Randomized clinical trial of laparoscopic versus open inguinal hernia repair

BACKGROUND: Several studies have suggested that better results are obtained after laparoscopic repair of inguinal hernia than after conventional operation. This is most obvious for bilateral and recurrent hernias but less accepted for primary unilateral hernias. METHODS: This was a randomized clinical trial comparing transabdominal preperitoneal laparoscopic repair with the Shouldice technique in patients with primary unilateral hernia. Some 138 patients were randomized to laparoscopic hernia repair and 130 to open surgical repair. RESULTS: The complication rates in the two groups were similar. In the laparoscopic group the patients returned to work more rapidly with a median time of 13 versus 18 days (P < 0.005) and had a shorter period of analgesia intake with a median time of 2.1 versus 2.7 days (P < 0.02). The follow-up was 97.8 per cent complete. At a median of 12 months, four recurrences (2.9 per cent) were detected in the laparoscopic group and three (2.3 per cent) in the open group. CONCLUSION: This study shows that in patients with a primary unilateral hernia laparoscopic repair results in less postoperative pain and a quicker recovery than open repair.     

Prospective evaluation of 6895 groin hernia repairs in women

BACKGROUND: Although 8 per cent of groin hernia repairs are performed in women, there is little published literature relating specifically to women. This study compared differences in outcome between women and men after groin hernia repair. METHODS: Data collected prospectively in the Swedish Hernia Register between 1992 and 2003 were analysed, including 6895 groin hernia repairs in women and 83 753 in men. RESULTS: A higher proportion of emergency operations was carried out in women (16.9 per cent) than men (5.0 per cent), leading to bowel resection in 16.6 and 5.6 per cent respectively. During reoperation femoral hernias were found in 41.6 per cent of the women who were diagnosed with a direct or indirect inguinal hernia at the primary operation. The corresponding proportion for men was 4.6 per cent. The hernia repair was not classified as a standard operation (e.g. Shouldice, Lichtenstein, Plug/Mesh, TAPP/TEP) in 38.2 per cent of women and 11.2 per cent of men. Women had a significantly higher risk of reoperation for recurrence than men, and techniques associated with the lowest risk for reoperation in men had the highest risk in women. CONCLUSION: A greater proportion of women than men require emergency groin hernia repair, with consequently higher rates of bowel resection, complications and death. Surgical techniques developed for use in men may put women at unnecessary risk.     

Re-recurrence after operation for recurrent inguinal hernia. A nationwide 8-year follow-up study on the role of type of repair

OBJECTIVES: We analyze, on a nationwide basis, the risk of re-reoperation with reference to previous inguinal hernia repair technique. SUMMARY BACKGROUND DATA: Operation for a recurrent inguinal hernia is common and the risk of re-recurrence is high. There are no large-scale data evaluating the surgical strategy and results after recurrent inguinal hernia repairs. METHODS: Prospective recording of all primary and subsequent recurrent inguinal hernia repairs from January 1, 1998 to December 31, 2005, in the national Danish Hernia Database, using the reoperation rate as a proxy for recurrence. The re-reoperation rate was analyzed with reference to the technique of primary and recurrent inguinal hernia repair. RESULTS: After 67,306 primary hernia repairs there were 2117 reoperations (3.1%) and 187 re-reoperations (8.8%). The cumulated re-reoperation rate after primary Lichtenstein repair (n = 1124) was significantly reduced after laparoscopic operation for recurrence (1.3% (95% CI: 0.4-3.0)) compared with open repairs for recurrence (Lichtenstein 11.3% (8.2-15.2), nonmesh 19.2% (14.0-25.4), mesh (non-Lichtenstein) 7.2% (4.0 - 11.8)). After primary nonmesh (n = 616), non-Lichtenstein mesh (n = 277), and laparoscopic repair (n = 100) there was no significant difference in re-reoperation rates between a laparoscopic repair and all open techniques of repair for recurrence. CONCLUSION: Laparoscopic repair is recommended for reoperation of a recurrence after primary open Lichtenstein repair.     

Randomized clinical trial of Lichtenstein's operation versus mesh plug for inguinal hernia repair

BACKGROUND: Two of the most commonly used open prosthetic tension-free techniques for inguinal hernia repair are Lichtenstein's operation and the mesh plug repair. The technique of choice remains a subject of ongoing debate. The objective of the present investigation was to compare the two surgical procedures with respect to associated morbidity and recurrence rates. METHODS: Five hundred and ninety-five patients with 700 primary or recurrent inguinal hernias were randomized to undergo either Lichtenstein's operation or mesh plug repair. The primary endpoint of the investigation was the recurrence rate 1 year after surgery. Secondary endpoints were perioperative complications and reoperation rates. RESULTS: At 12-month follow-up, 597 hernia repairs (85.3 per cent) were evaluated. There were no significant differences regarding recurrence rates and perioperative complications. However, there was a significant difference in the overall reoperation rate between the two treatment groups, with 13 reoperations (4.2 per cent) in the Lichtenstein group and four (1.4 per cent) in the mesh plug group (P = 0.047). CONCLUSION: Lichtenstein's operation and the mesh plug repair are comparable with respect to perioperative complications and recurrence rates.     

Risk of recurrence 5 years or more after primary Lichtenstein mesh and sutured inguinal hernia repair

BACKGROUND: The risk of recurrence of inguinal hernia within 5 years of repair is lower after mesh than sutured repair in men, but no large-scale studies have compared the risk of recurrence beyond 5 years. METHODS: The Danish Hernia Database prospectively collects data on almost all primary inguinal hernia repairs in men (older than 18 years). This study used data recorded over 8 years, analysing reoperations for recurrent hernia in the intervals 0-30 months, 30-60 months and 60-96 months after operation. RESULTS: The reoperation rate was significantly lower after Lichtenstein open mesh repairs than open sutured repairs (Cox hazard ratio (HR) 0.45 (95 per cent confidence interval (c.i.) 0.39 to 0.51) for 0-30 months after surgery; HR 0.38 (95 per cent c.i. 0.29 to 0.49) for 30-60 months). In 13 674 primary inguinal hernia repairs with an observation interval of 5 years or more, the risk of reoperation after Lichtenstein repair was a quarter of that after sutured repair (HR 0.25 (95 per cent c.i. 0.16 to 0.40) for 60-96 months after surgery). After 5 years, the reoperation rate increased continuously after sutured repair but not after mesh repair. CONCLUSION: Lichtenstein mesh repair for inguinal hernia prevented recurrence beyond 5 years after the primary operation, but sutured repair did not.     

Recurrences after prosthetic repair of inguinal hernias by the lichtenstein technique

Summary We report a 3.4% incidence of hernial recurrence (all recurrences were reoperated) after inguinal hernia repair by the Lichtenstein technique: 14 reoperated recurrences (in 13 patients) in a series of 440 inguinal hernias (375 primary and 65 recurrent) in 379 patients (62 bilateral) over 5 years (1994–1998). Some 2/3 of all recurrences appeared within a year of surgery. Eleven of these patients were operated on for bilateral and/or recurrent groin hernia, and eleven also showed at least one risk factor for recurrence, such as obesity and other general diseases (specially pulmonary and hepatic). The incidence of recurrence was 0.7% (2 in 272) for primary unilateral hernia, 3.8% for primary bilateral hernia (2 in 52), 11.1% for recurrent unilateral hernia (5 in 45) and 40% for recurrent bilateral hernia (4 in 10). Recurrences were 5 indirect hernias, 4 direct hernias and 5 femoral hernias. Indirect recurrence was attributed to technical errors, but femoral and direct hernias seem to be the consequence of a poor indication for the Lichtenstein technique. Log-rank tests showed very significant statistical differences (p<0.01) in the risk of hernial recurrence between recurrent and primary hernias. We suggest that certain conditions should be contraindications for the standard Lichtenstein technique (bilateral groin hernia, recurrent hernia, obesity, chronic pulmonary and liver disease), and propose for these either a preperitoneal repair or some modifications of the Lichtenstein technique (an extremely floppy mesh and simultaneous femoral repair with the mesh).     

Routine laparoscopic repair of primary unilateral inguinal hernias — a viable alternative in the Day Surgery Unit?

In September 2004 the NICE institute revised its guidelines on the management of primary inguinal hernias to include laparoscopic repair of unilateral hernias. While published trials have confirmed the equal efficacy of the two approaches, it is not clear what impact a switch to laparoscopic repairs would have on resources and patient throughput in a Day Surgery Unit. METHOD: All elective hernia repairs performed in a one-year period were considered. Data were obtained from operation notes, discharge summaries and out-patient records. Operating times are routinely documented in theatre. RESULTS: Of the 351 operations studied, 150 were performed laparoscopically predominantly by an extraperitoneal (TEP)approach. Six required conversion to an open procedure. There was no significant difference in operating times, total theatre time or recovery room times between the two groups (51 min, 75 min and 34 min for the laparoscopic group and 53 min, 74 min and 31 min for the open repair group). Among the laparoscopic repair group there were 48 bilateral hernias and 20 recurrent hernias while 190 of the 201 open repairs were for primary unilateral hernias. Rates of overnight stay and immediate complications were similar between the groups though haematoma was more common following open repair (7 vs 2). CONCLUSIONS: There is no difference in theatre times, immediate complication rates or rates of overnight stay between open and laparoscopic repair of inguinal hernia. Routine laparoscopic repair of primary unilateral inguinal hernia is a viable alternative within the Day Surgery Unit.     

Day-case laparoscopic hernia repair in a single unit

BACKGROUND: Laparoscopic groin hernia repair has been shown to be a safe, well-tolerated procedure. Here, we report a series of patients who underwent laparoscopic transabdominal preperitoneal (TAPP) mesh repair as day cases. RESULTS: We performed 984 repairs on 769 patients, 218 had bilateral repairs. Mean operating time was 25 min for unilateral and 38 min for bilateral repairs. Three were converted, and 39 required admission. Five were readmitted more than 48 h postoperatively. Three required reoperation for small bowel obstruction from herniation through a peritoneal defect. Only 57% of patients required analgesia for a mean of 1.9 days after discharge. Recovery times were similar for unilateral and bilateral herniae. Eight hernias have recurred to date. CONCLUSIONS: Laparoscopic hernia repair is suitable for day-case surgery for unilateral, bilateral, and recurrent herniae. TAPP repair allows inspection of the contralateral groin, with repair of defects as necessary.     

Surgical approach for recurrent inguinal hernias: a Nationwide Cohort Study

Purpose

Guidelines recommend that the reoperation of a recurrent inguinal hernia should be by the opposite approach (anterior–posterior) than the primary repair. However, the level of evidence supporting the guidelines is partially low. The purpose of this study was to compare re-reoperation rates between repairs performed according to the guidelines with the ones performed against it.

Methods

This cohort study was based on the Danish Hernia Database, including 4344 patients with two inguinal hernia repairs in the same groin. Four groups were compared as follows: Lichtenstein–Lichtenstein vs. Lichtenstein–Laparoscopy, and Laparoscopy–Laparoscopy vs. Laparoscopy–Lichtenstein. The outcome was re-reoperation rates, which were compared by crude rates, cumulated rates, and hazard ratios.

Results

There was no difference in the re-reoperation rates when the primary repair was laparoscopic, regardless of the type of reoperation. However, Lichtenstein–Lichtenstein had a significantly higher re-reoperation rate compared with Lichtenstein–Laparoscopy (crude rate 8.7 vs. 3.1 %, p value <0.0005; Hazard Ratio 2.46, 95 % CI 1.76–3.43). Further analysis showed that the higher risk of re-reoperation for Lichtenstein–Lichtenstein was only seen if the primary hernia was medial.

Conclusions

A primary Lichtenstein repair of a primary medial hernia should be reoperated with a laparoscopic repair. A primary Lichtenstein repair of a primary lateral hernia can be reoperated with either a Lichtenstein or a laparoscopic repair according to surgeon’s choice. For a primary laparoscopic operation, the method of repair of a recurrent hernia did not affect the re-reoperation rate.

     

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??Groin hernia repair in young males: mesh or sutured repair? Bisgaard T*,Bay-Nielsen M,Kehlet H. *Department of Surgery, Køge Sygehus, Køge, Denmark
Corresponding author: Bisgaard T,e-mail:thuebisgaard@tdcadsl.dk
Abstract Objective Large-scale data for the optimal inguinal hernia repair in younger men with an indirect hernia is not available. We analysed nationwide data for risk of reoperation in younger men after a primary repair using a Lichtenstein operation or a conventional non-mesh hernia repair. Methods Prospective recording of all inguinal hernia repairs from 1 January 1998 to 31 December 2005 in the national Danish Hernia Database, using reoperation rate as a proxy for recurrence. We included only men between the age of 18 and 30 years with a primary repair of a primary indirect inguinal hernia. Results A primary sutured repair was performed in 1,120 men (median age 23 years, range 18-30) and a Lichtenstein mesh repair in 2,061 young men (24 years, range 18-30) (total 3,181 patients). The observation time after conventional hernia repair was median 62 months (range 0-96) and 41 months (range 0-96) after a Lichtenstein repair. The cumulative incidence of reoperation at 5 years was 1.6% (Lichtenstein) versus 3.9% (sutured repair), while overall reoperation rates were almost three-fold as high after a sutured repair (39 reoperations, overall reoperation rate = 3.5%) compared to a Lichtenstein repair (24 reoperations, overall reoperation rate=1.2%;P=0.0003). Conclusion Lichtenstein repair for an indirect inguinal hernia reduces the risk of recurrence in young men between the age of 18 and 30 years compared with a sutured repair. The use of a Lichtenstein mesh repair in young males must be balanced against the risk of chronic pain.     

Complex inguinal hernia repairs

Introduction  Complex inguinal hernia treatment is a challenge for general surgeons. The gold standard for the repair of inguinal hernias is the Lichtenstein repair (anterior approach). However, when multiple recurrent hernias or giant hernias are present, it is necessary to choose different approaches because the incidence of poor results increases. There are many preperitoneal approaches described in the literature. For example: (a) open procedure—Nyhus and Stoppa (b) laparoscopic technique—transabdominal pre-peritoneal (TAPP) and totally extraperitoneal (TEP). In this study, we show how we repair complicated cases using open access in huge unilateral or bilateral, recurrent, or multiple recurrent inguinal hernias. Methods  The present study includes the period from November 1993 through December 2007. One hundred and eighty-eight patients, divided into 121 with unilateral hernias and 67 with bilateral hernias, totaling 255 inguinal hernia repairs, were treated by the Nyhus or Stoppa preperitoneal approach, depending on whether they were unilateral or bilateral. We used progressive preoperative pneumoperitoneum for oversize inguinal hernias in all patients. Results  Orchiectomy was necessary on only two occasions. Despite the repair complexity involved, we had only two known recurrences. The mortality was zero and the morbidity was acceptable. Conclusions  We conclude that an accurate open preperitoneal approach using mesh prosthesis for complex inguinal hernias is safe, with very low recurrent rates and low morbidity. Progressive preoperative pneumoperitoneum for giant hernias was shown to be an important factor in accomplishing good intraoperative and immediate postoperative results.     

Randomized clinical trial of Lichtenstein patch or Prolene Hernia System for inguinal hernia repair

BACKGROUND: In this randomized prospective study the short- and long-term outcomes of patients undergoing inguinal hernia repair with either Lichtenstein mesh or the Prolene Hernia System (PHS) were evaluated. METHODS: Postoperative pain and time to return to work, driving and sporting hobbies were recorded after 300 inguinal hernia repairs done by one of the two methods. Long-term sequelae and complications were assessed at follow-up visits 1 week, 1 month and 1 year after the operation. RESULTS: The median duration of operation for unilateral primary hernia was 37 min for the Lichtenstein operation and 27 min for the PHS procedure (P < 0.001). Postoperative pain was similar after both operations. Median sick leave was 7 days in both groups. Time to driving a car was 4 versus 3 days, and time to return to sporting hobbies 13 versus 11 days, in the Lichtenstein and PHS groups, respectively. Apart from a residual femoral hernia after Lichtenstein repair, no recurrent inguinal hernias were detected. CONCLUSION: Both Lichtenstein and PHS methods resulted in rapid recovery and low recurrence rates. The PHS operation was significantly quicker.     

Outcome of repair of bilateral groin hernias: a prospective evaluation of 1,487 patients.

OBJECTIVE: To find out whether simultaneous repair of bilateral hernias increases the risk of recurrence compared with unilateral repair. DESIGN: Prospective study. SETTING: Swedish hospitals participating in the Swedish Hernia Register (SHR). Interventions: Prospective collection of data from the SHR, 1992-1999 inclusive. The Cox proportional hazard test was used for calculating odds ratio (OR). MAIN OUTCOME MEASURES: Hernia repairs were followed up in a life table fashion until re-operation for recurrence or death of the patient. RESULTS: 33416 unilateral and 1487 bilateral operations on 2974 groin hernias were found. Direct hernias were more common in the bilateral than in the unilateral group, 1,825, 61% compared with 13,336, 40%, (p < 0.0001). A laparoscopic method was used for 1774 (60%) of bilateral and 3285 (10%) unilateral repairs, and 455 bilateral operations (31%) were done as day cases compared with 18376 (55%) unilateral ones (p < 0.0001 for both comparisons). The cumulative incidence of reoperation at three years for groin hernias after bilateral and unilateral repair was 4.1% (95% confidence interval 3.1% to 5.1%) and 3.4% (95% Cl 3.1% to 3.7%, respectively. After adjustment for other risk factors, the OR for reoperation for recurrence after bilateral repair was 1.2 (95% CI 0.9 to 1.5) with unilateral repair as reference. The OR for reoperation after laparoscopic bilateral repair compared with open bilateral repair was 0.9 (95% CI 0.6 to 1.4). CONCLUSIONS: Simultaneous repair of bilateral hernias does not increase the risk of reoperation for recurrence and there is no significant difference in the risk of reoperation after bilateral repair using open or laparoscopic techniques.     

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.     

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.     

Randomized clinical trial of lightweight composite mesh for Lichtenstein inguinal hernia repair

BACKGROUND: Almost half the patients who undergo hernia repair with mesh report a feeling of stiffness and a foreign body in the groin. This study evaluated whether patients noticed any difference between lightweight and standard polypropylene mesh for the repair of inguinal hernia. METHODS: Patients scheduled for elective repair of unilateral or bilateral, primary or recurrent inguinal hernia by the Lichtenstein technique were randomized to receive either a conventional densely woven polypropylene mesh (100-110 g/m(2)) or a lightweight composite multifilament mesh (polypropylene 27-30 g/m(2)). Quality of life was assessed using Short Form 36 before operation and 6 months after surgery. Pain was assessed by means of a visual analogue scale 2 days and 6 months after surgery. The primary outcome measure was the feeling of a foreign body in the groin at 6 months. RESULTS: Some 122 hernias were randomized; 117 were included in the analysis of perioperative data, and 106 were re-examined after 6 months. There were no differences between the treatment groups with respect to early and late surgical complications. Use of lightweight mesh was associated with significantly less pain on exercise after 6 months (P = 0.042). In addition, fewer patients reported the feeling of a foreign body after repair with lightweight mesh (17.2 versus 43.8 per cent with conventional mesh; P = 0.003). Quality of life was improved significantly at 6 months compared with the preoperative assessment, and there were no differences between the treatment groups. CONCLUSION: Lightweight polypropylene mesh may be preferable for Lichtenstein repair of inguinal hernia. Larger cohorts with longer follow-up are needed before it can be recommended for routine use.     

Laparoscopic repair of inguinal hernias with higher risk for recurrence: independent assessment of results from 121 repairs

This study attempts to determine by independent review the results of laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair for hernias with increased risk for recurrence. Indicators used for increased recurrence risk were recurrent hernias or simultaneously repaired bilateral inguinal hernias. Office and hospital records of all such patients who had undergone TAPP repair were reviewed from one surgeon's 242-patient laparoscopic inguinal hernia database from 1992 to 1998. All were called for assessment by an independent surgeon at least 4 months postoperatively (median 34 months). Those unable to come in person were interviewed by telephone. There were 121 hernias: 34 recurrent and 100 bilateral (13 overlap). Recurrence rate was 3 per cent, which was similar for repair of bilateral and recurrent hernias. All recurrences occurred within 3 months of surgery. No unknown recurrence was detected by the independent observer. Laparoscopic TAPP inguinal hernia repair, often claimed as the method of choice for bilateral and recurrent hernia repair, is indeed a safe and effective procedure with a low early recurrent rate in these higher-risk situations.     

Laparoscopic inguinal hernia repair: optimal technical variations and results in 1700 cases

A follow-up series of 1700 laparoscopic inguinofemoral herniorrhaphies by a single surgical team is presented (1381 patients). Two standard techniques were used: transabdominal preperitoneal (1452 cases) and totally extraperitoneal (248 cases). Mean follow-up was 5.3 years. There were 348 patients with bilateral hernias, 121 with recurrent hernias, and 27 with incarcerated hernias. Numerous technical variations were used as the study progressed. A SurgiPro mesh (USSC, Norwalk, CT) with staple/tack fixation was used in all patients. Average operating time was 41 minutes for unilateral repairs, and 97.3 per cent of the procedures were outpatient procedures. Five recurrences were reported. The postoperative permanent neuropathy rate was found to be negligible, but a 5.1 per cent rate of uncomplicated ipsilateral postoperative seromas is reported. All patients were instructed to return to unrestricted physical activities on postoperative day one. Ninety per cent of the patients were able to do so within 5 days versus 93 per cent in 7 days. Ninety-six per cent of all patients felt minimal pain and discomfort after 72 hours. There was no significant difference in recovery or morbidity between the transabdominal preperitoneal and totally extraperitoneal repairs. To date laparoscopic inguinal herniorrhaphy continues to be a difficult procedure with a significant learning curve. The reported surgical performance data and the described optimal technical variations make this procedure a viable and competitive repair in the surgical management of inguinofemoral hernia.     

Total endoskopische präperitoneale Netzplastik bei primären und Rezidivleistenhernien Gibt es Unterschiede?

INTRODUCTION: Since 1994 we perform laparoscopic total extraperitoneal hernia repair (TEP) for primary and recurrent inguinal hernias at our institution. The aim of this study was to investigate and compare the results of TEP in primary inguinal hernias and recurrent inguinal hernias and to determine whether there are differences in patient data, complication rates and outcome between these two groups. METHODS: In a prospective trial 338 patients were analyzed who underwent 500 laparoscopic TEP repairs. In all, 431 TEP repairs were performed for primary inguinal hernias, and 69 for recurrent inguinal hernias. For data acquisition the SALTC study protocol was used. All patients were clinically examined 3 and 12 months after the operation. RESULTS: The mean operation time was 67.3 min for TEP repair of primary hernias and 68.1 min for TEP repair of recurrent hernias, respectively. The conversion rate to an open procedure was 0%. Conversion from TEP into TAPP was required in 0.5% of patients with primary inguinal hernias and 1.4% of patients with recurrent inguinal hernias. As the sole difference between the two groups the intraoperative complication rate could be identified. In the TEP repair group of recurrent inguinal hernias a higher incidence of injury to the peritoneum and a higher occurrence of bleeding from the epigastric vessels was found (P = 0.03). The postoperative complication rate was identical in the two groups, amounting to 5.1% and 5.7%, respectively. No differences were found in the 1 year follow-up between the two groups. The 1-year recurrence rate was 0.5% for primary hernias. However, in the group of recurrent hernias there have been no recurrences to date. CONCLUSIONS: The use of laparoscopic TEP repair has proven to be a safe and effective treatment in patients with primary and recurrent inguinal hernias. Because of scar tissue with possible adhesions a higher intraoperative complication rate was observed in the TEP repair of recurrent hernias than in TEP repair of primary inguinal hernias. However, no single recurrence was observed in the TEP repair group of recurrent hernias. In our opinion TEP is the optimal hernia repair for recurrent and bilateral inguinal hernias.     

Preperitoneal prosthetic inguinal herniorrhaphy without a relaxing incision

A consecutive series of 276 men had 317 inguinal hernias repaired by the preperitoneal approach. Of these, 162 (59 per cent) had 194 (61 per cent) “complete” repairs using Marlex prostheses. Fifty-five of 152 indirect hernias (36 per cent) were patched similarly. Seventeen of twenty-two mixed bilateral defects (77 per cent) had a prosthetic patch. Thirty-three of forty-eight repairs (68 per cent) for recurrent hernia in forty-five men also employed Marlex. Two patients died postoperatively. Four of 194 repairs using Marlex failed. These preliminary results indicate that the advantages of preperitoneal exposure can be complemented by an initially satisfactory technic of repair using a prosthesis instead of the classic relaxing incision, which is difficult to use with this posterior approach.