LAPAROSCOPIC MESH REPAIR OF RECURRENT INGUINAL HERNIA

Background: Pre-peritoneal mesh repair has been a long-standing technique for recurrent hernias. Laparoscopic technique has been applied to this operation with the aim of assessing its results at early follow up of 1 year. Methods: The outcome in 56 patients was reviewed and all patients contacted 12 months after surgery. Results: There was one immediate failure at 1 week, needing a further operation. There were no other recurrences at 1 year. Ten patients had minor postoperative complications. Conclusions: At early follow up, this is a satisfactory technique for recurrent hernias.     

INGUINAL HERNIA REPAIR: A COMPARISON BETWEEN LOCAL AND GENERAL ANAESTHESIA

Background : A comparative analysis of outcomes of inguinal hernia repair performed under local (LA) and general anaesthesia (GA) by a single surgeon using a standardized technique of anterior transversalis repair was performed. Ninety-three cases were examined, 56 of which were cases of LA hernia repair. Methods : A retrospective analysis of the patient hospital record was performed with particular attention to intra-operative and postoperative analgesia requirements. Results : An overall series complication rate of 6.5% (6/93) is reported. Only one of 56 LA patients (2%) required more than 24 h of narcotic analgesic injections compared to 11% (4/37) in the GA group (P < 0.05). The mean total postoperative parenteral narcotic requirement in the LA group was 86 ± 14 mg of pethidine as compared to the GA group who had a mean total requirement of 121 ± 17 mg of pethidine (P > 0.08). Conclusions : The LA infiltration technique is an effective method for inguinal hernia repair. This series demonstrates benefits in terms of length of hospital stay and a lower incidence of postoperative parenteral narcotic analgesic requirement although when postoperative parenteral narcotics were required by the LA group of patients, the difference in mean total pethidine requirement was not statistically significant.     

REPAIR OF GIANT INGUINOSCROTAL INGUINAL HERNIA USING MARLEX MESH AND SCROTAL SKIN FLAPS

A new technique for the repair of giant inguinoscrotal hernia is described. It consists of: reduction of the hernia; repair of the hernial orifices with marlex mesh; creation of a midline anterior wall defect to increase intra-abdominal capacity; covering this defect with marlex mesh; then covering the midline marlex mesh with a rotation flap of inguinoscrotal skin. This technique increases intra-abdominal capacity and allows reduction of the hernia without compromising respiratory function, in patients with chronic airflow limitation, by using skin that would otherwise be discarded.     

EVALUATION OF THE SAFETY OF INGUINAL HERNIA REPAIR IN THE ELDERLY USING LIGNOCAINE INFILTRATION ANAESTHESIA

Repair of inguinal hernia using local anaesthesia is becoming increasingly popular as it avoids many of the systemic side effects associated with general or spinaVepidural anaesthesia and provides excellent early postoperative pain relief. Dosages of local anaesthetic approaching the recommended maximum are frequently required for adequate anaesthesia of the inguinal region. The present study describes the disposition and safety of lignocaine with adrenaline in 14 elderly patients to ascertain its safety with a view to more widespread application of the technique in more complicated hernia repairs. Serial plasma lignocaine concentrations were determined for up to 24 h following doses approaching the recommended maximum for infiltration (7 mg/kg). Peak lignocaine concentrations (normalized to 7 mg/kg) ranged from 0.23 to 0.90mg/L (mean of 0.54mg/L): that is, the maximum recorded concentration was less than one-fifth the toxicity threshold for lignocaine of 5 mg/L. The study suggested that the majority of patients tolerated the local anaesthetic approach very well and that the wide safety margin allowed ample scope to develop the local anaesthetic approach for the repair of more complex hernia repairs (e.g. large, bilateral or strangulated herniae, or those in obese patients) without risk of exposing patients to lignocaine concentrations which may cause toxic side effects.     

LAPAROSCOPIC EXTRAPERITONEAL INGUINAL HERNIA REPAIR USING A BALLOON DISSECTION TECHNIQUE

A laparoscopic extraperitoneal approach using a balloon dissection technique was used to repair 40 inguinal hernias in 35 patients. The initial experience with this method is presented. Thirty-four of these hernias were indirect, five direct and one sliding. Three were recurrent hernias. The operation time ranged from 40 to 135 min. Thirty-two of the patients stayed overnight in the hospital; Three stayed 2 nights. Return to normal activities ranged from 3 to 21 days. None of the patients had problems with nerve entrapment and to date there have been no recurrences of the hernias following the repairs. The procedure has been very well-tolerated by all patients.     

腹膜前Marlex网片植入法修补腹股沟复发疝

采用腹膜前Marlex网片植入法对21例腹股沟复发疝进行了修补。手术应用原切口入路的简化腹膜前修补法,显露腹股沟管壁结构,游离腹膜前间隙,植入Marlex网片。既能做到无张力修利,又能加强管壁结构。本组21例除1例术后皮下血肿,2例发生局部感觉异常外无其它并发症。随访2～5年无1例复发。作者认为,复发疝解剖层次改变、组织缺损重、瘢痕组织无弹性,采用传统方法修补易致复发;而采用人工假体植入则能有效防止复发。     

LAPAROSCOPIC INGUINAL HERNIOPLASTY: A COMPARISON BETWEEN TRANSPERITONEAL AND EXTRAPERITONEAL TECHNIQUES

Background: This study sequentially compares the results of 148 transperitoneal inguinal hernioplasties in 129 patients with 313 totally extraperitoneal hernioplasties in 254 patients. Methods: Patients were entered into the study prospectively and reviewed postoperatively at 1 day, 1 week, 5 weeks and 1 year. Results: There was no difference in length of hospital stay, postoperative analgesia requirements or the rate of early or late operative complications. The operating time was shorter and the return to normal activities was earlier for the totally extraperitoneal group. There were no intraperitoneal complications following the totally extraperitoneal operation. Conclusions: The extraperitoneal technique is favoured over the transperitoneal technique for laparoscopic inguinal hernioplasty.     

EARLY INCISIONAL HERNIA AFTER USE OF THE 12 MM PORT FOR LAPAROSCOPIC SURGERY

This paper reports the complication of early incisional hernia occurring in three patients at the site of entry of a 12 mm disposable port during laparoscopic surgery. To avoid this complication, it is recommended that a 12 mm port be introduced through muscle rather than fascia and, following its removal, the defect in the abdominal wall be closed by sutures.     

A TECHNIQUE FOR LAPAROSCOPY THROUGH THE DEEP RING DURING EMERGENCY OPEN INGUINAL HERNIA REPAIR

This techinque describes a simple, safe and reliable method of assessing intra-abdominal pathology during open inguinal hernia repair.     

腹股沟直疝治疗体会(附88例报告)

作者统计了1972～1996年手术治疗88例腹股沟直疝的临床资料。其中右侧46例(52.3％),左侧24例(27.3％),双侧18例(20.4％),骑跨疝4例(4.5％);修补方法采用McVay法59例(63.4％),Bassini法18例(19.3％),Halsted法12例(12.9％),改良McVay法2例(2.2％),疝成形2例(2.2％)。随访58例(65.9％),2例复发(2.3％)。文内对腹股沟直疝的特点及术式选择进行了讨论,提出术中应注意识别骑跨疝的存在,旨在提高腹股沟直疝手术的疗效。     

LAPAROSCOPIC CHOLECYSTECTOMY INITIAL EXPERIENCE

Twenty-five consecutive patients underwent percutaneous laparoscopic cholecystectomy (PCC). The gallbladder was removed successfully in 18 patients. The mean postoperative hospital stay was 1.4 days and patients returned to normal activity at a mean 8 days after operation. Postoperative pain was minimal. Formal laparotomy was performed in 7 patients due to: bleeding (3 patients), stone spillage (3 patients) and exploration of the common bile duct (1 patient). Complications were reduced with experience and strict adherence to the described operative technique. With obvious advantages for the patient, hospitals and the community an increased demand for PCC is inevitable. However, its role in the management of cholelithiasis and overall safety have yet to be determined. There is a significant learning curve and proper training is necessary. The widespread introduction of PCC has immediate implications for surgical training.     

INGUINAL SURGERY IN ATHLETES WITH CHRONIC GROIN PAIN: THE ‘SPORTSMAN'S’ HERNIA

Book reviews in this article: Fifty athletes with chronic undiagnosed groin pain underwent surgical exploration and inguinal hernia repair. Six months later, all athletes were sent questionnaires to assess their return to sport, level of pain (using analogue pain scores) and the overall result of their surgery. Operative findings revealed a significant bulge in the posterior inguinal wall in 40 athletes. Forty-four athletes (88%) replied to the questionnaire. Forty-one athletes (93% of respondents) had returned to normal activities. Pain scores indicated a marked improvement in their level of pain (P < 0.001). Thirty-three athletes (75%) rated the result as good and 10 (23%) as improved. It is concluded that athletes with chronic groin pain who are unable to compete in active sport should be considered for routine inguinal hernia repair if no other pathology is evident after clinical examination and investigation.     

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.     

不同微创术式治疗儿童腹股沟疝术后伤口恢复及外观情况比较

目的:探究腹腔镜全腹膜外腹股沟疝修补术(Totally extraperitoneal herniorrhaphy,TEP)与腹腔镜经腹腹膜前腹股沟疝修补术(Transabdominal preperitoneal herniorrhaphy,TAPP)治疗儿童腹股沟疝临床效果。方法:选取56例腹股沟疝患儿为研究对象,按照随机数表分为TEP组与TAPP组各28例,分别接受TEP、TAPP术式治疗,比较术后1h、6h、1d疼痛程度[东大略儿童医院疼痛量表(Children’s hospital of eastern ontario pain scale,CHEOPS)]变化,分析两组围术期基本指标、术后6个月瘢痕严重程度[温哥华瘢痕量表(Vancouver scar scale,VSS)]及并发症发生情况。结果:术后1h,两组患儿CHEOPS评分比较差异无统计学意义(P>0.05);术后6h、1d,两组患儿CHEOPS评分均较术后1h时有显著降低,差异有统计学意义(P<0.05),但组间同一时间比较差异均无统计学意义(P>0.05)。两组患儿手术时间、术中出血量、肛门排气时间、下床活动时间及住院时间比较差异均无统计学意义(P>0.05)。术后6个月,TEP组患儿VSS评分均明显低于TAPP组(P<0.05),但两组患儿切口感染、尿潴留、肠梗阻、血清肿并发症发生率及腹股沟疝复发率比较差异均无统计学意义(P>0.05)。结论:不同微创术式治疗小儿腹股沟疝均可取得理想疗效,但TEP相较于TAPP能减轻瘢痕严重程度,有利于维持其局部皮肤美观。     

Laparoscopic inguinal hernia repair in children

Childhood inguinal hernia is a result of a congenital patent processus vaginalis. In order to prevent strangulation of viscera trapped in the defect, surgery is necessary. Conventional operation for childhood inguinal hernia involves the use of a skin incision over the groin to dissect out the sac, taking care not to injure the adjacent important structures, namely the vas deferens and testicular vessels. The sac is then divided and the proximal end transfixed. With the advance in minimally invasive surgery, laparoscopic repair of childhood inguinal hernia has been attempted. Modification of the technique by injecting normal saline extraperitoneally before the purse‐string closure of the neck of the processus vaginalis has made the procedure safer. An advantage of the laparoscopic procedure is that it allows detection and repair of the contralateral hernia. Randomised controlled trials are still required to verify the suggested advantages of better cosmesis outcome and more efficient pain control. Long‐term follow up in a large‐scale study is also desirable, to evaluate the cost‐effectiveness and possible complications of this mode of treatment.      

Adult groin hernias: acute and elective

Groin hernias are a common general surgical condition and inguinal hernias will affect over a quarter of the male population in their lifetime. As a consequence, inguinal hernia repair remains one of the most frequently performed general surgical procedures carried out in the UK, at a cost of £100 million to the National Health Service per annum. Although hernia-related complications are relatively rare, they may be catastrophic and repair is recommended because of the potential functional consequences for the patient and the impact on quality of life. These issues need thorough consideration when deciding upon treatment, particularly in reference to the suitability of the patient, the nature of the hernia to be repaired and the type of surgical approach to be utilized. As with many other areas in medicine, improved outcomes in hernia surgery are achieved by experienced high-volume operators with a specialist interest in the condition. This is particularly the case with laparoscopic hernia surgery, which when introduced was associated with significant complications, and continues to have a steep learning curve. In light of the prevalence of the condition and the potential morbidity associated with hernia treatment, these factors have important global socio-economic implications.