Laparoscopic vs open inguinal hernia repair

Background: The role of laparoscopic inguinal hernia repair is controversial. The aim of this study was to find out whether it is justified to switch from the predominantly modified Bassini repair which the authors had been using to laparoscopic repair. Methods: Randomized controlled trial in 120 eligible patients admitted for elective hernia repair in a university hospital. Results: Sixty patients underwent laparoscopic transabdominal preperitoneal mesh repair; the other 60 patients had an open repair, mostly with the modified Bassini technique. Operative time for laparoscopic repair was significantly longer, mean (s.d.) 95 (28) min vs 67 (27) min (p < 0.001). The mean analogue pain score during the first 24 h after surgery was 36.2 (20.2) in the laparoscopic group and 49.3 (24.9) in the open group (p= 0.006). The requirement for narcotic injections and postoperative disability in walking 10 m and getting out of bed were also significantly less following laparoscopic repair. The postoperative hospital stay was not significantly different, mean 2.6 (1.2) days for laparoscopic repair and 3.0 (1.5) days for open repair (p= 0.1). Patients were able to perform light activities without pain or discomfort sooner after laparoscopic repair, median interquartile range 8 (5–14) days vs 14 (8–19) days (p= 0.013). Patients also resumed heavy activities sooner, but not significantly, after laparoscopic repair, median 28 (17–60) days vs 35 (20–56) days (p= 0.25). The return to work was not significantly different, median 14 (8–25) days after laparoscopic repair and 15 (11–21) days after open repair (p= 0.14). After a mean follow-up of 32 months one patient developed a recurrent hernia 3 months after a laparoscopic repair. Laparoscopic repair was more costly than open repair by approximately $400. Conclusions. Laparoscopic inguinal hernia repair was associated with less early postoperative pain and disability and earlier return to full activities than open repair, but there were no benefits regarding postoperative hospital stay and return to work; laparoscopic repair was also more costly. Received: 23 May 1997/Accepted: 1 August 1997     

Laparoscopic extraperitoneal inguinal hernia repair

We have devised a reproducible approach to the preperitoneal space for laparoscopic repair of inguinal hernias that is based on an understanding of the abdominal wall anatomy. Laparoscopic totally extraperitoneal herniorrhaphy was performed on 99 hernias in 90 patients at the Los Angeles County–University of Southern California Medical Center, using a standardized approach to the preperitoneal space. Operative times, morbidity, and recurrence rates were recorded prospectively. The median operative time was 37 min (range, 28–60) for unilateral hernias and 46 min (range, 35–73) for bilateral hernias. There were no conversions to open repair, and there was only one conversion to a laparoscopic transabdominal approach. Complications were limited to urinary retention in two patients, pneumoscrotum in one patient, and postoperative pain requiring a large dose of analgesics in one patient. All patients were discharged within 23 h. There were no recurrences or neuralgias on follow-up at 2 years. A standardized approach to the preperitoneal space based on a thorough understanding of the abdominal wall anatomy is essential to a satisfactory outcome in hernia repair. Received: 18 November 1998/Accepted: 19 March 1999     

Laparoscopic approach to incarcerated inguinal hernia

The safety and effectiveness of laparoscopic treatment for incarcerated inguinal hernia have not been clarified. Six patients who underwent laparoscopic reduction and repair of incarcerated inguinal hernias were reviewed retrospectively. All operations were initiated within 1 h after establishment of the diagnosis. Laparoscopically, the incarcerated small-bowel segments could be easily returned to the abdominal cavity by a combination of pulling them with Babcock forceps while pushing back the bowels from outside the abdominal wall. The hernial portals were not cut in three patients, while they were dissected in the other three. All incarcerated bowels were congested and red immediately after reduction; however, their color returned to normal during hernia repair and unnecessary bowel resection was therefore avoided. The mean operation time was 88 min. Although one patient underwent laparotomy because of the suspicion of necrosis of the incarcerated inguinal hernia, which was finally found to be due to postoperative paralytic ileus, the postoperative courses of the remaining five were uneventful. Laparoscopic reduction and repair of incarcerated inguinal hernia was useful, and unnecessary bowel resection could be avoided. Received: 9 February 1996/Accepted: 20 May 1996     

Meta-analyses of randomized controlled trials of laparoscopic vs conventional inguinal hernia repairs

Background: Despite randomized controlled trials, the merits of laparoscopic hernia repair remain poorly defined. A meta-analysis may provide a timely overview. Methods: An electronic MEDLINE search, supplemented by a manual search, yielded 14 randomized controlled trials with usable statistical data, involving 2,471 patients. The trials were grouped for separate meta-analyses according to the control operation, either a tension-free or sutured repair, used for comparison. The effect sizes for operating time, postoperative pain, return to normal activity, and early recurrence were calculated, using a random-effects model when the effect sizes were heterogeneous and without subcategories. Results: In all meta-analyses, the laparoscopic operation was significantly longer. When compared with tension-free repairs, the laparoscopic operation showed no advantage in terms of postoperative pain, but resulted in a shorter recovery (marginal significance). As compared with sutured repair, both postoperative pain and recovery were in favor of the laparoscopic operation. When all 14 trials were analyzed together, laparoscopic repairs still had moderately reduced postoperative pain and recovery time. Conclusions: Laparoscopic hernia repair has a modest advantage over conventional repairs. This advantage is more apparent when laparoscopic repairs are compared with sutured repairs rather than tension-free repairs. Received: 9 June 1998/Accepted: 12 January 1999     

Laparoscopic inguinal hernia repair using an anatomically contoured three-dimensional mesh

Background: Laparoscopic inguinal hernia repair frequently is performed with mechanical fixation of a flat polypropylene mesh. Mechanical fixation is associated with pain syndromes, and mesh migration may occur without fixation of flat prostheses. An anatomically contoured mesh (3D Max; Davol, Cranston, RI, USA) using no or minimal fixation would avoid these problems. Methods: A retrospective case study reviewed 212 transabdominal preperitoneal herniaplasties with 11 × 16-cm 3D Max mesh in 146 patients. Fixation with three helical tacks at the most was used early or with very large defects. Results: Fixation was used in 19% of the cases, but only for 1 of the last 98 patients. As reported, 94% of the patients returned to normal activities by 3 weeks, 97% returned to unrestricted sports by 6 weeks, and 92% complete recovery from surgery by 9 weeks. Fixation or bilateral repair did not alter recovery. Four patients had minor pain or numbness. Symptomatic recurrence was 0%. One asymptomatic indirect recurrence was noted on examination, during a mean follow-up period of 23 months, yielding a 0.55% hernia rate and a 0.42% patient-year recurrence risk. Conclusions: An anatomically contoured mesh for transabdominal preperitoneal hernia repair often requires no fixation, with minimal risk of neuropathy and less than a 0.5% patient-year recurrence rate. Recovery is excellent even with bilateral repair or some fixation. Financial support for this study was provided by Davol, Inc., Cranst, USA     

A randomized, controlled, clinical study of laparoscopic vs open tension-free inguinal hernia repair

Background: The aim of this prospective, randomized, controlled clinical study was to compare laparoscopic transabdominal preperitoneal (TAPP) hernia repair with a standard tension-free open mesh repair (open). Methods: A total of 108 low-risk patients with unilateral (primary or recurrent) or bilateral hernias were randomized to TAPP (group 1 = 52 cases) or open (group 2 = 56 cases). The outcome measures included operating time, complications, postoperative pain, return to normal activity, operating theater costs, and recurrences. Results: The mean operative time was longer for the TAPP than for the open group only in unilateral primary hernias. At rest, the median Visual Analog Scale (VAS) score was higher for group 1 than group 2 at 48 h postoperatively. Mild to discomforting pain in the inguinal region after 7 days, night pain after 30 days, and inguinal hardening after 3 months were more frequent in group 2 than group 1. No significant differences were observed in return to normal activities between the groups. One hernia recurrence was observed after 1 month in group 1. TAPP was significantly more expensive than open. Conclusions: TAPP was associated with less postoperative pain than open. The increase in operating theater costs, however, was dramatic and was not compensated by shorter time away from work. TAPP should not be adopted routinely unless its costs can be drastically reduced. Received: 10 June 1997/Accepted: 6 October 1997     

A simplified laparoscopic technique for mesh placement in ventral hernia repair

The use of a large synthetic mesh for laparoscopic repair of significant ventral abdominal wall defects may be accompanied by technical difficulties resulting from improper orientation and positioning of the mesh over the defect. We suggest a technique based on initial fixation of the mesh center to the central point of the defect, and subsequent centrifugal attachment of the mesh to the abdominal wall. This technique is advantageous because it leads to precise orientation and positioning of the synthetic patch and to significant reduction of the time needed for its reinforcement over and around the defect. Received: 25 September 1998/Accepted: 27 November 1998     

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目的探讨无张力疝修补术在腹股沟复发疝中的临床应用价值。方法自2000年8月至2003年5月应用无张力疝修补术治疗腹股沟复发疝病人52例,其中应用疝环填充法38例,三合一补片法14例,观察手术时间、伤口疼痛、术后自主功能的恢复、并发症及复发率。结果手术全部成功完成,平均手术时间50min,术后4例出现尿潴留,5例出现阴囊积液。术后5～7d出院,随访3～36个月未见复发病例。结论无张力疝修补术是治疗腹股沟复发疝的理想术式,具有手术安全、创伤小、痛苦小、术后恢复快、近期疗效满意和复发率低等优点,手术方式应“个体化”。     

Laparoscopic repair of a paraduodenal hernia

Paraduodenal hernias have traditionally been treated by conventional laparotomy. We report the first case of a left paraduodenal hernia treated laparoscopically. A 44-year-old man was admitted with abdominal pain and nausea. Computed tomography and an upper gastrointestinal series with small-bowel followthrough showed accumulation of the small bowel on the left side of the abdomen. A laparoscopic repair was performed. The small bowel was observed beneath a thin hernia capsule. Approximately 1.5 m of jejunum was easily reduced into the abdominal cavity. The hernia orifice (5-cm diameter) was closed intracorporeally with five interrupted sutures. Good exposure of the operative field is critical to this procedure; poor exposure may limit the applicability of the laparoscopic approach. This minimally invasive operation is currently indicated in nonobstructive paraduodenal hernias, especially on the left. Received: 7 October 1996/Accepted: 11 April 1997     

Laparoscopic repair of postoperation ventral hernia

Background: Laparoscopic repair is a new alternative approach to postoperation ventral hernia (POVH). Whether this procedure is accompanied with acceptable operation risk and recurrence rate is not yet established. Methods: During 1996, we performed laparoscopic repair of POVH in 53 patients. Twenty-nine (55%) of these patients had a history of at least one failed hernia repair. The size of the abdominal wall defect varied from 4 × 5 cm to 15 × 20 cm (median, 13 × 9 cm). All operations were performed with the patient under general anesthesia. In all cases, the Gore-Tex® Dual Mesh (W. L. Gore &; Associates, Flagstaff, AZ, USA) was used in sizes varying from 5 × 7 cm to 20 × 30 cm (median, 15 × 12 cm). Results: No deaths occurred as a result of the operations. Intraoperative small bowel injury occurred in two patients (3.6%), which necessitated conversion to laparotomy and performance of small bowel resection in one case and simple suture in the other. Small bowel obstruction developed during the immediate postoperation period in two patients (3.6%). In one of these patients, laparoscopic lysis of adhesions had to be performed. Graft infection with subsequent graft removal occurred in one patient (1.8%), and abdominal wall hematoma developed in another patient (1.8%). Length of hospital stay varied from 2 to 8 days (median, 3.3 days). Follow-up period ranged from 10 to 22 months (median, 17 months). During this period, recurrence of hernia occurred only in one patient in which the mesh had been removed. Conclusions: Laparoscopic repair of POVH is technically feasible. According to our experience, it is the preferred method for patients who have had an earlier failed open repair and patients in whom it is the first repair. Cases with a high likelihood for small bowel injury must be recognized and converted to routine open repair.     

Laparoscopic extraperitoneal inguinal hernia repair with spinal anesthesia and nitrous oxide insufflation

Background: Laparoscopic repair of inguinal hernia is traditionally performed under general anesthesia mainly because of the adverse effects that carbon dioxide pneumoperitoneum has on awake patients. Since a mandatory use of general anesthesia for all hernia repairs is questionable, the feasibility of laparoscopic extraperitoneal herniorraphy using spinal anesthesia combined with nitrous oxide insufflation was investigated. Methods: Over a 4-month period, February to May 1998, we performed 35 consecutive total extraperitoneal inguinal hernia procedures (24 unilateral, 11 bilateral) using spinal anesthesia and nitrous oxide extraperitoneal gas. Data on operative findings, self-reported operative and postoperative pain and discomfort (visual analog pain scale), procedure-related hemodynamics, and complications were collected prospectively. Results: All 35 procedures were completed laparoscopically without the need to convert to general anesthesia. Mean operative time was 39 ± 7 min for unilateral hernia and 65 ± 10 min for bilateral hernia. Incidental peritoneal tears occurred in 22 patients (63%) resulting in nitrous oxide pneumoperitoneum, which was well tolerated. The patients remained hemodynamically stable throughout the procedure, and operative conditions and visibility were excellent. Complications at a mean of 4 months after the procedure included seven uninfected seromas (20%), three patients with transient testicular pain, and one (3%) recurrence. Conclusions: Laparoscopic total extraperitoneal hernia repair can be safely and comfortably performed using spinal anesthesia with extraperitoneal nitrous oxide insufflation gas. This method provides a good alternative to general anesthesia. Received: 17 February 1999/Accepted: 1 July 1999     

Laparoscopic inguinal hernia repair in children.

BACKGROUND: This study aimed to document the authors' experience with laparoscopic inguinal hernia repair in children. METHODS: Ninety-three hernia repairs were performed in 64 children. The neck was closed with a purse string suture by using 4-0 absorbable suture. RESULTS: Ninety-three indirect inguinal hernial sacs were closed in 64 children. Nine percent of children had an ectopic testis. The mean operating time for laparoscopic ring closure was 25 minutes (range, unilateral 21 to 35; bilateral, 28 to 50). The contralateral processus vaginalis was patent in 20% of children. In 24% of children, the final procedure was modified based on the findings of a dilated internal ring. A laparoscopic ilio-pubic tract repair was done in these cases. Laparoscopic mobilization, orchiopexy followed by ilio-pubic tract repair was done in 9% of children. Scrotal swelling occurred in one child. Hydrocoele occurred in one patient. Recurrence rate was 3.1%. CONCLUSION: Laparoscopic inguinal hernia repair in children can be offered, as it is safe, reproducible, and technically easy for experienced laparoscopic surgeons. Ilio-pubic tract repair may be added in cases with dilated internal ring. Recurrence following laparoscopic ring closure can be managed with laparoscopic ilio-pubic tract repair. The long-term follow-up of laparoscopic ilio-pubic tract repair is awaited.     

Laparoscopic ventral hernia repair

Introduction: Effective surgical therapy for ventral and incisional hernias is problematic. Recurrence rates following primary repair range as high as 25–49%, and breakdown following conventional treatment of recurrent hernias can exceed 50%. As an alternative, laparoscopic techniques offer the potential benefits of decreased pain and a shorter hospital stay. This study evaluates the efficacy of the laparoscopic approach for ventral herniorrhaphy. Methods: A retrospective review was performed for 100 consecutive patients with ventral hernias who underwent laparoscopic repair at our institutions between November 1995 and May 1998. All patients who presented during this period and were candidates for a mesh hernia repair were treated via an endoscopic approach. Results: One hundred patients underwent a laparoscopic ventral hernia repair. There were 48 men and 52 women. The patients were typically obese, with a mean body mass index (BMI) of 31 kg/m². Each had undergone an average of 2.5 (range; 0–8) previous laparotomies. Forty-nine repairs were performed for recurrent hernias. An average of two patients (range; 1–7) had previously failed open herniorhaphies; in 20 cases, intraabdominal polypropylene mesh was present. There were no conversions to open operation. The mean size of the defects was large at 87 cm² (range; 1–480). In all cases, the mesh (average, 287 cm²) was secured with transabdominal sutures and metal tacks or staples. Operative time and estimated blood loss averaged 88 min (range; 18–270) and 30 cc (range; 10–150). Length of stay averaged 1.6 days (range; 0–4). There were 12 minor and (two) major complications: cellulitis of the trocar site (two), seroma lasting >4 weeks (three), postoperative ileus (two), suture site pain > 2 weeks (two), urinary retention (one), respiratory distress (one), serosal bowel injury (one), and skin breakdown (one) and bowel injury (one). Both of the latter complications required mesh removal. With an average follow-up of 22.5 months (range; 7–37), there have been (three) recurrences. Conclusion: The laparoscopic approach to the repair of both primary and recurrent ventral henias offers a low conversion rate, a short hospital stay, and few complications. At 23 months of follow-up, the recurrence rate has been 3%. Laparoscopic repair should be considered a viable option for any ventral hernia. Received: 11 February 1999/Accepted: 15 March 2000/Online publication: 28 April 2000     

Stapled and nonstapled laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair

Background: Controversy exists regarding whether it is necessary to secure the mesh prosthesis during laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair. It is unknown whether stapling the mesh affects recurrence rate, incidence of neuralgia, or port-site hernia. Methods: We conducted a prospective randomized trial comparing stapled with nonstapled laparoscopic TAPP inguinal hernia repairs in a series of 502 consecutive patients undergoing elective inguinal hernia repair at two institutions between January 1995 and March 1997. Results: In all, 263 nonstapled and 273 stapled repairs were performed in 502 patients. Patients were evaluated at a median follow-up of 16 months (range, 1–32 months) by independent surgeons. There was no statistical difference in the incidence of recurrence (0 to 263 nonstapled, 3 to 273 stapled; chi-square p= 0.09). The overall recurrence rate was 0.6%. There was no significant difference in operative time, port-site hernia, chronic pain or neuralgia between the two groups. Conclusion: It is not necessary to secure the mesh during laparoscopic TAPP inguinal hernia repair, allowing a reduction in the size of the ports. Received: 28 July 1998/Accepted: 25 November 1998     

Laparoscopic repair of bilateral spigelian and inguinal hernias

Spigelian hernias are rare and difficult to diagnose. Treatment has previously been limited to open surgical repair. We report the successful laparoscopic repair of bilateral spigelian and inguinal hernias using mesh. Received: 14 January 1997/Accepted: 11 April 1997     

Needlescopic extraperitoneal repair of inguinal hernias

Laparoscopic inguinal herniorrhaphy has traditionally been performed using one 5-mm and two 11-mm trocars. In this report, we evaluate the feasibility of the preperitoneal repair of inguinal hernias using the needlescopic method (2-mm ports) and describe the technique used in this repair. A total of 11 inguinal hernias were treated with needlescopic extraperitoneal repair. There were five direct and six indirect hernias. One patient had a bilateral hernia. The average operative time was 54 min. One patient was converted to the standard laparoscopic extraperitoneal method. All patients were discharged a few hours after the procedure. They were able to resume activity within a few days and required only minimal analgesic intake. Follow-up ranged from 1 to 6 months. All patients were followed up by one of the surgeons at 1, 3, and 6 weeks, and then at 6 months. No complications were encountered. There have been no recurrences to date. Overall, needlescopic extraperitoneal repair of inguinal hernias is a feasible procedure in male patients seeking better cosmetic results than can be achieved with standard laparoscopic extraperitoneal repair. This procedure is technically more demanding. The operative time is longer. The cosmetic aspect is the only advantage of this technique. Received: 22 July 1998/Accepted: 13 October 1998     

Laparoscopic extraperitoneal inguinal hernia repair in the day-care setting

Background: Totally extraperitoneal (TEP) laparoscopic inguinal hernia repair is gaining popularity, and our preference is to perform this procedure as a day case. This study evaluates the suitability of TEP repair in the day-care setting. Methods: A policy of day-care TEP repair, unless contraindicated, was adopted for inguinal hernia repair, and the outcome was prospectively evaluated. Of 87 consecutive inguinal hernia repairs, day-care TEP was possible in 54 (62%); 17 (20%) were in-patient TEP, 14 (16%) were open repairs, and 2 (2%) were converted from TEP to open repairs. Results: Among day-care TEP repairs, median visual analog pain score at discharge was 2.3/10, and 43% of patients had no pain. Complications included cord hematoma 2 (4%) and seroma 3 (6%). Median times for stopping analgesia, resumption of full activity, and return to work were 3, 3, and 6 days respectively. Complete satisfaction with day-care TEP was expressed by 91% of patients; 9% were moderately satisfied, and none expressed dissatisfaction. Conclusions: Day-care TEP repair is feasible in the majority of patients with inguinal hernias, and it is associated with minimal complications, excellent recovery, and a high degree of patient satisfaction. Received: 25 February 1998/Accepted: 28 May 1998     

Laparoscopic repair of recurrent inguinal hernias after endoscopic herniorrhaphy

Background: Although the recurrence rate for endoscopic herniorraphy is low (0–3%), it is still debatable whether these recurrences should be corrected laparoscopically or by the conventional method. The aim of this study was to investigate whether these recurrences can be repaired by means of the laparoscopic approach with acceptable complication and recurrence rates. Methods: From October 1992 to December 1997, 34 patients with recurrent inguinal hernias at physical examination underwent surgery at our institutions. All the recurrences occurred following endoscopic inguinal hernia repair with mesh prostheses. The recurrences were repaired endoscopically using a transabdominal approach. Depending on the size of the defect, a new polypropylene mesh was used. Results: Mean surgery time was 69 min. There were no conversions to the anterior approach. After a mean follow-up of 35 months, no recurrences had been diagnosed. Conclusion: The transabdominal preperitoneal approach is a reliable technique for recurrent inguinal hernia repair after previous endoscopic herniorrhaphy. Received: 7 September 1998/Accepted: 13 October 1998     

The open tension-free mesh repair of inguinal hernia Analysis of 1,235 cases

Summary 1235 outpatient repairs of inguinal hernias under local anesthesia with IV sedation were performed between September 1993 and June 1997. The average age was 63. Twelve percent were recurrent repairs. All indirect hernias and all focal diverticular type V direct defects were treated with a cone-shaped polypropylene plug plus an overlay mesh strip. All broad fusiform type IV direct defects were repaired either by the same plug method or in the manner of a Lichtenstein repair. Mortality was zero. There were 3 recurrences, 5 superficial hematomas, 5 seromas, 1 questionable neuralgia, 1 dysejaculation, 1 ischemie orchitis, 1 flare-up of gout and 1 TIA, for a complication rate of 1.46%. Infection rate was zero. Recurrence rate thus far is only 0.24%, 0.16% for primary repair and 0.67% for recurrent repair.