Surgical outcome and hospital cost analyses of laparoscopic and open tension-free hernia repair

Abstract Surgeons who favor the laparoscopic repair of groin hernias must limit the additional costs associated with this technique, which is not universally acknowledged to be superior to other less expensive open tension-free repairs. This retrospective study compared outcome and costs between laparoscopic and open tension-free hernia repair in 320 patients with inguinal hernias. Patients underwent either (a) transabdominal preperitoneal procedure (TAPP; 60 patients, 72 procedures), (b) totally extraperitoneal procedure (TEP; 174 patients, 202 procedures), or (c) open tension-free procedure (86 patients, 105 procedures). Regarding important postoperative complications there were two (3.3%) recurrences in the TAPP group and one (0.6%) in the TEP group, and six (9.9%) transient neuralgias in the TAPP group and one (1.2%) in the tension-free group. There were no deaths, no testicular atrophies, and no wound or mesh infections. The mean hospital postoperative stay was the same in the three groups (1 day). Mean operating time was shorter in the tension-free group concerning the unilateral cases and shorter in the TEP group concerning the bilateral cases. Fewer patients required analgesia during the first 6 h after the operative procedure in the TEP group than in the other two groups. The mean total costs were 483.90 euros in the open tension-free repair, 763.20 euros in the TAPP repair, and 572.50 euros in the TEP repair. The open procedure was the cheaper for the hospital. Laparoscopic hernia repair and tension-free repair as described by Gilbert are comparable in postoperative complications. TEP hernia repair is associated with less postoperative pain and earlier return to normal activities, but it is more expensive and continues to be a difficult procedure. Open tension-free repair is the least expensive method and is easier to learn than the other two procedures. Electronic Publication     

Advantages of laparoscopic transabdominal preperitoneal herniorrhaphy in the evaluation and management of inguinal hernias

BACKGROUND: Laparoscopic transabdominal preperitoneal (TAPP) herniorrhaphy provides an opportunity to definitively evaluate both inguinal areas without the need for additional dissection. We aimed to establish the rates and contributing patient factors to errors in the preoperative assessment. METHODS: A retrospective review of consecutive patients undergoing laparoscopic TAPP herniorrhaphy at 2 tertiary-care centers. Preoperative history and physical examination were used to classify the presence of hernia as "definite," "questionable," or "negative." Any discrepancies between preoperative and intraoperative findings were viewed as errors in preoperative assessment. RESULTS: Two hundred sixty-two patients underwent 328 laparoscopic TAPP hernia repairs. Of the 283 hernias diagnosed as "definite" preoperatively, 276 were confirmed at operation (97.8%). An additional 19 of 173 (11.0%) clinically unrecognized hernias were repaired at the time of surgery. Overall, our approach avoided unnecessary groin explorations and/or repairs in up to 16.4% patients and may have prevented inappropriate delays of herniorrhaphy in up to 19.8% of patients. The sensitivity, specificity, and positive predictive value of the clinical assessment of inguinal hernia were 94.5%, 80%, and 88.9%, respectively. Symptom and/or examination findings of inguinal mass were the only significant independent predictor of accuracy (P < .001). CONCLUSION: A high rate of discordance exists between the preoperative clinical assessment and true presence of inguinal hernias. Given the unique ability of laparoscopy to accurately evaluate the contralateral side and the limited added morbidity of bilateral repair, TAPP herniorrhaphy is beneficial in avoiding unnecessary explorations and allowing timely repairs in patients with occult inguinal hernias.     

Laparoscopic repair of strangulated hernias

Background Although laparoscopic transabdominal preperitoneal polypropylene (TAPP) hernia repair is now a recognized procedure for groin hernia repair in patients undergoing elective surgery, there is a scarcity of data on TAPP repair in emergency situations such as those involving strangulated hernias. Methods Unless contraindicated, the authors’ department considers laparoscopic TAPP repair the procedure of choice for all strangulated hernias. A prospective database of 1,532 consecutive hernia repairs performed between May 1998 and April 2004 was reviewed. Results A total of 28 irreducible strangulated hernias were observed and repaired through laparoscopic TAPP. There were three conversions (10.7%): one because of extensive adhesions and two because of bowel distention. Resection became necessary in 9 (36%) of the 25 cases involving effective TAPP repair of strangulated hernias. The mean operation time, with and without resection, was 103 and 55 min, respectively. The rate of postoperative morbidity was 4% because of one inguinal hematoma case. During a mean follow-up period of 340 days, there were no recurrences after TAPP repair. Conclusions For selected patients, the TAPP approach appears to be a good therapeutic option for strangulated hernias.     

腹腔镜经腹膜前、完全腹膜外和无张力疝修补术的前瞻性对照研究

目的通过对比研究腹腔镜经腹腹膜前补片植入术（TAPP）、完全腹膜外腹腔镜疝修补术（TEP）和开放无张力疝修补术,总结3种手术方法的优缺点。方法将124例腹股沟疝患者随机分为TAPP组44例、TEP组R40例及开放无张力修补组40例。分别行TAPP、TEP和无张力疝修补术（Lichtenstein修补）,术后对患者进行随访,比较3组患者的手术相关参数。结果TAPP组与TEP组在手术时间、住院天数、住院费用、恢复工作时间、术后疼痛程度方面比较差异无统计学意义。两组与开放无张力修补组比较差异有高度统计学意义（P〈0．01）。3组在并发症方面的差异无统计学意义。TAPP组与TEP组术后各有1例因补片曲卷移位而复发。结论与开放无张力疝修补手术相比,TAPP及TEP较安全可行,且患者疼痛轻、恢复快。TAPP对于复发性疝、双侧疝及隐形疝的优势更加明显,随着修补材料的不断改进及手术熟练程度的提高,TAPP会有更广阔的前景。     

Laparoscopic transabdominal preperitoneal (TAPP) hernia repair. A 7-year two-center experience in 3017patients

BACKGROUND: This report reviews our experience with 3530 transabdominal preperitoneal (TAPP) hernia repairs in 3017 patients (513 bilateral) over the 7-year period from May 1992 to July 1999. We have continually audited our practice and modified the techniques in response. METHODS: Unless contraindicated, laparoscopic TAPP repair is considered the procedure of choice at our institution for all reducible inguinal hernias. We initially stapled an 11 x 6 cm polypropylene mesh in the preperitoneal space but now place a 15 x 10 cm mesh in the preperitoneal space with sutured peritoneal closure. RESULTS: There have been a total of 22 recurrences, of which 17 were identified in the first 325 repairs (5%) using the 11 x 6 cm mesh. Five recurrences occurred in the later 3205 repairs (0.16%) (median follow up of 45 months). There was one 30-day death unrelated to the procedure. There have been seven conversions (four due to irreducibility, two due to extensive adhesions, one due to bleeding). Bladder perforations have occurred in seven cases, of which six were recognized immediately and treated laparoscopically without sequelae. There have been seven cases of small bowel obstruction from herniation through the peritoneal closure. Sutured repair of the peritoneum has reduced the incidence of this complication. Four patients had mesh infections, of whom three were treated conservatively. The incidence of postoperative seroma and hematoma was 8%. Median operation time remains at 40 min with a mean hospitalization of 0.9 nights. Sixty percent of TAPP hernia repairs are now performed on the Day Surgical Unit with a 3% admission rate. Median return to normal activities is 7 days. Forty percent of patients require no postoperative analgesia. These figures remain the same whether the hernia is primary, recurrent, unilateral, or bilateral. Consultants performed most operations early in the series, but latterly surgical trainees have performed the majority of these procedures under supervision. CONCLUSIONS: Laparoscopic TAPP hernia repair is technically difficult, but in the hands of a well-trained surgeon, it is safe and effective with a high degree of patient satisfaction. The low recurrence rate compares favorably to other tension-free mesh hernia repairs.     

Long-term results of a randomized clinical trial of Shouldice, Lichtenstein and transabdominal preperitoneal hernia repairs

INTRODUCTION: There is an ongoing debate about the preferred technique for inguinal hernia repair. In this randomized study the long-term results of Shouldice, Lichtenstein and transabdominal preperitoneal (TAPP) hernia repair were compared. METHODS: Some 280 men with a primary hernia were randomized prospectively to undergo Shouldice, tension-free Lichtenstein or laparoscopic TAPP repair. Patients were examined after 52 months to assess hernia recurrence, nerve damage, testicular atrophy and patient satisfaction. RESULTS: Hernia recurrence occurred in six patients after Shouldice repair, and in one patient each after Lichtenstein and TAPP repairs. All recurrences after tension-free repairs were diagnosed within the first year after surgery. Nerve injuries were significantly more frequent after open Shouldice and Lichtenstein repairs. Patient satisfaction was greatest after laparoscopic TAPP repair. CONCLUSION: Tension-free repair was superior to the non-mesh Shouldice technique. The open anterior approach to the groin was associated with demonstrable nerve injury, and laparoscopic TAPP repair was the most effective approach in the hands of an experienced surgeon.     

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.     

Allograft AlloDerm® tissue for laparoscopic transabdominal preperitoneal groin hernia repair: A case report

INTRODUCTION

Synthetic mesh is the prosthetic material used for most inguinal hernioplasties. However, when left in contact with intra-abdominal viscera, it often becomes associated with infection and migration, particularly in irradiated tissues, contaminated fields, immunosuppressed individuals, and patients with intestinal obstruction or fistula. AlloDerm^® Regenerative Tissue Matrix (LifeCell Corporation, Branchburg, NJ) is derived from human cadaver skin and may be associated with fewer visceral adhesions and more durability in infected fields than synthetic mesh.

PRESENTATION OF CASE

We report the first case in which AlloDerm was used in a laparoscopic transabdominal preperitoneal repair of a multiple recurrent right inguinal hernia, a left femoral hernia, and an umbilical hernia in the same patient. Use of AlloDerm greatly enhanced the maneuverability during laparoscopic hernia repair due to its pliability and strength and eliminated the need to cover the prosthetic with peritoneum.

DISCUSSION

Previous pelvic radiation and multiple previous groin repairs can render the peritoneum friable, resulting in obstacles to successful closure. AlloDerm is a reasonable choice for groin hernia repairs when such factors are present.

CONCLUSION

The long-term durability of AlloDerm for laparoscopic groin hernia repairs is yet to be determined, but based on current data it seems prudent to use this technique in laparoscopic repair of complex groin hernias where infection is suspected or inadequate prosthetic coverage with peritoneum is anticipated.     

Clinically diagnosed groin hernias without a peritoneal sac at laparoscopy—what to do?

Background

Groin or femoral hernias may be concealed behind intact peritonea when the laparoscopic transabdominal preperitoneal (TAPP) mesh technique is used. The aim of this study was to determine the causes, frequency, and surgical procedures in cases of clinically diagnosed hernias without peritoneal defects.

Methods

A prospective controlled study comprising 1795 consecutive patients undergoing 2190 laparoscopic TAPP herniorraphies was conducted. All hernias were first subjected to clinical investigations by the surgeons. Intraoperatively, all suspicious hernias were examined with regard to the presence of peritoneal hernial sacs.

Results

Of 2190 hernias, no hernia was seen transperitoneally in the laparoscopic procedures in 136 cases (6.2%). Forty-one femoral hernias (30.1%) were concealed behind intact peritonea. Forty-six lateral (33.8%) and 31 medial (22.8%) defects were sacless sliding fatty inguinal hernias.

Conclusions

When using the TAPP technique, in addition to femoral hernias, especially sacless sliding fatty inguinal hernias may be overlooked because of intact peritonea. Therefore, in cases of clinically diagnosed inguinal hernias, the preperitoneal space should be inspected intraoperatively to avoid unsatisfactory results.     

腹股沟疝网塞修补术与前入路腹膜前修补术前瞻性对照研究(附67例报告)

目的比较两种开放式无张力疝修补术的疗效。方法采用前瞻性随机对照方法,将67例69侧腹股沟疝分为两组:网塞修补组(34例)采用网塞行Rutkow术式,前入路腹膜前修补组(33例)采用15 cm×15 cm预裁剪聚丙烯平片行前入路腹膜前无张力疝修补术。结果均获随访,网塞修补组平均随访7.9个月,前入路腹膜前修补组随访8.1个月。两组平均手术时间、平均住院时间、恢复日常生活时间、切口并发症及阴囊积液发生率比较无显著性差异(P>0.05)。前入路腹膜前修补组平均费用明显少于网塞修补组,术后复发率、腹股沟区疼痛不适、异物感发生率也明显降低(P<0.05)。结论采用预裁剪补片行前入路腹膜前无张力腹股沟疝修补,可明显减少手术费用,降低术后疼痛不适、异物感的发生率,改善疗效,操作简便,安全经济,具有推广价值。     

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腹股沟疝无张力修补术可分为三大类术式:肌前修补、网栓充填术和腹膜前修补术,前两者修补腹股沟管后壁和疝环缺损,后者修补腹股沟部位的所有薄弱区域即肌耻骨孔。腹膜前修补术可以通过开放式手术完成,也可通过腹腔镜手术来完成。事实上,腹腔镜腹股沟疝修补术是众多腹膜前修补术中的一种方式,其特点是利用"腹腔镜器械"、通过"真正的后入路"、在"直视下操作"所进行的腹膜前手术。在临床上适用的人群主要有三大类:(1)具有腹膜前修补指征的人群,如腹横筋膜薄弱的老年病人、直疝或复合疝、存在腹内压增高因素的病人。(2)需要尽快恢复体力活动的病人。(3)复发疝和双侧疝。腹腔镜和开放式腹股沟疝修补术均是安全有效的修补方式,具有互补性,合理选择术式可获得最佳的临床和卫生经济学效益。     

Recurrence and complications after laparoscopic versus open inguinal hernia repair: results of a prospective randomized multicenter trial

BACKGROUND: The aim of this prospective randomized multicenter trial was to evaluate the recurrence rates and complications of open versus laparoscopic repairs of inguinal hernias. METHODS: Patients with primary unilateral inguinal hernias were randomized to Shouldice repair, Bassini operation, tension-free hernioplasty (Lichtenstein repair), laparoscopic transabdominal extraperitoneal hernioplasty (TEP), or laparoscopic transabdominal preperitoneal hernioplasty (TAPP). The primary outcome parameter was the rate of recurrence at 3 years. The secondary outcome was the rate of intraoperative, perioperative, and long-term complications. Follow-up comprised of clinical examination after 1, 2, and 3 years. RESULTS: Three hundred and sixty-five patients were randomly assigned to one of the five procedures. The intention-to-treat analysis showed that the cumulative 3-year recurrence rate was 3.4% in the Bassini group, 4.7% in the Shouldice group, 0% in the Lichtenstein group, 4.7% in the TAPP group, and 5.9% in the TEP group (p = 0.48). Comparing open (Bassini, Shouldice, Lichtenstein) versus laparoscopic (TAPP, TEP) techniques (p = 0.29) and comparing the use of mesh prostheses (Lichtenstein, TAPP, TEP) versus suturing techniques (Bassini, Shouldice) (p = 0.74) showed no significance in the rate of recurrence. The rates of intraoperative (p = 0.15), perioperative (p = 0.09), and long-term complications (p = 0.13) were without significance between the five groups. Comparing mesh techniques (Lichtenstein, TAPP, TEP) versus suturing techniques (Bassini, Shouldice) showed no significance in the rate of complications. The per-protocol analysis for the comparison of mesh (Lichtenstein, TAPP, TEP) versus suturing (Bassini, Shouldice) techniques revealed that recurrences (p = 0.74), intraoperative (p = 0.64), perioperative (p = 0.27), and long-term complications (p = 0.91) were evenly distributed. CONCLUSIONS: In this multicenter study, no significant difference in the recurrence rate and complications between laparoscopic and open methods of hernia repair was revealed.     

Comparison of the open tension-free mesh-plug, transabdominal preperitoneal (TAPP), and totally extraperitoneal (TEP) laparoscopic techniques for primary unilateral inguinal hernia repair: a prospective randomized controlled trial

Background  

The open tension-free mesh-plug hernia technique, transabdominal preperitoneal (TAPP) technique, and totally extraperitoneal (TEP) laparoscopic technique all are common surgical procedures for primary unilateral inguinal hernia repair. However, the choice of the right surgical procedure still is controversial in China. This study aimed to compare open tension-free hernioplasty with two laparoscopic hernia repairs.     

Longterm results of a prospective study of 225 femoral hernia repairs: indications for tissue and mesh repair

BACKGROUND: Femoral hernias are uncommon, and there are relatively few clinical studies of longterm outcomes after repair. Although the McVay repair has been classically described, the infrainguinal plug technique has gained popularity in recent years. Evidence supporting these repairs is sparse. STUDY DESIGN: A prospective study of elective femoral hernia repairs was done at the Shouldice Hospital from June 1999 until June 2003. The tissue-based complete groin repair (CGR) and a preperitoneal mesh repair were performed for specific indications. Patients were followed annually for 5 years to examine for recurrences and complications. RESULTS: Two hundred fifty-six patients were enrolled, with 225 completing 5 years of followup. Median age was 55 years, and hernias on the right side were more common (63.1%). Concurrent inguinal hernias were found in 115 patients (51%), and 41 (18.2%) had a previous inguinal hernia repair. A complete groin repair was performed in 120 patients and a preperitoneal mesh repair in 78. The remaining had an infrainguinal mesh repair. The overall recurrence rate was 3.1%, with a median time to recurrence of 12 months. There was no significant difference between mesh and suture repairs. Chronic postoperative pain was experienced by 20 patients (8.9%). CONCLUSIONS: Femoral hernias can be repaired electively with a tissue-based or a preperitoneal mesh technique, with durable longterm results. Mesh repair is indicated for recurrent femoral hernias, inguinofemoral hernias, prevascular hernias, association with concurrent direct hernias, and, if tension is anticipated, with complete groin repair. Infrainguinal mesh repair is used only when there has been a successful previous inguinal hernia repair.     

腹腔镜腹膜前疝修补和全腹膜外疝修补术治疗腹股沟疝的优劣比较

腹股沟疝是外科常见疾病。随着医学的发展,疝修补术从传统张力疝修补,转变到无张力修补,再到腹腔镜修补。腹腔镜疝修补术治疗优势明显,经腹腔腹膜前疝修补术(transabdominal preperitoneal,TAPP)和全腹膜外疝修补术(totally extra-peritoneal,TEP)是目前国内常用的两种修补术式。长期以来,两种术式各有优缺点,本文从TAPP和TEP在治疗原发单侧疝的手术时间、术中及术后并发症、术后疼痛、总住院时长、治疗复发疝及双侧疝的疗效等多方面进行对比,得出成人原发单侧腹股沟疝最好选用TEP。在治疗复发疝时,优先考虑TAPP。在治疗双侧疝时,TAPP和TEP暂时未见明显差异。临床医师在使用腹腔镜治疗腹股沟疝时应选用更熟悉更合理的手术方式。     

Totally extrafasdal endoscopie preperitoneal hernia repair: a merger of anatomy and surgery. The exact description to endoscopkally dissect the spermatic fascia

Summary  Stoppa introduced giant preperitoneal mesh repair after parietalisation of the cord in inguinal hernias. Based on this principle, a preperitoneal mesh is inserted during the laparoscopic transabdominal preperitoneal (TAPP) repair. Central to the Stoppa operation is identification of the bloodless plane between peritoneum and urogenital fascia. Dissection of this plane has not been described for the TAPP hernia repair. We present a reproducible, anatomicallybased method of finding and dissecting the urogenital fascia in the TAPP. Methods: After routine peritoneal incision, the urogenital fascia is identified late-rally in the Bogros space, where it is loosely adherent to the peritoneum. Here, developing the cleavage plane between the fascia and peritoneum is easy. The dissection is extended medially into the space of Retzius. Once the medial and lateral planes have been dissected, reducing the hernia sac is uncomplicated and bloodless. Because the urogenital fascia continues around the cord structures as the spermatic sheath, there is no danger of damaging these and it is easy to parietalise the vas deferens and testicular vessels. The mesh is then inserted true to the original dictates of Stoppa. Discussion: The precise preperitoneal dissection plane has not been elucidated for laparoscopy. The fascial anatomy in the groin is a complex arrangement between peritoneum, urogenital fascia and transversalis fascia. Dissection between the correct fascial layers allows rapid identification of the exact anatomy in an avascular plane. This ensures true parietalisation of the cord structures in an ordered and anatomically correct fashion.     

Groin Hernia Repair: Open Techniques

Since the introduction of the Bassini method in 1887, more than 70 types of pure tissue repair have been reported in the surgical literature. An unacceptable recurrence rate and prolonged postoperative pain and recovery time after tissue repair along with our understanding of the metabolic origin of inguinal hernias led to the concept of tension-free hernioplasty with mesh. Currently, the main categories of inguinal hernia repair are the open repairs and the laparoscopic repairs. In the open category, repair of the hernia is achieved by pure tissue approximation or by tension-free mesh repair. The most commonly performed tissue repairs are those of Bassini, Shouldice, and to a lesser extent McVay. In the tension-free mesh repair category, the mesh is placed in front of the transversalis fascia, such as with the Lichtenstein tension-free hernioplasty, or behind the transversalis fascia in the preperitoneal space, such as during the Nyhus, Rives, Read, Stoppa, Wantz, and Kugel procedures. Numerous comparative randomized trials have clearly demonstrated the superiority of the tension-free mesh repair over the traditional tissue approximation method. Placing mesh behind the transversalis fascia, although a sound concept, requires extensive dissection in the highly complex preperitoneal space and can lead to injury of the pelvic structures, major hematoma formation, or both. In addition, according to the prospective randomized comparative study of mesh placement in front of versus behind the transversalis fascia, the latter offers no advantage over the former, and it is more difficult to perform, learn, and teach. More importantly, preperitoneal mesh implantation (via open and laparoscopic procedure) leads to obliteration of the spaces of Retzius and Bogros, making certain vascular and urologic procedures, in particular radical prostatectomy and lymph node dissection, extremely difficult if not impossible. In conclusion, according to level A evidence from randomized comparative studies, (1) mesh repair is superior to pure tissue approximation repairs, and (2) mesh implantation in front of the transversalis fascia is superior, safer, and easier than open or laparoscopic mesh implantation behind the transversalis fascia.     

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??Appropriate selection of tension-free inguinal hernia repair procedures LI Jian-wen??YUE Fei. Department of General Surgery??Ruijin Hospital??Shanghai Jiao Tong University School of Medicine??Shanghai Clinical Minimally Invasive Surgery Center??Shanghai 200025??China
Corresponding author: LI Jian-wen??E-mail??ljw5@yeah.net
Abstract The tension-free hernioplasty for inguinal hernia consists of anterior and posterior repair. Anterior repair includes plain mesh repair as well as plug and patch repair. Plain mesh reinforces the posterior wall of inguinal box, while plug could reinforce local defect. Posterior repair includes various preperitoneal repairs based on the principle of myopectineal orifice reinforcement. Laparoscopic hernia repair applies laparoscopic instruments via posterior approach to accomplish posterior repair under direct vision. Both TAPP and TEP are major procedures for inguinal hernia repair. The selection of appropriate procedure depends on surgeons’ experiences and patients’ situation.