单孔腹腔镜双钩疝针内环结扎并脐内侧襞遮盖术

目的介绍一种使用双钩疝针辅助单孔腹腔镜内环结扎并脐内侧襞遮盖加强修补术。 方法59例小儿腹股沟巨大疝在脐单孔腹腔镜监视下,将双钩疝针钩挂结扎线经腹横纹内环体表投影处穿刺至内环前壁腹膜外,借助水分离技术于腹膜外套扎内环;疝针带线再次进针入腹,穿过同侧脐内侧襞后预置结扎线,疝针再返回内环外侧间隙至精索血管前穿透后腹膜、进入腹腔钩挂预置线牵出体外结扎,使脐内侧襞遮盖已结扎内环区域加强修补。 结果59例患儿的65侧巨大疝成功实施内环结扎并脐内侧襞遮盖术(包括3例复发疝和1例复合疝),其中16例对侧隐性疝给予同时单纯内环结扎。单侧和双侧腹股沟疝的手术时间分别为 (11.2 ± 2.2)min和 (15.8 ± 2.7)min。其中术后1例鞘膜积液和2例线结反应,无复发疝、医源性隐睾或睾丸萎缩等并发症发生。 结论双钩疝针腹膜外注水分离技术辅助单孔腹腔镜内环结扎并脐内侧襞加强修补术是一种安全有效的简便方法。瘢痕隐蔽、美观,是治疗小儿巨大腹股沟疝的可靠技术。     

Two-stage laparoscopic treatment for strangulated inguinal,femoral and obturator hernias: totally extraperitoneal repair followed by intestinal resection assisted by intraperitoneal laparoscopic exploration

Purpose

Total extraperitoneal preperitoneal (TEP) repair is widely used for inguinal, femoral, or obturator hernia treatment. However, mesh repair is not often used for strangulated hernia treatment if intestinal resection is required because of the risk of postoperative mesh infection. Complete mesh repair is required for hernia treatment to prevent postoperative recurrence, particularly in patients with femoral or obturator hernia.

Cases

We treated four patients with inguinocrural and obturator hernias (a 72-year-old male with a right indirect inguinal hernia; an 83-year-old female with a right obturator hernia; and 86- and 82-year-old females with femoral hernias) via a two-stage laparoscopic surgery. All patients were diagnosed with intestinal obstruction due to strangulated hernia. First, the incarcerated small intestine was released and then laparoscopically resected. Further, 8–24 days after the first surgery, bilateral TEP repairs were performed in all patients; the postoperative course was uneventful in all patients, and they were discharged 5–10 days after TEP repair. At present, no hernia recurrence has been reported in any patient.

Conclusion

The two-stage laparoscopic treatment is safe for treatment of strangulated inguinal, femoral, and obturator hernias, and complete mesh repair via the TEP method can be performed in elderly patients to minimize the occurrence of mesh infection.

     

Chronic pain after mesh versus nonmesh repair of inguinal hernias: A systematic review and a network meta-analysis of randomized controlled trials

Background

Chronic pain affects 10%–12% of patients after inguinal hernia repairs. Some have suggested that less foreign material may theoretically prevent pain. If the prevalence of chronic pain is less after nonmesh repairs, selected hernias might be repaired without mesh. Our aim was to clarify if nonmesh repairs are superior to mesh repairs regarding chronic pain.

Spigelian hernia in children: low versus classical

Purpose

Pediatric spigelian hernias are very rare. They are often missed or misdiagnosed. A series of cases with spigelian hernia, presented to a tertiary care center are presented here with emphasis on different anatomy of spigelian hernias with cryptorchidism and those without associated cryptorchidism.

Diagnosis of inguinal hernia by prone- vs. supine-position computed tomography

Purpose

The aim of this study was to investigate the efficacy of prone-position computed tomography (CT) for detecting and classifying inguinal hernia relative to supine-position CT before laparoscopic inguinal hernia repair.

Methods

Seventy-nine patients who underwent laparoscopic transabdominal preperitoneal repair of inguinal hernia were enrolled in this prospective study. Patients diagnosed with inguinal hernia by physical examination underwent abdominal CT in the supine and prone positions for preoperative assessment. The anatomy of the right and left inguinal regions was confirmed during the surgery and compared with the preoperative CT findings.

Results

The 79 cases included 87 operated lesions and 71 non-operated contralateral inguinal sites. Of the 84 clinical hernias, inguinal hernia was detected significantly more frequently on prone-position CT images (84, 100%) than on supine-position CT images (55, 65.5%). In addition, the inguinal hernia type was determined with significantly greater accuracy on prone-position CT images (96.4%) than on supine-position CT images (58.3%). Twenty-two occult hernias were detected by laparoscopy. The detection rate and accuracy for determining the type of occult hernia were significantly greater when using prone-position CT images [19 of 22 lesions (86.4%) and 77.3%, respectively] than when using supine-position CT images [8 of 22 lesions (36.4%) and 27.3%, respectively].

Conclusions

Prone-position CT is adequate for detecting and classifying inguinal hernia and for evaluating occult hernia.

     

Single-port versus conventional laparoscopic total extra-peritoneal inguinal hernia repair: a prospective,randomized, controlled clinical trial

Background

The advantage of single-port total extra-peritoneal (TEP) inguinal hernia repair over the conventional technique is still debatable. Our objective was to compare the outcomes of TEP inguinal hernia repair using either a single-port or conventional surgical technique, in two blind randomized groups of patients.

Methods

In this prospective, randomized, double-blind, controlled clinical trial, 100 patients undergoing surgery for unilateral inguinal hernia were randomized into two groups: One group underwent conventional laparoscopic TEP inguinal hernia repair, while the other was selected for single-port TEP repair. Primary endpoint is postoperative pain (VAS), while secondary endpoints are recurrence, chronic pain and complications.

Results

From 100 patients, 49 underwent single-port hernia TEP repair, 50 had conventional three-port TEP hernia repair, and one patient declined to participate after randomization. The two groups were comparable in terms of patient demographics and operative findings. Mean operative time was 49.1(±13.8) min in the conventional group and 54.1(±14.4) min in the single-port group (p = 0.08). Mean hospital stay was 19.7(±5.8) h in the conventional group and 20.5(±6.4) h in the single-port group (p = 0.489). No major complications and no recurrence reported at 11-month follow-up. No statistically significant difference noted in postoperative pain between the two groups at regular intervals.

Conclusions

The outcomes after laparoscopic TEP inguinal hernia repair with a single-port device are similar but not superior to the conventional technique.

     

Rives Technique for the Primary Larger Inguinal Hernia Repair: A Prospective Study of 1000 Repairs

Objective

We report a prospective study of repairs using the Rives technique of the more difficult primary inguinal hernias, focusing on the immediate post-operative period, clinical recurrence, testicular atrophy, and chronic pain. A mesh placed in the preperitoneal space can reduce recurrences and chronic pain.

Methods

For the larger primary inguinal hernias (Types 3, 4, 6, and some 7), we favour preperitoneal placement of a mesh, covering the myopectineal orifice by means of a transinguinal (Rives technique) approach. The Rives technique was performed on 943 patients (1000 repairs), preferably under local anaesthesia plus sedation in ambulatory surgery.

Results

The mean operative time was 31.8 min. Pain assessment after 24 h with an Andersen scale and a categorical scale gave two patients with intense pain on the Andersen scale, and four patients who thought their state was bad. Surgical wound complications were below 1%, and urinary retention was 1.2% mostly associated with spinal anaesthesia and, in one case, bladder perforation. There was spermatic cord and testicular oedema with some degree of orchitis in 17 patients. The clinical follow-up of 849 repairs (86.4%), mean (range) 30.0 (12–192) months, gave five recurrences (0.6%), three cases (0.4%) of testicular atrophy, and 37 (4.3%) of post-operative chronic pain (8 patients with visual analogue scale of 3–10).

Conclusions

The Rives technique requires a sound knowledge of inguinal preperitoneal space anatomy, but it is an excellent technique for the larger and difficult primary inguinal hernias, giving a low rate of recurrences and chronic pain.

     

Modified single-port vs two-port laparoscopic herniorrhaphy for children with concealed deferent duct: a retrospective study from a single institution

Purpose

Single-port laparoscopic herniorrhaphy is widely employed for indirect inguinal hernia repair in children. However, few surgeons utilize the single-port technique to repair such hernias with concealed deferent ducts. The aim of this study was to assess the application of the modified single-port laparoscopic technique (MSPT) in cases with concealed deferent ducts and to compare the results to those obtained with the two-port technique (TPT).

Methods

Between January 2006 and January 2012, all consecutive cases were retrospectively studied. The inclusion criteria were as follows: (1) age no more than 3 years; and (2) a concealed deferent duct identified by laparoscopy. Two-hundred and three children were treated using TPT from January 2006 to December 2008. One-hundred and ninety-three children were treated using MSPT from January 2009 to January 2012. The clinical variables and surgical outcomes were compared between the two groups.

Results

The differences in operation duration, vessel injury, conversion, postoperative hydrocele occurrence and umbilical hernia were not significant between the two groups. Ipsilateral groin swelling was more common in the MSPT group. No wound infection, recurrence, metachronous hernia or testicular atrophy occurred in either group.

Conclusions

Despite the high incidence of ipsilateral groin swelling, MSPT is a feasible alternative to TPT in children with indirect inguinal hernias with multiple peritoneal folds. Furthermore, we have developed a new method to explore the contralateral groin using a single-port technique.

     

Inguinal neuritis is common in primary inguinal hernia

Purpose

Establishing the existence of inguinal neuritis, and defining patterns of nerve involvement in primary inguinal hernia repair.

Methods

A retrospective chart review of 100 consecutive primary inguinal hernia repairs by Lichtenstein technique with frequent ilioinguinal nerve removal was performed. Nerves suspected of containing neuritis had been sent for histological examination. Objective clinical parameters and nerve pathology reports were reviewed. An independent biostatistician reviewed the data.

Results

There were 34 cases of inguinal neuritis in these primary inguinal hernia repairs. The nerve most affected in primary repairs was the ilioinguinal nerve, accounting for 88% of the neuritis cases. Inguinal neuritis occurred mainly at the external oblique neuroperforatum—where the nerve pierces the external oblique fascia, accounting for 83% in primary repair. The only clinical parameter with statistical significance was hernia laterality (P = 0.04), 46% of the patients who had a hernia on the left also had inguinal neuritis.

Conclusion

The overall incidence of inguinal neuritis was 34% in primary inguinal hernia repairs. The ilioinguinal nerve was most commonly affected in these primary inguinal hernia repairs, and inguinal neuritis was most likely to occur at the external oblique neuroperforatum.

     

Single-port laparoscopic percutaneous extraperitoneal closure of femoral hernia in children and adolescents: case series

Background

Femoral hernias are an often unexpected groin pathology during childhood. However, the pediatric surgeon has to be aware to diagnose femoral hernia and to repair this condition. This is the first report on laparoscopic percutaneous extraperitoneal closure of femoral hernia (LPEF) in children and adolescents.

Methods

Over a 6-year period in a bi-institutional clinical study, we retrospectively identified six children and one young adult who underwent LPEF repair.

Results

Femoral hernia was laparoscopically confirmed in seven patients. Ages at surgery were 3, 5, 7, 7, 8, 8.5, and 18 years, respectively. In the first case, we combined laparoscopic diagnosis with open repair. In the consecutive six cases, hernias were repaired minimally invasively with the percutaneous extraperitoneal technique described below. During a follow-up between 6 years and 6 months, no recurrence was observed.

Surgical technique

For LPEF, we percutaneously placed a peritoneal U-shape suture with integrated transfixation of the hernia sac, closed with an epifascial knot. We performed LPEF using two graspers. The peritoneum was percutaneously punctured with a venous cannula through which the suture was inserted. One grasper was inserted through the working channel of the laparoscope to invert the hernia sac into the abdominal cavity. A mini-grasping forceps inserted through the cannula retrieved the thread and completed LPEF.

Conclusion

We demonstrate that single-port laparoscopic percutaneous extraperitoneal closure of femoral hernia is successful and quick in children and in adolescents.

     

One trocar needlescopic assisted inguinal hernia repair in children: a novel technique

Background

Inguinal hernia repair using a percutaneous internal ring suturing technique is an effective alternative technique to conventional laparoscopic hernia repair. It is one of the most commonly used approaches for laparoscopic hernia repair in children. However, most percutaneous techniques have utilized extracorporeal knotting of the suture and burying the knot subcutaneously. This approach has several drawbacks. The aim of this study is to present a modified technique for single cannula needlescopic assisted hernia repair in children.

Risk factors for recurrence after thoracoscopic repair of congenital diaphragmatic hernia (CDH)

Purpose

To identify technical modifications concerning factors that may lower the risk of recurrence following thoracoscopic repair of congenital diaphragmatic hernia (CDH).

Feasibility of a new approach for creating a preperitoneal space in transabdominal preperitoneal repair inguinal hernia repair: using a sandwich approach

Purpose

In Japan, transabdominal preperitoneal (TAPP) inguinal hernia repair is performed by firmly pulling the peritoneum inwards to lift it from the underlying deep layer of subperitoneal fascia. It decreases the postoperative pain and discomfort in the inguinal area. The aim of this study was to evaluate the feasibility of the sandwich approach, which is a new technique for creating a preperitoneal space.

Methods

The operation was performed via the sandwich approach. We made sure to protect the preperitoneal fascia areolar layer when making the preperitoneal space.

Results

We performed TAPP in 745 patients (876 hernias) treated between October 2006 and April 2015 at Himeji Medical Center and Kurashiki Central Hospital. Before October 2010, we did not use the sandwich approach, and recurrence was observed in three patients. From October 2010, we always used the sandwich approach and never experienced any cases of recurrence. Clavien–Dindo classification Grade 3 or higher postoperative complications occurred in 6 patients (0.8%) between October 2006 and April 2015. Mesh-related ileus was the most frequently observed morbidity. There were no cases of vas differentia or spermatic vessel injury, postoperative chronic pain, or urinary retention.

Conclusion

The sandwich approach is feasible as another standard dissective procedure for TAPP.

     

Fertility in males after childhood,adolescent, and adult inguinal operations

Background/purpose

Inguinal hernia repair and orchidopexy are among the most common operations in boys. The impact on future fertility has not been conclusively defined. This study evaluates sperm quality after previous inguinal surgery.

Does the laparoscopic treatment of paediatric hydroceles represent a better alternative to the traditional open repair technique? A retrospective study of 1332 surgeries performed at two centres in China

Purpose

To evaluate the safety, efficacy and merits of laparoscopic repair in children with hydroceles by comparing the outcomes of laparoscopic repair and the traditional open repair (OR) procedure. The outcomes of the following three laparoscopic percutaneous extra-peritoneal closure (LPEC) approaches were also compared: conventional two-port surgery, transumbilical single-site two-port surgery and single-port surgery.

Methods

We retrospectively compared the demographic, perioperative and follow-up data from the consecutive records obtained for 382 boys who underwent OR and 950 boys who underwent LPEC at two children’s medical centres in China. In the LPEC group, regardless of the hydrocele form, one of the three approaches with percutaneous aspiration was performed: conventional two-port surgery was performed in 387 cases, single-site two-port surgery was performed in 468 cases and single-port surgery was performed in 95 cases. The clinical data and complications were statistically analysed.

Results

Postoperative follow-up data were obtained for all the patients. The mean follow-up time was 36 months (24–48 months) in the OR group and 32.5 months (20–44 months) in the LPEC group. Significant differences in recurrence were not observed between the groups (five in the OR and 10 in the LPEC; P = 0.69). However, the operation time, postoperative hospital stay, incidence of scrotal oedema, incision infection and contralateral metachronous hernia or hydrocele were significantly higher in the OR group than those in the LPEC group (P < 0.01). Eighteen children (4.71%) had a negative exploration of the patent processus vaginalis (PPV) in the OR group. Fourteen children (1.47%) in the LPEC group had a closed internal ring and were converted to a scrotal procedure. Significant differences in the clinical data or complications were not observed between the two centres for the laparoscopic procedure (P > 0.05). Contralateral PPV (cPPV) was found in 18 patients in the single-port group (18.9%). Of the patients affected with cPPV, significant differences were observed between the single-port group and the two-port LPEC group (122 patients, 31.5%, P = 0.016) and the single-site two-port group (the 148 patients, 31.6%, P = 0.013). A contralateral metachronous hernia or hydrocele was found in zero, zero and two cases in these groups, respectively, and significant differences were observed (P < 0.01) between the single-site surgery and the other two laparoscopic approaches.

Conclusions

LPEC is safe, feasible and effective for treating hydroceles in children and has the same recurrence rate as OR. However, LPEC is superior in operation time, hospital stay, occurrence of scrotal oedema, incision infection and occurrence of metachronous hernia or hydrocele. The transumbilical single-site two-port procedure has the same cosmetic effect as the single-port LPEC. According to our experience, the two-port LPEC approach is better for diagnosing cPPV and reducing metachronous hernia or hydrocele than the single-port LPEC procedure.

     

Lower recurrence rate with heavyweight mesh compared to lightweight mesh in laparoscopic totally extra-peritoneal (TEP) repair of groin hernia: a nationwide population-based register study

Purpose

Lightweight meshes (LWM) have shown benefits compared to heavyweight meshes (HWM) in terms of less postoperative pain and stiffness in open inguinal hernia repair. It appears to have similar advantages also in TEP, but concerns exist if it may be associated with higher recurrence rates. The aim of the study was to compare reoperation rate for recurrence of LWM to HWM in laparoscopic totally extra-peritoneal (TEP) repair.

Methods

All groin hernias operated on with TEP between 1 January 2005 and 31 December 2013 at surgical units participating in The Swedish Hernia Register were eligible. Data included clinically important hernia variables. Primary endpoint was reoperation for recurrence. Median follow-up time was 6.1 years (0–11.5) with minimum 2.5 years postoperatively.

Results

In total, 13,839 repairs were included for statistical analysis and 491 were re-operated for recurrence. Multivariate analysis demonstrated significantly increased risk of reoperation for recurrence in LWM 4.0% (HR 1.56, P?<?0.001) compared to HWM 3.2%. This was most evident in direct hernias (HR 1.75, P?<?0.001) and in hernia repairs with a defect >?3 cm (HR 1.54, P?<?0.021). The risk of recurrence with use of LWM in indirect hernias and in hernia repairs with a defect <?1.5 cm was more comparable to HWM.

Conclusions

Lightweight meshes were associated with an increased risk of reoperation for recurrence compared to HWM. While direct hernias and larger hernia defects may benefit from HWM to avoid increased recurrence rates, LWM is recommended to be used in indirect and smaller hernia defects in TEP repair.

     

Single-incision laparoscopic transabdominal preperitoneal mesh hernioplasty: results in 182 Japanese patients

Background

We introduced single-incision transabdominal preperitoneal (S-TAPP) herniorrhaphy (described herein) at our institution in June 2010. We recently conducted a retrospective study to assess the feasibility and safety of the procedure.

Methods

The study involved 182 patients (159 men, 23 women) who underwent S-TAPP herniorrhaphy between June 2010 and February 2015 for 202 groin hernias (162 unilateral hernias, 20 bilateral hernias). We examined patient characteristics, hernia type and presentation, operation time, conversion to another repair procedure, intraoperative blood loss, postoperative pain, morbidities, and postoperative hospital stay. We further evaluated operation time and morbidity by comparison between cases of simple unilateral hernia and cases of complicated unilateral hernia, which was defined as (1) a recurrent hernia, (2) hernia following radical prostatectomy, or (3) an incarcerated omental or bowel hernia.

Results

Five types of hernia were treated: indirect inguinal, direct inguinal, femoral, combined inguinal, and other (a urinary bladder hernia). Operation time was 92.5 ± 29.1 min for the unilateral hernias and 135.7 ± 24.5 min for the bilateral hernias. No major bleeding occurred. Postoperative pain was short-lived and easily managed. Overall morbidity was 8.2% (15/182 patients), and only one postoperative complication (recurrence) required surgical intervention (repeat S-TAPP). Average postoperative stay was 6.7 ± 2.6 days. Two patients experienced numbness in the outer thigh, but this resolved naturally. One superficial surgical site infection developed and was easily treated. Operation times were greater for the complicated vs. simple hernias, but the time differed significantly (p = 0.02) only between radical prostatectomy-associated hernia and simple hernia. No complicated hernia required conversion to traditional laparoscopic repair, but in simple unilateral hernia group one conversion to traditional laparoscopic repair was required for difficulties encountered in the dissection of the large indirect inguinal hernia sac. The incidence of seroma was higher, though not statistically, in the complicated (n = 3) vs. simple hernia group.

Conclusions

S-TAPP repair of groin hernia was shown to be a feasible, safe procedure. The advantages are well understood, and further studies are warranted to confirm the long-term benefits suggested by our study.

     

Laparoscopic inguinal hernioplasty after robot-assisted laparoscopic radical prostatectomy

Purpose

To evaluate the efficacy and safety of laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair in patients who have undergone robot-assisted laparoscopic radical prostatectomy (RALP).

Methods

From July 2014 to December 2016, TAPP inguinal hernia repair was conducted in 40 consecutive patients who had previously undergone RALP. Their data were retrospectively analyzed as an uncontrolled case series.

Results

The mean operation time in patients who had previously undergone RALP was 99.5 ± 38.0 min. The intraoperative blood loss volume was small, and the duration of hospitalization was 2.0 ± 0.5 days. No intraoperative complications or major postoperative complications occurred. During the average 11.2-month follow-up period, no patients who had previously undergone prostatectomy developed recurrence.

Conclusions

Laparoscopic TAPP inguinal hernia repair after RALP was safe and effective. TAPP inguinal hernia repair may be a valuable alternative to open hernioplasty.

     

Feasibility and limits of inguinal hernia repair under local anaesthesia in a limited resource environment: a prospective controlled study

Purpose

Local anaesthesia (LA) has proven effective for inguinal hernia repair in developed countries. Hernias in low to middle income countries represent a different issue. The aim of this study was to analyse the feasibility of LA for African hernia repairs in a limited resource environment.

Methods

Data from patients who underwent herniorrhaphy under LA or spinal anaesthesia (SA) by the 6th and 7th Forward Surgical Team were prospectively collected. All of the patients benefited from a transversus abdominis plane (TAP) block for postoperative analgesia. Primary endpoints concerned the pain response and conversion to general anaesthesia. Secondary endpoints concerned the complication and recurrence rates. Predictors of LA failure were then identified.

Results

In all, 189 inguinal hernias were operated during the study period, and 119 patients fulfilled the inclusion criteria: 57 LA and 62 SA. Forty-eight percent of patients presented with inguinoscrotal hernias. Local anaesthesia led to more pain during surgery and necessitated more administration of analgesics but resulted in fewer micturition difficulties and better postoperative pain control. Conversion rates were not different. Inguinoscrotal hernia and a time interval <50 min between the TAP block and skin incision were predictors of LA failure. Forty-four patients were followed-up at one month. No recurrence was noted.

Conclusions

Local anaesthesia is a safe alternative to SA. Small or medium hernias can easily be performed under LA in rural centres, but inguinoscrotal hernias required an ultrasound-guided TAP block performed 50 min before surgery to achieve optimal analgesia, and should be managed only in centres equipped with ultrasonography.