腹腔镜造口旁疝修补术13例报告

目的探讨采用腹腔镜钥匙孔手术行造口旁疝修补术的可行性。方法回顾性分析2007年11月～2011年10月采用钥匙孔技术及Proceed补片完成的13例腹腔镜造口旁疝修补术的临床资料。2例回肠代膀胱造瘘,11例左下腹永久性乙状结肠造瘘,其中1例为造口旁疝修补术后复发。术中游离疝周粘连后,将补片适当修剪,中间留圆孔,置于疝囊下方,用5mm螺旋钉枪固定于腹壁。结果所有患者均顺利完成手术。术中并发症2例：横结肠系膜血管损伤1例,造瘘肠管损伤1例;术后并发症3例：切口感染1例,血清肿2例。术后随访5-52个月,平均26个月,1例复发,1例死于肺部感染。结论采用腹腔镜钥匙孔手术及Proceed补片行腹腔镜造口旁疝修补术是安全可行的,临床疗效较为满意,在降低造口旁疝修补术后补片相关并发症发生率和复发率方面具有一定的意义。     

Laparoscopic treatment of ventral hernias

The use of mesh in incisional hernia repair has reduced the rate of hernia recurrence. Laparoscopic placement of mesh is a promising alternative to the classical open approach. Recent studies involving large numbers of patients have shown the laparoscopic approach to be feasible in 95% of cases; the incidence of postoperative complications was low and hernia recurrence occurred in 3-5% at three years. Several retrospective studies and one randomized study comparing open versus laparascopic ventral hernia repair suggest that the laparoscopic repair yields better results (fewer postoperative complications and lower recurrence rate) than the classical open approach.     

Laparoscopic treatment of ventral hernias

The use of mesh in incisional hernia repair has reduced the rate of hernia recurrence. Laparoscopic placement of mesh is a promising alternative to the classical open approach. Recent studies involving large numbers of patients have shown the laparoscopic approach to be feasible in 95% of cases; the incidence of postoperative complications was low and hernia recurrence occurred in 3-5% at three years. Several retrospective studies and one randomized study comparing open versus laparascopic ventral hernia repair suggest that the laparoscopic repair yields better results (fewer postoperative complications and lower recurrence rate) than the classical open approach.     

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。     

Long-term outcomes in laparoscopic vs open ventral hernia repair

OBJECTIVE: To investigate whether there was a difference in morbidity, recurrence rate, and length of hospital stay between patients undergoing open or laparoscopic incisional hernia repair. DESIGN AND SETTING: Single-institution cohort study. We compared prospectively collected patient cohorts undergoing laparoscopic or open intraperitoneal onlay mesh repair. Statistical analysis was performed by Fisher exact test and analysis of variance. PATIENTS: Between October 1995 and December 2005, data from 360 consecutive patients who had undergone open or laparoscopic intraperitoneal onlay mesh repair of a ventral hernia were prospectively collected in a database and were supplemented by record review. MAIN OUTCOME MEASURES: Morbidity, hernia recurrence, and length of hospital stay. Postoperative complications of Clavien grade II or greater were considered major complications. RESULTS: Intraperitoneal onlay mesh repair was performed in 233 patients by the open approach and in 127 patients using the laparoscopic approach. The groups were similar for sex and body mass index (calculated as the weight in kilograms divided by the height in meters squared); the mean age of the laparoscopic group was 3 years younger; and the mesh was larger in the laparoscopic group. Mean follow-up was 30 and 36 months for the laparoscopic and open groups, respectively; the conversion rate was 4%. Major morbidities were 15% in the open group vs 7% in the laparoscopic group (P = .01). Recurrence rates were 9% in the open group vs 12% in the laparoscopic group (P = .36). Postoperative inpatient admission was more frequent after the open procedure than after the laparoscopic procedure (28% vs 16%, respectively; P<.05). CONCLUSIONS: Outcomes did not differ with respect to recurrence rates after long-term follow-up; however, the lower rate of major morbidity and increased outpatient-based procedure rates favor laparoscopic repair in this study.     

Laparoscopic ventral hernia repair reduces wound complications

Postoperative wound complications can be a source of significant morbidity after open ventral hernia repair. By using smaller incisions a laparoscopic approach may decrease this complication. To determine the rate of wound complications after laparoscopic ventral hernia repair prospectively collected data on morbidity in 54 consecutive patients undergoing ventral hernia repair were analyzed. Wound complications were classified as major if there was an open wound or treatment with intravenous antibiotics was required. Minor wound complications consisted of wound erythema or drainage that was treated on an outpatient basis. Eighteen patients underwent open ventral hernia repair. Thirty-six patients underwent attempted laparoscopic repair; five required conversion to an open procedure. Wound complications occurred in 28 and 16 per cent of patients undergoing open and successful laparoscopic repairs, respectively. However, only 3 per cent of patients undergoing laparoscopic repair had a major wound complication as compared with 22 per cent of patients undergoing open herniorrhaphy. Two-thirds of the major wound complications in the attempted laparoscopic group occurred in patients requiring conversion to an open procedure. Laparoscopic ventral hernia repair is a safe and effective alternative to conventional open ventral hernia repair. The main advantage of this minimally invasive approach is a decrease in the rate of major wound complications.     

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.     

Laparoscopic ventral hernia repair: are there comparative advantages over traditional methods of repair?

Recent studies have noted advantages of laparoscopic over open repair of ventral hernias. Because few reports have involved comparison with traditional repair we report a comparison between laparoscopic and open approaches. We retrospectively reviewed the records of patients undergoing ventral hernia repair over a 28-month period. Patients were grouped into three categories: laparoscopic repair with mesh, open repair with mesh, and open repair without mesh. There were 295 ventral hernia repairs and there was no difference in age, gender, operative complications, or hospital stay between the groups. Mesh and defect size was greater in the laparoscopic group. The overall postoperative complication rate was greater in the open group with mesh. Yet when specific wound complications were analyzed there was no difference between the groups. Furthermore a death occurred in the laparoscopic group from an unrecognized bowel injury. The recurrence rate was greatest in the open repair without mesh group. Finally hospital cost was greatest in the laparoscopic group and third-party reimbursement was better for the open techniques. We were unable to demonstrate a significant advantage to laparoscopic ventral hernia repair. Although many patients with large fascial defects were well served with this approach it may not be a better option for these patients.     

Prospective study of open preperitoneal mesh repair for recurrent inguinal hernia

BACKGROUND: Recurrent inguinal hernia presents a significant clinical problem with high re-recurrence and complication rates, particularly when an anterior approach is used. This study evaluated the open preperitoneal approach for repair of recurrent inguinal hernia. METHODS: This was a prospective cohort study of 101 consecutive patients with 114 recurrent inguinal hernias. All were operated on using an open preperitoneal technique and prosthetic mesh by the method of Stoppa or Wantz. Follow-up was at 2-6 weeks, 15 and between 42 and 54 months. RESULTS: There were no major complications. There was one infection and one case of retention of urine. There were no testicular complications. There were five recurrences, all within 6 months of operation, four of which were among the first 20 cases. Modifications to the original technique were made, and one recurrence occurred in the remaining 81 patients (1 per cent) or 106 hernias (1 per cent). CONCLUSION: Preperitoneal mesh repair gives results far superior to those of the commonly used anterior approach. It is safer and easier to learn than laparoscopic repair and is the procedure of choice for complex multirecurrent inguinal hernia.     

老年腹壁切口疝的腹腔镜下修补术

目的 探讨腹腔镜下应用补片行老年腹壁切口疝修补术的方法、安全性及临床效果。方法 2004年11月至2006年6月对17例老年切口疝患者行腹腔镜下应用补片切口疝修补术。结果 16例腹腔镜下行腹腔粘连松解和补片固定,顺利完成切口疝修补手术,1例因肠管与腹壁粘连紧密而中转开腹修补术。手术时间65～132min,平均95min。术后恢复排便、排气时间平均为31h,术后住院5～7d。术后并发症：疼痛3个月以上者3例,浆液肿5例,穿刺口感染1例,均经保守治疗后好转,无手术死亡和肠瘘发生。随访7～26个月（平均13个月）,未见切口疝复发。结论 腹腔镜下行腹腔内粘连松解,采用缝合器和缝线贯穿腹壁固定补片修补老年腹壁切口疝安全、有效。     

Groin Hernia Repair by Laparoscopic Techniques: Current Status and Controversies

Laparoscopic hernia repair remains controversial, and its position in current hernia surgery remains in flux. In this article we attempt to put the laparoscopic approach in perspective by describing the rationale for its development. We summarize studies comparing it with open repairs, including recent publications, meta-analyses, and systematic reviews; and we then contrast the data with recent findings of the United States Veterans Affairs Cooperative study 456. We discuss the current and future status of the laparoscopic approach to inguinal hernia repair and present an update of our own laparoscopic totally extraperitoneal technique without mesh fixation. From 1994 to 2004 we performed 314 hernia repairs on 224 patients with no intraoperative complications, no conversions to an open procedure, and no mortality. Thirty (14%) minor postoperative complications occurred. There were three herniated lipomas (preperitoneal fat) but no true peritoneal reherniations. We evaluate critical points of laparoscopic hernia repair including extensive preperitoneal dissection, mesh configuration, size and fixation, cost reduction, and the learning curve.     

Safety of Laparoscopic Ventral Hernia Repair in Octogenarians

Background and Objectives:

The recurrence rate after laparoscopic ventral hernia repair is lower than the rate of recurrence via the open approach in many series. Studies have demonstrated the safety and efficacy of this procedure but have had relatively young patient populations. We present our experience in a significantly older population.

Methods:

A retrospective chart review of all patients 80 to 89 years of age undergoing a laparoscopic ventral hernia repair at our institution from May 2000 to June 2007 was performed. Data collected included demographics, number and type of previous abdominal operations, number of previous hernia repairs, defect and mesh size, postoperative complications, and follow-up.

Results:

Twenty octogenarian patients underwent laparoscopic ventral hernia repair. Nine were men and 11 were women. The mean age was 82 years. Thirteen patients (65%) had one or more associated comorbidities at the time of surgery. Eighteen patients (90%) had undergone a mean of 1.7 prior abdominal operations. Six (30%) patients had undergone a mean of 1.1 previous open hernia repairs; 5 (83%) with mesh. Eight patients (40%) had an additional operative procedure at the time of laparoscopic hernia repair. Ten minor complications occurred in 10 patients (50%). Four major complications occurred in 4 patients (20%). One patient required reoperation for evacuation of hematoma at a trocar site. No patients complained of pain at a transabdominal suture site or persistent seromas by 6 weeks of follow-up. At mean follow-up of 3.1 months, no recurrences occurred and no patients required mesh removal in this series. No deaths occurred.

Conclusion:

Laparoscopic ventral hernia repair is becoming an accepted technique for hernia repair in the United States, with a well-documented low recurrence rate. Our series demonstrates that this approach is equally safe and effective for a significantly older segment of the population.     

Anterior tension-free repair of recurrent inguinal hernia under local anesthesia: a 7-year experience in a teaching hospital

OBJECTIVE: To describe a 7-year experience with recurrent inguinal hernia repair performed mainly with tension-free mesh or plug technique under local anesthesia through the anterior approach, and to evaluate the safety and effectiveness of this method of treatment. METHODS: One hundred forty-five elective and 1 emergency herniorrhaphies for recurrent groin hernia were performed in 141 subjects (134 men and 7 women) with a mean age of 65 years (range 30-89). Concomitant medical and surgical problems were present in 73% and 8% of subjects, respectively. In 28 instances, the relapsed hernia had already been operated on once or twice for recurrence. A traditional hernioplasty had been previously performed in the vast majority of cases (136). Tension-free mesh or plug techniques through an anterior approach under local anesthesia were performed in 144 reoperations. Preperitoneal mesh repair and general or spinal anesthesia were used in all but one case when herniorrhaphy was performed during simultaneous operations. RESULTS: Mean hospital stay after surgery was 1.5 days (range 3 hours-14 days). No perioperative deaths occurred in this series. General complications were one case of acute intestinal bleeding and two cases of urinary retention. Local complications consisted of eight (5.5%) minor complications and one case of orchitis (0.7%) followed by testicular atrophy. In no instance was postoperative neuralgia or chronic pain reported. Two re-recurrences occurred. CONCLUSIONS: Given the low complication rate in this and other reported series and the absence of surgical or general complications described after preperitoneal open or laparoscopic repair and after general and spinal anesthesia, anterior mesh repair under local anesthesia seems to be a low-cost surgical technique that can be safely and effectively used even in a teaching hospital for the treatment of the majority of patients with recurrent groin hernias.     

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.     

Laparoscopic repair of inguinal hernia using Surgisis mesh and fibrin sealant.

OBJECTIVE: We tested the hypothesis that laparoscopic inguinal herniorrhaphy using Surgisis mesh secured with fibrin sealant is an effective long-term treatment for repair of inguinal hernia. This case series involved 38 adult patients with 51 inguinal hernias treated in a primary care center. METHODS: Between December 2002 and May 2005, 38 patients with 45 primary and 6 recurrent inguinal hernias were treated with laparoscopic repair by the total extraperitoneal mesh placement (TEP) technique using Surgisis mesh secured into place with fibrin sealant. Postoperative complications, incidence of pain, and recurrence were recorded, as evaluated at 2 weeks, 6 weeks, 1 year, and with a follow-up questionnaire and telephone interview conducted in May and June 2005. RESULTS: The operations were successfully performed on all patients with no complications or revisions to an open procedure. Average follow-up was 13 months (range, 1 to 30). One hernia recurred (second recurrence of unilateral direct hernia), indicating a 2% recurrence rate. CONCLUSIONS: Laparoscopic repair of inguinal hernia using Surgisis mesh secured with fibrin sealant can be effectively used to treat primary, recurrent, direct, indirect, and bilateral inguinal hernias in adults without complications and minimal recurrence within 1-year of follow-up.     

腹腔镜技术在切口疝修补术中的应用体会

目的探讨腹腔镜下应用补片修补切口疝的手术方法和II缶床效果。方法回顾性分析我科2006年1月至2008年12月对腹壁切口疝23例施行腹腔镜修补术的临床资料。结果本组成功施行腹腔镜下切口疝补片修补22例,因腹腔内严重粘连中转剖腹手术1例,术中发现多发切口疝3例。本组无手术死亡和肠瘘病例。术后出现疼痛4例,补片周围积液3例。全组获随访4～24个月,平均13．8个月,未见切口疝复发。结论腹壁切口疝病人行腹腔镜下补片修补大多是安全地,还可在术中发现隐性缺损。对腹腔内广泛粘连分离困难者,应及时中转剖腹手术。     

Inguinal hernia repair in Hospital Authority hospitals: The role of laparoscopic hernioplasty

Objective: Two major changes have occurred in inguinal hernia repair during the last two decades: (i) the use of tension‐free mesh repair; and (ii) the application of laparoscopic technique for repair. The aims of the present study were to study: (i) how inguinal hernia repair was carried out; and (ii) the outcome of inguinal hernia repair in Hospital Authority (HA) hospitals. Methodology: This was a retrospective analysis on 8311 elective inguinal hernia repairs performed in 16 HA hospitals from January 2001 to December 2003. The mean age was 63.9 ± 14.2 years, and the male to female ratio was 22.0 : 1.0. Among these, 869 (10.5%) repairs were performed with the laparoscopic approach and 7442 (89.5%) repairs with the open approach. The proportion of laparoscopic hernia repair increased from 8.7% to 12.6%. Results: For open repair, 39% of cases were carried out with regional anaesthesia, 32% with general anaesthesia and 29% with local anaesthesia (LA). Furthermore, mesh repair was used in 88% of the patients. For laparosocpic repair, 98.4% of cases were carried out under general anaesthesia, and all patients had mesh repair using the totally extraperitoneal approach. A significantly higher proportion of bilateral repair and recurrent hernia repair was performed with the laparoscopic approach (P = 0.000). For primary unilateral repair, there was no significant difference in the postoperative length of stay (LOS) and the total LOS between the laparoscopic and the open surgery groups. No difference in LOS was found in recurrent hernia repair between the two groups. With respect to bilateral repair, both the preoperative LOS (P = 0.036) and total LOS (P = 0.039) were shorter in the laparoscopic group. Furthermore, a significantly higher proportion of day‐surgery patients was observed in the laparoscopic group than the open surgery group (21.3%vs 16.9%, P = 0.001). Nevertheless, when only the results of 2003 were analyzed, the postoperative LOS (P = 0.000) and total LOS (P = 0.000) were significantly shorter in the laparoscopic group than the open surgery group. The LOS parameters were significantly shorter in the open surgery LA subgroup compared with the non‐LA subgroup (P = 0.000), and they were not different from those in the laparoscopic group. Conclusions: The open mesh repair is the predominant approach for inguinal hernia repair in HA hospitals. The originally described local anaesthetic approach was under utilized, although it resulted in good outcome. The use of laparoscopic hernia repair is increasing and a learning curve was recently observed with improved outcome.     

Totally extraperitoneal laparoscopic inguinal hernia repair is a safe option in patients with previous lower abdominal surgery

BACKGROUND: History of inguinal hernia repair changed over the decades from repair by tissue approximation to the insertion of synthetic mesh and the introduction of laparoscopic repair. Despite accounting for 15-20% of hernia operations worldwide, many surgeons considered previous lower abdominal surgery as a contraindication to performing totally extraperitoneal (TEP) repair. AIM: The aim of this study was to assess the feasibility of TEP in primary and recurrent inguinal hernias in patients with previous lower abdominal surgery. PATIENTS AND METHODS: This study was a retrospective review of patients who underwent TEP inguinal hernia repair from January 2001 to July 2005. Variables studied included patient demographics, type of hernia, type of previous surgery, conversion to open repair, postoperative complications, and overnight admission. RESULTS: One hundred eight patients (107 males, 1 female), with a median age of 55 years (range 87-24), underwent TEP repair. Ninety-four patients had primary inguinal hernias, and 13 patients had recurrent inguinal hernias. Seventeen patients had a previous lower abdominal surgery (13 primary and 4 recurrent inguinal hernias). There was 1 conversion to open repair and 1 case of postoperative bleeding that required an exploration-both in the group with no previous surgery. Postoperative complications were minimal. All cases were performed as day cases; however, patients with recurrent hernia stayed longer in the hospital than those with primary hernia (P = 0.006). CONCLUSION: TEP repair is feasible in patients with previous lower abdominal surgery. TEP was planned as a day-case procedure; however, patients with recurrent hernias needed a planned admission, as an overnight stay was required.     

Laparoscopic ventral hernia repair is safe and cost effective

BACKGROUND: Ventral hernia repair is increasingly performed by laparoscopic means since the introduction of dual-layer meshes. This study aimed to compare the early complications and cost effectiveness of open hernia repair with those associated with laparoscopic repair. METHODS: Open ventral hernia repair was performed for 92 consecutive patients using a Vypro mesh, followed by laparoscopic repair for 49 consecutive patients using a Parietene composite mesh. RESULTS: The rate of surgical-site infections was significantly higher with open ventral hernia repair (13 vs 1; p = 0.03). The median length of hospital stay was significantly shorter with laparoscopic surgery (7 vs 6 days; p = 0.02). For laparoscopic repair, the direct operative costs were higher (2,314 vs 2,853 euros; p = 0.03), and the overall hospital costs were lower (9,787 vs 7,654 euros; p = 0.02). CONCLUSIONS: Laparoscopic ventral hernia repair leads to fewer surgical-site infections and a shorter hospital stay than open repair. Despite increased operative costs, overall hospital costs are lowered by laparoscopic ventral hernia repair.     

Polyester (Parietex) mesh for total extraperitoneal laparoscopic inguinal hernia repair

Polypropylene mesh is the most commonly used mesh for open and laparoscopic hernia repair in the United States. A variety of newly developed polyester mesh products have recently become available. This is the first U.S. multiinstitutional study evaluating the initial experience of polyester mesh use for total extraperitoneal (TEP) laparoscopic inguinal hernia repair. Between January 2000 and June 2001, 337 patients underwent 495 TEP laparoscopic inguinal hernia repairs using polyester mesh. There were 309 men and 28 women in the study, whose average age was 45 years (range, 17–80 years). The average operative time for all cases was 54.3 min (range, 18–157 min). There were no conversions to open repair and no mortality. Complications included 12 seromas/hematomas (six aspirated), chronic pain in three patients, urinary retention in two patients, and one incidence each of the following: epididimitis, prostatitis, hydrocele, and port-site cellulitis. Additionally, one patient had carbon dioxide (CO2) in the Foley bag at the end of the surgery, but a normal cystogram showed no identified bladder injury. There has been one recurrence (0.2%), occurring 4 months after surgery, which was repaired using a transabdominal laparoscopic approach. The mean follow-up period was 11 months (range, 2–22 months). There have been no documented infections of the mesh, and no mesh has been removed. This study documents a favorable initial experience with polyester mesh for TEP laparoscopic inguinal hernia repair. There were no complications related to the mesh. There may be technical and long-term advantages with the use of polyester mesh for laparoscopic inguinal hernia repair. Longer follow-up evaluation and additional studies are warranted to evaluate these potential advantages.