Long-term results of a randomized clinical trial of Shouldice, Lichtenstein and transabdominal preperitoneal hernia repairs

INTRODUCTION: There is an ongoing debate about the preferred technique for inguinal hernia repair. In this randomized study the long-term results of Shouldice, Lichtenstein and transabdominal preperitoneal (TAPP) hernia repair were compared. METHODS: Some 280 men with a primary hernia were randomized prospectively to undergo Shouldice, tension-free Lichtenstein or laparoscopic TAPP repair. Patients were examined after 52 months to assess hernia recurrence, nerve damage, testicular atrophy and patient satisfaction. RESULTS: Hernia recurrence occurred in six patients after Shouldice repair, and in one patient each after Lichtenstein and TAPP repairs. All recurrences after tension-free repairs were diagnosed within the first year after surgery. Nerve injuries were significantly more frequent after open Shouldice and Lichtenstein repairs. Patient satisfaction was greatest after laparoscopic TAPP repair. CONCLUSION: Tension-free repair was superior to the non-mesh Shouldice technique. The open anterior approach to the groin was associated with demonstrable nerve injury, and laparoscopic TAPP repair was the most effective approach in the hands of an experienced surgeon.     

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腹股沟疝无张力修补术可分为三大类术式:肌前修补、网栓充填术和腹膜前修补术,前两者修补腹股沟管后壁和疝环缺损,后者修补腹股沟部位的所有薄弱区域即肌耻骨孔。腹膜前修补术可以通过开放式手术完成,也可通过腹腔镜手术来完成。事实上,腹腔镜腹股沟疝修补术是众多腹膜前修补术中的一种方式,其特点是利用"腹腔镜器械"、通过"真正的后入路"、在"直视下操作"所进行的腹膜前手术。在临床上适用的人群主要有三大类:(1)具有腹膜前修补指征的人群,如腹横筋膜薄弱的老年病人、直疝或复合疝、存在腹内压增高因素的病人。(2)需要尽快恢复体力活动的病人。(3)复发疝和双侧疝。腹腔镜和开放式腹股沟疝修补术均是安全有效的修补方式,具有互补性,合理选择术式可获得最佳的临床和卫生经济学效益。     

Comparison of the open tension-free mesh-plug, transabdominal preperitoneal (TAPP), and totally extraperitoneal (TEP) laparoscopic techniques for primary unilateral inguinal hernia repair: a prospective randomized controlled trial

Background  

The open tension-free mesh-plug hernia technique, transabdominal preperitoneal (TAPP) technique, and totally extraperitoneal (TEP) laparoscopic technique all are common surgical procedures for primary unilateral inguinal hernia repair. However, the choice of the right surgical procedure still is controversial in China. This study aimed to compare open tension-free hernioplasty with two laparoscopic hernia repairs.     

不同术式治疗腹股沟疝的临床疗效及预后分析

目的探讨传统开放式腹股沟疝修补术和腹腔镜腹股沟疝无张力修补的安全性和有效性。 方法收集2014年3月至2017年3月,佛山市第一人民医院、十堰市人民医院和广州市花都区人民医院共完成腹股沟疝修补术124例患者的临床资料,按照术式不同分为2组。试验组患者66例,行腹腔镜无张力腹股沟疝修补术;对照组患者58例,行传统开放式腹股沟疝修补术。跟踪随访记录术后并发症及复发情况。 结果试验组手术时间低于对照组,差异有统计学意义（P<0.01）;2组术后并发症及复发率的构成比较,异物感、血肿和阴囊积液等并发症之间比较,差异无统计学意义（P>0.05）,而切口感染、尿潴留及术后复发方面,试验组明显低于对照组,差异有统计学意义（P<0.05）;患者术前合并症与术后出现并发症具有相关性,差异有统计学意义（P<0.05）。 结论腹腔镜无张力疝修补术是腹股沟疝修补术的一个安全有效的方法,加强术前合并症的治疗有助于提高腹股沟疝修补术的疗效。     

Long-term follow-up of pediatric open and laparoscopic inguinal hernia repair

BackgroundPediatric laparoscopic inguinal hernia repair is not widely accepted.Study designChildren 0–14 years who underwent inguinal hernia repair during 2010–2016 at Kaiser Permanente Northern California were classified into five groups: (1) open unilateral repair without contralateral exploration; (2) open unilateral repair with contralateral laparoscopic exploration (“open + explore”); (3) open bilateral repair; (4) laparoscopic unilateral repair; and (5) laparoscopic bilateral repair. Outcomes included ipsilateral reoperation, metachronous contralateral repair, incision time, and complications.ResultsThe study included 1697 children. Follow-up averaged 3.6 years after open (N = 1156) and 2.6 years after laparoscopic (N = 541) surgery. Metachronous contralateral repair was performed in 3.8% (26/683) of patients with open unilateral surgery without contralateral exploration, 0.7% (2/275) of open + explore patients, and 0.9% (3/336) of laparoscopic unilateral patients (p < 0.01). Ipsilateral repair was performed in 0.8% (10/1156) of open repairs and 0.3% (2/541) of laparoscopic repairs. Chart review confirmed 5 postoperative infections in 1156 patients with open surgery (0.43%) and 6 infections in 541 patients with laparoscopic surgery (1.11%) (p = 0.11).ConclusionOur study's laparoscopic and open approaches have similar low ipsilateral reoperation rates, incision times, and complications. The use of laparoscopy to visualize the contralateral side resulted in a significantly lower rate of metachronous contralateral repair.Level of evidenceLevel III.     

Attendance at a pain clinic with severe chronic pain after open and laparoscopic inguinal hernia repairs

BACKGROUND: The aim was to compare the frequency of severe chronic pain that required attendance at a pain clinic after open and laparoscopic inguinal hernia repairs. METHODS: This was a retrospective analysis of 7999 patients who underwent inguinal hernia repair between January 1994 and December 2001. The definition of severe chronic pain was pain related to inguinal hernia surgery that was bad enough for the patient to seek further medical help and be referred to the specialist pain clinic after exclusion of surgically correctable pathology such as hernia recurrence. RESULTS: During the study there were 7153 open repairs and 846 laparoscopic repairs. Sixty-nine patients (1.0 per cent) were referred to the pain clinic a median of 16.9 (range 5.1-69.4) months after open hernia repair. Three patients (0.4 per cent) were referred a median of 16.5 (range 7.3-21.5) months after laparoscopic hernia repair (P = 0.045). CONCLUSION: Laparoscopic inguinal hernia repair was associated with a significantly lower frequency of attendance at the pain clinic with severe chronic pain.     

腹腔镜经腹腹膜前疝修补术与开放无张力疝修补术治疗腹股沟疝的疗效比较

目的比较腹腔镜经腹腹膜前疝修补术（TAPP）与开放无张力疝修补术治疗腹股沟疝的临床疗效。 方法选取2016年11月至2019年11月,包头医学院第一附属医院普外科一病区腹股沟疝住院患者209例,按照术式不同分为2组。试验组患者102例,行腹腔镜经腹腹膜前疝修补术;对照组患者107例,行开放式无张力疝修补术。观察记录2组患者的手术时间、术中出血量、术后住院时间及术后使用镇痛药物情况等指标,并进行对比分析。 结果2组手术均获成功,试验组无中转开放手术。试验组与对照组比较,手术时间延长（46.87±4.94）min vs（38.40±4.29）min,术中出血量降低（5.40±1.64）ml vs（11.12±2.09）ml,术后住院时间减少（4.18±1.09）d vs（5.08± 1.58）d,术后使用镇痛药和疼痛评分均减少,差异均有统计学意义（均P<0.05）。术后随访均恢复良好,随访时间为6～42个月,2组患者均未复发,无明显术后并发症发生。 结论TAPP治疗腹股沟疝与开放式无张力疝修补术相比,具有微创、安全有效、无明显瘢痕等特点,是临床上可靠的治疗腹股沟疝选择之一。     

Simultaneous repair of bilateral inguinal hernias: a prospective, randomized study of open, tension-free versus laparoscopic approach

No randomized trial exists that specifically addresses the issue of laparoscopic bilateral inguinal hernia repair. The purpose of the present prospective, randomized, controlled, clinical study was to assess short- and long-term results when comparing simultaneous bilateral hernia repair by an open, tension-free anterior approach with laparoscopic "bikini mesh" posterior repair. Forty-three low-risk male patients with bilateral primary inguinal hernia were randomly assigned to undergo either laparoscopic preperitoneal "bikini mesh" hernia repair (TAPP) or open Lichtenstein hernioplasty. There was no difference in operating time between the two groups. The mean cost of laparoscopic hernioplasty was higher (P < 0.001). The intensity of postoperative pain was greater in the open hernia repair group at 24 hours, 48 hours, and 7 days after surgery (P < 0.001), with a greater consumption of pain medication among these patients (P < 0.05). The median time to return to work was 30 days for the open hernia repair group and 16 days for the laparoscopic "bikini mesh" repair group (P < 0.05). Only 1 asymptomatic recurrence (4.3%) was discovered in the open group. The laparoscopic approach to bilateral hernia with "bikini mesh" appears to be preferable to the open Lichtenstein tension-free hernioplasty in terms of the postoperative quality of life and interruption of occupational activity.     

Routine laparoscopic repair of primary unilateral inguinal hernias — a viable alternative in the Day Surgery Unit?

In September 2004 the NICE institute revised its guidelines on the management of primary inguinal hernias to include laparoscopic repair of unilateral hernias. While published trials have confirmed the equal efficacy of the two approaches, it is not clear what impact a switch to laparoscopic repairs would have on resources and patient throughput in a Day Surgery Unit. METHOD: All elective hernia repairs performed in a one-year period were considered. Data were obtained from operation notes, discharge summaries and out-patient records. Operating times are routinely documented in theatre. RESULTS: Of the 351 operations studied, 150 were performed laparoscopically predominantly by an extraperitoneal (TEP)approach. Six required conversion to an open procedure. There was no significant difference in operating times, total theatre time or recovery room times between the two groups (51 min, 75 min and 34 min for the laparoscopic group and 53 min, 74 min and 31 min for the open repair group). Among the laparoscopic repair group there were 48 bilateral hernias and 20 recurrent hernias while 190 of the 201 open repairs were for primary unilateral hernias. Rates of overnight stay and immediate complications were similar between the groups though haematoma was more common following open repair (7 vs 2). CONCLUSIONS: There is no difference in theatre times, immediate complication rates or rates of overnight stay between open and laparoscopic repair of inguinal hernia. Routine laparoscopic repair of primary unilateral inguinal hernia is a viable alternative within the Day Surgery Unit.     

Comparison of open and laparoscopic prosthetic repair of large ventral hernias.

BACKGROUND AND OBJECTIVES: Open ventral hernia repair is associated with significant morbidity and high recurrence rates. Recently, the laparoscopic approach has evolved as an attractive alternative. Our objective was to compare open with laparoscopic ventral hernia repairs. METHODS: Fifty laparoscopic and 22 open ventral hernia repairs were included in the study. All patients underwent a tension-free repair with retromuscular placement of the prosthesis. No significant difference between the 2 groups was noted regarding patient demographics and hernia characteristics except that the population in the open group was relatively older (59.4 vs 47.82, P < 0.003). RESULTS: We found no significant difference in the operative time between the 2 groups (laparoscopic 132.7 min vs open 152.7 min). Laparoscopic repair was associated with a significant reduction in the postoperative narcotic requirements (27 vs 58.95 mg i.v. morphine, P < 0.002) and the lengths of nothing by mouth (NPO) status (10 vs 55.3 hrs. P < 0.001), and hospital stay (1.88 vs 5.38 days, P < 0.001). The incidence of major complications (1 vs 4, P < 0.028), the hernia recurrence (1 vs 4, P < 0.028), and the time required for return to work (25.95 vs 47.8, P < 0.036) were significantly reduced in the laparoscopic group. CONCLUSIONS: Laparoscopic ventral hernioplasty offers significant advantages and should be considered for repair of primary and incisional ventral hernias.     

Surgical outcome and hospital cost analyses of laparoscopic and open tension-free hernia repair

Abstract Surgeons who favor the laparoscopic repair of groin hernias must limit the additional costs associated with this technique, which is not universally acknowledged to be superior to other less expensive open tension-free repairs. This retrospective study compared outcome and costs between laparoscopic and open tension-free hernia repair in 320 patients with inguinal hernias. Patients underwent either (a) transabdominal preperitoneal procedure (TAPP; 60 patients, 72 procedures), (b) totally extraperitoneal procedure (TEP; 174 patients, 202 procedures), or (c) open tension-free procedure (86 patients, 105 procedures). Regarding important postoperative complications there were two (3.3%) recurrences in the TAPP group and one (0.6%) in the TEP group, and six (9.9%) transient neuralgias in the TAPP group and one (1.2%) in the tension-free group. There were no deaths, no testicular atrophies, and no wound or mesh infections. The mean hospital postoperative stay was the same in the three groups (1 day). Mean operating time was shorter in the tension-free group concerning the unilateral cases and shorter in the TEP group concerning the bilateral cases. Fewer patients required analgesia during the first 6 h after the operative procedure in the TEP group than in the other two groups. The mean total costs were 483.90 euros in the open tension-free repair, 763.20 euros in the TAPP repair, and 572.50 euros in the TEP repair. The open procedure was the cheaper for the hospital. Laparoscopic hernia repair and tension-free repair as described by Gilbert are comparable in postoperative complications. TEP hernia repair is associated with less postoperative pain and earlier return to normal activities, but it is more expensive and continues to be a difficult procedure. Open tension-free repair is the least expensive method and is easier to learn than the other two procedures. Electronic Publication     

A randomized comparison of driver reaction time after open and endoscopic tension-free inguinal hernia repair

BACKGROUND: The aim of this study was to assess whether prosthetic tension-free inguinal hernia repair would cause less impairment of reaction times, thus allowing an earlier return to driving than previously recommended after conventional hernia repair. METHODS: Driver reaction times were measured in 64 patients randomized to open tension-free repair or totally extraperitoneal endoscopic inguinal hernia repair. Measurements were made preoperatively and on postoperation days 1, 3, and 6. RESULTS: In the endoscopic group, there was a gradual improvement in hand and foot reaction times over the days tested. In the open group, there was a slowing in both hand and foot reaction times on postoperation days 1 and 3. The difference in foot reaction times between the open and endoscopic groups was significant on these days (p = 0.01 and 0.003, respectively). By day 6, the foot reaction times in the open group were slightly faster than before surgery. CONCLUSIONS: After prosthetic tension-free inguinal hernia repair, patients can return to driving 1 week after the operation.     

Robotic inguinal hernia repair: Is it a new era in the management of inguinal hernia?

ObjectiveWe compared outcomes of elective inguinal hernia repair performed at one institution by three approaches: robotic-assistance, laparoscopic, and open.MethodsCharacteristics of the patients, the hernia and the procedures performed during 2014–2016 were accessed from patient electronic medical files of 137 elective inguinal hernia repairs. 24 surgeries were robotic-assisted, 16 laparoscopic and 97 open repairs.ResultsDistributions of age, sex and BMI did not differ between the groups. Bilateral repair was more common in the robotic (70.8%) than the laparoscopic (50.0%) and open groups (12.4%) (p < 0.001). Direct hernias were more common in the open (45.4%) than the robotic (20.8%) and laparoscopic (12.5%) groups (p < 0.001). Only 3 hernias were inguinoscrotal, all in the robotic group. The median operation times were 44.0, 79.0 and 92.5 min for the open, laparoscopic and robotic methods, respectively (p < 0.001). Among the unilateral repairs, the median operative times were the same for the robotic and laparoscopic procedures, 73 min, and less for the open procedures, 40 min. The proportion of patients hospitalized for 2–3 days was higher for open repair (13.4% vs. 6.2% and 0% for laparoscopic and robotic), but this difference was not statistically significant. The median maximal postoperative pain according to a 0-10-point visual analogue score was 5.0, 2.0 and 0 for open, laparoscopic and robotic procedures, respectively (p < 0.001).ConclusionsThis report demonstrated the safety and feasibility of robotic-assisted inguinal hernia repair.     

Conversion to Stoppa Procedure in Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair

Background and Objectives:

Conversion to open surgery is an important problem, especially during the learning curve of laparoscopic totally extraperitoneal (TEP) inguinal hernia repair.

Methods:

Here, we discuss conversion to the Stoppa procedure during laparoscopic TEP inguinal hernia repair. Outcomes of patients who underwent conversion to an open approach during laparoscopic TEP inguinal hernia repair between September 2004 and May 2010 were evaluated.

Results:

In total, 259 consecutive patients with 281 inguinal hernias underwent laparoscopic TEP inguinal hernia repair. Thirty-one hernia repairs (11%) were converted to open conventional surgical procedures. Twenty-eight of 31 laparoscopic TEP hernia repairs were converted to modified Stoppa procedures, because of technical difficulties. Three of these patients underwent Lichtenstein hernia repairs, because they had undergone previous surgeries.

Conclusion:

Stoppa is an easy and successful procedure used to solve problems during TEP hernia repair. The Lichtenstein procedure may be a suitable option in patients who have undergone previous operations, such as a radical prostatectomy.     

腹腔镜疝修补术与开放无张力修补术治疗腹股沟疝的疗效

目的探讨腹腔镜疝修补术与无张力修补术治疗腹股沟疝的效果比较。 方法选取2018年1月至2020年12月于恩施土家族苗族自治州中心医院就诊的腹股沟疝患者320例,以随机数字表分为腔镜组和开放组,每组患者160例。腔镜组行腹腔镜下疝修补术治疗,开放组以无张力修补术进行治疗。对比2组患者的手术出血量、手术时间、切口长度、切口美观评分、住院时间、下床活动时间、第一次排气时间、住院费用、术后并发症情况及治疗效果。 结果与开放组比较,腔镜组患者手术出血量少、手术时间短及切口长度短（P<0.05）,切口美观评分明显高于开放组（P<0.05）,住院时间、下床活动时间、第一次排气时间均明显短于开放组,但在住院费用方面明显高于开放组（P<0.05）。治疗后2组患者的复发率、治愈率比较,差异无统计学意义（P>0.05）;腔镜组患者的总并发症发生率（5.00%）明显低于开放组（19.38%）,差异有统计学意义（P<0.05）。 结论相较于开放式无张力修补术,腹腔镜疝修补术治疗腹股沟疝能减少手术中的出血量,手术用时少,切口长度小的特点,且术后患者下床活动时间更早,疼痛持续的时间少,还能缩短住院时间,手术后出现的并发症也较低,但住院费用较高。     

Hernioplasty and simultaneous laparoscopic cholecystectomy: a prospective randomized study of open tension-free versus laparoscopic inguinal hernia repair

BACKGROUND: The laparoscopic repair of unilateral primary groin hernia remains controversial. This randomized study evaluates the outcome of the laparoscopic technique in hernia repair in patients undergoing simultaneous laparoscopic cholecystectomy (LC) and compares laparoscopic repair with tension-free open groin hernia repair. METHODS: Sixty-four low-risk patients with symptomatic chronic calculous cholecystitis and synchronous unilateral primary inguinal hernia were randomized to undergo either laparoscopic transabdominal preperitoneal mesh hernia repair (TAPP) and LC or LC and open tension-free hernia repair. RESULTS: The operating time was longer in the TAPP and LC group (mean +/- SD = 121 +/- 32 minutes) than in the LC and open group (95 +/- 27 minutes) (P <.01). The mean operating costs were higher in the TAPP and LC group ($1235 versus $1080) (P <.03). The intensity of postoperative pain at rest was greater in the LC and open group at 24 hours (P <.01) and 48 hours (P <.05), with a greater consumption of pain medication (P <.01). No differences between the 2 groups were found in terms of postoperative complications, disability period before return to work, or hernia recurrences. CONCLUSIONS: The totally laparoscopic procedure does not result in a significant benefit other than improved comfort in the first 2 postoperative days. However, laparoscopic hernia repair is considerably more difficult to perform than open tension-free hernioplasty. Thus, the totally laparoscopic approach should be performed only by experienced laparoscopic surgeons with special expertise in hernia surgery.     

不同手术路径下腹股沟疝修补术后疼痛比较及慢性疼痛因素分析

目的探究不同手术路径下腹股沟疝修补术后疼痛比较及慢性疼痛因素分析。 方法选取2016年2月至2018年1月，广东省第二中医院进行手术治疗的腹股沟疝患者150例，根据单双数字法将患者分为无张力组和腹腔镜组，每组75例。无张力组采用无张力修补术，腹腔镜组采用腹腔镜下腹股沟疝修补术。观察并比较2组患者的急性和慢性疼痛情况，并采用Logistic模型探讨影响慢性疼痛的因素。 结果腹腔镜组的手术时间长于无张力组，术后住院时间、术中出血量、术后下床活动时间均低于无张力组，差异有统计学意义（P<0.05）。腹腔镜组患者的社会功能、生理职能、情感职能、精神状态、躯体疼痛和精力得分均高于无张力组，差异有统计学意义（P<0.05）。腹腔镜组术后1、3、5 d的疼痛评分均低于无张力组，差异有统计学意义（P<0.05）。术后6和12个月，腹腔镜组慢性疼痛率为4.00%和2.67%，无张力组为3.33%和12.00%，差异有统计学意义（P<0.05）。Logistic回归分析显示年龄<45岁、性别为女、有吸烟史、疝环直径>3.0 cm和切口感染是术后6个月慢性疼痛的危险因素，腹腔镜手术是保护因素。 结论腹腔镜腹股沟疝修补术能显著降低术后早期疼痛，是腹股沟疝修补术后慢性疼痛的保护因素。     

腹腔镜经腹腔补片修补术治疗腹股沟疝的评价

目的：探讨腹腔镜经腹腔腹膜前网片修补术（transabdominal preperitoneal prosthesis,TAPP）治疗腹股沟疝的特点及疗效。方法：回顾分析2004年11月至2007年4月19例男性患者单侧腹股沟疝采用TAPP手术治疗的临床资料。结果：19例手术均在腹腔镜下完成,无中转手术,手术时间50～76min,平均63min。术后24～48h患者下床活动,住院5～7d,无并发症发生,术后随访2～25个月,1例复发（5．2％）。结论：TAPP治疗腹股沟疝是安全可行的疝修补方法,遵循疝修补无张力的原则,具有患者痛苦轻,康复快等特点,是治疗腹股沟疝的有效手段。     

Laparoscopic inguinal hernia repair

The safest and most effective inguinal hernia repair (laparoscopic versus open mesh) is being debated. As the authors point out, the former accounts for the minority of hernia repairs performed in the United States and around the world. The reasons for this are a demonstration in the literature of increased operative times, increased costs, and a longer learning curve. But the laparoscopic approach has clear advantages, including less acute and chronic postoperative pain, shorter convalescence, and earlier return to work. This article describes the transabdominal preperitoneal and totally extraperitoneal techniques, provides indications and contraindications for laparoscopic repair, discusses the advantages and disadvantages of each technique, and provides an overview of the literature comparing tension-free open and laparoscopic inguinal hernia repair.