Physiological repair of inguinal hernia: a new technique (study of 860 patients)

The author has developed a new operation technique based on the physiological principle that provides dynamic posterior wall for inguinal hernia repair. Results of the first series of 400 patients were published in 2001 (ANZ J Surg 71:241–244, 2001). Now the author has described the results of the second series of 860 patients having 920 hernias with follow-up for more than 7 years. An undetached strip of the external oblique aponeurosis (EOA) is sutured to the inguinal ligament below and the muscle arch above, behind the cord, to form a new posterior wall. External oblique muscle gives additional strength to the weakened muscle arch to keep this strip physiologically dynamic. In this prospective study, 920 inguinal hernia repairs were performed between August 1990 and December 2003 in 860 patients. Follow-up was done for 7 years. The main outcome measure was early and late morbidities and especially recurrence in a long-term follow-up. Mean patient age was 50.5 years (range 18–90). A total of 851 (98.95%) patients were operated under local or regional anesthesia; 838 (97.4%) patients were ambulatory with limited movements in 6 h and free movements in 18–24 h; 792 (92%) patients had a hospital stay of one night and 840 (97.6%) patients returned to normal activities within 1–2 weeks. Hematoma formation requiring drainage was observed in one patient, while seven patients had wound edema during the postoperative period which subsided on its own. Follow-up was completed in 623 patients (72.5 %) by clinical examination or questionnaire. The median follow-up period was 7.8 years (range 1–12 years). There was no recurrence of hernia or postoperative neuralgia. This operation is simple to perform, does not require foreign body like a mesh or complicated dissection of the inguinal floor as in Bassini/Shouldice. It has shown excellent results with virtually zero recurrence rates.     

Inguinal hernia and occurrence on the other side: a prospective analysis in Iran

Background  Indirect inguinal hernia (IH) is the most common type of hernia. Routine contralateral inguinal exploration, without clinical evidence of a hernia is still controversial especially in children. The purpose of our study was to determine incidence of contralateral IH. Methods  This is a prospective study of 301 patients during a one-year period. History of groin mass, positive findings, demonstrable hernia, or communicating hydrocele were our criteria for diagnosis. Results  Our study includes 301 infants and children, 270 (89.7%) males and 31 (10.3%) females with mean age of two years and 40.9% under six months. In the follow-up period, we found 33 new IH in our patients. 23 (12%) of 196 patients less than two years old underwent contralateral herniorrhaphy in the follow-up period (P = 0.02). Six patients of 30 premature children underwent contralateral herniorrhaphy (P = 0.03). Conclusion  The incidence of contralateral hernia is approximately 10% and in our study it is approximately 1.7%. There is a significant difference between the occurrence of contralateral hernia in preterm compared with term infants (P = 0.03). We think that the incidence is still too low to recommend routine contralateral exploration.     

Inguinal hernia repair in a developing country

Hernia surgery is typically same-day surgery and can be safely conducted in a developing country. We describe a collaborative effort of the American Hernia Society, the Institute of Latin American Concerns, medical industries, the United States Peace Corps, physicians, surgical residents and nurses from many institutions. During three 5-day periods, we operated on 236 patients and repaired 252 hernias (73% inguinal). In addition, an education day for local physicians was conducted on three occasions and included televised live surgical demonstrations and interactive lectures with question and answer sessions. We suggest this to be a viable public health initiative and demonstrate the role of surgeons in advancing and providing state-of-the-art inguinal hernia surgery to a developing country and its underserved population.     

A comparison of laparoscopic and open hernia repair as a day surgical procedure

To evaluate the merits of laparoscopic inguinal hernia repair (LHR) compared to conventional open hernia repair (OHR) a randomized study has been conducted.All patients were day surgical cases, of which 44 were randomized to a standardized OHR under local anesthetic (LA) and 42 to an LHR under general anesthesia (GA). Fifteen LHR patients had bilateral repairs.Operative time for OHR was 30.5 min, for unilateral LHR 35 min, and for bilateral LHR 60 min. OHR patients were discharged after a median of 134.5 min, which was significantly shorter than LHR patients, whose median discharge was 225 min (P<0.01). Pain scores, activity levels, analgesia requirements, and time taken to return to work were not significantly different following surgery in either group (P<0.05). There have been two recurrent hernias and one small bowel obstruction in the LHR group.We conclude that both repairs can be successfully performed as day surgical procedures. The added cost of LHR at this stage does not warrant its widespread use in unilateral hernia repairs. Which procedure is adopted should be individualized; however, patients with bilateral hernias on presentation can be successfully managed as day cases, obviating the need for hospitalization or two operations.     

Prolene Hernia System compared with Lichtenstein patch: a randomised double blind study of short-term and medium-term outcomes in primary inguinal hernia repair

Abstract Background. Refinements in the configuration of mesh may ease handling and placement and reduce postoperative discomfort. Material and Methods. A total of 206 patients were randomly and blindly allocated to receive the Prolene Hernia System (PHS) or Lichtenstein patch. Collected data included: surgical incision size, procedure time, pain scores, analgesic medication, complications, return to activity and work, and quality of life as measured by Short-Form 36 on days 3 and 14. Results. Immediate post-operative pain was significantly lower with PHS than with the patch. The proportion of PHS patients taking longer than 3 days to return to normal activity was 15.5%, compared to 28.4% of patch patients. Operating time was significantly shorter with PHS (34.1 vs. 38.3 min). There was no treatment effect on any of the quality of life scales as measured by Short-Form 36. There were two recurrences in the patch group. Conclusions. The study indicates a reduction in operating time (4 min) and postoperative recovery with the PHS compared with patch. Electronic Publication     

A randomized controlled trial of laparoscopic extraperitoneal hernia repair as a day surgical procedure

Background: A randomized controlled trial was conducted in a day surgery setting comparing a standardized variant of the Shouldice hernioplasty with extraperitoneal laparoscopic herniorrhaphy. Methods: The laparoscopic repair was technically challenging, evidenced by conversion from extraperitoneal to transabdominal repairs in 6.25% of patients. It was free from the inherent dangers of intraperitoneal laparoscopy. Surgical morbidity was low and comparable to that for patients randomized to the open repair. Results: Outcome following laparoscopic extraperitoneal herniorrhaphy varied depending on the parameter measured. It was comparable to the open repair with respect to postoperative activity levels and the number of days required for return to work but inferior to the open repair in terms of operation time and time to hospital discharge. The extraperitoneal approach was superior to the open repair with respect to postoperative pain levels and analgesic requirements. No attempt was made to compare recurrence rates due to the short follow-up period. Conclusions: Laparoscopic extraperitoneal herniorrhaphy should not supercede conventional hernia repair until subjected to further trials with the aid of larger study populations and greater technical expertise; the results of long-term recurrence rates are awaited.     

腹腔镜完全腹膜外疝修补术治疗腹股沟疝不同补片固定方式探讨

目的 分析腹腔镜完全腹膜外疝修补术治疗腹股沟疝中不同补片固定方式的有效性.方法 选择2013年12月至2018年12月在武警北京市总队医院接受腹腔镜下全腹膜外疝修补术的患者为研究对象.依照使用补片方式不同,将其分为A组(144例)以及B组(118例)、C组(90例).A组受试者用3D免固定补片,B组受试者使用钉合固定平...     

腹腔镜腹股沟疝修补术1034例临床分析

目的分析总结腹腔镜腹股沟疝修补术的临床经验。方法回顾分析武汉大学中南医院2012年1月至2017年4月1 034例腹股沟疝病人行腔镜腹股沟疝修补术的临床资料。结果所有腹股沟疝病人均顺利行腹腔镜经腹腹膜前修补术(transabdominal preperitoneal,TAPP)或全腹膜外修补术(totally extraperitoneal,TEP)。手术时间为25~180 min(平均40 min),术中出血5~30ml(平均12 ml),住院时间为3~9 d(平均4 d)。随访1~48个月,有5例病人出现腹膜前间隙血肿,腹股沟区血清肿37例,阴囊水肿7例,术后局部疼痛不适16例,术后复发1例,术后感染1例。结论腹腔镜腹股沟疝修补术恢复快,复发率低,并发症少;手术应由经验丰富的疝专科医生完成。     

Inguinal hernia repair in the perinatal period and early infancy: clinical considerations

Contemporary neonatal intensive care has resulted in survival of many seriously ill preterm and older infants that frequently present with symptomatic inguinal hernia. Controversy exists concerning timing and safety of early repair in prematures or other neonates, especially those hospitalized with concurrent illness. This study examines this topic by evaluating predisposing factors, presentation, and postoperative complications in 100 recent consecutive hernia repairs in previously hospitalized infants less than 2 months of age. There were 85 boys and 15 girls. Thirty percent were premature (less than 36 wks gestation). Forty-two infants were hospitalized for RDS with assisted ventilation in 16 infants, hydrocephalus and ventriculoperitoneal (VP) shunt in 7 infants, and congenital heart disease (CHD) in 19 infants. Clinical presentation was on the right side in 44 infants, bilateral in 42, and on the left side in 14. Incarceration occurred in 31 cases with nine babies having overt intestinal obstruction. The incidence of cryptorchidism was 12.9%. All (VP) shunt, CHD patients, and incarcerated cases were treated with preoperative antibiotics. Following discharge, 49 preterm or previously ill infants developed a symptomatic hernia at home and were readmitted. Nine full-term infants were treated as outpatients. Bilateral inguinal exploration was performed in 92 cases with second hernia or patent processus found in 81. Seven of eight with unilateral exploration had acute incarceration with obstruction at the time of the procedure. Three subsequently required a second hernia repair. Two infants with incarceration and cryptorchid testis or ovarian slider had gonadal infarction. There were eight postoperative complications.(ABSTRACT TRUNCATED AT 250 WORDS)     

Inguinal hernia masquerading as a Spigelian hernia in a child

Inguinal hernia is one of the most common conditions requiring surgical management in childhood. The usual presentation of congenital inguinal hernia in the pediatric age group is an inguino-scrotal swelling. We report a case of inguinal hernia in a child that presented as an abdominal wall swelling clinically suggestive of a Spigelian hernia.     

Inguinal hernia repair: results using an open preperitoneal approach

Background: Laparoscopic surgical approaches to the repair of inguinal hernias have shown the advantages of placing mesh in the preperitoneal space. Despite those advantages, laparoscopic hernia repairs have been associated with increased cost, longer operating times, and advanced laparoscopic skills. An open preperitoneal approach has the benefit of mesh in the preperitoneal position without the disadvantages of a laparoscopic procedure.Methods: We present our experience with the use of an open preperitoneal mesh repair (KugelMesh, Bard, Inc.). The study was conducted in a prospective fashion from January 1998 through October 2001. 1072 hernias were repaired in two community hospitals by three general surgeons. Patients with recurrent hernias were excluded if the initial repair was from a preperitoneal approach. Operative time, cost, post-operative pain, and complications were analyzed.Results: Recurrences occurred in five patients (0.47%) during a mean follow-up time of 23 months (range: 2–47). The average operating time was 32.4 min (range: 16–62). Post-operative narcotic pain medication usage averaged 5.8 pills (range: 0–26) per repair. Average surgical charges were less for the open preperitoneal approach ($2253) than for laparoscopic repairs ($4826).Conclusions: The open preperitoneal hernia repair using the Kugel mesh offers many advantages. It is inexpensive, has a low recurrence rate, and allows the surgeon to cover all potential defects with one piece of mesh. Postoperative recovery is short and postoperative pain is minimal.     

Inguinal hernia repair: are ASA grades 3 and 4 patients suitable for day case hernia repair?

The American Society of Anaesthesiologists (ASA) 3 and 4 patients are generally considered unsuitable for day case hernia repair. There are minimal data regarding the acceptability of day case repair in these patients. This study analysed day case hernia rates with special emphasis on ASA grades. A retrospective review of all adult inguinal hernia repairs, under the care of one surgeon over a 9-year period, was performed. The data collected included demographics, ASA grades, the mode of anaesthesia and early complications. 577 patients underwent inguinal hernia repair during the study period. 204 (35%) patients were ASA grade 1, 214 (37%) ASA grade 2, 132 (23%) ASA grade 3 and 29 (5%) ASA grade 4. Day case rates for ASA grades 1–4 under LA were 86, 83, 77 and 76% and under GA, 59, 36, 32 and 0%, respectively (P<0.05). There was no significant difference in the wound complication rates for different ASA grades under GA and LA. ASA grades 3 and 4 patients can undergo day case inguinal hernia repair, with similar complication rates to ASA grades 1 and 2 patients, when surgery is performed under local anaesthesia. ASA grades 3 and 4 patients need not be excluded from day case hernia repair.     

Inguinal hernia: a patch covering only the myopectineal orifice is effective

A large mesh in the preperitoneal space, spread on iliac vessels and bladder, can cause future difficulties in a case of urogenital or vascular disease. Since all recurrences are located in the area of the myopectineal orifice, a mesh covering only this area, as in the Rives procedure, is effective and avoids these drawbacks. However, the Rives procedure is demanding, which is why we tried to simplify the technique. A mesh 8–10 cm long and 6–7 cm wide was spread in the preperitoneal space using the inguinal approach, without any fixation or with only a few stitches; the fascia was then simply approximated over the mesh without tension. A total of 161 hernias (99% Nyhus type III and IV) were repaired using this technique. Only six benign complications (3.7%) occurred. With a median follow-up of 63 months (range, 18–94 months), only one recurrence occurred (0.7%), due to misplacement of the mesh, eight patients complained of mild pain, and no late complications were observed. In conclusion, placement of a small mesh covering only the myopectineal orifice using the inguinal approach is effective and is associated with a low risk of drawbacks and complications. Electronic Publication     

腹股沟疝腹腔镜手术在我国逐步推广的可行性探讨

目的:分析腹腔镜腹股沟疝修补术(LIHR)在我国逐步开展的可行性。方法:回顾性分析2001年1月至2010年9月在我院接受LIHR的1 401例病人(包括疝1 670侧)的临床资料;其中行经腹腹膜前修补术(TAPP)者553例(637侧),全腹膜外修补术(total extraperitoneal prosthesis,TEP)838例(1 020侧),腹腔内网片植入术(intraperitoneal onlay mesh,IPOM)7例(7侧),TAPP+IPOM 3例(各3侧)。所有手术均由同组医师完成;术式选择由术者决定;随访时间1～60个月(中位时间34个月)。结果:LIHR的例数和TEP/TAPP比例逐年上升,补片固定/不固定的比例逐年下降。手术无中转;手术时间(32.2±13.6)min;术后住院天数(1.9±1.6)d;术后第1天的疼痛分数(VAS)为2.6±1.4;2周和4周内恢复非限制性活动人数比例99.0%和99.9%。复发率0.36%(6/1 670)。累计并发症发生率为8.2%(137/1 670);有3例发生严重并发症,分别为戳孔疝、肠管损伤和机械性肠梗阻;其他并发症依次为血清肿87例(5.2%)、尿潴留23例(1.4%)、暂时性神经感觉异常21例(1.3%)、麻痹性肠梗阻3例(0.18%)。Ⅲ、Ⅳ型疝的并发症发生率高于Ⅰ、Ⅱ型疝(P=0.027)。按学习曲线分组(每组200例),第1组的复发率和并发症发生率均高于后6组(P0.05);后6组间的差异无统计学意义(P0.05)。第1组的手术时间长于第2组,第2组长于后5组(P0.05),后5组间差异无统计学意义(P0.05)。结论:在我国逐步开展LIHR有可行性。     

完全腹膜外腹腔镜疝修补术82例临床总结

目的探讨完全腹膜外腹腔镜疝修补术（total extraperitoneal hernia repair，TEP）的临床价值。方法2005～2007年行TEP手术82例97侧。男76例，女6例。年龄21～88岁，平均52岁。单侧腹股沟斜疝50例、直疝9例，双侧腹股沟斜疝9例，双侧腹股沟斜疝合并直疝6例，复发腹股沟斜疝8例。结果5例因下腹部手术史，腹壁严重粘连，腹膜损伤，其中1例无法修补，中转开放手术；4例以5-0可吸收缝线连续缝合，封闭腹膜破13。手术时间30～180min，平均单侧58min，双侧97min。术后无需使用镇痛剂。住院时间4～12d，平均7d。阴囊血清肿9例，局部穿刺抽液及理疗治愈。82例随访13～38个月，平均26个月，术后无复发。结论TEP是一种安全可靠的疝修补术，创伤小，术后疼痛轻，恢复快，特别适用于复发疝、双侧疝。     

Inguinal hernia repair: the choice of prosthesis outweighs that of technique

Background The use of prostheses in inguinal hernia repair reduces the incidence of recurrence. Quality of life and pain after hernia repair are largely correlated with the technique and type of prosthesis. Aims of study To evaluate the 2-year incidence of recurrence and pain for two types of hernioplasty, Lichtenstein repair and laparoscopy (totally extraperitoneal approach or TEP), and two types of mesh, polypropylene mesh and beta-d-glucan-coated mesh (Glucamesh). Patients A total of 410 consecutive patients of mean age 54 years (18–84) underwent repair of inguinal hernias, 96 (23%) of which were bilateral and 56 (13%) recurrent. A total of 273 (66.5%) patients underwent Lichtenstein repair: 215 (78.7%) with polypropylene mesh, 58 (21.3%) with Glucamesh; 137 patients underwent laparoscopy: 80 (58.4%) with polypropylene mesh, 57 (41.6%) with Glucamesh. In each group, the populations were comparable and the techniques utilized were identical. Methods The patients were followed-up for at least 2 years, after which the incidence of recurrence was determined, and chronic pain was assessed by means of a visual analog scale and a validated questionnaire. Results A total of 349 patients (85.1%) were reassessed, 117 of whom had undergone laparoscopy and 232 Lichtenstein repair. There were ten recurrences (2.8%), and incidence which was independent of the technique (laparoscopy 1.7% vs. Lichtenstein 3.4%) (ns) and the type of prosthesis (Glucamesh 1.9% vs. polypropylene 2.4%) (ns). Chronic pain was noted in 69 patients (19.7%) and severe pain in 11 (3.1%). The incidence of chronic pain was the same for the two techniques: laparoscopy 17.9% vs. Lichtenstein 20.7% (ns). The same was true for severe pain: laparoscopy 3.4% vs Lichtenstein 3% (ns). The incidence of chronic pain was closely correlated with the type of prosthesis utilized: Glucamesh 4.8% vs. polypropylene 26.5% (P = 0.02), irrespective of the technique. The same was true for severe pain (0.9 vs. 4%) (P = 0.02). Conclusion The utilization of beta-d-glucan-coated mesh did not involve more recurrence and was accompanied by a significant decrease in chronic pain at 2 years, independent of the technique. After 2 years, the results of hernia repair show that the choice of prosthesis was more determinant than choice of technique.     

Pediatric inguinal hernia repair—a critical appraisal

Inguinal hernia repair in infants and babies is a routine operation, but many issues have not been addressed scientifically. Thus, it is not known, e.g., if all children with a hernia should be operated on, what is the best timing of surgery, or if the operation should be performed with an open approach or laparoscopically. The review is a critical discussion of these and other issues in pediatric herniorrhaphy pointing out the need for further research.     

无张力疝修补术与传统疝修补术治疗腹股沟疝的疗效分析

目的探讨无张力疝修补术与传统疝修补术治疗腹股沟疝的疗效,为基层医院的治疗提供参考。方法将86例患者按照随机原则分为观察组与对照组,每组43例,观察组采用无张力疝修补术进行治疗,对照组采用传统疝修补术进行治疗,比较两组患者的手术时间、住院时间、住院费用、术后恢复时间、并发症及复发情况。结果两组患者的手术时间比较,差异无统计学意义（P〉0.05）;两组患者的住院时间、术后恢复时间、住院费用比较,差异有统计学意义（P〈0.05）。两组患者的并发症发生率,观察组为30.2%,对照组为58.1%,两组比较,差异有统计学意义（P〈0.05）。两组患者的复发率对照组为18.6%、观察组为2.3%,两组比较,差异有统计学意义（P〈0.05）。结论无张力疝修补术操作简单、复发率低、并发症少,易为患者接受,较适合在基层医院推广应用。     

Laparoscopic flip-flap technique versus conventional inguinal hernia repair in children.

BACKGROUND AND OBJECTIVES: Inguinal hernia repair is one of the most frequently performed pediatric surgical operations. Several pediatric laparoscopic inguinal hernia repair techniques have been introduced. But debate is unresolved regarding the feasibility of laparoscopy for treating pediatric inguinal hernias. METHODS: A retrospective cohort study enrolled 33 patients who underwent congenital inguinal hernia repair by either the new laparoscopic flip-flap technique or conventional open repair. Patients were divided into 2 groups according to the type of surgery: Group A included those who underwent the new laparoscopic technique, and Group B included those who underwent conventional open repair. RESULTS: Group A comprised 15 patients (mean age, 39 months), and group B comprised 18 (mean age, 44 months). Mean operative time was 47.5 minutes for Group A versus 27.5 minutes for Group B. Intraoperative complications for Group A included 1 case (7%) of vas deferens injury, and 3 cases (20%) in which the flaps were torn during suturing. In Group B, no intraoperative complications were encountered. In both groups, the mean postoperative hospital stay was 5.5 hours. Postoperative follow-up of 3 months revealed recurrence in 4 patients in Group A (27%), while there were no recurrences in Group B. CONCLUSION: Our preliminary experience shows unsatisfactory outcomes with laparoscopic flip-flap hernia repair in children. In spite of advancement in the application of laparoscopy in pediatric surgery, conventional open hernia repair is still the gold standard for children, in our experience. Future studies with more numbers and longterm follow-up should be conducted.