Chronic pain after hernia repair: a randomized trial comparing Shouldice, Lichtenstein and TAPP

Introduction Chronic pain after hernia repair is common, and it is unclear to what extent the different operation techniques influence its incidence. The aim of the present study was to compare the three major standardized techniques of hernia repair with regard to postoperative pain.Patients and methods Two hundred and eighty male patients with primary hernias were prospectively, randomly selected to undergo Shouldice, tension-free Lichtenstein or laparoscopic transabdominal pre-peritoneal (TAPP) hernioplasty repairs. Patients were examined after 52 months with emphasis on chronic pain and its limitations to their quality of life.Results Chronic pain was present in 36% of patients after Shouldice repair, in 31% after Lichtenstein repair and in 15% after TAPP repair. Pain correlated with physical strain in 25% of patients after Shouldice, in 20% after Lichtenstein and in 11% after TAPP repair. Limitations to daily life, leisure activities and sports occurred in 14% of patients after Shouldice, 13% after Lichtenstein and 2.4% after TAPP repair.Conclusion Chronic pain after hernia surgery is significantly more common with the open approach to the groin by Shouldice and Lichtenstein methods. The presence of the prosthetic mesh was not associated with significant postoperative complaints. The TAPP repair represents the most effective approach of the three techniques in the hands of an experienced surgeon.     

腹腔镜经腹腹膜前疝修补术与Lichtenstein修补术的随机对照研究

目的:研究腹腔镜经腹腹膜前疝修补术(TAPP)的安全性和临床疗效.方法:2005年3月至2008年3月期间,我们采用前瞻性随机对照法,将252例成人腹股沟疝患者随机分成两组,TAPP组126例,Lichtenstein组126例.比较两组平均手术时间、术后平均住院时间、术中术后并发症、术后疼痛评分(NRS)、使用镇痛药物、平均下床活动时间、平均恢复正常活动时间、术后复发以及手术费用等项,随访10.1(2～36)个月.结果:使用镇痛药物、下床活动时间、住院天数、恢复正常活动时间、术后疼痛程度,TAPP组优于Lichtenstein组,两组比较差异有显著性(P(0.05).手术时间、总并发症发生率、复发率在TAPP组少于Lichtenstein组,但差异无显著性(P>0.05).手术费用方面,TAPP组高于Lichtenstein组(P<0.05).结论:TAPP治疗腹股沟疝是安全、可行的,具有创伤小、恢复快、切口美观等优势,尤其适用于Ⅲ型和Ⅳ型病人.但TAPP费用比Lichtenstein高,这可能是目前TAPP尚未广泛开展的主要原因.     

Controlled multicenter trial of laparoscopic transabdominal preperitoneal hernioplasty vs Shouldice herniorrhaphy

Background: In February 1993 a prospective randomized multicenter trial was initiated to compare laparoscopic transabdominal preperitoneal hernioplasty to Shouldice herniorrhaphy as performed by surgeons of nonspecialized clinics. Methods: Until January 1994, 87 patients with 108 hernias took part in the trial (43 Shouldice and 44 laparoscopic repairs). Results: The laparoscopic procedure took significantly longer than did the open operation but caused less pain as measured by pain analogue score and consumption of paracetamol and narcotics. The postoperative complication rate was 26% in the open and 16% in the laparoscopic group. The patients in the laparoscopic group were discharged earlier and their convalescence was shorter than after open hernia repair. There has been one early recurrence in the laparoscopic and two in the open group to date with a mean follow-up of 201 days. Conclusions: Laparoscopic hernia repair causes less pain than the conventional operation and enables the patient to return to full work and usual activities earlier. The recurrence rate will not be known for 5 years.     

Randomized controlled trial of laparoscopic transabdominal preperitoneal hernioplasty vs Shouldice repair

Background: There is a scarcity of data on long-term results after laparoscopic hernia repair. Herein we report on the outcome of a group of patients who were followed up for 5 years in a multicenter study on hernia repair. Methods: A total of 100 patients with 127 hernias were randomized to undergo either transabdominal preperitoneal (TAPP) or Shouldice hernia repair. Follow-up was by clinical examination and standardized questionnaire. Results: Of the 100 patients who underwent surgery, 84 were available for follow-up at 5 years. The TAPP procedure was less painful than the Shouldice repair, with fewer patients receiving narcotic analgesics. The median time to return to 100% activity was shorter in the laparoscopic group (21 days) than in the Shouldice group (40 days). Up to 60 months after the operation, the complication rate was lower in laparoscopically repaired hernias (19/66) than in the open group (25/61). There were two recurrences (3.9%) in the TAPP group and five in the Shouldice group (10.2%). Conclusion: The TAPP hernia repair yields comparable or better results than Shouldice herniorrhaphy in terms of postoperative pain, recovery, and recurrence rate.     

腹腔镜腹膜前疝修补术与Lichtenstein平片疝修补术治疗腹股沟疝的疗效比较

目的:比较腹腔镜腹膜前(TAPP)疝修补术与Lichtenstein平片疝修补术治疗腹股沟疝的临床效果。方法:回顾性收集2013年12月—2015年12月受手术治疗的120例腹股沟疝患者资料,其中53例行腹腔镜TAPP术(TAPP组),67例行Lichtenstein术(Lichtenstein组),分析并比较两组患者的相关临床指标。结果:与Lichtenstein组比较,TAPP组手术时间(52.2 min vs.79.6 min)、术后进食时间(12.2 h vs.20.5 h)、下床活动时间(9.6 h vs.21.8 h)、住院时间(3.9 d vs.6.1 d)均减少(均P0.05);但治疗费用(6 632.7元vs.3 853.7元)增加(P0.05)。两组术中出血量、术后并发症发生率及复发率差异均无统计学意义(均P0.05)。结论:与Lichtenstein术相比,腹腔镜TAPP术治疗腹股沟疝创伤更小,且安全可靠,是临床上较佳的治疗选择之一。     

腹腔镜经腹腔腹膜前腹股沟疝修补术与Lichtenstein疝修补术对比研究

目的比较腹腔镜经腹腔腹膜前腹股沟疝修补术(TAPP)与Lichtenstein修补术治疗腹股沟疝的临床应用价值。方法分别对46例接受TAPP手术与140例接受Lichtenstein修补术的腹股沟疝患者的临床资料进行回顾性分析。结果两组在手术时间、术后下床活动时间、生活自理时间、住院天数、恢复日常工作天数方面,均无显著性差异(P0.05),两组术后均无复发。结论腹腔镜经腹腔腹膜前腹股沟疝修补术与Lichtenstein修补术均为腹股沟疝的良好修补法,但复发疝、双侧疝及腹腔联合手术的患者更适合选择腹腔镜手术。     

Outcome and cost comparison of laparoscopic transabdominal preperitoneal hernia repair versus Open Lichtenstein technique

Laparoscopic hernia repair has all the advantages of a tension free repair. This study compares the laparoscopic transabdominal preperitoneal (TAPP) approach with tension-free open hernia repair in terms of operative time, postoperative pain, hospital stay, complications, and cost. Open and TAPP repairs using polypropylene mesh were performed in two groups of 25 male patients. The difference in operative times between the groups was not significant. Mean pain scores (0-100) for the open group were 54.12 +/- 13.06 at 12 hours and 37.24 +/- 11.38 at 24 hours, significantly higher than the corresponding scores of 38.36 +/- 8.21 at 12 hours and 20.92 +/- 8.73 at 24 hours for the TAPP group (P < 0.05). The mean postoperative analgesic dose was 6.72 +/- 2.72 in the TAPP group, which was insignificantly lower than 7.52 +/- 2.00 in the open group. Mean hospital stay was 2.24 +/- 0.97 days in the open group and 1.52 +/- 0.51 in the TAPP group, which was significant (P < 0.05). Twenty patients (80%) in the TAPP group rated themselves highly satisfied with the surgery as compared to 11 patients (44%) in the open group (P < 0.05). There was no recurrence in either group during a mean followup period of 13.5 months (range, 8-28 months). Laparoscopic hernia repair was significantly more expensive than open (1100 US dollars versus 629 US dollars). TAPP repair is superior to open repair in terms of shorter hospital stay, lower postoperative pain, and better patient satisfaction. It is also safe, with no recurrence in a short-term period. This technique will be the operation of choice for the treatment of groin hernia after long-term results have been established in our center.     

Randomized trial of Lichtenstein versus Shouldice hernia repair in general surgical practice

BACKGROUND: The aim of the present randomized trial was to compare the Shouldice procedure and the Lichtenstein hernia repair with respect to recurrence rate, technical difficulty, convalescence and chronic pain. A further aim was to determine to what extent general surgeons in routine surgical practice were able to reproduce the excellent results reported from specialist hernia centres. METHODS: Three hundred patients with primary inguinal hernia were randomized to either a Shouldice repair or to a tension-free Lichtenstein repair. In a pretrial training programme the five participating general surgeons were taught to perform the two techniques in a standard manner. Follow-up was performed after 8 weeks, 1 year and 3 years. The last examination was performed by an independent blinded assessor. RESULTS: There was a significant difference in operating time in favour of the Lichtenstein technique. After a follow-up of 36-77 months seven recurrences were found in the Shouldice group (95 per cent confidence interval (c.i.) 1.3 to 8.1) and one in the mesh group (95 per cent c.i. 0.0 to 2.0). Chronic groin pain was reported by 4.2 and 5.6 per cent in the Shouldice and Lichtenstein groups respectively. It was characterized as mild or moderate in all except two patients who had the Shouldice operation. CONCLUSION: Lichtenstein hernia repair was easier to learn, took less time and resulted in fewer recurrences. It was possible to achieve excellent results with this technique in a general surgical unit.     

Long-term results after laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair under spinal anesthesia

Background

Laparoscopic transabdominal preperitoneal (TAPP) repair is indicated for recurrent and bilateral inguinal hernias and traditionally is performed under general anesthesia. However, the feasibility of performing TAPP under spinal anesthesia has been recently reported by our team.

Aim

To assess the long-term results of TAPP repair under spinal anesthesia for primary inguinal hernia.

Materials and methods

Between January 2006 and October 2009, 94 consecutive patients with primary unilateral inguinal hernia were submitted to laparoscopic transabdominal preperitoneal repair under spinal anesthesia. We looked at the immediate postoperative outcome as well as the long-term outcome, mainly recurrences and incidence of chronic pain.

Results

One patient experienced a scrotal hematoma, one patient a trocar site infection, two patients were diagnosed with an operation-related orchitis, while 31 patients (33?%) developed symptoms of urinary retention. At a median follow-up of 35?months (range 14-59), four patients (4.3?%) were diagnosed with a recurrence, while 89?% of patients reported satisfied from the procedure in the long-term. Chronic pain was not encountered in any of the patients studied. Four patients (4.3?%) reported an intermitted foreign body sensation and/or rigidity and two patients (2.1?%) numbness in the operated inguinal area.

Conclusion

Laparoscopic TAPP hernia repair under spinal anesthesia is associated with satisfactory short- and long-term results. Use of regional anesthesia instead of the traditional general anesthesia does not seem to adversely affect the quality of repair, and moreover, it offers the patient an attractive anesthetic alternative.     

Lichtenstein vs anterior preperitoneal prosthetic mesh placement in open inguinal hernia repair: A prospective,randomized trial

Male veterans with unilateral primary inguinal hernia, classified intraoperatively as Gilbert Type III or IV, were randomized to subaponeurotic (Lichtenstein, n=126) or preperitoneal (Read-Rives, n=121) repair under general or spinal anesthesia. The two groups of patients were comparable in age, body weight index, comorbidities, and size and type of hernia. Of the 247 patients enrolled, 224 were followed for at least 2 years (median 82 months, range 24–110 months), 16 were lost to follow-up, and seven died from causes unrelated to the surgery. The average operative time of the Read-Rives repair was 9 min longer than that of the Lichtenstein repair. There were no wound infections, and the frequencies of other short- and long-term complications were low and similar in the two groups. Six patients developed hernia recurrence, five in the Lichtenstein group (4.3%), and one in the Read-Rives group (<1%), (P=0.21). Both anterior repairs are associated with low postoperative morbidity and recurrence rates. The Lichtenstein repair is technically easier and less time consuming. There is no statistically significant difference in the recurrence rate between the two repairs.     

Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair

BACKGROUND: Laparoscopic herniorrhaphy has emerged as a recognized operative method for inguinal hernia repair. This study compared the short-term results of two tension-free methods of repair: totally extraperitoneal (TEP) laparoscopic patch repair and the open Lichtenstein mesh technique. METHODS: A total of 1513 men from 11 hospitals who presented with a primary unilateral inguinal hernia were randomized to one of the two methods. Operating time, short-term complications, reoperations, postoperative pain, consumption of analgesics, sick leave and time to resumption of normal physical activities were recorded. RESULTS: Some 1371 of the 1513 men underwent surgery, 665 in the TEP group and 706 in the Lichtenstein group. The median duration of operation was 55 min for both procedures and 91.0 percent of the patients in both groups were discharged on the day of operation. Patients in the TEP group experienced less postoperative pain (P<0.001), consumed fewer analgesics (P<0.001), had a shorter period of sick leave (7 versus 12 days; P<0.001) and a shorter time to resumption of normal physical activity (20 versus 31 days; P<0.001). CONCLUSION: The TEP technique took no longer to perform, and was associated with less postoperative pain, a shorter period of sick leave and a faster recovery, compared with open Lichtenstein hernia repair.     

腹腔镜经腹腹膜前疝修补术与Lichtenstein术在成人腹股沟嵌顿疝的疗效

目的探讨腹腔镜经腹腹膜前疝修补术（TAPP）与Lichtenstein术在成人腹股沟嵌顿疝治疗中的临床应用比较。 方法回顾分析2014年1月至2019年1月,上海中医药大学附属普陀医院急诊收治并完成无张力疝修补手术病例共82例成人腹股沟嵌顿疝患者临床资料,根据手术方式不同分为2组。观察组38例,行TAPP术;对照组44例,行Lichtenstein术。将2组手术时间,术后住院时间,术后疼痛评分,术后血清肿,术后其他并发症（复发、术后感染、术后肠坏死、出血）,术后总费用等进行统计学分析。 结果2组在术后血清肿及其他并发症上比较,差异无统计学意义（P>0.05）;研究组手术时间及住院费用明显高于对照组,差异有统计学意义（P<0.05）;研究组术后住院时间及术后疼痛评分低于对照组,差异有统计学意义（P<0.05）。 结论TAPP术较Lichtenstein术手术时间长,术后总费用相对高,但其具有创伤小、疼痛轻、恢复快、复发率低等特点。     

Three-year results of a randomized clinical trial of lightweight or standard polypropylene mesh in Lichtenstein repair of primary inguinal hernia

BACKGROUND: This randomized trial examined whether lightweight (LW) polypropylene mesh (large pore size, partially absorbable) could have long-term benefits in reducing chronic pain and inflammation after inguinal hernia repair. METHODS: Six hundred men with a primary unilateral inguinal hernia were randomized to Lichtenstein repair using a standard polypropylene mesh or a LW mesh in one of six centres. The patients were blinded to which mesh they received. Clinical examination was performed and a pain questionnaire completed 3 years after surgery. RESULTS: Of the 590 men who had surgery, 243 (82.7 percent) of 294 in the standard mesh group and 251 (84.8 percent) of 296 in the LW mesh group were examined in the clinic, a median of 37 (range 30-48) months after hernia repair. There were nine recurrent hernias in each group (3.7 percent with standard mesh and 3.6 per cent with LW mesh). Patients who had LW mesh had less pain on examination, less pain on rising from lying to sitting, fewer miscellaneous groin problems and felt the mesh less often than patients with standard mesh. CONCLUSION: Use of LW mesh for Lichtenstein hernia repair did not affect recurrence rates, but improved some aspects of pain and discomfort 3 years after surgery.     

DeGarengeot hernia: transabdominal preperitoneal hernia repair and appendectomy.

BACKGROUND: The incarcerated appendix in the femoral hernia represents a rare clinical case that was first described by the Frenchman de Garengeot in 1731. Besides the open procedures, laparoscopy presented itself as a treatment option. CASE REPORT: Our case concerns a 38-year-old patient with a right femoral hernia with an inflamed incarcerated appendix. Because of the clinically inconclusive finding, we chose transperitoneal preperitoneal hernia repair (TAPP) combined with a laparoscopic appendectomy. The intra- and postoperative course was uneventful. This case shows that a laparoscopic procedure is possible even in the case of an incarceration in conjunction with an appendicitis that has not spread to the adjacent peritoneum. DISCUSSION: Compared with open interventions, the subjective social advantages (shorter hospital stay, earlier return to work, less need for pain killers, and others) of laparoscopic hernia treatment have been extensively studied. The use of both methods in the case of an incarcerated hernia is open to dispute, though various small series confirm the feasibility. CONCLUSION: Here, TAPP seems to be the more reliable method in terms of patient safety because of the simultaneous possibility of using laparoscopy.     

Comparison of Lichtenstein and laparoscopic transabdominal preperitoneal repair of recurrent inguinal hernias

The aim of our study was the comparative analysis of the results of two surgical methods: tension-free repair by the Lichtenstein technique and laparoscopic transabdominal preperitoneal (TAPP) repair. In total 52 patients with recurrent inguinal hernia were randomly assigned to the two groups: Lichtenstein (28 patients) and TAPP (24 patients). Comparisons between these groups were done by several preoperative, intraoperative, and postoperative factors. For postoperative factors both short-term and long-term results were considered. Average operation time for Lichtenstein group was 59.6 +/- 9.9 minutes, compared with 64.4 +/- 8.4 minutes for TAPP patients (P = 0.068). In TAPP patients there was less pain in the postoperative period (P = 0.002) and fewer sick-leave days (13.4 +/- 1.7 versus 17.5 +/- 2.6 days; P < 0.001) and, correspondingly, faster recovery. In the Lichtenstein group a total of 4 postoperative complications (infection, hematoma, seroma, urinary retention) were observed, compared with 8 in the TAPP group (P = 0.19). Statistically significant difference was only by urinary retention (0 for Lichtenstein, 4 for TAPP; P = 0.039). There were no cases of hernia recurrence observed during the followup. Chronic pain developed in 5 patients from the Lichtenstein group (17.9%) and 2 patients from the TAPP group (8.3%; P = 0.28) more than 1 year after the operation; 4 Lichtenstein patients (14.3%) and 1 TAPP patient (4.2%; P = 0.23) more than 2 years after the operation; and 3 Lichtenstein patients (10.7%) and 1 TAPP patient (4.2%; P = 0.36) more than 3 years after the operation. For the treatment of recurrent inguinal hernias, which are developed after use of conventional (nonmesh) methods, the first choice should be given to the laparoscopic method, especially for young, physically active, nonobese patients, and if there are any contraindications for the laparoscopy, the Lichtenstein approach should be recommended.     

Pain during sexual activity and ejaculation following hernia repair: A retrospective comparison of transabdominal preperitoneal versus Lichtenstein repair

Pain during sexual activity and ejaculation are the unspoken long-term complications of groin hernia repair. Laparoscopic surgical techniques are associated with decreased post-operative pain and earlier return to daily activities, but its effect on these complications is unclear. This study aims to investigate the effect of transabdominal preperitoneal repair (TAPP) on de-novo pain during sexual intercourse and ejaculation and to compare with open repair. For this reason, two groups were determined according to the surgical technique: the Lichtenstein repair and the TAPP groups and a questionnaire was sent to the patients a minimum of 6 months following the surgery. A total of 317 patients included, as 115 in TAPP and 202 in Lichtenstein repair group. No significant difference was observed concerning pre-operative pain during sexual activity and ejaculation in both groups (p = .75, p = .56). Following the surgery, the number of patients experiencing painful sexual activity was significantly higher in the Lichtenstein repair group compared to the TAPP group (19.3% vs. 11.3%, respectively, p = .03). The post-operative painful ejaculation rate was also significantly lower for the TAPP group (p = .04). The lower rates of post-operative dysejaculation and pain during sexual activity can be achieved with the advantage of laparoscopic surgery.     

从荟萃分析认识李金斯坦和腹膜前间隙修补术

目的比较李金斯坦（Lichtenstein）修补术与腹膜前间隙修补术的临床效果及并发症情况.方法 通过检索2000年1月至2012年11月PubMed、EMBase、Springer及Cochrane图书馆公开发表的英文文献,对纳入研究的14篇文献中采用Lichtenstein修补术与腹膜前间隙修补术的3 364例患者的复发率、慢性疼痛、局部麻木感、感觉异常、血肿/血清肿、切口感染、睾丸并发症、手术时间进行荟萃分析（meta-analysis）.结果 腹膜前间隙修补术组的复发率低于Lichtenstein组,差异有统计学意义[OR=0.51,95%CI （0.29,0.89）];与Lichtenstein组比较,腹膜前间隙组的手术时间短,差异有统计学意义[MD=-2.78,95%CI （-5.51,-0.006）].其他并发症,包括慢性疼痛、局部麻木感、感觉异常、血肿/血清肿、切口感染、睾丸并发症在二组之间差异无统计学意义.结论 开放腹膜前间隙腹股沟疝修补术是安全有效的修补技术,复发率更低,手术时间更短.