Review of the management of recurrent inguinal hernia

Background: There is little available evidence on the optimal management of recurrent inguinal hernia, particularly if the original procedure involved the use of mesh. This study was a review of recurrent hernia repair in a district hospital, involving both laparoscopic and open procedures. Methods: The case notes of all patients who had a repair of a recurrent hernia between 1991 and 2000, inclusive, were examined; 171 procedures were included. Where known, the original repair was a nylon darn in 31%, mesh repair in 18%, and laparoscopic repair in 8%. Results: The recurrent hernia was repaired using a Lichtenstein open mesh technique in 63% and by the totally extraperitoneal (TEP) method in 22%. Complication rates were highest after emergency surgery (all had open surgery), where 71% had complications and one patient died. For elective repairs, complication rates were similar after open (13%) and TEP (8%) repairs. The duration of hospital stay was also similar (1.2 vs 1.3 days, respectively), and a single recurrence was seen in each group. Patients with recurrence after primary mesh repair were also managed by both techniques with similar results. Open re-operation for mesh failure was technically straightforward. Conclusions: Most recurrent hernias are still repaired by open techniques. There was no convincing evidence of different outcomes for open and TEP repairs in this review. Even when the original hernia repair involved the use of mesh, further open repair by an experienced surgeon is justified.     

Ventral Hernia Repair: Outcomes Change with Long-Term Follow-Up

Background and Objectives:

Ventral hernia repairs continue to have high recurrence rates. The surgical literature is lacking data assessing the time trend to hernia recurrence after ventral hernia repairs and whether over time the recurrence rates change with laparoscopic technique compared to open repairs. Our aim was to carry out a long-term comparative analysis of ventral hernia repairs performed at our hospital over the last 10-y period to assess if outcomes change during the follow-up period.

Methods:

We conducted a retrospective observational study analyzing electronic medical records of all consecutive patients who had a ventral hernia repair from January 2001 to February 2010 at our hospital.

Results:

During the study period, 436 ventral hernia repairs were performed: laparoscopic repairs (n=156; 36%), laparoscopic converted to open (n=8; 2%), and open repairs (n=272; 62%). We analyzed the time distribution to hernia recurrence after surgery and found that 85% of recurrences after laparoscopic repairs and 77% of recurrences after open repairs occurred within 2 y of surgery. We did a Kaplan-Meier analysis for the subgroup of patients for whom we had a minimum 4-y follow-up and found that there continued to be a low subsequent yearly recurrence rate for open repairs after the initial 2-y follow-up.

Conclusion:

Most hernia recurrences occur within 2 y after surgery for ventral hernias. There appears to be a continued although low subsequent yearly rate of recurrence for open repairs.     

Is laparoscopic umbilical hernia repair with mesh a reasonable alternative to conventional repair?

BACKGROUND: Laparoscopic mesh repair has been advocated as treatment of choice for ventral hernias. The term "ventral hernia" refers to a variety of abdominal wall defects and laparoscopic papers have not reported defect specific analysis. The purpose of this study was to determine any advantages to laparoscopic mesh repair of umbilical hernias. METHODS: A retrospective review (January 1998 to April 2001) was made of patients undergoing umbilical hernia repair. Patients were categorized into three groups: laparoscopic repair with mesh, open repair with mesh, and open repair without mesh. Comparative analysis was performed. RESULTS: One-hundred and sixteen umbilical hernia repairs were performed in 112 patients: 30 laparoscopic mesh repairs, 20 open mesh repairs, and 66 open nonmesh repairs. The laparoscopic technique was used for larger defects and took more time with a trend toward fewer postoperative complications and recurrences. CONCLUSIONS: Laparoscopic umbilical hernia repair with mesh presents a reasonable alternative to conventional methods of repair.     

Laparoscopic versus open ventral hernia mesh repair: a prospective study

Background An incisional hernia develops in 3% to 13% of laparotomy incisions, with primary suture repair of ventral hernias yielding unsatisfactory results. The introduction of a prosthetic mesh to ensure abdominal wall strength without tension has decreased the recurrence rate, but open repair requires significant soft tissue dissection in tissues that are already of poor quality as well as flap creation, increasing complication rates and affecting the recurrence rate. A minimally invasive approach was applied to the repair pf ventral hernias, with the expectation of earlier recovery, fewer postoperative complications, and decreased recurrence rates. This prospective study was performed to objectively analyze and compare the outcomes after open and laparoscopic ventral hernia repair. Methods The outcomes for 50 unselected patients who underwent laparoscopic ventral hernia repair were compared with those for 50 consecutive unselected patients who underwent open repair. The open surgical operations were performed by the Rives and Stoppa technique using prosthetic mesh, whereas the laparoscopic repairs were performed using the intraperitoneal onlay mesh (IPOM) repair technique in all cases. Results The study group consisted of 100 patients (82 women and 18 men) with a mean age of 55.25 years (range, 30–83 years). The patients in the two groups were comparable at baseline in terms of sex, presenting complaints, and comorbid conditions. The patients in laparoscopic group had larger defects (93.96 vs 55.88 cm²; p = 0.0023). The mean follow-up time was 20.8 months (95% confidence interval [CI], 18.5640–23.0227 months). The mean surgery durations were 90.6 min for the laparoscopic repair and 93.3 min for the open repair (p = 0.769, nonsignificant difference). The mean postoperative stay was shorter for the laparoscopic group than for the open hernia group (2.7 vs 4.7 days; p = 0.044). The pain scores were similar in the two groups at 24 and 48 h, but significantly less at 72 h in the laparoscopic group (mean visual analog scale score, 2.9412 vs 4.1702; p = 0.001). There were fewer complications (24%) and recurrences (2%) among the patients who underwent laparoscopic repair than among those who had open repair (30% and 10%, respectively). Conclusions The findings demonstrate that laparoscopic ventral hernia repair in our experience was safe and resulted in shorter operative time, fewer complications, shorter hospital stays, and less recurrence. Hence, it should be considered as the procedure of choice for ventral hernia repair.     

A Collective Review on Mesh-Based Repair of Umbilical and Epigastric Hernias

In accordance with the tension-free principles for other hernias, umbilical and epigastric hernia repair should probably be mesh-based. The number of randomized studies is increasing, most of them showing significantly less recurrences with the use of a mesh. Different devices are available and are applicable by several approaches. The objective of this review was to evaluate recent literature for the different types of mesh for umbilical and epigastric hernia repair and recurrences after mesh repair. A multi-database search was conducted to reveal relevant studies since 2001 reporting mesh-based repair of primary umbilical/epigastric hernia and their outcomes in adult patients. A total of 20 studies were included, 15 of them solely involved umbilical hernias, whereas the remaining studies included epigastric hernias as well. A median of 124 patients (range, 17–384) was investigated per study. Three quarters of the included studies had a follow-up of at least 2 years. Six studies described the results of laparoscopic approach, of which one reported a recurrence rate of 2.7 %; in the remaining studies, no recurrences occurred. Two comparative studies reported a lower incidence of complications and postoperative pain after laparoscopic repair compared to open repair. Seventeen studies reported results of open techniques, of which seven studies showed no recurrence. Other studies reported recurrence rates up to 3.1 %. A wide range of complication rates were reported (0–33 %). This collective review showed acceptable recurrence rates for mesh-based umbilical and epigastric hernia repair. A wide range of devices was investigated. A tendency toward more complications after laparoscopic repair was found compared to open repair.     

Prospective nationwide analysis of laparoscopic versus Lichtenstein repair of inguinal hernia

BACKGROUND: According to a Cochrane review, laparoscopic inguinal hernia repair compares favourably with open mesh repair, but few data exist from surgical practice outside departments with a special interest in hernia surgery. This study compared nationwide reoperation rates after laparoscopic and Lichtenstein repair, adjusting for factors predisposing to recurrence. METHODS: Some 3606 consecutive laparoscopic repairs were compared with 39 537 Lichtenstein repairs that were prospectively recorded in a nationwide registry between 1998 and 2003. Patients were subgrouped according to type of hernia: primary or recurrent and unilateral or bilateral. Overall reoperation rates and 95 per cent confidence intervals were calculated. Long-term reoperation rates were estimated using the Kaplan-Meier method. RESULTS: The overall reoperation rates after laparoscopic and Lichtenstein repair of unilateral primary indirect hernia (0 versus 1.0 per cent), primary direct hernia (1.1 versus 3.1 per cent), unilateral recurrent hernia (4.6 versus 4.8 per cent) and bilateral recurrent hernia (2.6 versus 7.6 per cent) did not differ. However, laparoscopic repair of a bilateral primary hernia was associated with a higher reoperation rate than Lichtenstein repair (4.8 versus 3.0 per cent) (P = 0.017). CONCLUSION: Laparoscopic repair compared favourably with Lichtenstein repair for primary indirect and direct hernias, and unilateral and bilateral recurrent hernias, but was inferior for primary bilateral hernias.     

A prospective study comparing the complication rates between laparoscopic and open ventral hernia repairs

Background: Although ventral hernia repair is increasingly performed laparoscopically, complication rates with this procedure are not well characterized. For this reason, we performed a prospective study comparing early outcomes after laparoscopic and open ventral hernia repairs. Methods: We identified all the patients undergoing ventral (including incisional) hernia repair at a single tertiary care center between September 1, 1999 and July 1, 2001 (overall n = 257). To increase the homogeneity of the sample, we excluded umbilical hernia repairs, parastomal hernia repairs, nonelective procedures, procedures not involving mesh, and repairs performed concurrently with another surgical procedure. Postoperative complications (in-hospital or within 30-days) were assessed prospectively according to standardized definitions by trained nurse clinicians. Results: Of the 136 ventral hernia repairs that met the study criteria, 65 (48%) were laparoscopic repairs (including 3 conversions to open surgery) and 71 (52%) were open repairs. The patients in the laparoscopic group were more likely to have undergone a prior (failed) ventral hernia repair (40% vs 27%; p = 0.14), but other patient characteristics were similar between the two groups. Overall, fewer complications were experienced by patients undergoing laparoscopic repair (8% vs 21%; p = 0.03). The higher complication rate in the open ventral hernia repair group came from wound infections (8%) and postoperative ileus (4%), neither of which was observed in the patients who underwent laparoscopic repair. The laparoscopic group had longer operating room times (2.2 vs 1.7 h; p = 0.001), and there was a nonsignificant trend toward shorter hospital stays with laparoscopic repair (1.1 vs 1.5 days; p = 0.10). Conclusions: The patients undergoing laparoscopic repair had fewer postoperative complications than those receiving open repair. Wound infections and postoperative ileus accounted for the higher complication rates in the open ventral hernia repair group. Otherwise, these groups were very similar. Long-term studies assessing hernia recurrence rates will be required to help determine the optimal approach to ventral hernia repair. Drs. Birkmeyer and Finlayson were supported by Career Development Awards from the VA Health Services Research and Development program. The views expressed herein do not necessarily represent the views of the Department of Veterans Affairs or the United States Government.     

Laparoscopic incisional hernia mesh repair with the "double-crown" technique: a case-control study

BACKGROUND: Incisional hernia is a main complication of abdominal surgery. Laparoscopic hernia mesh repair has been demonstrated to be as effective as open repair. However, the mesh fixation method is, to date, a matter of debate, and there are few clinical studies evaluating a single technique. This was a case-control study to assess the "double-crown" fixation method. METHODS: From March 2000 to November 2005, we prospectively collected operative and outcome data on 94 laparoscopic mesh repairs of large incisional hernias performed by using the double-crown technique. The data were compared with those from a retrospective review of 87 matched open incisional hernia repairs done from January 1995 to January 2000. RESULTS: The open and laparoscopic repair groups were comparable in patient age, sex, and hernia size. Operative time was significantly longer in the laparoscopic group; the duration of hospitalization and number of early postoperative complications (e.g., wound infection and prolonged ileus) were significantly greater in the open group. Recurrence rate after a mean follow-up of 38 months (range, 12-72) was 2.1% in the laparoscopic group and 6.9% in the open repair group (mean follow-up, 8 years; range, 5-10) (P > 0.05). CONCLUSIONS: Medium-term results indicate that laparoscopic incisional hernia repair with the double-crown technique has a low complication rate and a comparable recurrence rate to open repair.     

腹腔镜脐内侧襞瓣加强内环口疝修补术在儿童及青少年腹股沟斜疝中的应用

目的 探讨腹腔镜脐内侧襞瓣加强内环口疝修补术在治疗儿童和青少年腹股沟斜疝中的可行性及优越性.方法 从2001年10月至2005年1月,我院对110例(140侧)儿童实施了疝囊高位结扎术(A组).2005年1月至2011年2月,对于300例(405侧)患儿疝囊高位结扎术(B组)中,对有疝复发危险因素的47例患儿,加做脐内侧襞瓣覆盖加强内环口.结果 B组具有疝复发危险因素患儿47例,经腹腔镜脐内侧襞腹膜瓣加强内环口疝修补术均顺利完成.A组随访2～122个月,平均56个月,4例复发(2.8%).B组随访5～74个月,平均34个月,尚未见复发.二组患者随访期间均未见睾丸萎缩等并发症.结论 腹腔镜疝囊高位结扎合并脐内侧襞瓣覆盖内环口疝修补术是安全可靠的,对有选择的腹股沟斜疝患儿以及青少年腹股沟斜疝有进一步降低疝复发的作用.     

Recurrences after conventional anterior and laparoscopic inguinal hernia repair: a randomized comparison

OBJECTIVE: To study the long-term recurrence rate and other complications after conventional and laparoscopic inguinal hernia repair. SUMMARY BACKGROUND DATA: Reliable long-term follow-up of patients with inguinal hernias treated by laparoscopic repair techniques is lacking. METHODS: The authors performed a randomized, multicenter trial in which 487 patients with inguinal hernia were treated by totally extraperitoneal laparoscopic repair and 507 patients were treated by conventional anterior hernia repair. Patients were followed and examined for recurrence and chronic inguinal pain 2, 3, and 5 years after surgery. Risk factors for recurrence and chronic inguinal pain were assessed. RESULTS: Patients who underwent conventional repair had a high risk for recurrence compared to patients who underwent laparoscopic repair. Risk factors for recurrence were operative time and type of conventional repair. Predictive independent risk factors for chronic inguinal pain were conventional repair (Bassini repairs and non-bassini repairs), inguinal pain before surgery, and perioperative lesion of the ilioinguinal nerve. CONCLUSIONS: Patients with inguinal hernia who undergo laparoscopic repair have fewer recurrences and less chronic inguinal pain than those who undergo conventional open repair. The Bassini repair produces unacceptably high recurrence rates.     

Improved outcomes with the Prolene Hernia System mesh compared with the time-honored Lichtenstein onlay mesh repair for inguinal hernia repair

BACKGROUND: Inguinal hernia repairs are commonly performed operations. Recently, Neumayer et al examined the gold standard Lichtenstein onlay mesh repair (LMR) against laparoscopic inguinal hernia repair and showed that the recurrence rates are higher for laparoscopic mesh repairs when compared with the open onlay mesh repair (laparoscopic = 10.1% versus open = 4.9%). In 1998, the Prolene Hernia System (PHS) mesh, consisting of an onlay and an underlay patch attached with a connector, was introduced as an option for tension-free open repair of inguinal hernias combining the benefits of a posterior and anterior repair from an open approach. Our objective was to evaluate the PHS mesh repair versus the LMR for inguinal hernias. We hypothesized that the recurrence rate of PHS mesh would be lower compared with the LMR with overall similar complication rates. METHODS: PHS mesh hernia repairs performed from January 2003 to July 2005 and LMR repairs from January 2000 to July 2002 were included. Demographic data such as age, race, and gender as well as comorbid conditions such as chronic obstructive pulmonary disease, congestive heart failure, previous myocardial infarction, diabetes, hypertension, prostatism, and chronic cough were collected. Complications such as cord injury, seroma, hematoma, urinary retention, urinary tract infection, orchitis, and wound infection were recorded. Recurrences in each group were also recorded. A student t test and chi-square analysis were used for statistical analysis. RESULTS: Six hundred twenty-two charts were reviewed during the 2 time periods (PHS mesh = 321, LMR = 302). The median follow-up for the study was 17 months. There was no significant difference with regards to age, race, gender, or comorbidities between the 2 groups. Overall, there was a trend toward decreased complications in the PHS mesh group compared with the LMR group (PHS mesh = 17%, LMR = 23%, P = .07), with a significant difference in the hematoma/seroma rates (PHS mesh = 6.9%, LMR = 12.6%, P = .015). Finally, there was a significant decrease in the recurrence rate for the PHS mesh group when compared with the LMR group (PHS mesh = 0.6%, LMR = 2.7%, P = .04). CONCLUSION: Our study shows, during a median follow-up of 17 months, improved outcomes by using the PHS mesh compared with the gold standard Lichtenstein onlay mesh for inguinal hernias with significantly lower recurrence rates. Additionally, in the PHS mesh group, there was a trend toward decreased overall complication rates with significantly less seroma/hematoma rates. Therefore, the PHS mesh repair may represent a superior alternative for the repair of inguinal hernias.     

Parastomal hernia: short-term outcome after laparoscopic and conventional repairs

The purpose of this study was to evaluate the short-term outcomes after laparoscopic and conventional parastomal hernia repairs. A retrospective review of parastomal hernia repairs was performed. Conventional repairs included primary suture repair, stoma relocation, and mesh repair. Laparoscopic repairs included the Sugarbaker and keyhole techniques. Forty-nine patients underwent repair of symptomatic parastomal hernias: 19 ileostomies, 13 colostomies, and 17 urostomies. Thirty patients underwent 39 conventional repairs. Nineteen patients underwent laparoscopic surgical repairs. Operative times were longer for laparoscopic repair (208 +/- 58 vs 162 +/- 114 minutes, P = .06). The mean length of stay was 6 days for both groups (P = .74). The mean follow-up was shorter in the laparoscopic group (20 vs 65 months, P < or = .001). There were no significant differences in the incidence of surgical site infections (11% laparoscopic vs 5% conventional, P = .60) or complication rates (63% laparoscopic vs 36% conventional, P = .67). Laparoscopic parastomal hernia repair is a feasible operation with similar short-term outcomes to conventional repairs.     

Current concepts on adult umbilical hernia

Summary Umbilical hernia has not received as much attention as other abdominal wall defects. Prevalence in the adult population is 2% and is much more common in cirrhotic patients and obese middle-aged multiparous women. Adult umbilical hernias have an acquired origin as a consequence of increases in pressure (pregnancy, ascites, etc.), the pull of the abdominal muscles, and the deterioration of connective tissue. Attention needs to be paid to the development of umbilical hernias after laparoscopic trocar insertion. All trocar sites larger than 10 mm should be properly closed after operation. The high morbidity and mortality associated with incarcerated umbilical hernias demand an elective repair in all circumstances. There is a lack of control trials evaluating the results of surgical repairs based on the tight overlapping closure of the umbilical ring described by Mayo, while recurrence after umbilical herniorrhaphy is thought to be a common event. The possibility of the application of biomaterials to the surgical correction of umbilical hernias that have been successfully used in the inguinal canal opens a new field for further clinical investigation. Control studies with long follow-up are now required in order to establish evidence based umbilical surgery.     

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.     

Laparoscopic parastomal hernia repair

Background Management of the parastomal hernia represents a common clinical dilemma for both the surgeon and patient. Once established, these defects are notoriously difficult to treat. Although most parastomal hernias can be managed nonoperatively, approximately 30% will require intervention secondary to complications such as obstruction, pain, bleeding, poorly fitting appliances, or leakage. Overall complication rates of up to 88%, combined with a growing body of literature citing decreased patient morbidity and improved outcomes with laparoscopic tension-free mesh repair of ventral hernias, have led many surgeons to apply these techniques to this difficult problem. Methods This was a retrospective review of 21 consecutive patients who underwent laparoscopic repair of their parastomal hernias with ePTFE mesh. Results Nine (43%) were ileal conduits, seven (33%) were ileostomies, and five (24%) were colostomies. Eight patients had undergone prior hernia repair. Follow-up ranges from 1 to 36 months (average 14 months). There has been one recurrence (5%). Other complications included laparoscopic re-operation for obstruction of a urinary conduit (n = 1), mesh removal for infection (n = 2), Clostridium Difficile colitis (n = 1), pneumonia (n = 2), renal failure (n = 1), surgical site infection (n = 1), and bowel obstruction at a site remote from the hernia repair (n = 2). Conclusion The laparoscopic approach to parastomal hernias is a new technique that offers many potential advantages over conventional open repairs. Based on our initial experience, this repair seems to be associated with a low recurrence rate. Poster presentation at Society of American Gastrointestinal Endoscopic Surgeons, April 18–22, Las Vegas, Nevada, USA.     

Management of primary and recurrent inguinal hernia by surgeons from the South West of England

BACKGROUND: The National Institute of Clinical Excellence (NICE) has advocated open mesh repair for primary hernia but suggested laparoscopic repair may be considered for recurrent hernias. AIM: To establish current surgical practice by surgeons from the South West of England. METHODS: A postal survey was distributed to 121 consultant surgeons and a response rate of 75% was achieved. RESULTS: The majority (86%) of the surgeons surveyed performed hernia repairs, and most (95%) of these used open mesh repair as standard for primary inguinal hernia. Only 8% used laparoscopic repair routinely for primary hernias. Few consultants (only 28%) were able to quote formally audited hernia recurrence rates. A total of 90% of respondents still employed open mesh repair routinely for recurrent hernias; however, if mesh had been used for the primary repair, this figure fell to 55%. Some 7% of respondents recommended laparoscopic repair for recurrent hernia, but this increased to 17% if the primary repair was done with mesh. All laparoscopic surgeons in the South West employed the totally extraperitoneal approach (TEP). There was a range of opinion on the technical demands of repair of a recurrent hernia previously mended with mesh; the commonest cause of mesh failure was thought to be a medial direct recurrence (insufficient mesh medially). CONCLUSIONS: Current surgical practice for primary hernias in the South West England reflects NICE guidelines although many surgeons continue to manage recurrent hernias by further open repair. In this survey, there was anecdotal evidence to suggest that hernia recurrence can be managed effectively by open repair.     

Advanced Age: Is It an Indication or Contraindication for Laparoscopic Ventral Hernia Repair?

INTRODUCTION: Ventral hernias are common surgical problems in the geriatric population. Although ventral hernias are electively repaired in younger patients, the safety and efficacy of elective laparoscopic hernia repair in the geriatric age group is not well documented in the literature. METHODS: A review of 155 patients undergoing laparoscopic ventral hernia repair was undertaken. The patients were classified according to their age into 2 groups, Group A (n=126) for those who are 65 years old. The patient demographics, comorbidities, hernia characteristics, and operative and postoperative data were compared. RESULTS: Younger patients were found to have a significantly increased BMI, while the older group had an increased number of comorbidities. No difference was found in the complication or recurrence rates between the 2 groups. CONCLUSION: Elective laparoscopic ventral hernia repair in senior citizens is safe and feasible in our experience. We believe that the decision to perform an elective hernia repair in this patient population should be based on the general condition of the patient rather than the patient's chronological age.     

More than 150 consecutive open umbilical hernia repairs in a major Veterans Administration Medical Center

Background

The purpose of this study was to determine the rate of surgical site infection for open elective umbilical hernia repairs and to identify the factors related to an increased risk of infection and/or recurrence.

Methods

A retrospective analysis of 152 open elective umbilical hernia repairs between 2003 and 2007 was performed.

Results

Overall, 19% of repairs became infected. Both high ASA classification (P = .01) and mesh repair (P = .01) significantly predicted wound infection, whereas age >60 years, body mass index >30, smoking, immunosuppression, diabetes, and hernia size did not. Only 2 of 17 infected mesh repairs required removal of the mesh. The recurrence rate was 1.5% for mesh and 9.2% for suture repairs.

Conclusions

Umbilical hernia repair is associated with a high rate of infection, and most superficial mesh infections can be treated with antibiotics alone. In addition, mesh repair of umbilical hernias decreased the rate of recurrence but increased the risk of infection compared with suture repairs.     

Total endoskopische präperitoneale Netzplastik bei primären und Rezidivleistenhernien Gibt es Unterschiede?

INTRODUCTION: Since 1994 we perform laparoscopic total extraperitoneal hernia repair (TEP) for primary and recurrent inguinal hernias at our institution. The aim of this study was to investigate and compare the results of TEP in primary inguinal hernias and recurrent inguinal hernias and to determine whether there are differences in patient data, complication rates and outcome between these two groups. METHODS: In a prospective trial 338 patients were analyzed who underwent 500 laparoscopic TEP repairs. In all, 431 TEP repairs were performed for primary inguinal hernias, and 69 for recurrent inguinal hernias. For data acquisition the SALTC study protocol was used. All patients were clinically examined 3 and 12 months after the operation. RESULTS: The mean operation time was 67.3 min for TEP repair of primary hernias and 68.1 min for TEP repair of recurrent hernias, respectively. The conversion rate to an open procedure was 0%. Conversion from TEP into TAPP was required in 0.5% of patients with primary inguinal hernias and 1.4% of patients with recurrent inguinal hernias. As the sole difference between the two groups the intraoperative complication rate could be identified. In the TEP repair group of recurrent inguinal hernias a higher incidence of injury to the peritoneum and a higher occurrence of bleeding from the epigastric vessels was found (P = 0.03). The postoperative complication rate was identical in the two groups, amounting to 5.1% and 5.7%, respectively. No differences were found in the 1 year follow-up between the two groups. The 1-year recurrence rate was 0.5% for primary hernias. However, in the group of recurrent hernias there have been no recurrences to date. CONCLUSIONS: The use of laparoscopic TEP repair has proven to be a safe and effective treatment in patients with primary and recurrent inguinal hernias. Because of scar tissue with possible adhesions a higher intraoperative complication rate was observed in the TEP repair of recurrent hernias than in TEP repair of primary inguinal hernias. However, no single recurrence was observed in the TEP repair group of recurrent hernias. In our opinion TEP is the optimal hernia repair for recurrent and bilateral inguinal hernias.     

Laparoscopic repair of incidentally found Spigelian hernia

Background and Objectives:

A Spigelian hernia is a rare type of hernia that occurs through a defect in the anterior abdominal wall adjacent to the linea semilunaris. Estimation of its incidence has been reported as 0.12% of all abdominal wall hernias. Traditionally, the method of repair has been an open approach. Herein, we discuss a series of laparoscopic repairs.

Methods:

Case series and review of the literature.

Cases:

Three patients are presented. All were evaluated and taken to surgery initially for a different disease process, and all were incidentally found to have a spigelian hernia. These patients underwent laparoscopic repair of their hernias; 2 were repaired intraperitoneally and one was repaired totally extraperitoneally. Two patients initially underwent a mesh repair, while the third had an attempted primary repair.

Conclusions:

There is evidence that supports the use of laparoscopy for both diagnosis and repair of spigelian hernias. There are also reports of successful repairs both primarily and with mesh. In our experience with the preceding 3 patients, we found that laparoscopic repair of incidentally discovered spigelian hernias is a viable option, and we also found that implantation of mesh, when possible, resulted in satisfactory results and no recurrence.