUSION

In patients who underwent TAPP hernia repair, tacks are associated with decreased operative time but increased postoperative pain at 24 h and one week.

Comparing stapler and sutured mesh fixation techniques for laparoscopic TAPP repair: a study on chronic groin pain on 3-year follow-up

Trans-abdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repairs are the available surgeries for inguinal hernias, with both methods of laparoscopic repairs requiring mesh applications. This study analyzes the correlation between sutured versus stapler mesh fixation in a laparoscopic TAPP for unilateral groin hernia regarding chronic pain during 3-year follow-up. A total of 130 patients with laparoscopic hernia undergoing TAPP repair were randomized into 2 groups based on their fixation technique-one with sutures and the other with stapler. Postoperative complications and chronic groin pain were noted for each technique. Equal number of participants was present in the stapler and suture groups, with the majority having an ASA score of one. The mean age was 42.50 ± 13.86 years, and the body mass index (BMI) was 27.47 ± 5.88. The stapler group presented a shorter mean operative time than the suture group. However, the stapler group had a significantly higher mean VAS score than the suture group. Most participants in the suture group (89.2%) had LOS for 1 day, while a 2-day LOS was significantly higher in the stapler group (12.3%) than in the suture group (9.2%). No patient reported mesh erosion, conversion, recurrence, testicular atrophy, and mesh infection. Early postoperative pain was more in stapler group along with long hospital stay, but both were non-significant. Chronic postoperative pain results and recurrence incidences over 3-year follow-up were also similar. Re-admission rates were minimal, no significant complications occurred.

Risk of conversion after intended total extraperitoneal hernia repair for inguinal hernia depends on type of previous abdominal surgery

PURPOSE

Risk of total extraperitoneal hernia repair (TEP) in patients with previous lower abdominal surgery (PLAS) is still debated. The present study was designed to assess the rate of conversion in TEP for inguinal hernia stratified by type of PLAS.

METHODS

Variables on patients undergoing TEP inguinal hernia repair at our center were prospectively collected between July 2012 and May 2018. Patients with PLAS were compared to patients without PLAS. Furthermore, the most frequent subtypes of PLAS were defined and TEP conversion rate was stratified according to type of PLAS.

RESULTS

A total of 1589 patients with TEP inguinal hernia repair were identified including 152 (9.6%) patients with PLAS. Operative time was increased in patients with PLAS (70 vs. 60 min, p < 0.001). Conversion from TEP to transabdominal preperitoneal patch plasty (TAPP) or Lichtenstein open inguinal hernia repair was eight-times more frequent after PLAS (8% vs. 1%, p < 0.001). Considering type of PLAS, open appendectomy was most frequently encountered, followed by multiple PLAS and surgery to the bladder and prostate (53%, 11% and 10%). After stratification for type of PLAS, conversions were most frequently found after previous surgery to the bladder or prostate and after multiple PLAS (conversion rate of 20% and 24%, p < 0.001). In contrast, conversion rate after open appendectomy was not increased.

CONCLUSION

PLAS to the bladder and prostate is associated with TEP conversion. Selected patients might profit from a different operative approach for inguinal hernia repair.

Totally extraperitoneal repair of groin hernia in liver transplant patients: a case series study (TOHER)

PURPOSE

The present study aims to describe the feasibility and the postoperative results of groin hernia repair in liver transplant patients using a totally extra-peritoneal (TEP) repair approach.

METHODS

From May 2022 to March 2023, liver transplant patients with groin hernia underwent TEP groin hernia repair, by the single common senior experimented surgeon. Background information, intraoperative findings, postoperative complications, postoperative pain, health, and well-being were registered.

RESULTS

Thirteen TEP approach groin hernioplasties were performed in 10 patients, completing the procedure in all cases without the need for conversion either to open or transabdominal preperitoneal approaches. 70% of surgical explorations revealed multiple hernia defects: lateral hernias in all patients, medial defects in 62%, and femoral defects in 30.8%. Median hospital stay was 1 day [range (0.3)], with 30% treated as outpatients. Post-surgical complications occurred in 30% of cases: 1 hematoma and 2 seromas. Postoperative pain and physical functioning scored 100 (IQR 44) and 90 (IQR 15), respectively.

CONCLUSION

TEP groin hernioplasty is safe and feasible for liver transplant patients, with low complication rates, short hospital stays, and a significant proportion treated as outpatients. The posterior approach allows comprehensive repair of myopectineal defects, crucial due to associated hernial defects.

The impact of previous inguinal mesh hernioplasty on oncological and patient-reported outcomes following radical prostatectomy

BACKGROUND

The impact of previous inguinal mesh hernioplasty (MH) with non-resorbable mesh prostheses on surgical performance of radical prostatectomy (RP) has been controversially discussed, with unknown impact of MH on oncologic outcomes and health-related quality of life (HRQOL) following RP. We therefore aimed to assess the influence of previous MH on metastasis-free survival (MFS), biochemical recurrence-free survival (BRFS), and HRQOL following RP.

METHODS

We identified 344 patients with previous MH prior RP within our prospectively assessed institutional database of 6275 patients treated with RP for PC (2008-2019). A 1:3 propensity-score matched analysis of 1345 men (n = 319 previous MH, n = 1026 no previous MH) was conducted. Primary endpoint was MFS and secondary endpoints were BRFS and HRQOL (based on EORTC QLQ-C30). Binary logistic regression, Kaplan-Meier, and Cox regression models tested the effect of previous MH on MFS, BRFS, and HRQOL (p < 0.05).

RESULTS

Median follow-up was 47 months. Patients with previous MH had significantly lower 5-year MFS (72% vs. 85%, p < 0.001) and 5-year BRFS estimates (43% vs. 57%, p < 0.001). In multivariate analysis, previous MH was confirmed as an independent predictor for impaired MFS (hazard ratio [HR]: 3.772, 95% CI 1.12-12.64, p = 0.031) and BRFS (HR: 1.862, 95% CI: 1.22-2.85, p = 0.004). These results held true if stratified for surgical approach or limited to patients with successful PLND. We found significantly shorter median time to continence recovery for patients without previous MH (p = 0.001) without significant differences in total continence recovery rates, erectile function recovery, and HRQOL.

CONCLUSIONS

Our findings show an impaired oncologic outcome for patients with previous MH following RP with no significant differences regarding continence recovery, erectile function recovery, and general HRQOL.

Assessment of Surgical and Quality-of-Life Outcomes Between Laparoscopic Versus Open Inguinal Hernia Repair in Geriatric Patients

Introduction: Inguinal hernia repair is a common surgery, especially in the elderly population. However, the decision to perform surgery in elderly patients can be challenging due to higher complication rates. Laparoscopic inguinal hernia surgery is less commonly used in the elderly population despite its advantages. In this study, we aimed to investigate the safety and advantages of laparoscopic inguinal hernia surgery in elderly patients. Methods: We retrospectively compared the preoperative and postoperative (PO) data and Short Form-36 (SF-36) forms of elderly patients who underwent laparoscopic transabdominal preperitoneal and open inguinal hernia surgery. The primary outcomes were PO pain scores and complication rates. Results: A total of 79 patients with an age range between 65 and 86 years, who presented with inguinal hernias to Cekirge State Hospital's General Surgery Department between January 2017 and November 2019, were included. Seventy-nine patients underwent laparoscopic transabdominal preperitoneal technique and Lichtenstein hernia repair. The laparoscopic group had a lower rate of PO complications and less analgesic medication consumption and usage time compared with the open group. Furthermore, compared with the open group, the laparoscopic group had lower PO pain scores and higher SF-36 scores for physical function, physical role, pain, and general health at the 30th and 90th days after surgery. Conclusion: Our study suggests that laparoscopic inguinal hernia surgery can be safely performed in elderly patients with lower complication rates and faster recovery times compared with open surgery. The advantages of laparoscopic surgery, such as lower PO pain scores and faster recovery times, were also observed in elderly patients.

Transabdominal Preperitoneal Versus Lichtenstein Procedure for Inguinal Hernia Repair in Adults: A Comparative Evaluation of the Early Postoperative Pain and Outcomes

Inguinal hernia repairs are one of the most common procedures in general surgery. In addition to classical open surgery, laparoscopic techniques, such as transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) hernia repair, have gained acceptance and are increasingly used for inguinal hernia repairs, and these three techniques are the only standards for inguinal hernia repairs. This study aimed to compare the results of inguinal hernia repairs in adult patients using the TAPP patch technique and Lichtenstein techniques regarding the level of pain perceived one day after surgery and the number of days of hospitalization. A two-year study was performed on 129 patients who underwent TAPP vs. 109 patients who underwent Liechtenstein hernia repair. Our results revealed statistical significance for both variables (Tpain(233) = -7.12, p< 0.001, d=2.92; Tdays of hospitalization(233) = -31.34, p< 0.001, d=4.01). TAPP is a safe method for inguinal hernia repairs, allowing quick recovery and less postoperative pain than the classical Liechtenstein technique.

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.

Bilateral inguinal transabdominal pre-peritoneal laparoscopic hernioplasty associated to bilateral laparoscopic varicocelectomy in the same intervention: a feasibility study

INTRODUCTION

Inguinal hernia and varicocele are common conditions in male population. Laparoscopy brings the opportunity to treat them simultaneously, through the same incision. However, there are different opinions about the risks for testicular perfusion of multiple procedures in the inguinal region. In this study, we assessed the feasibility of simultaneous laparoscopic procedures by studying clinical and surgical outcomes of patients undergoing bilateral inguinal hernioplasty using the transabdominal preperitoneal (TAPP) technique with and without concomitant bilateral laparoscopic varicocelectomy (VLB).

METHODS

a sample of 20 patients from the University Hospital of USP-SP with indirect inguinal hernia and varicocele with indication for surgical correction was selected. Patients were randomized into two groups, 10 undergoing TAPP (Group I) and 10 undergoing simultaneous TAPP and VLB (Group II). Data regarding total operative time, complications and postoperative pain was gathered and analyzed.

RESULTS

there was no statistical difference between groups regarding total operative time and postoperative pain. Only one complication (spermatic cord hematoma) was observed in Group I and no complications were observed in Group II.

CONCLUSIONS

simultaneous TAPP and VLB in was shown to be effective and safe, which provides a basis for conducting studies on larger scales.

Influence of the hernia sac treatment method on the occurrence of seroma after laparoscopic transabdominal preperitoneal hernia repair

PURPOSE

To determine whether transection of the hernia sac during laparoscopic transabdominal preperitoneal hernia repair (TAPP) affects the occurrence of seroma, and to explore the risk factors for seroma.

METHODS

In total, 330 consecutive male patients with indirect inguinal hernia who underwent TAPP repair at the Qingdao University Affiliated Hospital from January 2020 to June 2021 were retrospectively enrolled in this study. According to the intraoperative hernia sac treatment, patients were divided into a completely reduced sac group and a transected sac group.

RESULTS

Among the 330 inguinal hernia male patients, 240 received hernia sac reduction and 90 received hernia sac transection. Fifty-four patients developed seroma, with an incidence of 16.4%. In patients with a hernia defect measuring ≥3 cm and extension into the scrotum, the difference in the incidence of seroma between the two treatment groups approached significance (P = 0.052). The risk factors for seroma, high body mass index, hernia sac ≥3 cm, extension of the hernia into the scrotum and operation time were significantly associated with postoperative seroma.

CONCLUSION

This study showed that the incidence of seroma after TAPP was as high as 16.4%. For patients with a hernia sac that is too large and descended extends into the scrotum, transection may be better than complete dissection of the hernia sac and preventive measures should be taken for patients with high body mass index, hernia sac measuring ≥3 cm, and a high risk of the hernia extending into the scrotum.

Diagnostic Accuracy of Imaging Modalities on Occult Groin Hernias According to Hernia type and a Surgeon-centered Individualized Groin Hernia Management Algorithm

BACKGROUND

The purpose of this study is to evaluate the diagnostic performance of imaging techniques for the identification of groin hernias based on the type of hernia and to demonstrate the efficacy of an algorithm based on the surgeon and surgical technique.

MATERIALS AND METHODS

Medical records of 561 patients who were operated on for groin hernia were retrospectively analyzed. A total of 102 patients who had both pelvic computed tomography (CT) and ultrasonography (USG) recordings preoperatively and underwent transabdominal preperitoneal repair were included in the study.

RESULTS

A contralateral asymptomatic occult groin hernia was detected in 25.5% of all patients. The overall sensitivity of USG and CT on contralateral asymptomatic occult hernia was 42.3% and 65.4%, respectively. The sensitivity of USG according to the contralateral occult hernia type was 66.7%, 35.7%, 33.3%, and 50% for direct, indirect, femoral, and pantaloon hernias, respectively. The sensitivity of CT according to the contralateral occult hernia type was 0%, 57.1%, 100%, and 100% for direct, indirect, femoral, and pantaloon hernias, respectively.

CONCLUSIONS

The handicap created by the variability in the diagnostic sensitivity of imaging modalities can be overcome with the choice of transabdominal preperitoneal repair in the surgical technique.

Hernioplastia inguinal pré-peritoneal transabdominal bilateral e varicocelectomia laparoscópica bilateral na mesma intervenção: um estudo de viabilidade

RESUMO Introdução: hérnia inguinal e varicocele são doenças comuns na população masculina. O advento da laparoscopia traz a oportunidade de tratá-las simultaneamente, pelo mesmo acesso. Entretanto, existem divergências sobre os riscos para a perfusão testicular de múltiplos procedimentos na região inguinal. Neste estudo, avaliamos a viabilidade de procedimentos laparoscópicos simultâneos estudando resultados clínicos e cirúrgicos de pacientes submetidos à hernioplastia inguinal bilateral pela técnica transabdominal préperitoneal (TAPP) com e sem varicocelectomia laparoscópica bilateral (VLB) concomitante. Métodos: uma amostra de 20 pacientes do Hospital Universitário da USP-SP com hérnia inguinal indireta e varicocele com indicação de correção cirúrgica foi selecionada. Os pacientes foram randomizados em dois grupos, sendo 10 submetidos à TAPP (Grupo I) e 10 submetidos à TAPP e VLB simultâneas (Grupo II). O tempo operatório total, complicações e dor pós-operatória foram coletados e analisados. Resultados: não houve diferença estatística entre os grupos com relação ao tempo operatório total e à dor pós-operatória. Apenas uma complicação (hematoma do cordão espermático) foi observada no Grupo I e não foram observadas complicações no Grupo II. Conclusões: no mesmo procedimento, submeter pacientes à TAPP e à VLB no mesmo procedimento se mostrou eficaz e seguro, o que fornece embasamento para a realização de estudos em maiores escalas.

A novel model for hands-on laparoscopic pelvic surgery training on Genelyn-embalmed body: an initial feasibility study

The human donor body provides a well-accepted ex vivo model for laparoscopic surgical training. Unembalmed, or fresh-frozen, bodies comprise high-fidelity models. However, their short life span and high cost relatively limit the hands-on training benefits. In contrast, soft embalmed body of donors has a relatively longer usability without compromising tissue flexibility. This study reports the initial experience of the utility and feasibility of human donor Genelyn-embalmed body as a novel soft-embalmed cadaveric model for laparoscopic surgical training. An expert laparoscopic surgeon, who organised many fresh-frozen body donor courses, performed deep laparoscopic pelvic dissection and laparoscopic surgical tasks including suturing and electrosurgery on a single Genelyn-embalmed body. The three sessions were performed over a course of 3 weeks. The body was fully embalmed using the Genelyn technique. The technique consisted of a single-point closed arterial perfusion of embalming solution via the carotid artery with no further exposure to or immersion in embalming fluids thereafter. The donor's Genelyn-embalmed body provided a feasible model for laparoscopic surgical training. Initial experience shows evidence of this model being feasible and realistic. There was reproducibility of these qualities across a minimum of 3 weeks in this single-donor study. Initial experience shows that donor's Genelyn-embalmed body provides a novel model for laparoscopic surgical training, which possesses fidelity and is feasible for laparoscopic training. While further studies are needed to validate these findings, this technical note provides perspectives from an expert trainer regarding this model and provides a photographic and videographic atlas of this model's use in laparoscopy.

Clinical effectiveness and cost-effectiveness of emergency surgery for adult emergency hospital admissions with common acute gastrointestinal conditions: the ESORT study

Background

Evidence is required on the clinical effectiveness and cost-effectiveness of emergency surgery compared with non-emergency surgery strategies (including medical management, non-surgical procedures and elective surgery) for patients admitted to hospital with common acute gastrointestinal conditions.

Objectives

We aimed to evaluate the relative (1) clinical effectiveness of two strategies (i.e. emergency surgery vs. non-emergency surgery strategies) for five common acute conditions presenting as emergency admissions; (2) cost-effectiveness for five common acute conditions presenting as emergency admissions; and (3) clinical effectiveness and cost-effectiveness of the alternative strategies for specific patient subgroups.

Methods

The records of adults admitted as emergencies with acute appendicitis, cholelithiasis, diverticular disease, abdominal wall hernia or intestinal obstruction to 175 acute hospitals in England between 1 April 2010 and 31 December 2019 were extracted from Hospital Episode Statistics and linked to mortality data from the Office for National Statistics. Eligibility was determined using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis codes, which were agreed by clinical panel consensus. Patients having emergency surgery were identified from Office of Population Censuses and Surveys procedure codes. The study addressed the potential for unmeasured confounding with an instrumental variable design. The instrumental variable was each hospital’s propensity to use emergency surgery compared with non-emergency surgery strategies. The primary outcome was the ‘number of days alive and out of hospital’ at 90 days. We reported the relative effectiveness of the alternative strategies overall, and for prespecified subgroups (i.e. age, number of comorbidities and frailty level). The cost-effectiveness analyses used resource use and mortality from the linked data to derive estimates of incremental costs, quality-adjusted life-years and incremental net monetary benefits at 1 year.

Results

Cohort sizes were as follows: 268,144 admissions with appendicitis, 240,977 admissions with cholelithiasis, 138,869 admissions with diverticular disease, 106,432 admissions with a hernia and 133,073 admissions with an intestinal obstruction. Overall, at 1 year, the average number of days alive and out of hospitals at 90 days, costs and quality-adjusted life-years were similar following either strategy, after adjusting for confounding. For each of the five conditions, overall, the 95% confidence intervals (CIs) around the incremental net monetary benefit estimates all included zero. For patients with severe frailty, emergency surgery led to a reduced number of days alive and out of hospital and was not cost-effective compared with non-emergency surgery, with incremental net monetary benefit estimates of –£18,727 (95% CI –£23,900 to –£13,600) for appendicitis, –£7700 (95% CI –£13,000 to –£2370) for cholelithiasis, –£9230 (95% CI –£24,300 to £5860) for diverticular disease, –£16,600 (95% CI –£21,100 to –£12,000) for hernias and –£19,300 (95% CI –£25,600 to –£13,000) for intestinal obstructions. For patients who were ‘fit’, emergency surgery was relatively cost-effective, with estimated incremental net monetary benefit estimates of £5180 (95% CI £684 to £9680) for diverticular disease, £2040 (95% CI £996 to £3090) for hernias, £7850 (95% CI £5020 to £10,700) for intestinal obstructions, £369 (95% CI –£728 to £1460) for appendicitis and £718 (95% CI £294 to £1140) for cholelithiasis. Public and patient involvement translation workshop participants emphasised that these findings should be made widely available to inform future decisions about surgery.

Limitations

The instrumental variable approach did not eliminate the risk of confounding, and the acute hospital perspective excluded costs to other providers.

Conclusions

Neither strategy was more cost-effective overall. For patients with severe frailty, non-emergency surgery strategies were relatively cost-effective. For patients who were fit, emergency surgery was more cost-effective.

Future work

For patients with multiple long-term conditions, further research is required to assess the benefits and costs of emergency surgery.

Study registration

This study is registered as reviewregistry784.

Funding

This project was funded by the National Institute for Health and Care Research (IHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 1. See the NIHR Journals Library website for further project information.

Cost-effectiveness of Staple Line Reinforcement in Laparoscopic Sleeve Gastrectomy

OBJECTIVE

To perform a cost-effectiveness analysis of staple-line reinforcement in laparoscopic sleeve gastrectomy.

SUMMARY OF BACKGROUND DATA

Exponential increases in surgical costs have underscored the critical need for evidence-based methods to determine the relative value of surgical devices. One such device is staple-line reinforcement, thought to decrease bleeding rates in laparoscopic sleeve gastrectomy.

METHODS

Two intervention arms were modeled, staple-line reinforcement and standard nonreinforced stapling. Bleed and leak rates and 30-day treatment costs were obtained from national and state registries. Quality-adjusted life-year (QALY) values were drawn from previous literature. Device prices were drawn from institutional data. A final incremental cost-effectiveness ratio was calculated, and one-way and probabilistic sensitivity analyses were performed.

RESULTS

A total of 346,530 patient records from 2012 to 2018 were included. Complication rates for the reinforced and standard cohorts were 0.05% for major bleed in both cohorts ( P = 0.8841); 0.45% compared with 0.59% for minor bleed ( P < 0.0001); and 0.24% compared with 0.26% for leak ( P = 0.4812). Median cost for a major bleed was $5552 ($3287, $16,817) and $2406 ($1861, $3484) for a minor bleed. Median leak cost was $9897 ($4589, $21,619) and median cost for patients who did not experience a bleed, leak, or other serious complication was $1908 ($1712, $2739). Mean incremental cost of reinforced stapling compared with standard was $819.60/surgery. Net QALY gain with reinforced stapling compared with standard was 0.00002. The resultant incremental cost-effectiveness ratio was $40,553,000/QALY. One-way and probabilistic sensitivity analyses failed to produce a value below $150,000/QALY.

CONCLUSIONS

Compared with standard stapling, reinforced stapling reduces minor postoperative bleeding but not major bleeding or leaks and is not cost-effective if routinely used in laparoscopic sleeve gastrectomy.

Cost and Quality Comparison of Hernia Surgery in Stationary, Day-Patient and Outpatient Care

BACKGROUND

Medical progress is increasingly enabling more and more stationary treatment to be provided in the outpatient sector. This development should be welcomed, as healthcare costs have been rising for years. The design of efficient processes and a needs-based infrastructure enable further savings. According to international recommendations (EHS/IEHS), outpatient treatment of unilateral inguinal hernias is recommended.

METHOD

Data from patients in GZO Hospital Wetzikon/Zurich between 2019 and 2021 for unilateral inguinal hernia repair was included in this study (n = 234). Any over- or under-coverage correlated with one of the three treatment groups: stationary, partially stationary and patients treated in outpatients clinic. Complications and 30-day readmissions were also monitored.

RESULTS

Final revenue for all patients is -95.36 CHF. For stationary treatments, the mean shifts down to -575.01 CHF, for partially stationary treatments the mean shifts up to -24.73 CHF, and for patients in outpatient clinic final revenue is 793.12 CHF. This result is also consistent with the operation times, which are lowest in the outpatient clinic with a mean of 36 min, significantly longer in the partially stationary setting with 58 min, and longest in the stationary setting with 76 min. The same applies to the anesthesia times and the relevant care times by the nurses as the most important cost factors in addition to the supply and allocation costs.

CONCLUSIONS

We show that cost-effective elective unilateral inguinal hernia care in the outpatient clinic with profit (mean 793.12 CHF) is possible. Stationary unilateral hernia care (mean -575.01 CHF) is loss-making. Crucial factors for cost efficiency are optimized processes in the operating room (anesthesia, surgical technique and quality, operating time), as well as optimized care processes with minimal preoperative services and care times for the patient. However, at the same time, these optimizations pose a challenge to surgical and anesthesiology training and structures with high levels of preoperative and Postoperative services and pay-as-you-go costs. The complication rate is 0.91% lower than in a comparable study. The readmission within 30 days post-operation results with a positive deviation of -3.53% (stationary) and with a negative deviation of +2.29% (outpatient clinic) compared to a comparative study.

Cost-Utility Analysis of Open Hernia Operations in Bulgaria

Background: Hernia surgery procedures are among the most frequently performed in Bulgaria. An open, mesh-based repair is a standard method for hernia repair. From a societal perspective, a cost-utility analysis of open hernia surgical procedures performed in Bulgaria is necessary in light of the economic and social burden that poses this health issue. The aim of the study was to perform an economic evaluation of the quality of health results after a conventional elective hernia operation with implanted light and standard meshes.

Methods: The cost of elective hernia operation with standard and light meshes was calculated as a sum of direct and indirect costs. Incremental cost-effectiveness ratio (ICER) for conventional hernia operation was calculated as health improvement was measured in quality-adjusted life years (QALY) reported in a previous study. Deterministic sensitivity analysis was applied to evaluate the changes in the ICER values in case of planned inguinal hernia operation.

Results: The cost of operation with standard meshes is less than operation with light meshes. The difference is in the range 55-200 EUR. The additional costs per one QALY gained for light meshes are far below the recommended threshold values which identified these meshes as cost-effective.

Conclusions: The study presents evidence for cost-effectiveness of light meshes.

Teleophthalmology-enabled and artificial intelligence-ready referral pathway for community optometry referrals of retinal disease (HERMES): a Cluster Randomised Superiority Trial with a linked Diagnostic Accuracy Study-HERMES study report 1-study protocol

INTRODUCTION

Recent years have witnessed an upsurge of demand in eye care services in the UK. With a large proportion of patients referred to Hospital Eye Services (HES) for diagnostics and disease management, the referral process results in unnecessary referrals from erroneous diagnoses and delays in access to appropriate treatment. A potential solution is a teleophthalmology digital referral pathway linking community optometry and HES.

METHODS AND ANALYSIS

The HERMES study (Teleophthalmology-enabled and artificial intelligence-ready referral pathway for community optometry referrals of retinal disease: a cluster randomised superiority trial with a linked diagnostic accuracy study) is a cluster randomised clinical trial for evaluating the effectiveness of a teleophthalmology referral pathway between community optometry and HES for retinal diseases. Nested within HERMES is a diagnostic accuracy study, which assesses the accuracy of an artificial intelligence (AI) decision support system (DSS) for automated diagnosis and referral recommendation. A postimplementation, observational substudy, a within-trial economic evaluation and discrete choice experiment will assess the feasibility of implementation of both digital technologies within a real-life setting. Patients with a suspicion of retinal disease, undergoing eye examination and optical coherence tomography (OCT) scans, will be recruited across 24 optometry practices in the UK. Optometry practices will be randomised to standard care or teleophthalmology. The primary outcome is the proportion of false-positive referrals (unnecessary HES visits) in the current referral pathway compared with the teleophthalmology referral pathway. OCT scans will be interpreted by the AI DSS, which provides a diagnosis and referral decision and the primary outcome for the AI diagnostic study is diagnostic accuracy of the referral decision made by the Moorfields-DeepMind AI system. Secondary outcomes relate to inappropriate referral rate, cost-effectiveness analyses and human-computer interaction (HCI) analyses.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the London-Bromley Research Ethics Committee (REC 20/LO/1299). Findings will be reported through academic journals in ophthalmology, health services research and HCI.

TRIAL REGISTRATION NUMBER

ISRCTN18106677 (protocol V.1.1).

Time-efficiency and hospital costs of open compared with laparoscopic groin hernia repair in a teaching hospital

BACKGROUND

Time efficiency and hospital costs may influence the preferred method of groin hernia repair. Despite growing expertise in laparoscopic hernia repair, knowledge on the actual costs and the potential financial advantages over open hernia repair are limited.

METHODS

A single-center retrospective cohort study comparing hospital costs and time-efficiency of open-mesh (Lichtenstein) and laparoscopic groin hernia repair between 2010 and 2015, including a comparison of surgeons and residents, was conducted. Secondary outcomes were length of hospital stay, complication and recurrence rates.

RESULTS

Nine hundred forty-seven open and 449 laparoscopic groin hernia repairs were included. Unilateral open repair showed a shorter operation theatre occupancy (63.5 min±17.2 vs. 71.9 min±19.9, P<0.001) and lower total costs (€ 974.51±266.67 vs. € 1165.32±285.94, P<0.001) compared with laparoscopic repair. Residents had longer operative times compared with surgeons in the unilateral open procedure (43.8±13.4 min vs. 34.5±16.3 min, P<0.001), in the unilateral laparoscopic procedure (46.9±16.6 min vs. 41.7±18.7 min, P<0.001) and higher total costs in the unilateral open procedure (€ 1007.47±238.58 vs. € 909.35±305.00, P<0.001). There were no significant differences in complication and recurrence rates between residents and surgeons.

CONCLUSIONS

Open-mesh hernia repair appears to be superior in costs for both uni- and bilateral groin hernias when performed by surgeons as well as residents. Residents had higher total costs and longer operation times in the unilateral open groin hernia group when compared with surgeons, yet overall complications and recurrence rates were similar in all groups suggesting that residents are sometimes more expensive and slower, but just as safe.

Health economic analysis of total extraperitoneal repair versus Lichtenstein surgery for inguinal hernia: data from a randomized clinical trial

Background

The aim was to compare cost-effectiveness of Lichtenstein under local anaesthesia (LLA) with total extraperitoneal repair (TEP) under general anaesthesia for primary inguinal hernia in men. An endoscopic approach to inguinal hernia repair is often considered costlier. The cost of endoscopic hernia repair, however, has not been compared to open inguinal hernia repair in a cost-effective setting.

Methods

Data from an RCT comparing TEP and Lichtenstein in a cost-effective setting, with health economy as a secondary endpoint, were used. Data on costs were collected prospectively. Data on sick leave were obtained from the Swedish Social Insurance Agency in order to compare lengths of sick leave.

Results

In total, 384 patients were included and 374 (97.4 per cent) patients were available for analysis, 189 in the LLA group and 185 in the TEP group. The median operating time for LLA was 70 (i.q.r. 60–80) min compared with 60 (i.q.r. 50–75) min in the TEP group (P < 0.001). The median time in operating theatre was 114 (i.q.r. 95–-125) min for LLA and 125 (i.q.r. 110–145) min for TEP (P < 0.001). The median cost including all materials was 2433 (i.q.r. 2084–2734) Euros for LLA and 2395 (i.q.r. 2093–2784) Euro for TEP (P = 0.650). Mean sick leave was 4.2 days in the LLA group and 6.2 days in the TEP group (P = 0.830).

Conclusion

The overall cost to the hospital or length of sick leave did not differ between LLA and TEP.

The Comparison of Balloon and Camera Dissection of the Preperitoneal Space in Totally Extraperitoneal Repair Hernia Repair. Our Initial Experience!

Purpose. To perform totally extraperitoneal repair of a hernia, it is essential to create a working space for the placement of instruments. In this study, we aimed to compare balloon dissection (BD) and camera or telescopic dissection (CD) with respect to the surgical outcomes, without considering the cost-effectiveness. Methods. Forty consecutive, healthy, unilateral inguinal hernia patients who underwent Totally Extraperitoneal Repair hernia repair were randomized into 2 groups according to whether they received BD or CD. The perioperative demographic characteristics were recorded. All the operations were video recorded from the beginning to the end of each procedure. The virtually constructed periods of the procedures were evaluated by another surgeon who watched each video. The time spent for each period, the severity score assigned by the surgeon, the total operation time, the peritoneal laceration rate, the presence of early and late postoperative pain, the number of postoperative visits, the total analgesic requirements, and the complications were recorded. Results. The demographic properties of the patients, the perioperative and postoperative complications, and the severity scores in the BD and CD groups were statistically similar. The total operating time and the time from the dissection of the peritoneum to the reduction of the hernia sac were significantly longer in the CD group. Post-discharge analgesic consumption, Visual Analog Scale scores, and the number of visits were similar between the groups. Conclusions. The dissection of the working space in the preperitoneal area can be achieved using camera dissection without the risk of common complications associated with balloon dissection, particularly balloon rupture.

Robotic TAPP inguinal hernia repair: lessons learned from 97 cases

OBJECTIVES

minimally invasive inguinal hernia repair has proven advantages over open procedures including less pain and earlier return to normal activity. Robotic surgery adds ergonomics, a three-dimensional high definition camera and articulating instruments overcoming some laparoscopic limitations. We aimed to report the outcomes of the early experience of over 97 robotic inguinal hernia repairs performed by a referred surgical group in Brazil.

METHODS

a review of a prospective mantined database was conducted in patients submitted to robotic transabdominal preperitoneal (TAPP) inguinal hernia repairs between March 2016 and February 2020. Descriptive statistics were performed. Surgical outcomes data and patient follow-ups are reported.

RESULTS

retrospective chart review identified 97 patients submitted to robotic TAPP inguinal hernia repair. Mean age was 36.4 years, with median BMI of 26.9 kg/m2. Mean console time was 58 min (range 40-150) and patients were discharged within 24 hours of their stay in a majority of cases. Mesh was placed in all procedures and there were no conversion rates. Complications were low grade and no recurrence was seen after a mean follow-up of 642 days.

CONCLUSION

this study represents to-date the first brazilian case series of robotic TAPP inguinal hernia repair. Our results encourage that robotic assisted TAPP inguinal hernia repair appears to be technically feasible and safe in experienced hands, with good outcomes achieving high health-related quality of life and low recurrence rates in the short and long term.

Safety of two common laparoscopic inguinal herniorrhaphy approaches: an updated systematic review with meta-analysis of randomized clinical trials

Background

Previous evidence indicated that total extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) are advantageous in efficacy of inguinal herniorrhaphy. Therefore, our aim in this study was to evaluate the association of the two laparoscopic approaches on safety of inguinal herniorrhaphy.

Methods

In this update study, we searched the Cochrane Library, EMBASE, PubMed, Scopus, and Web of Science and identified randomized clinical trials comparing complications in TEP and TAPP herniorrhaphy. We mainly used Peto odds ratio with 95% confidence interval (CI) for meta-analysis because of zero-cell.

Results

Fourteen eligible trials recruited 659 and 682 patients in TEP and TAPP respectively. In overall pooling, although TEP had a higher seroma rate than TAPP (Peto odds ratio =2.01; 95% CI, 1.39 to 2.91), it had a lower scrotal/cord edema rates at immediate postoperative (Peto odds ratio =0.22; 95% CI, 0.09 to 0.57) and 1 week after inguinal hernia repair (Peto odds ratio =0.58; 95% CI, 0.37 to 0.91) than TAPP.

Conclusions

TEP and TAPP have their own advantages in inguinal herniorrhaphy. TAPP was associated with a lower seroma rate, and TEP was associated with a lower edema rate. Therefore, shared decision-making on laparoscopic inguinal herniorrhaphy with TEP and TAPP is still needed.

Changing the innate consensus about mesh fixation in trans-abdominal preperitoneal laparoscopic inguinal hernioplasty in adults: Short and long term outcome. Randomized controlled clinical trial

INTRODUCTION

Inguinal hernioplasty is the standard treatment for inguinal hernia in adults. Mesh fixation was used to keep mesh in place for which various mesh fixation techniques have been used in laparoscopic inguinal hernia repair in adults, but their effectiveness has remained inconclusive.

AIM OF THE WORK

to evaluate non fixation method of mesh laparoscopic inguinal hernioplasty as safe and effective as regard short and long term outcomes.

PATIENTS AND METHODS

Over the period from July 2013 to July 2018, 798 patients with oblique inguinal hernias undergoing Trans abdominal preperitoneal technique (TAPP) were randomized into 3 groups: Group A; mesh non fixation 266 patients. Group B; tacker mesh fixation 266 patients Group C: Cyanoacrylic tissue glues (Histoacryl) mesh fixation 266 patients. Clinical effects were assessed by the following variables: intraoperative data, postoperative outcome as regard recurrence rate, postoperative pain [on visual analogue score (VAS)], analgesic consumption, operation time, hospital stay, and patient costs. Follow up was 18 months.

RESULTS

There was no statistical difference between groups (A) and Group (C) regarding operative time, postoperative complications, and length of hospital stay and risk of chronic groin pain, postoperative pain score. In Group (B): the postoperative pain and complications were higher. There were 5 cases of hernia recurrence in all groups, but no significant differences among the three groups.

CONCLUSION

Tacker Mesh fixation increased the risk of chronic groin pain. Pain score was higher with tacker mesh fixation. Laparoscopic TAPP inguinal hernia repair without tacker mesh fixation was safe and feasible with no significant increase in recurrence rates. Furthermore, mesh fixation with tacker procedure increased the risk of postoperative complications and patient costs. All ethical approval was given by our Faculty of Medicine medical ethical committee.

Surgical Strategy for Contralateral Groin Management in Patients Scheduled for Unilateral Inguinal Hernia Repair: An International Web-Based Surveymonkey® Questionnaire: Strategy for Contralateral Groin Management during Inguinal Hernia Repair

BACKGROUND

A contralateral occult inguinal hernia is frequently observed in patients planned for a unilateral laparoscopic inguinal hernia repair. Surgical strategy for contralateral groin management in patients scheduled for an endo-laparoscopic unilateral inguinal hernia repair is controversial and based on questionable evidence. This study aimed to gather international opinion concerning the surgical strategy for the contralateral asymptomatic side when no hernia or lipoma is clinically evident at the preoperative examination or anamnesis.

METHODS

An international Internet-based questionnaire was sent to all the members of the European Hernia Society, the Americas Hernia Society, and the Asia Pacific Hernia Society. The clinical scenario for responders was a patient with a unilateral symptomatic inguinal hernia planned for endo-laparoscopic repair with no preoperative symptoms/lump on the contralateral side.

RESULTS

A total of 640 surgeons replied (response rate = 26%), of whom 506 were included for analysis. Most surgeons had performed > 300 repairs. The preferred surgical technique was evenly distributed between laparoscopic total extraperitoneal repair and laparoscopic transabdominal preperitoneal repair. In total, 54% preferred to implant a prophylactic mesh on the contralateral side when an occult hernia was found, 47% when a lipoma was found, and 6% when no occult hernia/lipoma was identified.

CONCLUSIONS

Mesh implementation was preferred by half of the endo-laparoscopic hernia surgeons for a contralateral occult hernia and/or lipoma. Although not supported by strong evidence, mesh implantation on the asymptomatic contralateral side might be cost-effective and perhaps beneficial in the long term but could be offset by increased risk of chronic pain and sexual dysfunction.

Evaluation of a Biocomposite Mesh Modified with Decellularized Human Amniotic Membrane for Intraperitoneal Onlay Mesh Repair

Various materials and approaches have been used to optimize the biocompatibility of mesh to reduce the implant-induced host response in intraperitoneal onlay mesh (IPOM) repair. Ineffective host integration, limited resistance to contamination, and untargeted administration hinder the wider application of the currently available clinical options. In this study, human amniotic membrane (HAM) was decellularized, fully characterized, and compared with porcine small intestinal submucosa (SIS) in terms of its structure, components, and bioactivity. In an in vivo study, HAM was reinforced with silk fibroin (SF) membrane, which was fabricated as a biodegradable submicroscale template by electrospinning, to construct a bilayer composite mesh. The independent SF membrane, associated with HAM and SIS, was evaluated for tissue remodeling in vitro. The HAM-SF and SIS meshes were then characterized morphologically and implanted intraperitoneally into Sprague-Dawley rats for 28 days for macroscopic investigation of their integration into the host via interactions of regulatory factors. After decellularization, HAM formed a bioagent-rich collagen-based acellular structure. HAM was superior to SIS in concurrently suppressing the expression of transforming growth factor β1 (TGF-β1) and proangiogenic proliferation. When HAM, SF, and SIS were used as regenerative scaffolds, they showed qualified biocompatibility, cell infiltration, and degradation in vitro. Comparatively, macroscopic observation after implantation indicated that HAM-SF induced less-intensive intraperitoneal adhesion and weaker inflammatory responses at the interface but greater angiogenesis in the explant than SIS. Analysis of the expression of regulatory factors showed a greater quantity of hepatocyte growth factor (HGF) in HAM, which partly inhibited the expression of TGF-β1 and promoted vascular endothelial growth factor (VEGF)-induced angiogenesis. This bioactive interaction appeared to be responsible for the better host integration, making HAM more biocompatible than SIS in IPOM repair. When combined with SF, HAM displayed similar mechanical properties to SIS. In conclusion, HAM displayed better bioactivity and biocompatibility than SIS. After its reinforcement with SF, HAM-SF is a promising biocomposite mesh for IPOM repair.

Ten golden rules for a safe MIS inguinal hernia repair using a new anatomical concept as a guide

BACKGROUND

Although laparoscopic inguinal hernia repair was described about 30 years ago and advantages of the technique have been demonstrated, the utilization of this approach has not been what we would expect. Some reasons may be the need for surgeons to understand the posterior anatomy of the groin from a new vantage point, as well as to acquire advanced laparoscopic skills. Recently, however, the introduction of a robotic approach has dramatically increased the adoption of minimally invasive techniques for inguinal hernia repair.

METHODS

Important recent contributions to this evolution have been the establishment of a new concept known as the critical view of the Myopectineal Orifice (MPO) and the description of a new way of understanding the posterior view of the antomy of the groin (inverted Y and the five triangles). In this paper, we describe 10 rules for a safe MIS inguinal hernia repair (TAPP, TEP, ETEP, RTAPP) that combines these two new concepts in a unique way.

CONCLUSIONS

As the critical view of safety has made laparoscopic cholecystectomy safer, we feel that following our ten rules based on understanding the anatomy of the posterior groin as defined by zones and essential triangles and the technical steps to achieve the critical view of the MPO will foster the goal of safe MIS hernia repair, no matter which minimally invasive technique is employed.

Comparison of endoscopic surgery and Lichtenstein repair for treatment of inguinal hernias: A network meta-analysis

BACKGROUND

This study aimed to identify the best procedure for addressing inguinal hernias by comparing results after transabdominal preperitoneal (TAPP), totally extraperitoneal (TEP), and Lichtenstein repairs using a network meta-analysis.

METHODS

We conducted a systematic search of MEDLINE, Web of Science, the Cochrane Central Library, and ClinicalTrials.gov up to September 1, 2018 for randomized controlled trials (RCTs) comparing the TAPP, TEP, and Lichtenstein procedures. The study outcome were the hernia recurrence, chronic pain, hematoma, seroma, wound infection, operation time, hospital stay, and return-to-work days.

RESULTS

Altogether, 31 RCTs were included in the meta-analysis. The results of this network meta-analysis showed there were no significantly differences among the 3 procedures in terms of hernia recurrence, chronic pain, hematoma, seroma, hospital stays. Lichtenstein had a shorter operation time than TAPP+TEP [MD (95%Crl)]: 12 (0.51-25.0) vs 18 (6.11-29.0) minutes, respectively) but was associated with more wound infections than TEP: OR 0.33 (95%Crl 0.090-0.81). Our network meta-analysis suggests that TAPP and TEP require fewer return-to-work days [MD (95%CI)]: - 3.7 (-6.3 to 1.3) vs -4.8 (-7.11 to 2.8) days.

CONCLUSION

Our network meta-analysis showed that there were no differences among the TAPP, TEP, and Lichtenstein procedures in terms of safety or effectiveness for treating inguinal hernias. However, TAPP and TEP could decrease the number of return-to-work days. A further study with more focus on this topic for inguinal hernia is suggested.

Home-based cognitive training in pediatric patients with acquired brain injury: preliminary results on efficacy of a randomized clinical trial

Cognitive rehabilitation may compensate for cognitive deficits of children with acquired brain injury (ABI), capitalizing on the use-dependent plasticity of a developing brain. Remote computerized cognitive training (CCT) may be delivered to patients in ecological settings, ensuring rehabilitation continuity. This work evaluated cognitive and psychological adjustment outcomes of an 8-week multi-domain, home-based CCT (Lumosity Cognitive Training) in a sample of patients with ABI aged 11–16 years. Two groups of patients were engaged in five CCT sessions per week for eight weeks (40 sessions). According to a stepped-wedge research design, one group (Training-first Group) started the CCT immediately, whereas the other group (Waiting-first Group) started the CCT after a comparable time of waiting list. Changes after the training and after the waiting period were compared in the two groups. Both groups improved in visual-spatial working memory more after the training than after the waiting-list period. The Training-first group improved also in arithmetic calculation speed. Findings indicate that a multi-domain CCT can produce benefits in visual-spatial working memory, probably because, in accordance with previous research, computer games heavily tax visuo-spatial abilities. This suggests that the prolonged stimulation of the same cognitive ability may generate the greatest benefits in children with ABI.

Perioperative outcomes and cost of robotic-assisted versus laparoscopic inguinal hernia repair

BACKGROUND

Utilization of robotic-assisted inguinal hernia repair (IHR) has increased in recent years, but randomized or prospective studies comparing outcomes and cost of laparoscopic and Robotic-IHR are still lacking. With conflicting results from only five retrospective series available in the literature comparing the two approaches, the question remains whether current robotic technology provides any added benefits to treat inguinal hernias. We aimed to compare perioperative outcomes and costs of Robotic-IHR versus laparoscopic totally extraperitoneal IHR (Laparoscopic-IHR).

METHODS

Retrospective analysis of consecutive patients who underwent Robotic-IHR or Laparoscopic-IHR at a dedicated MIS unit in the USA from February 2015 to June 2017. Demographics, anthropometrics, the proportion of bilateral and recurrent hernias, operative details, cost, length of stay, 30-day readmissions and reoperations, and rates and severity of complications were compared.

RESULTS

183 patients had surgery: 45 (24.6%) Robotic-IHR and 138 (75.4%) Laparoscopic-IHR. There were no differences between groups in age, gender, BMI, ASA class, the proportion of bilateral hernias and recurrent hernias, and length of stay. Operative time (Robotic-IHR: 116 ± 36 min, vs. Laparoscopic-IHR: 95±44 min, p < 0.01), reoperations (Robotic-IHR: 6.7%, vs. Laparoscopic-IHR: 0%, p = 0.01), and readmissions rates were greater for Robotic-IHR. While the overall perioperative complication rate was similar in between groups (Robotic-IHR: 28.9% vs. Laparoscopic-IHR: 18.1%, p = 0.14), Robotic-IHR was associated with a significantly greater proportion of grades III and IV complications (Robotic-IHR: 6.7% vs. Laparoscopic-IHR: 0%, p = 0.01). Total hospital cost was significantly higher for the Robotic-IHRs ($9993 vs. $5994, p < 0.01). The added cost associated with the robotic device itself was $3106 per case and the total cost of disposable supplies was comparable between the 2 groups.

CONCLUSIONS

In the setting in which it was studied, the outcomes of Laparoscopic-IHR were significantly superior to the Robotic-IHR, at lower hospital costs. Laparoscopic-IHR remains the preferred minimally invasive surgical approach to treat inguinal hernias.

Variation in outcomes and use of laparoscopy in elective inguinal hernia repair

Background

The early outcomes of inguinal hernia repair in routine practice and the extent to which the laparoscopic approach is used are unknown. The aims of this study were to identify national benchmarks for early reoperation and readmission rates, to identify the degree to which the laparoscopic approach is used for elective hernia surgery in England, and to identify whether there is any variation nationally.

Methods

All adults who underwent publically funded elective inguinal hernia repair in England during the six financial years from 2011–2012 to 2016–2017 were identified in the Surgeon's Workload Outcomes and Research Database (SWORD). Patients were grouped according to whether they had a primary, recurrent or bilateral hernia, and according to sex. Overall rates of readmission, reoperation and laparoscopic approach were calculated, and variation was assessed using funnel plots.

Results

Some 390 777 patients were included. Overall, 11 448 patients (2·9 per cent) were readmitted to hospital as an emergency within 30 days of surgery and 2872 (0·7 per cent) had a further operation. Laparoscopic repair was performed for 65·5 per cent of bilateral inguinal hernias compared with 17·1 per cent of primary unilateral inguinal hernias, 31·3 per cent of recurrent hernia repairs and 14·0 per cent of primary unilateral hernias in women. The unadjusted readmission, reoperation and laparoscopy rates varied significantly between hospitals.

Conclusion

The likelihood of a patient being readmitted to hospital, having an emergency reoperation or undergoing laparoscopic inguinal hernia repair varies significantly depending on the hospital to which they are referred. Hospitals and service commissioners should use this data to drive service improvement and reduce this variation.

Transfascial suture versus tack fixation of mesh in totally extraperitoneal repair of inguinal hernia: A prospective comparative study

Purpose:

Among laparoscopic surgeries in inguinal hernias, totally extraperitoneal (TEP) repair has demonstrated favourable results in reduction of post-operative pain and mean operative times with early return to physical activity. We have done a prospective comparative study on two different techniques of mesh fixation, i.e., transfascial suture and tack fixation.

Materials and Methods:

It was a prospective, non-randomised comparative study done on inguinal hernia patients operated by TEP repair from October 2014 to September 2016. These data were compared in two techniques of mesh fixation (tack and transfascial sutures) in terms of post-operative complications, pain scores by visual analogue scale (VAS) and cost analysis of the procedure.

Results:

Our study on 69 total patients (44 tack fixation and 25 suture fixation group) revealed that mean VAS scores for post-operative pain were not having any statistically significant difference in the tack group versus suture group (2.42 ± 0.24 vs. 2.2 ± 0.24) at 24 h, but VAS scores in the follow-up period at 1 week, 1 month, 3 months and 6 months were 1.14 ± 0.33 versus 0.67 ± 0.27; 0.78 ± 0.24 versus 0.07 ± 0.06; 0.42 ± 0.17 versus 0.07 ± 0.06 and 0.5 ± 0.11 versus 0.07 ± 0.06, respectively, which showed significant difference at 1 and 3 months, suggesting less pain in the suture group. No significant difference was noted in other post-operative complications.

Conclusion:

Transfascial suture fixation of mesh in TEP repair of inguinal hernia can be a cost-effective procedure with a comparable safety profile as compared to tack fixation.

Laparoscopic total extraperitoneal inguinal hernia repair is safe and feasible in patients with continuation of antithrombotics

Aims

We aimed to evaluate the safety and feasibility of laparoscopic total extraperitoneal (TEP) inguinal hernia repair in patients with the continuation of their antithrombotic agents.

Settings and Design

This was prospective cohort study.

Materials and Methods

A total of 115 patients who underwent TEP inguinal hernia repair between January 2015 and September 2016 were included in the analysis. Seventeen patients continued their antithrombotics (antithrombotic group); the other 98 had not been on antithrombotics (control group).

Statistical Analysis Used

The analysis was performed by using Mann-Whitney U-test, Chi-square or Fisher's exact test.

Results

The antithrombotic group had a greater mean age (65.9 ± 8.0 vs. 57.7 ± 13.6,P= 0.002) and higher prevalence of hypertension (64.7% vs. 33.7%,P= 0.015), cardiovascular diseases (64.7% vs. 7.1%,P < 0.001), atrial fibrillation (23.5% vs. 0,P < 0.001), ischaemic heart disease (35.3% vs. 0,P < 0.001) and the American Society of Anaesthesiologists ≥2 (94.1% vs. 81.6%,P= 0.005). The operation time for the antithrombotic group was longer than that of the control group (92.06 ± 32.81 min vs. 72.33 ± 20.99 min,P= 0.015). None experienced conversion to open surgery in either group. There was no difference in the post-operative complications (29.4% vs. 28.6%) and sero-haematoma formation (23.5% vs. 11.1%). The analgesic requirement, hospital stays (23.72 ± 7.74 vs. 22.35 ± 10.33 h) and the time for return to normal daily activity (3.56 ± 1.74 vs. 3.63 ± 1.90) were not statistically different between the two groups. None in either group experienced major cardiovascular events within 30 days.

Conclusions

Laparoscopic TEP inguinal hernia repair can be safely performed in patients with the continuation of their antithrombotic agents in experienced hands.

Reoperation for inguinal hernia recurrence in Ontario: a population-based study

PURPOSE

Despite the frequency with which inguinal hernia repairs (IHR) are performed, the real-world comparative effectiveness of laparoscopic versus open repairs is not well established. We compared the rate of recurrent inguinal hernia after laparoscopic and open mesh procedures.

METHODS

We designed a population-based retrospective cohort study using linked administrative databases including adult patients in Ontario, Canada, who underwent primary IHR from April 1, 2003 to December 31, 2012. Patients were followed to August 31, 2014. Our primary outcome was reoperation for recurrent IHR, with covariate adjustment using Cox proportional hazards modeling. We constructed separate models to evaluate the effect of surgeon caseload on recurrence rates.

RESULTS

We identified 93,501 adults undergoing primary IHR (85.4% open with mesh and 14.6% laparoscopic) with a median follow-up of 5.5 years. The 5-year cumulative risk of recurrent IHR was 2.0% in the open group and 3.4% in the laparoscopic group. After adjusting for patient and surgeon factors, we found that patients who underwent laparoscopic repair had a higher risk of recurrent IHR than those who underwent open repair when annual surgeon volume in the preceding year was ≤25 technique-specific cases (HR 1.76; 95% CI 1.45-2.13) or 26-50 technique-specific cases (HR 1.78; 95% CI 1.08-2.93). Few high-volume laparoscopic surgeons (> 50 cases/year) could be identified. Laparoscopic IHR did not carry a higher risk of recurrence for patients whose surgeons had performed > 50 technique-specific cases in the preceding year (HR 1.21; 95% CI 0.45-3.26).

CONCLUSION

Laparoscopic IHR is generally associated with a higher risk of recurrence than open IHR. Though high-volume surgeons may be able to achieve equivalent results with laparoscopic and open techniques, few surgeons in our study population met this volume criterion for laparoscopic repairs.

Surveying the Cost-Effectiveness of the 20 Procedures with the Largest Public Health Services Waiting Lists in Ireland: Implications for Ireland's Cost-Effectiveness Threshold

OBJECTIVES

To survey the cost effectiveness of procedures with the largest waiting lists in the Irish public health system to inform a reconsideration of Ireland's current cost-effectiveness threshold of €45,000/quality-adjusted life-year (QALY).

METHODS

Waiting list data for inpatient and day case procedures in the Irish public health system were obtained from the National Treatment Purchase Fund. The 20 interventions with the largest number of individuals waiting for inpatient and day case care were identified. The academic literature was searched to obtain cost-effectiveness estimates from Ireland and other high-income countries. Cost-effectiveness estimates from foreign studies were adjusted for differences in currency, purchasing power parity, and inflation.

RESULTS

Of the top 20 waiting list procedures, 17 had incremental cost-effectiveness ratios (ICERs) lower than €45,000/QALY, 14 fell below €20,000/QALY, and 10 fell below €10,000/QALY. Only one procedure had an ICER higher than the current threshold. Two procedures had ICERs reported for different patient and indication groups that lay on either side of the threshold.

CONCLUSIONS

Some cost-effective interventions that have large waiting lists may indicate resource misallocation and the threshold may be too high. An evidence-informed revision of the threshold may require a reduction to ensure it is consistent with its theoretical basis in the opportunity cost of other interventions foregone. A limitation of this study was the difficulty in matching specific procedures from waiting lists with ICER estimates from the literature. Nevertheless, our study represents a useful demonstration of a novel concept of using waiting list data to inform cost-effectiveness thresholds.

The Safety and Feasibility of the Single-Port Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair Through Retropubic Radical Prostatectomy Scar, Prospective, Case Series

Introduction: To avoid an additional scar, our novel single-port laparoscopic inguinal hernia repair technique that utilizes the previous prostatectomy scar was conducted. Inguinal hernia is one of the most common complications of radical prostatectomy that require surgical repair. At present, such surgical repair inevitably leaves additional scars on the abdominal wall. This case series study was performed to determine the safety and feasibility of this procedure in patients with inguinal hernia after radical prostatectomy. Subjects and Methods: All patients who underwent retropubic radical prostatectomy (RRP) in 2012-2016 and developed an inguinal hernia as a complication of RRP agreed to undergo single-port laparoscopic transabdominal preperitoneal (TAPP) repair of the inguinal hernia through the RRP scar. TAPP repair was performed using a homemade glove single port through a 2 cm wide incision into the upper part of the RRP scar. The duration between RRP and the development of inguinal hernia, TAPP repair operative time, follow-up duration, TAPP repair-related complications, and rate of inguinal hernia recurrence were recorded. Results: Of the 131 patients who underwent RRP in the study period, 12 (mean age, 67.58 ± 5.73 years) developed inguinal hernia during an average follow-up duration of 33.58 ± 16.49 months. None had a previous history of inguinal hernia. The inguinal hernias developed on average 3.83 ± 1.70 months after RRP. The mean operative time was 64.58 ± 6.20 minutes. There were no surgical complications or recurrence of inguinal hernia during follow-up. Conclusions: Single-port laparoscopic TAPP inguinal hernia repair through the previous prostatectomy scar is safe and feasible.

Elective "True Day Case" Laparoscopic Inguinal Hernia Repair in a District General Hospital: Lessons Learned from 1000 Consecutive Cases

Introduction

Laparoscopic inguinal hernia repair (LIHR) is ideal for day case surgery. It is recommended that at least 70% should be day cases as a measure of cost-effectiveness. The aims of this study were to (i) assess the rate of true day case (TDC) surgery and (ii) identify predictors associated with unexpected overnight stay (UOS).

Methods

Data was collected prospectively on 1000 consecutive elective LIHR performed in a District General Hospital (DGH) over a 7-year period. Data was collected on baseline patient demographics, ASA grade, and intraoperative details. A multivariate analysis was performed in order to identify predictors of UOS.

Results

1000 patients (927 males) underwent elective LIHR. Mean age was 57.3±15.2 years. 915 patients were planned as day case procedures. 822/915 day cases (89.8%) were discharged on the same day and 93 (10.2%) stayed overnight unexpectedly. Patient age, duration of procedure, and patient slot in the operating list were found to be independent predictors (p<0.05) of UOS.

Conclusion

Our results demonstrate that LIHR is a "true" day case procedure in a DGH. Although some factors associated with UOS cannot be altered, careful patient selection and operating list planning are of paramount importance in order to minimise the burden on healthcare resources.

Desarda's technique versus Lichtenstein technique for the treatment of primary inguinal hernia: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

The Lichtenstein technique (LT) has been recognized as the standard treatment for inguinal hernia in adults owing to the high recurrence rates of tissue-based repairs. However, Desarda technique (DT) appeared as promising tissue-based repair that provided low incidence of recurrence without the need for implanting prosthetic or foreign materials in the inguinal canal. This meta-analysis of randomized controlled trials (RCTs) comparing DT and LT for primary inguinal hernia in adults aimed to determine which technique had better clinical outcome regarding recurrence and complication rates.

METHODS

A systematic literature search for RCTs comparing between DT and LT was conducted using electronic databases and Google scholar service. Patients' characteristics, technical details, recurrence and complication rates, and time to resume daily activities were extracted from the original studies and analyzed.

RESULTS

Six RCTs comprising 2159 patients (89% males) were included. No significant difference in the incidence of recurrence between both techniques was detected (OR = 0.946; P = 0.91). The overall complication rate of LT was significantly higher than DT (OR = 1.86; P < 0.001). LT had significantly higher rates of seroma formation and surgical site infection (OR = 2.17; P = 0.007) and (OR = 2.17; P = 0.029), respectively. Postoperative pain, operation time, and time to resume normal activities were comparable in both groups.

CONCLUSION

Both DT and LT provided satisfactory treatment for primary inguinal hernia with low recurrence rates and acceptable rates of complications that were significantly less after DT. More well-designed RCTs with longer follow-up are required for further validation of the DT.

Transition from Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair to Robotic Transabdominal Preperitoneal Inguinal Hernia Repair: A Retrospective Review of a Single Surgeon's Experience

BACKGROUND

There is a paucity of literature comparing laparoscopic to robotic inguinal hernia repair. We present a single surgeon's transition from laparoscopic totally extraperitoneal (L-TEP) to robotic transabdominal preperitoneal (R-TAPP) inguinal hernia repair and compare outcomes from the two approaches.

METHODS

This retrospective review and analysis of prospectively collected data compare outcomes during the transition from L-TEP to R-TAPP inguinal hernia repair by a single surgeon at one institution. Operating times and surgical outcomes and complications are analyzed. All consecutive L-TEP cases from November 2012 to August 2014 and all consecutive R-TAPP cases from March 2013 to October 2015 were included in the analysis.

RESULTS

A total of 157 and 118 patients underwent L-TEP and R-TAPP inguinal hernia repair, respectively. The groups were similar regarding demographics and ASA class. A significantly higher number of complex cases were performed in the R-TAPP group compared to L-TEP group (n = 11 vs. n = 1, p = 0.0001). Mean surgical times were nearly identical (69.12 ± 35.13 min, R-TAPP; 69.05 ± 26.31, L-TEP) as were intraoperative and postoperative complication rates-despite the significantly higher number of complex cases in the R-TAPP group.

CONCLUSIONS

This is the largest study in the literature comparing a single surgeon's experience transitioning from L-TEP to R-TAPP inguinal hernia repair. Results from the R-TAPP cases were similar to those achieved from laparoscopic cases. The robotic platform may have facilitated the execution of complex hernia cases during the proficiency phase.