免补片法腹腔镜腹股沟疝修补术

目的 探讨免补片法腹腔镜下腹股沟疝修补的有效性.方法 回顾分析广东省第二人民医院2001年1月至2004年3月,应用腹腔镜免补片法治疗92例腹股沟疝的手术后恢复情况及随访结果,并与同期91例腹腔镜完全腹膜外疝修补手术(totally extraperitoneal laparoscopichemioplasty,TEP)的结果相比较.结果 免补片组与TEP组手术时间分别为(21±4)min与(70±16)min(t=28.01,P<0.05)、住院天数分别为(3.5±1.0)d与(4.8±1.2)d(t=7.96,P<0.05)、下床活动时间分别为(1.0±0.5)d与(1.8±0.7)d(t=8.90,P<0.05)、术后疼痛持续时间分别为(1.0±0.5)d与(2.5±0.7)d(t=16.69,P<0.05)、住院总费用分别为(4500±500)元与(8000±820)元(t=34.89,P<0.05),免补片组均明显优于TEP组,差异有统计学意义.免补片组无皮下血肿及阴囊水肿发生,TEP组皮下血肿8例(8.7%)(χ~2=6.48,P<0.05).免补片组与TEP组术后48h C-反应蛋白(CRP)分别为(3.9±0.3)mg/dl与(8.8±0.5)mg/dl(t=80.48,P<0.05).所有病例随访(56.9±6.2)个月,免补片组复发率为0,TEP组复发率为2.1%(χ~2=0.51,P>0.05).结论 腹腔镜免补片治疗腹股沟疝安全、可行,恢复快、住院时间短、费用少.     

Simultaneous bilateral laparoscopic inguinal hernia repair

BACKGROUND: We compare the use of unilateral and simultaneous bilateral laparoscopic hernioplasty [transabdominal preperitoneal patch (TAPP)] METHOD: We employed a prospective consecutive single-center trial lasting from April 1993 to December 2000. RESULTS: In our study, 5524 consecutive patients underwent 6860 laparoscopic hernia repairs. The median age in group A (unilateral repair, n = 4188) was 58 years (16-94 years), and that in group B (simultaneous bilateral repair, n = 1336) was 60 years (19-97 years) in (simultaneous bilateral repair, n = 1336). Morbidity in group A was 3.2% (135/4188) with a 0.6% reoperation rate (24/4188); in group B morbidity was 5.0% (67/1336) with a 1.4% reoperation rate. (19/1336). Morbidity and reoperation rates showed no statistically significant difference between the two groups in relation to number of repairs in group B. After a median 24-month clinical follow-up period (1-84 months) (follow-up rate 93.1%) 38 recurrences were observed in group A (0.9%) and 17 in group B (0.6%; 17/2672) (p = 0.2668). Median time off work was 14 days after unilateral (2-63 days) and 17 days after bilateral repair (3-100 days) (p = 0.1359). Pain levels (numerical analogue scale) and incidence of persistent inguinal and scrotal pain are not higher after bilateral repair. CONCLUSION: Compared to unilateral repair, bilateral simultaneous laparoscopic hernia repair (TAPP) is safe, comfortable for patients, and cost-effective, without increased morbidity or recurrence risk. Bilateral inguinal hernia is an ideal indication for endoscopic transabdominal repair.     

Pseudo-recurrence after laparoscopic inguinal hernia repair

Aim-Background

Pseudo-recurrence after laparoscopic hernia repair, though known, is poorly understood. Common causes of pseudo-recurrence are pneumoscrotum, haematoma, seroma, cord thickening and persistent cough impulse.

Aim

To analyze the incidence of pseudo-recurrence and its impact on morbidity after laparoscopic inguinal hernia repair.

Methods

All laparoscopic inguinal hernia repair cases performed by a single surgical unit over a period of five years from April 2007 till March 2012 were retrospectively analyzed.

Results

Among 243 operated laparoscopic inguinal hernia repairs (TEP and TAPP) included in the study, twenty (8.26%) cases displayed a pneumoscrotum, eighteen (7.43%) a haematoma, twenty-four (9.98%) a seroma, eight (3.29%) cord thickening, and six (2.46%) persistent cough impulse. All patients were managed conservatively with the exception of one case of seroma which had to be aspirated.

Conclusion

Pseudo-recurrence following laparoscopic inguinal hernia repair, though common, has no significant impact on morbidity. Recognition of the problem is important to continue conservative management and avoid intervention.

     

腹腔镜腹股沟疝修补与开放性腹股沟疝修补的疗效对比研究

【摘要】〓目的〓比较腹腔镜腹股沟疝修补与开放性腹股沟疝修补的优缺点。方法 对2012年5月~2013年5月中山市中医院240例成人腹股沟疝修补术进行回顾性分析,其中开放性疝修补术(开腹疝修补组)148例,腹腔镜疝修补术(腔镜疝修补组)92例。收集两组患者的手术时间、住院时间、住院费用、术后复发、术后慢性疼痛、术后阴囊积液及术后感染的临床资料并进行比较。 结果 开腹疝修补组患者在平均手术时间、平均住院费用少于腔镜疝修补(P均<0.01);开腹疝修补组术后复发(3例)、术后慢性疼痛(11例)、术后阴囊积液(2例)及术后感染(1例)等总并发症高于腔镜疝修补组(P<0.05);两组的平均住院时间差异无统计学意义。结论 腔镜组腹股沟疝修补术具有较少的术后并发症,但在住院时间、住院费用方面没有优势。     

Adhesions after laparoscopic inguinal hernia repair

Prosthetic mesh for laparoscopic inguinal hernia repair has become popular but the method of its placement is controversial. Mesh placed within the peritoneum may cause adhesion formation and further complications. The aim of this study was to examine the laparoscopic placement of a mesh, comparing intraperitoneal vs extraperitoneal insertion. In a porcine model (n=15) a polypropylene mesh was placed laparoscopically over the anterior abdominal wall. On the left side the mesh was stapled on the parietal peritoneum. On the right side the peritoneum was incised, an extraperitoneal space was dissected, the mesh was inserted, and the peritoneum was closed over it. The animals were maintained for 2 weeks. At postmortem there were adhesions in two of those placed extraperitoneally and five of those placed intraperitoneally (P=0.19, Fisher's exact test). The adhesions comprised fibrous peritoneal bands to loops of small intestine. Both methods of laparoscopic mesh placement were associated with a small but significant incidence of adhesion formation.Paper based on a communication to the European Association for Endoscopic Surgery in Cologne, Germany, June 1993     

腹腔镜腹股沟疝修补术的初期应用体会

目的:探讨初期开展腹腔镜腹股沟疝修补术的注意事项,术中、术后常见并发症及其处理措施。方法:回顾分析2012年10月至2013年5月为21例患者行腹腔镜腹股沟疝修补术的临床资料,其中19例行全腹膜外疝修补术(totally extraperitoneal,TEP),2例行经腹腹膜前疝修补术(transabdominal preperitoneal,TAPP)。结果:1例TEP患者中转行TAPP。手术时间TEP平均(92±41.38)min,TAPP平均(122±26.38)min,术中腹壁下血管损伤1例,腹膜撕裂5例,均无血清肿、内脏损伤、尿潴留及输精管损伤,未见切口及深部创面感染,术后未使用止痛剂。患者均于术后第1天恢复正常饮食并下床活动。患者术后第1、3、6个月获得电话随访,无腹股沟区慢性疼痛及复发。结论:熟悉、掌握腹腔镜下腹膜前间隙及其重要结构、选择合适的手术方式是避免腹腔镜腹股沟疝修补术中、术后并发症发生的关键。     

Single-incision laparoscopic herniorrhaphy for inguinal hernia repair

Purposes

Single-incision laparoscopic surgery improves the cosmetic outcome after surgery. We herein report six cases of successful single-incision laparoscopic (SILS) herniorrhaphy.

Methods

Six patients, five with unilateral inguinal hernias and one with bilateral inguinal hernias, underwent SILS herniorrhaphy. A Covidien SILS port was inserted via an umbilical incision, through which three trocars of 5, 5 and 12 mm (or 5 mm) were inserted. The peritoneum was then opened with flexible scissors and electrocoagulation, after which, the preperitoneal space was dissected. A mesh was then fixed, and the peritoneum was finally closed using Covidien SILS Stitch or AbsorbaTack.

Results

The mean length of the operation for the unilateral cases was 136 min. The increased time was due to difficulties unrelated to this methodology. However, the length of the operation in the bilateral case was 94 min. All patients were discharged without complications.

Conclusions

SILS herniorrhaphy requires experience and more time than conventional three-port herniorrhaphy. However, if the length of the operation can be shortened, then this novel surgical technique is considered to be feasible and it is expected to improve the cosmetic outcome without any additional risk.     

腹腔镜治疗腹股沟疝的合理选择

腹腔镜腹股沟疝修补术（LIHR）是20世纪90年代初期发展起来的一项新技术，具有“微创”、“后入路”和“无张力”的特点，允许植入足够大的补片，并且符合“工程力学”的原理，其临床安全性、合理性、有效性通过前瞻性随机对照研究得到证实。2000年和2003年，Cochrane医学数据库两次公布了LIHR的系统评价和meta分析结果，均证明了LIHR具有复发率低、恢复正常活动时间快、术后疼痛轻、并发症发生率低于传统手术的特点.     

经济型完全腹膜外腹腔镜腹股沟疝修补术

目的探讨较经济的完全腹膜外腹腔镜腹股沟疝修补术（TEP）的可行性，总结经济型TEP的操作经验，为TEP的推广提供借鉴。方法回顾性分析我院2006年6月至2007年12月对23例腹股沟疝进行TEP的临床资料；采用连续硬膜外麻醉，免气囊扩张器建立腹膜外间隙，使用国产聚丙烯补片且不予钉合固定等系列降低手术成本的手术方法。结果23例腹股沟疝患者腹膜撕裂3例，中转开放手术2例，中转全麻1例（均发生于斜疝）；手术时间40～180min，平均住院5d，住院费用4500．00—5000．00元；术后无疼痛、血清肿、感染、疝复发等并发症发生。结论采用连续硬膜外麻醉，免气囊分离器，国产聚丙烯补片不予钉合固定的TEP是可行的，为其在基层医院的开展提供了借鉴作用。     

Adhesion formation in laparoscopic inguinal hernia repair

Background: In laparoscopic inguinal hernia repair controversy exists concerning the most appropriate repair method and implant material to use if intraabdominal adhesions are to be minimized. Methods. In 108 pigs, we implanted three different types of mesh by both the TAPP (transabdominal preperitoneal) and Onlay (prosthesis placed directly upon the peritoneum) methods. Specimens were harvested in three time periods and adhesion formation was compared. Results. Average adhesions at 3 days were TAPP 18% and Onlay 49% (p < 0.001). At 3 weeks average adhesions were TAPP 8% and Onlay 23% (p < 0.04). Three-month figures were TAPP 1% and Onlay 13% (p < 0.001). In contrast, there were no differences in adhesion formation due to material type in any of the three time periods (all p > 0.17). Conclusions: A peritoneal covering over a laparoscopic inguinal implant significantly reduced adhesions. Prosthetic material type did not affect adhesion formation in this study.     

Meralgia paraesthetica following laparoscopic inguinal hernia repair

Entrapment of the lateral cutaneous nerve of the thigh (LCNT) is a recognized complication of laparoscopic hernia repair. In our first 10 patients in a series of 30 laparoscopic herniorrhaphies we encountered two cases of meralgia paraesthetica, leading us to review our surgical technique and analyze the local anatomy in 20 LCNT cadaver dissections. The distances of the LCNT from fixed anatomical points were analyzed and safe margins of mesh placement at laparoscopic herniorrhaphy were defined.     

Pain characteristics after laparoscopic inguinal hernia repair

Background  

Previous studies have shown different pain characteristics in different types of laparoscopic operations, but pain pattern has not been studied in detail after laparoscopic inguinal hernia repair. To optimise preoperative patient information and postoperative analgesic treatment the present study investigated postoperative pain in terms of time course, pain intensity and individual pain components during the first 4 days after transabdominal preperitoneal hernia repair (TAPP).     

Tension-free laparoscopic versus open inguinal hernia repair

AIM: During the last decade laparoscopic techniques have been applied to the treatment of inguinal hernia to combine tension-free technique, esthetic, and functional benefits of mini-invasive surgery. Anyway controversy persists regarding the most effective inguinal hernia repair. The aim of this study is to compare the open technique and the laparoscopic approach concerning: complications, recurrences, recovery time and return to usual activity. METHODS: A randomized prospective analysis of 121 consecutive inguinal hernia repairs was performed over a 12-month period. Male well-informed patients with primary monolateral inguinal hernia (ASA I-II) were divided into 2 groups and consecutively treated; group A was treated with laparoscopic transabdominal preperitoneal approach (TAPP) (median age 47+/-7 years, 57 patients), group B with open mesh herniorrhaphy (45+/-6 years, 64 patients). RESULTS: Complication rate was 5.26% for group A (none needed conversion) and 4.68% for group B. All complications were considered minor. No recurrences were observed over a 12-month follow-up in both groups. Post-operative hospital stay and return to activity show statistically significant differences. Median post-hospital stay was 1.7 days for group A while it was longer (2.9 days) for group B. Significant difference was observed in the duration of convalescence too (group A 9.3+/-7.2 days; group B 12.1+/-7. 1 days). CONCLUSION: On the basis of our experience, even if a longer follow-up is needed, the validity of laparoscopic approach to inguinal hernia is confirmed. General anesthesia and higher costs are reasonable compromises for a shorter period of discomfort in patients with a low ASA index and busy job/sport activity.     

Intestinal obstruction after totally extraperitoneal laparoscopic inguinal hernia repair.

Laparoscopic hernia repair is a frequently performed operation. Although it has many advantages over open inguinal hernia repair, laparoscopic surgery is not without complications. Small bowel obstruction is a complication unique to laparoscopic repair of inguinal hernias. It is reported following transabdominal preperitoneal repairs. We present a case of small bowel incarceration through a peritoneal defect after a totally extraperitoneal inguinal hernia repair. Techniques to avoid this complication are presented. The literature is reviewed.     

Causes of recurrence in laparoscopic inguinal hernia repair

Purpose

Recurrence after laparoscopic inguinal herniorrhaphy is poorly understood. Reports suggest that up to 13% of all inguinal herniorrhaphies worldwide, irrespective of the approach, are repaired for recurrence. We aim to review the risk factors responsible for these recurrences in laparoscopic mesh techniques.

Methods

A search of the Medline, Embase, Science Citation Index, Current Contents and PubMed databases identified English language, peer reviewed articles on the causes of recurrence following laparoscopic mesh inguinal herniorrhaphy published between 1990 and 2018. The search terms included ‘Laparoscopic methods’, ‘Inguinal hernia; Mesh repair’, ‘Recurrence’, ‘Causes’, ‘Humans’.

Results

The literature revealed several contributing risk factors that were responsible for recurrence following laparoscopic mesh inguinal herniorrhaphy. These included modifiable and non-modifiable risk factors related to patient and surgical techniques.

Conclusions

Recurrence can occur at any stage following inguinal hernia surgery. Patients’ risk factors such as higher BMI, smoking, diabetes and postoperative surgical site infections increase the risk of recurrence and can be modified. Amongst the surgical factors, surgeon’s experience, larger mesh with better tissue overlap and careful surgical techniques to reduce the incidence of seroma or hematoma help reduce the recurrence rate. Other factors including type of mesh and fixation of mesh have not shown any difference in the incidence of recurrence. It is hoped that future randomized controlled trials will address some of these issues and initiate preoperative management strategies to modify some of these risk factors to lower the risk of recurrence following laparoscopic inguinal herniorrhaphy.