Conversion to Stoppa Procedure in Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair

Background and Objectives:

Conversion to open surgery is an important problem, especially during the learning curve of laparoscopic totally extraperitoneal (TEP) inguinal hernia repair.

Methods:

Here, we discuss conversion to the Stoppa procedure during laparoscopic TEP inguinal hernia repair. Outcomes of patients who underwent conversion to an open approach during laparoscopic TEP inguinal hernia repair between September 2004 and May 2010 were evaluated.

Results:

In total, 259 consecutive patients with 281 inguinal hernias underwent laparoscopic TEP inguinal hernia repair. Thirty-one hernia repairs (11%) were converted to open conventional surgical procedures. Twenty-eight of 31 laparoscopic TEP hernia repairs were converted to modified Stoppa procedures, because of technical difficulties. Three of these patients underwent Lichtenstein hernia repairs, because they had undergone previous surgeries.

Conclusion:

Stoppa is an easy and successful procedure used to solve problems during TEP hernia repair. The Lichtenstein procedure may be a suitable option in patients who have undergone previous operations, such as a radical prostatectomy.     

Retromuscular Preperitoneal Repair of Flank Hernias

Introduction

Flank hernias represent a challenging problem to reconstructive surgeons. Their anatomic proximity to the bony prominence and major neurovascular structures limits fixation options and restricts mesh overlap. We present our technique and outcomes of a preperitoneal repair with wide mesh overlap.

Methods

This study is a retrospective analysis of patients undergoing open flank hernia repair with a retromuscular preperitoneal approach.

Results

Between September 2007 and April 2011, 16 patients, mean age 55?years (range 34?C80) and BMI 33?kg/m² (range 26?C46), underwent open flank hernia repair. Eight were recurrent hernias; six previously had mesh placed; nine were incarcerated. Mean hernia defect size was 232?cm² (range 25?C800). Mean operative time was 178?min (range 105?C245). One intraoperative complication, ureteral injury in a transplant recipient, occurred and was primarily repaired without sequela. Two patients developed wound complications, one requiring superficial debridement and another requiring partial excision (<5?%) of the mesh with secondary healing. With a mean follow-up of 16.8?months (range 2?C49), no recurrent hernias were noted.

Conclusion

Open retromuscular preperitoneal repair of flank hernias with iliac bone fixation is technically feasible, allowing wide mesh overlap for a durable repair. This approach may offer advantages of treating abdominal wall laxity and repair of larger defects when compared to laparoscopic approaches.     

Female ‘groin’ hernia: totally extraperitoneal (TEP) endoscopic repair seems the most appropriate treatment modality

Background

About 30% of all female ‘groin’ hernias are femoral hernias, although often only diagnosed during surgery. A Lichtenstein repair though, as preferred treatment modality according to guidelines, would not diagnose and treat femoral hernias. Totally extraperitoneal (TEP) hernia repair, however, offers the advantage of being an appropriate modality for the diagnosis and subsequent treatment of both inguinal and femoral hernias. TEP therefore seems an appealing surgical technique for women with groin hernias.

Methods

This study included all female patients ≥18?years operated for a groin hernia between 2005 and 2009.

Results

A total of 183 groin hernias were repaired in 164 women. TEP was performed in 85% of women; the other 24 women underwent an open anterior (mesh) repair. Peroperatively, femoral hernias were observed in 23% of patients with primary hernias and 35% of patients with recurrent hernias. There were 30 cases (18.3%) of an incorrect preoperative diagnosis. Peroperatively, femoral hernias were observed in 17.3% of women who were diagnosed with an inguinal hernia before surgery. In addition, inguinal hernias were found in 24.0% of women who were diagnosed with a femoral hernia preoperatively. After a follow-up of 25?months, moderate to severe (VAS 4-10) postoperative pain was reported by 8 of 125 patients (6.4%) after TEP and 5 of 23 patients (21.7%) after open hernia repair (P?=?0.03). Five patients had a recurrent hernia, two following TEP (1.4%) and three following open anterior repair (12.5%, P?=?0.02). Two of these three patients presented with a femoral recurrence after a previous repair of an inguinal hernia.

Conclusion

Femoral hernias are common in women with groin hernias, but not always detected preoperatively; this argues for the use of a preperitoneal approach. TEP hernia repair combines the advantage of a peroperative diagnosis and subsequent appropriate treatment with the known good clinical outcomes.     

Two-stage laparoscopic treatment for strangulated inguinal,femoral and obturator hernias: totally extraperitoneal repair followed by intestinal resection assisted by intraperitoneal laparoscopic exploration

Purpose

Total extraperitoneal preperitoneal (TEP) repair is widely used for inguinal, femoral, or obturator hernia treatment. However, mesh repair is not often used for strangulated hernia treatment if intestinal resection is required because of the risk of postoperative mesh infection. Complete mesh repair is required for hernia treatment to prevent postoperative recurrence, particularly in patients with femoral or obturator hernia.

Cases

We treated four patients with inguinocrural and obturator hernias (a 72-year-old male with a right indirect inguinal hernia; an 83-year-old female with a right obturator hernia; and 86- and 82-year-old females with femoral hernias) via a two-stage laparoscopic surgery. All patients were diagnosed with intestinal obstruction due to strangulated hernia. First, the incarcerated small intestine was released and then laparoscopically resected. Further, 8–24 days after the first surgery, bilateral TEP repairs were performed in all patients; the postoperative course was uneventful in all patients, and they were discharged 5–10 days after TEP repair. At present, no hernia recurrence has been reported in any patient.

Conclusion

The two-stage laparoscopic treatment is safe for treatment of strangulated inguinal, femoral, and obturator hernias, and complete mesh repair via the TEP method can be performed in elderly patients to minimize the occurrence of mesh infection.

     

Transabdominal Preperitoneal Repair for Obturator Hernia

Background

A laparoscopic surgical approach for obturator hernia (OH) repair is uncommon. The aim of the present study was to assess the effectiveness of laparoscopic transabdominal preperitoneal (TAPP) repair for OH.

Methods

From 2001 to May 2010, 659 patients with inguinal hernia underwent TAPP repair at in our institutes. Among these, the eight patients with OH were the subjects of this study.

Results

Three of the eight patients were diagnosed as having occult OH, and the other five were diagnosed preoperatively, by ultrasonography and/or computed tomography, as having strangulated OH. Bilateral OH was found in five patients (63%), and combined groin hernias, either unilaterally or bilaterally, were observed in seven patients (88%), all of whom had femoral hernia. Of the five patients with bowel obstruction at presentation, four were determined not to require resection after assessment of the intestinal viability by laparoscopy. There was one case of conversion to a two-stage hernia repair performed to avoid mesh contamination: addition of mini-laparotomy, followed by extraction of the gangrenous intestine for resection and anastomosis with simple peritoneal closure of the hernia defect in the first stage, and a Kugel hernia repair in the second stage. There was no incidence of postoperative morbidity, mortality, or recurrence.

Conclusions

Because TAPP allows assessment of not only the entire groin area bilaterally but also simultaneous assessment of the viability of the incarcerated intestine with a minimum abdominal wall defect, we believe that it is an adequate approach to the treatment of both occult and acutely incarcerated OH. Two-stage hernia repair is technically feasible in patients requiring resection of the incarcerated intestine.     

The Incidence and Success of Treatment for Severe Chronic Groin Pain After Open, Transabdominal Preperitoneal, and Totally Extraperitoneal Hernia Repair

Background

Chronic groin pain (CGP) is a significant cause of postoperative morbidity after inguinal hernia repair. Open, transabdominal preperitoneal (TAPP), and totally extraperitoneal (TEP) repair are all commonly performed methods of herniorrhaphy. The aim of this study was to compare the frequency of attendance at a chronic pain clinic (CPC) for CGP after open, TAPP or TEP repair.

Methods

A retrospective review of all inguinal hernia repairs between January 1997 and December 2006 identified patients attending the CPC for CGP post-herniorrhaphy. In this study CGP post-herniorrhaphy was defined as pain that limited daily activities despite simple analgesia thereby requiring referral to the specialist CPC following surgical review.

Results

A total of 8513 patients underwent 9607 inguinal hernia repairs; 6497 (75.5%) were open, 1916 (22.3%) were TAPP, and 198 (2.3%) were TEP. Of these, 46 (0.71%) open, 22 (1.15%) TAPP, and 6 (3.03%) TEP repairs required attendance at CPC. A statistically significant difference in frequency of CPC attendance following laparoscopic versus open (P = 0.008), TEP versus open (P ≤ 0.001), and TEP versus TAPP repair (P = 0.027) was observed. After an average of 1 year, 69% of patients were discharged symptom-free from the CPC. In 16%, CGP resolved prior to CPC attendance.

Conclusions

In contrast to previous reports, laparoscopic hernia repair is associated with a greater frequency of attendance at CPC than open repair, a finding that merits further investigation. Of those requiring treatment, the majority were discharged pain-free after an average of 1 year.     

Endoscopic surgeons’ preferences for inguinal hernia repair: TEP, TAPP, or OPEN

Introduction

The use of endoscopic inguinal hernia repair has slowly increased in the past years, but the indications have remained vague. Some surgeons perform a tailored approach depending on patient or hernia characteristics, whereas others perform the same approach and technique for all hernias.

Methods

Based on these principles, a survey of 19 questions was conducted during the 18th Congress of the European Association of Endoscopic Surgeons, which took place in Geneva, Switzerland, in 2010, to determine surgeons’ preference depending on the hernia and the patient.

Results

All surgeons who attended the session (N?=?100) responded to all questions. Eighty two percent of surgeons preferred a tailored approach, whereas 18?% used the same technique in all cases. Endoscopic techniques are used more frequently than the open approach in bilateral (7 vs. 93?%) and recurrent hernias (19 vs. 81?%), whereas in primary unilateral hernias all three techniques were used with almost similar frequency (32?% open, 39?% TAPP vs. 29?% TEP). TAPP was used more frequently than TEP, and even those surgeons who are expert in TEP preferred to perform a TAPP in difficult hernias, such as in obese patients and large scrotal hernias. Based on the age of patients, the open approach is preferred in patients younger than 18 years and older than 70 years, whereas the endoscopic approach is preferred in young active males and females, with a trend to use TAPP (44?%) more frequently than TEP (40?%) in females. Surgeons tended to use the open (vs. endoscopic) approach in patients with hematologic disorders (58?% open vs. 42?% endoscopic), previous laparotomy (59?% open vs. 41?% endoscopic) or emergency surgery (66 vs. 33?% in incarcerated hernias and 74 vs. 26?% in strangulated hernia).

Conclusions

This survey showed that most surgeons who perform an endoscopic approach for inguinal hernia as the first option are convinced that not all hernias are good indications for this approach. On the other hand, most surgeons think that it is better to be able to offer patients an endoscopic technique or an open approach depending on the case.     

Laparoscopic transabdominal preperitoneal inguinal hernia repair using needlescopic instruments: a 15-year, single-center experience in 317 patients

Background

Laparoscopic inguinal hernia repair is associated with a decrease in postoperative pain, shortened hospital stay, earlier return to normal activity, and decrease in chronic pain. Moreover, laparoscopic surgery performed with needlescopic instruments has more advantages than conventional laparoscopic surgery. However, there are few reports of large-scale laparoscopic transabdominal preperitoneal inguinal hernia repair using needlescopic instruments (nTAPP). This report reviews our experiences with 352 nTAPP in 317 patients during the 15-year period from April 1996 to April 2011.

Methods

We performed nTAPP as the method of choice in 88.5% of all patients presenting with inguinal hernia. To perform the nTAPP, 3-mm instruments were used. A 5-mm laparoscope was inserted from the umbilicus, and surgical instruments were inserted through 5- and 3-mm trocars. After reduction of the hernia sac and dissection of the preperitoneal space, we placed polyester mesh or polypropylene soft mesh with staple fixation. The peritoneum was closed with 3–0 silk interrupted sutures.

Results

The mean operative time was 102.9?min for unilateral hernias and 155.8?min for bilateral hernias. There was no conversion to open repair. Forty-three patients (13.6%) used postoperative analgesics, and the mean frequency of use was 0.5 times. Regarding intraoperative complications, we observed one bladder injury, but no bowel injuries or major vessel injuries. Postoperative complications occurred in 32 patients (10.1%). One patient with a retained lipoma required reoperation. There was no incidence of chronic pain or mesh infection. The operative time for experienced surgeons (≥20 repairs) was significantly shorter than that of inexperienced surgeons (<20 repairs; P?Conclusions The nTAPP was a safe and useful technique for inguinal hernia repair. Large prospective, randomized controlled trials will be required to establish the benefit of nTAPP.     

Which is the best laparoscopic approach for inguinal hernia repair: TEP or TAPP? A systematic review of the literature with a network meta-analysis

Background

Totally extraperitoneal (TEP) repair and transabdominal preperitoneal (TAPP) repair are the most used laparoscopic techniques for inguinal hernia treatment. However, many studies have shown that laparoscopic hernia repair compared with open hernia repair (OHR) may offer less pain and shorter convalescence. Few studies compared the clinical efficacy between TEP and TAPP technique. The purpose of this study is to provide a comparison between TEP and TAPP for inguinal hernia repair to show the best approach.

Methods

We performed an indirect comparison between TEP and TAPP techniques by considering only randomized, controlled trials comparing TEP with OHR and TAPP with OHR in a network meta-analysis. We considered the following outcomes: operative time, postoperative complications, hospital stay, postoperative pain, time to return to work, and recurrences.

Results

The two techniques improved some short outcomes (such as time to return to work) with respect to OHR. In the network meta-analysis, TEP and TAPP were equivalent for operative time, postoperative complications, postoperative pain, time to return to work, and recurrences, whereas TAPP was associated with a slightly longer hospital stay compared with TEP.

Conclusions

TEP and TAPP improved clinical outcomes compared with OHR, but the network meta-analysis showed that TEP and TAPP efficacy is equivalent. TAPP was associated with a slightly longer hospital stay compared with TEP.     

Internal plug mesh without fixation in laparoscopic total extraperitoneal (TEP) repair of inguinal hernias: a pilot study

Purpose

Mesh fixation is essential in laparoscopic total extraperitoneal (TEP) repair of inguinal hernia; however, fixation sometimes causes post-operative pain. This study investigated a novel method of laparoscopic TEP repair without mesh fixation.

Methods

This study reviewed data from about two-hundred and forty-one laparoscopic TEP repairs on 219 patients, which were performed between December 2004 and October 2005.

Results

There were no statistically significant differences in the recurrence rate, seroma formation, and hospital stay. However, the mean operation time was shorter in the internal plug mesh group than the fixation group (p = 0.009), and post-operative pain only occurred in 4 cases in the internal plug mesh group in comparison to 29 cases in the mesh fixation group (p = 0.014).

Conclusions

An internal plug mesh without fixation might reduce post-operative pain after laparoscopic TEP repair of an inguinal hernia. Internal plug mesh without fixation may be an alternative method in laparoscopic TEP repair, especially for those involving indirect hernias.     

A comparison of outcomes between open and laparoscopic surgical repair of recurrent inguinal hernias

Background

Inguinal hernia recurrence after surgical repair is a major concern. The authors report their experience with open and laparoscopic repair of recurrent inguinal hernias.

Methods

After institutional review board approval, a retrospective review was performed with the charts of 197 patients who had undergone surgical repair of recurrent inguinal hernias from January 2000 through August 2009, and the data for 172 patients who met the inclusion criteria were analyzed. Surgical variables and clinical outcomes were compared using Student??s t test, the Mann?CWhitney U test, chi-square, and Fisher??s exact test as appropriate.

Results

The review showed that 172 patients had undergone either open mesh repair (n?=?61) or laparoscopic mesh repair (n?=?111) for recurrent inguinal hernias. Postoperative complications were experienced by 8 patients in the open group and 17 patients in laparoscopic group (p?=?0.70). Five patients (8.2%) in the open group and four patients (3.6%) in the laparoscopic group had re-recurrent inguinal hernias (p?=?0.28). Four patients in the open group (9.5%) and no patients in the laparoscopic group had recurrence during long-term follow-up evaluation (p?=?0.046). In the laparoscopic group, 76 patients (68.5%) underwent total extraperitoneal (TEP) repair, and 35 patients (31.5%) had transabdominal preperitoneal (TAPP) repair. Postoperative complications were experienced by 13 patients in the TEP group and 4 patients in the TAPP group (p?=?0.44). Two patients (2.6%) in the TEP group and two patients (5.7%) in the TAPP group had re-recurrent inguinal hernias (p?=?0.59).

Conclusions

This retrospective review showed no statistical difference in the re-recurrence rate between the two techniques during short-term follow-up evaluation. However, the laparoscopic technique had a significantly lower re-recurrence rate than the open technique during long-term follow-up evaluation. Both procedures were comparable in terms of intra- and postoperative complications. Among laparoscopic techniques, TEP and TAPP repair are acceptable methods for the repair of recurrent inguinal hernia. A multicenter prospective randomized control trial is needed to confirm the findings of this study.     

Comparison of hospital costs and length of stay associated with open-mesh, totally extraperitoneal inguinal hernia repair, and transabdominal preperitoneal inguinal hernia repair: An analysis of observational data using propensity score matching

Background

Laparoscopic inguinal hernia surgery is increasingly seen as the superior technique in hernia repair. Compared to open-mesh hernia repair, laparoscopic approaches are often reported to be more cost-effective but incur higher costs for the provider. The objective of this study was to analyze the effect of transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repair of nonincarcerated inguinal hernias in men on hospital costs and length of stay (LoS).

Methods

We used routine administrative, highly standardized, patient-level cost data from 15 German hospitals participating in the national cost data study. We compared TEP, TAPP, and open-mesh repair. We conducted propensity score matching to account for baseline differences between treatment groups and subsequently estimated the treatment effect on costs and LoS.

Results

Total costs for both TEP and TAPP surgery were significantly lower than those for open-mesh repair (p < 0.0001 and p < 0.05, respectively). TEP repair also had a slight but nonsignificant advantage in total costs compared to TAPP repair, while TAPP surgery was associated with a significantly shorter LoS than TEP (p < 0.001).

Conclusion

Results suggest that laparoscopic approaches in hernia repair are not necessarily associated with higher hospital resource consumption than open-mesh repair.     

Single-port hernia repair: a prospective cohort of 102 patients

Background

Single-port laparoscopic surgery (SPLS) for totally extraperitoneal (TEP) groin hernia repair is a novel procedure, ensuring safe and effective repairs. The aim of this study was to assess the intra-operative and post-operative outcome for 102 patients undergoing SPLS TEP inguinal hernia repair at the Royal Surrey County Hospital in Guildford, UK. This follows on from our previously published series of 16 patients, demonstrating the safety and feasibility of SPLS in our cohort (Agrawal et al. in Surg Endosc 24:952–956, 2010).

Methods

Between October 2008 and August 2010, we performed hernia repairs on 102 patients (98 men, 4 women) aged between 21 and 89?years (median 60). Patient demographics, type of hernia, incision length, operating time, complications, post-operative hospital stay, and recurrence were collected prospectively. Post-operative outcome was measured in terms of days to return to normal activities, work, and analgesia required.

Results

Sixty patients had unilateral and 39 bilateral hernias, with 2 femoral hernias and one lipoma of cord. Operating time was 15–120?min (median 35 for unilateral and 45 for bilateral repairs). The incision length ranged between 15 and 40?mm (median 25). There was 1 intra-operative complication (major peritoneal incursion) and 13 minor post-operative complications, with 8 urinary retentions. There were no mortalities and one recurrence at follow-up (up to 713?days).

Conclusion

The authors’ experience has shown that SPLS TEP groin hernia repair is a feasible and safe alternative to three-port laparoscopic hernia repairs in a large patient cohort. There were minimal post-operative complications and good post-operative outcome. Recurrence rate was 0.98?%. Further studies are required to assess the long-term outcome of SPLS hernia repairs in direct comparison with three-port technique.     

Total extraperitoneal approach for incarcerated obturator hernia repair

Purpose

To compare the feasibilities and efficacies of the total extraperitoneal (TEP) technique and laparotomy for incarcerated obturator hernia repair.

Methods

All study subjects were diagnosed with incarcerated obturator hernia, preoperatively and TEP was performed as for TEP groin hernia repair. The incarcerated intestine was retracted into the peritoneal cavity with the hernia sac. The obturator foramen was then covered with a rectangular mesh (9 × 13 cm), which also covered the internal inguinal ring, Hesselbach’s triangle, and the femoral ring. Non-ischemia of the incarcerated bowel was confirmed laparoscopically. In patients undergoing laparotomy, the obturator foramen was closed by continuous sutures, and no prosthesis was used. We recorded the length of hospital stay, operative time, amount of intraoperative bleeding, and postoperative complications.

Results

Twenty-two patients underwent obturator hernia repair in our hospital between January 2000 and December 2012, of whom 10 were treated with laparotomy and the remaining 12 via TEP. Three patients undergoing TEP were converted to laparotomy. The operation time was significantly longer in the conversion group compared with either the laparotomy or the TEP groups. There was no difference between the laparotomy and TEP groups regarding intraoperative bleeding. Patients who underwent TEP without conversion had a significantly shorter hospital stay than those who underwent laparotomy or required conversion.

Conclusions

TEP provides a suitable approach for incarcerated obturator hernia repair, with favorable results regarding hospital stay. TEP is a feasible, minimally invasive technique for the repair of incarcerated obturator hernias.

     

Laparoscopic inguinal hernia repair by the hook method in emergency setting in children presenting with incarcerated inguinal hernia

Background

The development of laparoscopic hernia repair has provided an alternative approach to the management of incarcerated inguinal hernia in children. Different laparoscopic techniques for hernia repair have been described. However, we hereby review the role of laparoscopic hernia repair using the hook method in the emergency setting for incarcerated inguinal hernias in children.

Methods

A retrospective review was conducted of all children who presented with incarcerated inguinal hernia and underwent laparoscopic hernia repair using the hook method in emergency setting between 2004 and 2010.

Results

There were a total of 15 boys and 1 girl with a mean age of 30 ± 36 months (range, 4 months to 12 years). The hernia was successfully reduced after sedation in 7 children and after general anesthesia in 4 children. In 5 children, the hernia was reduced by a combined manual and laparoscopic-assisted approach. Emergency laparoscopic inguinal hernia repair using the hook method was performed after reduction of the hernia. The presence of preperitoneal fluid secondary to recent incarceration facilitated the dissection of the preperitoneal space by the hernia hook. All children underwent successful reduction and hernia repair. The median operative time was 37 minutes. There was no postoperative complication. The median hospital stay was 3 days. At a median follow-up of 40 months, there was no recurrence of the hernia or testicular atrophy.

Conclusions

Emergency laparoscopic inguinal hernia repair by the hook method is safe and feasible. Easier preperitoneal dissection was experienced, and repair of the contralateral patent processus vaginalis can be performed in the same setting.     

Laparoscopic totally extraperitoneal versus open preperitoneal mesh repair for inguinal hernia recurrence: a decision analysis based on net health benefits

Background

The aim of this study is to evaluate the most cost-effective treatment strategy using preperitoneal mesh for patients with recurrent inguinal hernia. Currently, the issue of cost-effectiveness is entirely unresolved.

Methods

A decision analysis was carried out based on the results of a systematic literature review of articles concerning recurrent inguinal hernia repair that were published between 1979 and 2011. A virtual cohort was programmed to undergo three different treatment procedures: (1) laparoscopic totally extraperitoneal hernia repair (TEP), (2) open preperitoneal mesh repair according to Stoppa, and (3) open preperitoneal mesh repair according to Nyhus. We carried out a base-case analysis and varied all variables over a broad range of reasonable hypotheses in multiple one-way and two-way sensitivity analyses.

Results

The average cost-effectiveness ratio of Nyhus, Stoppa, and TEP per quality-adjusted life year was US $ ($)1,942, $1,948, and $2,011, respectively. In terms of the incremental cost-effectiveness ratio (ICER), Stoppa was dominated. The choice between TEP or Nyhus procedure depends on the combination of a specific center’s rates of recurrence and morbidity as disclosed by three-way sensitivity analysis.

Conclusions

Nyhus and TEP repairs are possible optimal choices depending primarily on the institution’s rates of recurrence and morbidity. Based on our net benefit-related decision analysis, a hypothetical “fixed budget trade-off” suggests potential annual incremental health system cost savings of $200,000 attained by shifting care for 1,000 patients from TEP to Nyhus repair (depending on clinical end-points, which is a decisive factor).     

Current national practice patterns for inpatient management of ventral abdominal wall hernia in the United States

Background

The health-care burden related to ventral hernia management is substantial, with more than 3 billion dollars in expenditures annually in the US. Previous studies have suggested that the utilization of laparoscopic repair remains relatively low although national volume estimates have not been reported. We sought to estimate the inpatient national volume of elective ventral hernia surgery and characterize the proportion of laparoscopic versus open operations.

Methods

We analyzed data from the Nationwide Inpatient Sample to identify adults with a diagnosis of an umbilical, incisional, or ventral hernia who underwent an elective inpatient repair between 2009 and 2010. Cases that involved other major abdominal or pelvic operations were excluded. Covariates included patient demographics, surgical approach, and use of mesh. National surgical volume estimates were generated and length of stay and total hospital charges were compared for laparoscopic versus open repairs.

Results

A total of 112,070 ventral hernia repairs were included in the analysis: 72.1 % (n = 80,793) were incisional hernia repairs, while umbilical hernia repairs comprised only 6.9 % (n = 7,788). Laparoscopy was utilized in 26.6 % (n = 29,870) of cases. Mesh was placed in 85.8 % (n = 96,265) of cases, including 49.3 % (n = 3,841) of umbilical hernia repairs and 90.1 % (n = 72,973) of incisional hernia repairs. Length of stay and total hospital charges were significantly lower for laparoscopic umbilical, incisional, and “other” ventral hernia repairs (p values all <0.001). Total hospital charges during this 2-year period approached 4 billion dollars ($746 million for laparoscopic repair; $3 billion for open repair).

Conclusions

Utilization of laparoscopy for elective abdominal wall hernia repair remains relatively low in the US despite its excellent outcomes. Given the substantial financial burden associated with these hernias, future research focused on preventing the development and optimizing the surgical treatment of ventral abdominal wall hernias is warranted.     

Laparoscopic repair of a perineal hernia

Introduction

Perineal hernias are rare occurrences with statistics ranging from <1 to 3% incidence after open abdominoperineal resection (APR). The incidence of perineal hernia after laparoscopic APR is less certain due to the relatively recent advent of laparoscopic proctectomy. Here we discuss an occurrence of a perineal hernia after a laparoscopic APR and its subsequent laparoscopic repair with mesh.

Discussion

Repair of a perineal hernia can be technically challenging, with a variety of approaches each with its own risk of potential complications. Laparoscopic advancements have allowed a theoretically less invasive approach while having greater view of the necessary anatomical landmarks to achieve safe and tension-free repair of such hernias.

Conclusion

There are several case reports available to describe perineal repair but the numbers remain skewed due to the sparse reporting of complications post APR surgery. This may in fact be due to the asymptomatic aspect these hernias can have. Laparoscopic repair is a challenging yet viable approach to the correction of such occurrences.     

Combined Laparoscopic and Open Technique for the Repair of Large Complicated Incisional Hernias

Background

During laparoscopic incisional hernia repair, conversion to open surgery is sometimes needed, especially in cases of large complicated incisional hernias. No guidelines exist for determining when conversions should be considered. This study aimed to investigate the safety of a combined technique as an alternative to conversion in the laparoscopic repair of large complicated incisional hernias and to evaluate the impact of early conversion to the combined technique on patient outcome.

Methods

Beginning in November 2008, early conversion was initiated for patients with large complicated incisional hernia when dense extensive intraabdominal adhesions were present. Two cohorts of patients with large complicated incisional hernia were retrospectively analyzed: 21 patients before the initiation of early conversion (group 2) and 21 patients after its inception (group 1). The data analyzed included patient demographics, operative parameters, complications, and recurrence.

Results

No significant differences were found between the two groups with respect to age, gender, body mass index, coexisting conditions, number of previous laparotomies, number of previous repairs, or features of the hernia. Groups 1 and 2 differed significantly in terms of mean operative time (110.7 vs 138.8 min), enterotomy rate (0 vs 29 %), and postoperative hospital stay (4.7 vs 6.1 days). In group 1, early conversion to the combined technique was necessary for 16 patients (76 %), and no delayed conversion occurred. In group 2, delayed conversion to the combined technique was necessary for 11 patients (52 %), and no early conversion occurred. During the follow-up period, neither wound/mesh infection nor trocar-site hernia occurred.

Conclusion

The combined technique proved to be a safe and minimally invasive alternative to conversion in laparoscopic repair of large complicated incisional hernias. Early conversion to the combined technique was associated with less technical difficulty, deceased operative time, lower enterotomy rate, and shorter postoperative hospital stay.