Stoppa procedure in bilateral inguinal hernia

The Stoppa procedure is a very safe repair of bilateral inguinal hernia, but it requires a learning period to achieve optimal results. We present a study with our experience and learning curve for this technique. Two hundred and ten patients with bilateral inguinal hernia (420 hernias) were repaired with Stoppa procedure from January 1995 to December 2003 with an average age of 57.2 years (range 28–89 years), with 8 women and 202 men (96%). Emergency surgery was performed for incarcerated hernia in six cases (2.8%). The rates of recurrent hernias, concomitant disease and associated surgical techniques were similar in all the years. Operative time decreased from 100 min (1995) to 61–66 min (2001–2003). Drain remained in place in 100% (1995), and 0% (2003). Regional anaesthesia was performed in 25% (1995) and 80–90% in the last years; hospital stay decreased from 5.1 to 1.2 days (2003), and morbidity from 50% (1995) to 12–16% (P<0.0001). There were three recurrences, two in the first 30 cases (6.6%), and one in the remaining 180 (0.5%) (4–92 months follow-up). The procedure was introduced in 1995 by one surgeon, performing 100% of cases, being accepted progressively by other surgeons. The first 25–30 cases of a surgical technique are the learning curve, with the highest rate of morbidity, time, technical and operative difficulties, and long hospital stay. As a result of the first surgeon’s experience, some modifications of the technique are developed and results improved.     

Femoral vessel blood flow dynamics following totally extraperitoneal vs Stoppa procedure in bilateral inguinal hernias

Background

Both totally extraperitoneal (TEP) and open preperitoneal (Stoppa) procedures involve the placement of prosthetic material preperitoneally. Because the prosthetic material overlies the femoral artery and vein, the aim of this study was to assess its effect on the velocities and diameters of the artery and vein using color Doppler ultrasonography in both approaches.

Methods

Sixty-four patients with bilateral groin hernias were prospectively randomized to undergo either TEP (n = 32) or Stoppa (n = 32) repair. All patients underwent color Doppler ultrasound 6 months after the procedures, and the median follow-up period was 18 months.

Results

Neither mean diameter nor mean flow velocity was changed by the insertion of the mesh preperitoneally. The only change was observed in peak systolic femoral arterial blood velocity, which was significantly decreased in the Stoppa group. Also, no patient in this study developed clinically significant deep venous thrombosis during 6 months of follow-up.

Conclusions

The insertion of a prosthetic mesh during TEP and Stoppa procedures does not influence the mean peak flow velocities and cross-sectional areas of the vessels in the inguinal region and can be used safely for open and laparoscopic preperitoneal approaches.     

The laparoscopic technique for bilateral inguinal hernias

From March 1994 to March 1999 359 laparoscopic hernioplasties have been performed on 295 patients. In 349 cases (97.2%) TAPP (transabdominal preperitoneal), in 10 cases (2.8%) TEP (total extraperitoneal) method was used for the treatment. In 64 cases (21.7%) bilateral hernias were operated using TAPP-method only. There were 15 hidden hernias and 14 recurrences on the contralateral side in this group. The hernial ring was covered with two smaller meshes or one bigger. There were no intraoperative complications. In 21 cases (32.8%) subcutaneous emphysema and in 3 cases (4.6%) sero-haematoma was developed. The emphysemas were solved spontaneously in 2-3 hours after the surgery. One haematoma was needed punction. The patients were discharged from the hospital on the second or third postoperative day. The authors found that the bilateral laparoscopic hernioplasty much more favourable for the patients.     

Comparison of Stoppa and Lichtenstein techniques in the repair of bilateral inguinal hernias

Summary The feasibility of tension-free repairs in bilateral inguinal hernias has not been well documented. In this prospective randomized study patients' characteristics, intra- and postoperative parameters including pain, return to daily activity and work, were assessed in patients undergoing bilateral hernia repair by means of either the Stoppa or the Lichtenstein techniques. A total of 45 patients having bilateral inguinal hernia repairs were randomly assigned to one of the two treatment groups. Patients in Group I had operations with the simultaneous Lichtenstein technique (n23) and were further randomized to either spinal (n11) or local anesthesia (n12) subgroups. Those in Group II underwent a Stoppa hernioplasty (n22). Complications and recurrences were sought for two years postoperatively. Patients with bilateral Lichtenstein repairs under local anesthesia had lower pain scores at rest and leg-raising test, and returned to pain-free normal daily activity and work on the 15th and 30th days, respectively. Although smaller than those of other groups, none of these parameters were statistically significant. The only prominent difference was seen in the operating time. The Stoppa repair took significantly less time than the Lichtenstein repairs (51 vs. 65 min, p < 0.01). In this study we were unable to demonstrate the superiority of either technique or type of anesthesia used in the repair of bilateral hernias. Both techniques were capable of producing favorable postoperative results, and were well accepted by most of the patients.     

Historical overview of the bilateral approach to pediatric inguinal hernias

An historical overview of the treatment of pediatric inguinal hernias has been presented, including changing methods of repair, discussion of the bilateral approach, and a condensation of requested responses from 80 recognized authorities in various centers. Prospective analysis of 440 personal cases is presented. The patent processus and its relationship to clinical hernia have been discussed. Contralateral exploration is favored under controlled circumstances. The decreased danger of incarceration in these instances has been evaluated and separate second procedures can be avoided. Basic requirements of training for treating pediatric hernias, particularly those in the very young patient, are suggested in accordance with my philosophy which is shared with the majority of pediatric surgeons as a group.     

改良Stoppa入路手术治疗双侧耻骨支骨折

目的:探讨改良Stoppa入路手术治疗骨盆双侧耻骨支骨折的临床疗效。方法:自2010年1月至2014年1月,采用改良Stoppa入路手术治疗双侧耻骨支骨折患者16例,其中男11例,女5例;年龄17～59岁,平均40.5岁。按Tile骨折分类法:A型8例,B型6例,C型2例。16例中单独使用改良Stoppa入路11例,联合髂窝入路4例,联合后路1例。观察患者的手术切口长度、手术时间、术中出血量及术后并发症情况,并采用Matta影像学骨折复位评价标准和Majeed功能评分系统对骨折复位及术后功能进行评价。结果:改良Stoppa手术入路切口长度为8～10 cm,平均9 cm;手术时间75～135 min,平均95 min;术中出血量400～900 ml,平均600 ml.16例术后均获随访,时间7～18个月,平均12.5个月。所有患者获骨性愈合,愈合时间2.7～5个月,平均3.1个月。术后无伤口化脓感染、异位骨化,无螺钉松动、钢板断裂,无腹壁疝发生。根据Matta影像学骨折复位标准,耻骨支骨折复位优9例,良6例,可1例。术后6个月Majeed功能评分,总分85.32±8.50,其中优8例,良6例,一般2例。结论:改良Stoppa手术入路具有切口方便直接、手术视野清晰、易于复位、并发症少和恢复快等特点,是治疗双侧耻骨支骨折一个理想的手术入路。     

Simultaneous repair of bilateral inguinal hernias: a prospective, randomized study of open, tension-free versus laparoscopic approach

No randomized trial exists that specifically addresses the issue of laparoscopic bilateral inguinal hernia repair. The purpose of the present prospective, randomized, controlled, clinical study was to assess short- and long-term results when comparing simultaneous bilateral hernia repair by an open, tension-free anterior approach with laparoscopic "bikini mesh" posterior repair. Forty-three low-risk male patients with bilateral primary inguinal hernia were randomly assigned to undergo either laparoscopic preperitoneal "bikini mesh" hernia repair (TAPP) or open Lichtenstein hernioplasty. There was no difference in operating time between the two groups. The mean cost of laparoscopic hernioplasty was higher (P < 0.001). The intensity of postoperative pain was greater in the open hernia repair group at 24 hours, 48 hours, and 7 days after surgery (P < 0.001), with a greater consumption of pain medication among these patients (P < 0.05). The median time to return to work was 30 days for the open hernia repair group and 16 days for the laparoscopic "bikini mesh" repair group (P < 0.05). Only 1 asymptomatic recurrence (4.3%) was discovered in the open group. The laparoscopic approach to bilateral hernia with "bikini mesh" appears to be preferable to the open Lichtenstein tension-free hernioplasty in terms of the postoperative quality of life and interruption of occupational activity.     

Repeated laparoscopic treatment of recurrent inguinal hernias after previous posterior repair

Background

The reported recurrence rates after laparoscopic inguinal hernia repair are 0–4 %. It is unclear which technique could best be offered to a patient with a recurrent hernia after a previous posterior repair. The purpose of this retrospective study was to determine the safety, feasibility, and reliability of a repeated laparoscopic repair (TAPP) for a recurrent hernia after a previous posterior inguinal hernia repair.

Methods

The study group contains 2,594 consecutive transabdominal inguinal hernia repairs (TAPP). Of these, 53 repairs were attempted in 51 patients for recurrent hernias after a previous posterior repair. During the follow-up period, patients were examined for recurrences and for presence of a port-site hernia. Pain was scored by the visual analogue pain scale (VAS).

Results

Fifty-one patients underwent a TAPP repair for a recurrent inguinal hernia after previous posterior hernia repair. Two patients presented a bilateral recurrent inguinal hernia. In two thirds of the patients, the recurrence was located caudally or medially from the previously placed mesh. Two attempted repairs had to be converted to an open technique due to severe adhesions. One intraoperative complication was encountered when the vas deferens was ligated during surgery due to adhesions of the previous placed mesh. Nine patients encountered an adverse event postoperatively, but none of them were serious events. No mesh infections were reported. The mean follow-up was 70 (range, 1–198) months. At follow-up, no recurrences were found at physical examination. Four patients developed a port-site hernia. Four patients had complaints of postoperative pain and were restricted in daily activities due to groin pain. The mean VAS score (scale 0–100), including the four patients with persistent pain, was 5.7 (range, 0–61).

Conclusions

It is concluded that repeated laparoscopic hernia repair (TAPP) is a definite repair for recurrent inguinal hernias. The procedure is feasible, safe, and reliable.     

Laparoscopic repair of bilateral spigelian and inguinal hernias

Spigelian hernias are rare and difficult to diagnose. Treatment has previously been limited to open surgical repair. We report the successful laparoscopic repair of bilateral spigelian and inguinal hernias using mesh. Received: 14 January 1997/Accepted: 11 April 1997     

开放式双侧腹股沟疝腹膜前修补术防治血清肿的临床研究

目的放式双侧腹股沟疝腹膜前修补术后血清肿对患者的影响及其防治。方法对2008年4月至2010年6月我院收治的43例双侧腹股沟疝患者随机分为治疗组和对照组分别行开放式腹膜前修补术。治疗组术中于腹膜前间隙放置引流管,对照组术中不放置引流管,分别观察、统计治疗组腹膜前间隙引流液性状、引流量及术后两组病例的体温、切口愈合情况、住院时间等指标,分析讨论术区血清肿对患者的影响及治疗组中血清肿的防治效果。结果治疗组和对照组病例比较,术后体温情况、住院时间、切口愈合情况等方面均有统计学差异（P〈0．05）,其中住院时间有显著性的差异（P〈0．01）,而术后异物感、紧缩感、疝复发、疼痛程度方面的比较无统计学差异（P〉0．05）。结论双侧腹股沟疝行开放式腹膜前疝修补术,术中留置腹膜前间隙引流管可防治腹股沟区血清肿形成及预防因血清肿可能引起的切口愈合不良等。     

Comparison of quality-of-life outcomes of Stoppa vs bilateral Lichtenstein procedure

Hernia repair is one of the most frequent procedures in surgery. The aim of this study is to compare the early and long-term health status and clinical outcomes of patients in the postoperative period of Stoppa and bilateral Lichtenstein hernia repair in bilateral groin hernias. The Stoppa group consisted of 22 patients, and the bilateral Lichtenstein group had 23 patients. Both groups were similar with respect to age, gender, ASA score, and postoperative follow-up periods. A multidimensional measure of health status, the Short Form-36 (SF-36), was administered at 15 days and 6 months postoperatively. Although there is no difference between the two groups in the early postoperative period, three of eight health concepts measured with SF-36 (physical functioning, role limitation-physical, general health perception) showed a significant difference in long-term health status. We conclude that long-term quality of life following Stoppa operations is superior to bilateral Lichtenstein hernia repair in bilateral groin hernias.     

腹股沟疝的腹膜前修补

腹股沟疝的腹膜前修补术（preperitoneal approach repair of inguinal hernias）也称之为后进路修补（posterior approach repair）手术,是指手术进路经由腹直肌后（非传统术式经腹股沟管的前入路途径）直接进入腹膜前间隙（Bogros间隙）,不打开腹股沟管,不强调游离精索;修补的理念和方法主要强调覆盖髂耻束和耻骨梳韧带等耻骨肌孔结构;可选用单层网片修补（不需网塞）。代表现代微创外科技术进展的腹腔镜疝修补即是一种后人路的无张力修补技术。它是应用网片在疝和腹壁缺损之间进行修补。腹膜前修补是近年来疝外科研究中较为热点的手术方法。本文仅就此作一阐述。     

Postoperative pulmonary dysfunction after bilateral inguinal hernia repair: a prospective randomized study comparing the Stoppa procedure with laparoscopic total extraperitoneal repair (TEPP)

The infraumbilical incision required for open repair of bilateral inguinal hernia with a giant prosthesis is associated with postoperative pain and respiratory impairment. The aim of this study was to evaluate the postoperative respiratory dysfunction after bilateral hernia surgery. Thirty-nine patients were randomized into two groups: open repair according to the Stoppa technique and laparoscopic extraperitoneal repair (TEPP). Respiratory function tests were performed before and 24 hours after surgery. The two groups were well matched for age, American Society of Anesthesiologists (ASA) risk score, type of hernia, and preoperative lung function. The postoperative forced vital capacity (FVC), peak expiratory flow (PEF), and forced expiratory volume in 1 second (FEV 1.0) were significantly altered in both groups. The PEF dropped 15% in both groups. The FVC dropped 22% after Stoppa versus 25% after laparoscopy (P = 0.7). The FEV 1.0 dropped 21% after Stoppa versus 9% after laparoscopy (P = 0.12). We conclude that laparoscopic preperitoneal and open bilateral hernia repair are followed by similar ventilatory dysfunction, although a trend toward better postoperative FEV 1.0 was noted after laparoscopy. This might play a role in selected patients with severe pulmonary limitations. Overall, the limited drop in pulmonary function following bilateral hernia repair under general anesthesia may serve to explain the low pulmonary morbidity that follows these procedures.     

Surgical treatment of inguinal hernias

Experience with 1633 surgeries performed in 1592 patients with inguinal hernia is analyzed. In the first period (1979-1987) choice of plastic surgery was empirical, recurrences were diagnosed in 19.6% of examined patients. In the second period (1988-1993) anterior wall was strengthened in simple inguinal hernias, posterior wall -- in difficult, recurrences were seen in 4.9%. In the third period (1994-2000) strengthening of the posterior wall with fascial-aponeurotic methods was performed in all types of hernias. Choice of the method depended on height of inguinal space. Recurrences were diagnosed in 0.5% of examined patients.     

Long-term recurrence after laparoscopic surgery of inguinal hernias

Laparoscopic treatment of inguinal hernias has expanded rapidly during the last decade. Several studies have evaluated the early results of this technique, and the rate of recurrence was estimated less than 5% with a range from 0.5% to 10%. The long-term recurrence after such treatment is still not well known. This study reports the 2 year follow-up of laparoscopic treatment of 236 inguinal hernias (220 patients) from January 1996 to December 1997. All patients were contacted by telephone, 196 (90%) (193 men and 3 women) were examined by a senior surgeon. The average time from operation to examination was 34 months (range 20–42 months). We observed a 15% recurrence rate (35 hernias in 34 patients) of which 5% (12 cases) were symptomatic but 10% (23 cases) were totally asymptomatic and diagnosed on clinical examination. The postoperative inguinal haematoma and the physical activity of the patients seem to predispose the recurrence. Chronic pain was rarely observed in this study. Electronic Publication     

Method of inguinal hernias treatment

New pathogenetically substantiated method of operative treatment for complicated inguinal hernias has been developed by the author (patent R.F. No 2007128) and used in clinical practice. It provides to restore anatomo-topographic and functional parameters of the inguinal channel, to eliminate traumatic effect of the operation and to decrease the risk of recurrence of the disease. The method consists in correction of the walls of the inguinal channel by (-shaped goffered sutures from polymerous monothreads, on which frame a reliable regenerate connective tissue is being developed. This method was used in 97 patients with large complicated inguinal hernias. 1-5 year follow-up results has been studied. There were no relapses of the disease. By virtue of the simplicity of this method and its efficacy it is accessible for great majority of surgeons.     

Laparoscopic diagnosis and repair of asymptomatic bilateral inguinal hernias

BACKGROUND: This study was designed to investigate age, sex, and side of hernia presentation at clinical examination as potential intrinsic risk factors for bilateral inguinal hernia (BIH), and to quantify the characteristics of clinical examination versus laparoscopy as a diagnostic tool for BIH. METHODS: A cross-sectional study was utilized to analyze 99 consecutive patients undergoing laparoscopic inguinal hernia repair. RESULTS: The incidence of BIH based on clinical examination alone was 49%, compared with 71% laparoscopically. Clinical examination of BIH resulted in 69% sensitivity, 100% specificity, 100% predictive value for bilateral diagnosis, and 57% predictive value for unilateral diagnosis. Left hernia presentation at clinical examination (prevalence rate ratio = 10.5, 95% confidence interval: 3.6 to 30.7) and male sex (prevalence rate ratio = 6.6, 95% confidence interval: 1.3 to 35.0) were found to be independent risk factors for BIH. CONCLUSIONS: Laparoscopy yields detection of BIH that would be missed by clinical examination alone. Furthermore, left-sided hernia and male sex were associated with BIH.