The role of endoscopic extraperitoneal herniorrhaphy: where do we stand in 2005?

Inguinal hernia repair is a common surgical procedure, but the most effective surgical technique remains controversial. The evolution of laparoscopic techniques has allowed reproduction of open preperitoneal repair via an endoscopic total extraperitoneal (TEP) approach. More recently, the advent of comprehensive training in laparoscopy has allowed TEP to continue evolving as the feasibility of this approach gains recognition as a preferable technique. Once considered very difficult to learn, TEP currently is adequately taught in many surgical training programs. This report reviews the fundamentals and details various modifications that make this procedure more desirable than open procedures and other laparoscopic techniques. A resultant decrease in operative time, cost of the procedure, and morbidity to the patient is routine. In addition, the authors review their institutional experience and examine other current evidence-based data.

Treating recurrence after a totally extraperitoneal approach

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Totally extraperitoneal (TEP) hernia repair after an original TEPIs it safe, and is it even possible?

BACKGROUND

There are only scant published reports of totally extraperitoneal (TEP) repair of recurrence after a primary TEP procedure. Furthermore, at least two authors have made the statement that such an operation is virtually impossible.

METHODS

We have been performing TEP repair of recurrence after TEP since we 1996, and here we present a retrospective review of our experience with the procedure. We employ a method not varying greatly from the standard TEP done for primary hernia.

RESULTS

All cases were started laparoscopically, and only one of 20 had to be converted to open. Of these cases, 12 were for same-side recurrence and eight for a contralateral new hernia. With a follow-up of 28-74 months, there have been no fatalities, no complications, and no re-recurrence.

CONCLUSION

We have found that TEP repair of recurrent inguinal hernia after a primary TEP repair is entirely feasible technically as well as entirely safe.

Obstructive symptoms associated with the Lap-Band in the first 24 hours

BACKGROUND

The Lap-Band is a gastric restrictive procedure for the treatment of morbid obesity. We review the etiology of obstructive complications that present in the first postoperative 24 h.

METHODS

Fifty-six Lap-Band procedures were performed by one surgeon between January and September 2002.

RESULTS

Six patients presented with obstruction within 24 h of surgery: gastric slippage in three patients, gastric edema in one patient, and esophageal hypomotility in two patients.

CONCLUSIONS

Placing the band in an esophagogastric position as per Belachew and Weiner reduced our incidence of gastric slippage to none. Endoscopy with placement of a nasogastric feeding tube can relieve obstruction caused by esophageal hypomotility. Gastric edema with no clinical signs of obstruction will resolve with time. Clinicians must be aware of the unique complications that come with the advent of this new procedure.

The routine use of diagnostic laparoscopy in the intensive care unit

BACKGROUND

Delay in the diagnosis of intraabdominal pathology is a major contributor to the morbidity and mortality of intensive care unit (ICU) patients. Laparoscopy is a valuable diagnostic tool that can be used safely and efficiently in the evaluation of intraabdominal processes that may be difficult to diagnose with conventional methods. Our goal was to show that laparoscopy performed at the bedside in the ICU could be used as a routine diagnostic tool in the evaluation of critically ill patients, just as computed tomography (CT), ultrasonography (US), and radiography are.

METHODS

We present 11 patients who underwent 12 bedside examinations in the ICU of a community teaching hospital. Several different surgeons with varying degrees of laparoscopic experience performed these procedures over a 1-year period.

RESULTS

Four patients had previously undergone recent abdominal operations. Nontherapeutic laparotomy was avoided in six patients because of diagnostic laparoscopy. One patient also underwent a therapeutic maneuver at the time of diagnostic laparoscopy. None of the patients required general anesthesia, although local anesthetics and sedation with midazolam or propofol were used. One patient underwent the procedure without endotracheal intubation. There were no complications or mortalities directly related to the procedure.

CONCLUSION

We conclude that bedside laparoscopy in the ICU under local anesthesia is a diagnostic and potentially therapeutic tool that can be used safely in the work-up of potential abdominal pathology in critically ill patients.

Laparoscopic autopsies

BACKGROUND

In recent years, autopsy consent rates have fallen nationwide. In our institution they have declined from 15% to 7% in 10 years. We perceived that family reluctance to grant permission for autopsy was related to the invasiveness of the open procedure, so we began to do autopsies by needle biopsy, with an increase in consents to 25% during the first year. However, the procedure is inherently inaccurate, so we recently have introduced minimally invasive laparoscopic autopsy.

METHODS

From July through October 1999, needle biopsy was performed on 25 patients who died at our institution, which was followed by laparoscopic evaluation. Consent for full conventional autopsy had been granted in nine cases, and these then were performed. Data from these autopsies were compared with those from the laparoscopic procedures.

RESULTS

Of the patients for whom consent was obtained for open autopsy, there was complete agreement as to cause of death between the laparoscopic and conventional procedures. In one case, a liver hemangioma was missed by laparoscopy, and in two other cases, colon polyps were not discovered. Biopsies of internal organs were accurately performed on the pancreas, kidneys, and adrenals, all of which had been troublesome for needle biopsy alone.

CONCLUSIONS

Laparoscopic autopsy is much more acceptable to the families of patients than the conventional form, resulting in a higher consent rate. On the basis of our study group, this procedure provides accurate data concerning the cause of death. In addition, performing these autopsies gives surgical residents invaluable training in laparoscopic skills.

Prospective randomized study of stapled versus unstapled mesh in a laparoscopic preperitoneal inguinal hernia repair

BACKGROUND

In 1975, researchers introduced the use of a large unsutured polyester mesh prosthesis placed in the preperitoneal space for inguinal hernia repair. Different stapling devices have been used to secure this mesh, and the most common complication of the procedure is nerve damage secondary to the staples. The necessity of stapling has never been demonstrated. We designed a prospective randomized study of the need for stapling in laparoscopic extraperitoneal repair of inguinal hernias with 1-year and 3-year followup.

STUDY DESIGN

Inclusion criteria of the study were men older than 18 years and first-time inguinal hernia repair. Patients with recurrence and previous abdominal operations were excluded to avoid confounding variables. Each patient's hernia was assigned a consecutive random number chosen by computer, with each number corresponding to an assigned group. The first group had stapled mesh and the second had unstapled mesh.

RESULTS

Data were collected over a 15-month period, with each procedure having a mean followup time of 8 months. A total of 100 procedures was performed in 92 patients. The two groups of patients were well matched for age and the type of hernia repaired. There were no recurrences in either group and no complications or deaths.

CONCLUSIONS

The initial 12-month followup showed no significant differences in recurrence or complication rates between the stapled and unstapled groups. Both groups returned to work within an average of 4 days. A net savings of $120 was realized for each hernia repair performed without stapled mesh. In addition, stapling presents an inherent risk of nerve damage.

Cost effectiveness of routine type and screen testing before laparoscopic cholecystectomy

BACKGROUND

The aim of this study was to assess the cost effectiveness of routine preoperative blood type and screen testing before laparoscopic cholecystectomy.

METHODS

All 2,589 laparoscopic cholecystectomies and 603 open cholecystectomies performed at our institution between January 1990 and December 1996 were retrospectively reviewed to identify the incidence and causes of blood transfusions. With the use of ICD-9-CM coding, a computerized retrospective research was done to match the corresponding codes for the aforementioned operations and blood transfusion. Individual charts were reviewed to identify the indications for blood transfusion.

RESULTS

Of the 2,589 laparoscopic cholecystectomies performed, 12 patients required blood transfusion, and of the 603 open cholecystectomies, 33 patients required blood transfusion. The incidence of blood transfusions was 0.46% for laparoscopic cholecystectomy and 5.47% for open cholecystectomy. Two of the blood transfusions given intraoperatively were due to major vascular injury in the laparoscopic cholecystectomy group. The remaining blood transfusions were found to be the result of preexisting medical conditions including sickle-cell anemia, end-stage renal disease, and chronic iron deficiency anemia.

CONCLUSIONS

Laparoscopic cholecystectomy has become a widely used therapeutic modality in general surgery. The procedure is safe, effective, and well tolerated by the patient. In the era of managed healthcare, the cost effectiveness of commonly ordered tests is frequently questioned. In the absence of preoperative indications, routine preoperative blood type and screen testing should be eliminated for laparoscopic cholecystectomy. The elimination of routine preoperative blood type and screen testing could have saved our institution $79,800 during a 6-year period.

Laparoscopic splenectomy in a Jehovah's Witness with profound anemia

Open surgery in a severely anemic patient may be complicated by a substantial blood loss from a large incision and subsequent poor wound healing secondary to the anemia. We report our success in performing a splenectomy laparoscopically in a profoundly anemic patient. A 50-year-old white male Jehovah's Witness who was HIV positive was referred for splenectomy after he developed profound, worsening anemia secondary to hypersplenism that was refractory to medical management. His preoperative hemoglobin and hematocrit levels were 2.7 g/dl and 8.8%, respectively, but his religious beliefs precluded transfusion. A laparoscopic splenectomy by the posterior gastric approach was performed. The patient tolerated the surgery well and experienced no additional morbidity. On postoperative day 7, his hemoglobin and hematocrit were 6.8 g/dl and 22%, respectively. We conclude that laparoscopic splenectomy is an attractive procedure in a severely anemic patient who requires splenectomy and refuses blood transfusion.

Advanced breast cancer biopsy instrumentation: a critique

BACKGROUND

Large-core biopsies or open biopsies with needle localization have been the mainstay of treatment for evaluating nonpalpable mammographic abnormalities. The newly introduced Advanced Breast Biopsy Instrumentation (ABBI) system combines digital stereotactic imaging with a highly developed single-use biopsy device to locate and remove a radiographically discovered breast lesion to an accuracy of 1 mm.

STUDY DESIGN

We conducted a review of the first 58 cases involving the use of the ABBI system. This article evaluates the accuracy of specimen targeting, the success rate of lesion removal, the operative complications, the mechanical difficulties, and patient satisfaction with the ABBI system.

RESULTS

The lesion was removed successfully in 47 of the 58 cases. Nine patients were eliminated in initial screening and the procedure could not be completed in two. Although the success rate was high, 14 of the procedures required conversion to "open" ABBI procedures for completion of the biopsy.

CONCLUSIONS

The ABBI system is an alternative to open biopsy with needle localization or large-core biopsy for nonpalpable mammographic abnormalities. This technique allows complete removal of the lesion in a one-step procedure. The ABBI system has certain limitations and mechanical problems, at least currently, and offers an advantage over current diagnostic modalities in a very limited number of cases only.

Chief resident experience with laparoscopic cholecystectomy

Resident competence in both open and laparoscopic cholecystectomy (LC) has been a concern among general surgeons. Laparoscopic surgery was late in coming at many surgical residency programs in the United States, and many residents have graduated with limited experience in LC. We are chief residents who were fortunate enough to start our training when LC was first introduced at our institution in 1990. This report summarizes our experience with LC in our chief year, during which we performed LC on 147 patients. The average operating time was 37 minutes (range, 12-82 minutes). Six patients (4%) required conversion to an open procedure. There were three complications (2 postoperative cystic duct leaks and 1 intraoperative common bile duct injury) for an overall complication rate of 2%. There was no mortality. It is our conclusion that graduating chief residents with 5 years' exposure to LC may perform the procedure with a complication rate comparable to that reported in the current literature. Insuring that graduating chief residents have adequate training in open cholecystectomy may become a more pressing issue in the near future.

A three-trocar technique for limited laparoscopic renal surgery

Laparoscopic renal surgery usually involves the use of five or six trocars. This report concerns the authors' technique for performing such surgery through only three trocars. Semilateral patient positioning, along with additional table rotation, is utilized to facilitate visceral rotation and optimize exposure of the kidney. Four laparoscopic renal procedures were performed: one renal cyst decortication and three upper pole partial nephrectomies with ureterectomies for duplications of the collecting system. Mean operative time was 148 min with no conversions; there were no intra- or postoperative complications. All patients tolerated a liquid diet on postoperative day 1, and the median hospital stay was 2 days. In selected cases laparoscopic renal surgery may be approached safety through three trocars.

Hernia repair during endoscopic extraperitoneal lymph node dissection

The objective of this study was to determine whether extraperitoneal lymph node dissection for the staging of prostate cancer and extraperitoneal herniorrhaphy could be performed concomitantly with acceptable operative time and morbidity. Sixty patients underwent endoscopic extraperitoneal lymph node dissection (EEPLND) between 1991 and 1996. Eleven of these had 14 hernias repaired with polypropylene mesh. Endoscopic hernia repair added an average of 15 to 20 minutes to the EEPLND, resulting in an average operative time of 127 minutes (range 90 to 182 minutes). There was no difference in postoperative pain between patients undergoing combined operations and those undergoing EEPLND alone. The mean hospital stay after either procedure was 48 hours. There were no complications in the group undergoing herniorrhaphy. We conclude that extraperitoneal endoscopic hernia repair can be safely performed with EEPLND when necessary.

A simplified approach to laparoscopic fundoplication

BACKGROUND

There is a certain amount of controversy regarding the need to divide the short gastric vessels (SGV) in laparoscopic fundoplication for treatment of gastroesophageal reflux disease (GERD). In addition, there is often difficulty in identifying the crural fibers when encircling the lower esophagus.

METHODS

We determine whether it is necessary to divide the SGV by trying to appose the gastric fundus to the anterior abdominal wall intraoperatively. If this could be done easily, the SGV are preserved. When their division is required, a posterior gastric approach is employed. We have also found that the injection of methylene blue into the left crural fibers anterior to the esophagus is helpful in identifying the left side when dissection posterior to the gastroesophageal junction is difficult.

RESULTS

Between 1992 and 1995 we performed 20 laparoscopic fundoplications for GERD. All patients had at least grade 3 esophagitis (Savary-Miller scale), increased esophageal exposure to acid (median DeMeester score of 195), and decreased lower esophageal sphincter (LES) pressure. The median operative time was 175 min. There were no conversions to open surgery, and there was no mortality. Three patients developed transient postoperative dysphagia and one patient had pneumonia. The median hospital stay was 3 days; all patients were free of reflux symptoms at follow-up ranging from 7 to 42 months.

CONCLUSION

We conclude that the techniques described by us aid in intraoperative decision making and allow laparoscopic fundoplication to be both simple and effective.

Initial experience with breast biopsy utilizing the advanced breast biopsy instrumentation (ABBI)

The Advanced Breast Biopsy Instrumentation (ABBI) system combines a cylindrical single-use biopsy device with digital stereotactic imaging that achieves targeting of radiographic lesions to +/- 1 mm. This allows complete removal of specimens in a one-step procedure that does not involve separate trips to radiology and then surgery. The ABBI system improves on core needle biopsy and fine-needle aspiration and may reduce the need for open biopsy. The authors' initial 34 cases utilizing the ABBI system were reviewed. The accuracy of specimen targeting, the success rate of lesion removal, and operative complications were some of the issues assessed. Six cases were not suitable for the procedure: the mammographic lesion was not visualized in four, and the breast was too thin on compression in two. There was successful removal of the lesion in 27 of the remaining 28 cases. There were no local wound complications, and patient satisfaction was high in all completed biopsies. The ABBI system is an effective new form of minimally invasive breast surgery. It provides complete excision of mammographic abnormalities. Its use of the most direct path to these lesions allows for minimal removal of adjacent normal tissue. In this study there were no complications and very little patient pain.

The role of the endoscopic extraperitoneal approach in large inguinal scrotal hernias

The role of endoscopic extraperitoneal herniorrhaphy (EEPH) in the management of giant scrotal hernias has not been well defined, and the technical details relating to operations on such hernias have not been described. We present our experience with 17 patients undergoing repair of giant scrotal hernias. Foley catheter bladder decompression was routinely employed. The Retzius space was developed early in the procedure and hernia sac contents were reduced in all cases. The inferior epigastric vessels were likewise divided in all patients. The average operative time was 76 min and all patients were discharged home the same day. There have been no recurrences on follow-up. There was no mortality, and morbidity was limited to seroma formation in two patients. We conclude that with certain technical modifications, EEPH can be safely employed for the treatment of giant scrotal hernias.

Pneumothorax as a complication of laparoscopic inguinal hernia repair

Pneumothorax was identified as a complication of endoscopic hernia repair in two patients with insufflation pressures of 15 mmHg and operating times exceeding 2 h. These patients also showed intraoperative perturbations in both oxygen saturation and end-tidal CO2 production. A prospective study was undertaken to determine whether similar complications would arise if preperitoneal insufflation pressures were limited to 10 mmHg. Postoperative chest x-rays were obtained on all patients to check for pneumothoraces, even clinically occult ones. Fifty patients were studied, with average operating times of 67 min. No patient demonstrated any hemodynamic or ventilatory changes, and none had any evidence of pneumothorax on x-ray. We conclude that these complications were not present when insufflation pressure was maintained at 10 mmHg and that routine x-ray is not warranted. Larger randomized trials of insufflation pressures are needed.

Laparoscopic common bile duct exploration: a review

The use of laparoscopic methods to explore the common bile duct is now well-established, although they continue to undergo continuous evolution and improvement. In experienced hands laparoscopic management of choledocholithiasis may be undertaken with morbidity and mortality at least as good as that of open surgery. The use of diagnostic endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy before or after laparoscopic intervention must be evaluated. The degree of acceptance that laparoscopic techniques for common bile duct exploration (CBDE) will achieve within the surgical community remains to be determined, but will likely increase as more practicing surgeons familiarize themselves with them.

Endoscopic extraperitoneal herniorrhaphy in 316 patients

The posterior approach for groin hernia repair as popularized by Stoppa and Nyhus is one of the most solid repairs available. It requires a larger incision than the anterior approach, which has limited its use to recurrent and bilateral hernias. The endoscopic extraperitoneal herniorrhaphy (EEPH) accomplishes a similar repair via three minute incisions. This study suggests that EEPH is at least as safe and efficient as the open preperitoneal repair. Three hundred sixteen male patients underwent 405 hernia repairs by an endoscopic extraperitoneal approach. Ages ranged from 18 to 82 years old. There were 204 indirect, 182 direct, 13 pantaloon, and six femoral hernias. Eighty-nine were bilateral and 42 were recurrent. All repairs were done using polypropylene mesh. Follow-up has been achieved in 89% of patients and ranged from 7 to 50 months, with a median of 25 months. Seven patients (2.2%) required conversion to an open approach. Five recurrences have developed to date. Complications (5.7%) have included urinary retention, bladder injury, groin and/or scrotal hematoma, trocar site infection, lateral femoral cutaneous nerve neuralgia, and cardiac arrhythmia. Endoscopic extraperitoneal herniorrhaphy may provide an appropriate alternative to other methods of hernia repair when performed by experienced laparoscopists.

Extraperitoneal endoscopic inguinal herniorrhaphy performed without carbon dioxide insufflation

Laparoscopic extraperitoneal herniorrhaphy is an alternative to the standard open inguinal herniorrhaphy. The procedure is usually done with general or epidural anesthesia and carbon dioxide (CO2) insufflation. Previously, if the peritoneum was perforated in a patient on whom epidural anesthesia was used, conversion to general anesthesia was required because of the resulting pneumoperitoneum. Eliminating CO2 insufflation from the procedure would obviate this problem. The following is a description of the first 5 reported cases of extraperitoneal endoscopic herniorrhaphy done without the need for CO2 insufflation.

The utility of laparoscopic common bile duct exploration in the treatment of choledocholithiasis

Laparoscopic common bile duct exploration (CBDE) was performed in 24 patients over a 23-month period. Fourteen of these patients were suspected preoperatively of harboring common bile duct (CBD) calculi. Of these, endoscopic sphincterotomy was unsuccessful in eight. Laparoscopic CBDE was performed either transcystically or via a choledochotomy. In all cases, completion cholangiography demonstrated that the CBD was free of stones. All patients were sent home with drains placed in their extrahepatic biliary system. Mean hospital stay was 2.7 days. There was no mortality. The overall morbidity rate was 29.1%. It included one trocar site infection (4.1%), four cases of mild postoperative amylasemia (16.6%), and two cases of retained stones (8.3%) seen in two patients on follow-up tube cholangiography that were successfully extracted percutaneously. The authors feel that laparoscopic CBDE is a safe and effective method of CBD stone removal that offers an alternative to preoperative ERCP and sphincterotomy.

Combined use of laparoscopy and endoscopy in diagnosing and treating Dieulafoy's vascular malformations of the stomach

We present the case of a 70-year-old female successfully treated for a bleeding Dieulafoy's gastric lesion with a combined laparoscopic/endoscopic approach. An increasing percentage of surgery is now being performed laparoscopically and the authors feel that combined laparoscopic/endoscopic surgery offers advantages to the patient over either of these methods individually and over open surgery. This report demonstrates that a bleeding point anywhere on the gastric wall is amenable to laparoscopic intervention if the localization techniques we describe are utilized.

A study of 101 patients treated with extraperitoneal endoscopic laparoscopic herniorrhaphy

One hundred twenty-two hernias were repaired in 101 male patients through a total extraperitoneal approach. Patients ranged from 18 to 78 years old. All repairs were done with polypropylene mesh. Five patients (5%) required conversion to an open or transabdominal approach. Patients have been followed from 6 to 20 months, with a mean of 12 months. No recurrence has developed to date. Complications included urinary retention, groin hematoma, trocar site infection, and lateral femoral cutaneous nerve neuralgia. Six patients underwent simultaneous extraperitoneal endoscopic pelvic lymph node dissections, and two patients had varicoceles repaired simultaneously. Patients returned to usual activity within 1 week.

Extraperitoneal endoscopic inguinal hernia repair

The endoscopic extraperitoneal hernioplasty as reported in this study is a similar repair to that achieved by the conventional preperitoneal repair as described by Stoffa, Nyhus, and Rignault. However, this new repair is completed via a totally extraperitoneal approach. Thus, it eliminates all early and late complications related to the violation of the peritoneal cavity as proposed by other intraperitoneal laparoscopic approaches to hernia repair. This report demonstrates the safety and feasibility of this procedure while offering the patient the advantages of a minimally invasive surgical procedure which can be performed under regional anesthesia.

Laparoscopic ureterolithotomy

We describe the successful laparoscopic removal of a distal ureteral cystine stone not amenable to ureteroscopic or medical therapy. This approach offers an alternative to open ureterolithotomy in patients when less invasive measures fail.