Cost-effectiveness analysis of local, regional and general anaesthesia for inguinal hernia repair using data from a randomized clinical trial

BACKGROUND: Inguinal hernia repair is a common operation in general surgery and can be performed under local, regional or general anaesthesia. This multicentre randomized trial was undertaken to compare the costs of the three anaesthetic methods in general surgical practice. METHODS: Between January 1999 and December 2001, 616 patients at ten hospitals who underwent primary inguinal hernia repair were randomized to local, regional or general anaesthesia. The primary endpoints were direct costs. Secondary endpoints were indirect costs and recurrence rates. RESULTS: Total intraoperative, as well as total early postoperative, data showed local anaesthesia to have significant cost advantages over regional and general anaesthesia (P < 0.001). The advantage was also significant for total hospital and total healthcare costs (P < 0.001), whereas there was no significant difference between regional and general anaesthesia. CONCLUSION: The use of local anaesthesia for inguinal hernia repair was significantly less expensive than regional or general anaesthesia.     

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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.     

Prospective nationwide analysis of laparoscopic versus Lichtenstein repair of inguinal hernia

BACKGROUND: According to a Cochrane review, laparoscopic inguinal hernia repair compares favourably with open mesh repair, but few data exist from surgical practice outside departments with a special interest in hernia surgery. This study compared nationwide reoperation rates after laparoscopic and Lichtenstein repair, adjusting for factors predisposing to recurrence. METHODS: Some 3606 consecutive laparoscopic repairs were compared with 39 537 Lichtenstein repairs that were prospectively recorded in a nationwide registry between 1998 and 2003. Patients were subgrouped according to type of hernia: primary or recurrent and unilateral or bilateral. Overall reoperation rates and 95 per cent confidence intervals were calculated. Long-term reoperation rates were estimated using the Kaplan-Meier method. RESULTS: The overall reoperation rates after laparoscopic and Lichtenstein repair of unilateral primary indirect hernia (0 versus 1.0 per cent), primary direct hernia (1.1 versus 3.1 per cent), unilateral recurrent hernia (4.6 versus 4.8 per cent) and bilateral recurrent hernia (2.6 versus 7.6 per cent) did not differ. However, laparoscopic repair of a bilateral primary hernia was associated with a higher reoperation rate than Lichtenstein repair (4.8 versus 3.0 per cent) (P = 0.017). CONCLUSION: Laparoscopic repair compared favourably with Lichtenstein repair for primary indirect and direct hernias, and unilateral and bilateral recurrent hernias, but was inferior for primary bilateral hernias.     

Inguinal Hernia Repair: Local or General Anaesthesia?

INTRODUCTION

Specialist hernia centres and public hospitals with a dedicated hernia service (Plymouth Hernia Service) have achieved remarkable results for inguinal hernia repair with the use of local anaesthesia and set the standards for groin hernia surgery. There is minimal data in the literature as to whether such results are reproducible in the National Health Service in the UK.

PATIENTS AND METHODS

A retrospective analysis of all inguinal hernia repairs performed in one district general hospital over a 9-year period was performed. The outcome measures were type of anaesthesia used, early and late postoperative complications and recurrence. A postal questionnaire survey was conducted to obtain satisfaction rates. In addition, a postal questionnaire survey of consultant surgeons in Wales was performed to determine the use of local anaesthesia and day-case rates for inguinal hernia repair.

RESULTS

A total of 577 hernia repairs were performed during the study period. Of these, 369 (64%) repairs were performed under local anaesthesia (LA) and 208 (36%) under general anaesthesia (GA). Day-case repair was achieved in 70% (400) of cases. The day-case rates were significantly higher under LA compared to GA (82.6% versus 42.6%; P < 0.05). Patients operated under LA had lower postoperative analgesic requirements and lower incidence of urinary retention compared with the GA group (P < 0.05). There were 7 (1.2%) recurrences at a median follow-up of 5.1 years (range, 10.3–2.5 years). Postal questionnaire revealed higher satisfaction rates with LA compared to GA repair. Only 15% of surgeons in Wales offer the majority of their patients local anaesthetic repair.

CONCLUSIONS

The use of LA results in increased day-case rates, lesser postoperative analgesic requirements and fewer micturition problems. The excellent results obtained by specialist hernia centres can be reproduced by district general hospitals by increasing the use of LA to repair inguinal hernias.     

10 Years’ controlled results of suture repair

Summary Background: Over a period of 10 years, we prospectively evaluated the Shouldice technique for primary inguinal hernia repair with regard to recurrence rates and hernia type-related risk profiles. Methods: 196 unselected patients with 237 primary inguinal hernias were prospectively examined 1, 5 and 10 years after hernia repair was performed by 36 different surgeons (71% senior surgeons) using the standardized Shouldice technique. Follow-up included primarily physical examination and comprised 91.1%, 85.6% and 73% of the patients after 1, 5 and 10 years. Results: Early and late complications of inguinal hernia repair occurred in 11.4%. Eighty-eight per cent were not limited in their daily life activities 10 years after the operation. Recurrent hernia was found in 1.3% after 5 years and 2.95% (7 out of 237) after 10 years. The rate of recurrence tended to be higher after direct (4.8%) and combined hernias (4.2%) than after indirect hernia (1.6%). Almost all recurrences were found in stage III hernias. Conclusions: Ten years after Shouldice repair, 97% of the patients are free of recurrence. These results indicate that there is no need to abandon the Shouldice technique with local anaesthesia as the standard procedure for primary inguinal hernia repair.      

Repair of recurrent hernia is often performed at a different clinic

Purpose

The aim of this study was to assess the extent of reoperations after hernia repair in Denmark that are being performed at a different facility than the primary repair and thereby investigate whether or not reoperation is a reliable basis for assessment of personal- or facility recurrence rates.

Methods

On a national level, we included all groin hernia repairs that had been reoperated a least once from January 1, 1998, to August 19, 2015.

Results

A total of 14,264 hernia repairs were included comprising a total of 7371 reoperations. We found that 26 % (n = 1883) of all reoperations were performed at a different healthcare facility. Time to reoperation, age at time of repair and having the primary repair performed at a private facility were all independent risk factors for being reoperated at a different facility in a logistic regression model.

Conclusion

One in four patients underwent repair for recurrent hernia at a different facility than the prior repair. Having the primary repair performed at a private hospital increased the risk of being reoperated at a different facility compared to having it performed at a public facility. This indicates that personal or institutional reoperation rates are underestimating the true reoperation rates, unless they can be followed in central registries or personal contact is made to all patients.

     

Groin hernia repair in young males: mesh or sutured repair?

Background  

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.     

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.     

青年男性病人的腹股沟疝修补:用补片还是单纯缝合?

目的目前还没有治疗青年男性腹股沟疝病人的最佳修补方法的大宗病例报道。该文分析了丹麦全国青年男性病人接受Lichtenstein术或传统非补片修补术后复发再手术的风险。方法在丹麦国家疝数据库内前瞻性地记录了1998-01-01至2005-12-31所有接受手术治疗的腹股沟疝病例,以复发再次接受手术作为判定复发的标准。该研究的入组标准为数据库中年龄在18～30岁之间的原发性腹股沟斜疝并在研究阶段内接受了第一次修补手术的病例。结果在纳入该研究的3181例病人中,1120例(中位年龄23岁,范围18～30岁)接受了单纯的缝合修补术,2061例(中位年龄24岁,范围18～30岁)接受了Lichtenstein术。单纯缝合组的中位随访时间为62(0～96)个月,Lichtenstein组的中位随访时间为41(0～96)个月。两组的5年累积复发再手术率分别为1.6%(Lichtenstein组)和3.9%(单纯缝合组),单纯缝合组的术后总复发再手术率(39例,3.5%)为Lichtenstein组(24例,1.2%)的将近3倍(P=0.003)。结论与传统单纯缝合修补术相比,在18～30岁的青年腹股沟斜疝病人中应用Lich...     

Nationwide quality improvement of groin hernia repair from the Danish Hernia Database of 87,840 patients from 1998 to 2005

Background Increased focus and research on surgical technique and anaesthesia in groin hernia repair have improved outcomes from centres of interest in hernia surgery, but little information is available from nationwide data to document the incorporation of scientific evidence into general clinical practice. Aim To review outcomes after groin hernia repair in Denmark from the Danish Hernia Database 1998–2005 in 87,840 patients. Results The nationwide Danish hernia collaboration with two annual meetings discussing own results and those of others has led to >50% reduction in reoperation rates, increased use of the Lichtenstein hernia technique, higher rate of outpatient surgery, near elimination of regional anaesthesia, and documentation and focus on incidence and mechanisms of chronic pain. Conclusion Establishment of nationwide groin hernia databases leads to general improvement in outcomes and, due to the large number of patients, allows analyses of specific sub-groups or complications which otherwise could not be obtained from single centres. Nationwide collaboration is important for multi-centre research and further improvement of outcomes, especially in chronic pain.     

Acceptable nationwide outcome after paediatric inguinal hernia repair

Purpose

The primary objective was to describe 30-day outcomes after primary inguinal paediatric hernia repair.

Methods

Prospectively collected data from the National Patient Registry covering a 2-year study period 1 January 2005 to 31 December 2006 were collected. Unexpected outcomes were defined as either/or hospital stay for >1 day (i.e. 2 nights at hospital or more), readmission within 30 days, reoperations within 12 months after repair including repair for recurrence, and death within 30 days after repair.

Results

The study cohort comprised 2,476 patients, and unexpected outcome was found in 267 patients/repairs (10.8 %). Prolonged hospital stay was by far the most prevalent indicator of unexpected outcome. Prolonged hospital stay was in 8.2 %, readmission in 2.1 %, reoperation in 0.7 %, and complications were observed in 1.1 %. One patient died within 30 days after repair, but death was not associated with the inguinal hernia repair. The usual technique was a simple sutured plasty (96.5 %). Emergency repair was performed in 54 patients (2.2 %) mainly in children between 0 and 2 years (79.6 %). During the 1 year follow-up, reoperation for recurrent inguinal hernia was performed in 8 children after elective repair (recurrence rate 0.3 %). Paediatric repairs were for most parts performed in surgical public hospitals, and most departments performed less than 10 inguinal hernia repairs within the 2 years study period.

Conclusion

These nationwide results are acceptable with low numbers of patients staying more than one night at hospital, low morbidity, and no procedure-related mortality.     

Inguinal herniorrhaphy in women

Inguinal hernias in women are relatively rare, and an outcome in this specific subgroup of hernias has not been documented in the literature. An analysis was performed using data from the prospective recording of 3,696 female inguinal hernia repairs in the national Danish hernia database, in the 5.5 year period from January 1, 1998 to June 30, 2003, where observation time specific reoperation rates were used as a proxy for recurrence. In the 3,696 female inguinal herniorrhaphies recorded, the overall reoperation rate was 4.3%, which is slightly higher compared to male inguinal herniorrhaphies (3.1%) (P=0.001). The reoperation rate was independent of the type of surgical repair. In 41.5% of the reoperations a femoral hernia was found, compared to 5.4% in males. Female inguinal herniorrhaphy is followed by a higher reoperation rate than in males, and is unrelated to the type of repair. The frequent finding of a femoral hernia at reoperation suggests the need for the exploration of the femoral canal at the primary operation.     

Location of recurrent groin hernias at TEP after Lichtenstein repair: a study based on the Swedish Hernia Register

Purpose

To investigate which type of hernia that has the highest risk of a recurrence after a primary Lichtenstein repair.

Methods

Male patients operated on with a Lichtenstein repair for a primary direct or indirect inguinal hernia and with a TEP for a later recurrence, with both operations recorded in the Swedish Hernia Register (SHR), were included in the study. The study period was 1994–2014.

Results

Under the study period, 130,037 male patients with a primary indirect or direct inguinal hernia were operated on with a Lichtenstein repair. A second operation in the SHR was registered in 2236 of these patients (reoperation rate 1.7 %). TEP was the chosen operation in 737 in this latter cohort. The most likely location for a recurrence was the same as the primary location. If the recurrences change location from the primary place, we recognized that direct hernias had a RR of 1.51 to having a recurrent indirect hernia compared to having a direct recurrence after an indirect primary hernia repair.

Conclusions

Recurrent hernias after Lichtenstein are more common on the same location as the primary one, compared to changing the location.

     

Direct inguinal hernias and anterior surgical approach are risk factors for female inguinal hernia recurrences

Purpose

The purpose of this study was to establish the risk of recurrence after direct and indirect inguinal hernia operation in a large-scale female population and to establish the relationship between the type of hernia at the primary and recurrent procedure.

Methods

Using data from the Danish Hernia Database (DHDB), a cohort was generated: all females operated on electively for a primary inguinal hernia by either Lichtenstein’s technique or laparoscopy from 1998 to 2012. Within this prospectively collected cohort, the hernia type at the primary procedure (direct inguinal hernia (DIH), indirect inguinal hernia (IIH), combination hernia), the hernia type at the recurrent procedure (DIH, IIH, combination hernia, femoral hernia), anesthesia type, and time from primary procedure to reoperation were registered.

Results

A total of 5,893 females with primary elective inguinal hernia operation on in the study period (61 % IIH, 37 % DIH, 2 % combined hernias) were included with a median follow-up time of 72 months (range 0 to 169). A total of 305 operations for suspected recurrences were registered (61 % inguinal recurrences, 38 % femoral recurrences, 1 % no hernias), which corresponded to an overall reoperation rate of 5.2 %. All femoral recurrences occurred after a previous open anterior operation. The crude reoperation rate after primary DIH operation was 11.0 %, 3.0 % after primary IIH operation and 0.007 % after combined hernia operation (p?<?0.001). The multivariate adjusted analysis found that DIH at primary operation was a substantial risk factor for recurrence with a hazard ratio of 3.1 (CI 95 % 2.4–3.9) compared with IIH at primary operation (p?<?0.001), and that laparoscopic operation gave a lower risk of recurrence with a hazard ratio of 0.57 (CI 95 % 0.43–0.75) compared with Lichtenstein’s technique (p?<?0.001). The risk of femoral recurrence was correlated to operation for DIH with a hazard ratio of 2.4 (CI 95 % 1.7–3.5) compared with operation for IIH.

Conclusion

In a female nationwide prospectively gathered cohort, we found that operation for a DIH resulted in a higher risk of reoperation than operation for an IIH. We found that femoral hernia recurrences exclusively existed after anterior open primary operation.     

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.     

Slowly resorbable biosynthetic mesh: 2-year results in VHWG grade 3 hernia repair

Introduction

Information on the long-term performance of biosynthetic meshes is scarce. This study analyses the performance of biosynthetic mesh (Phasix?) over 24 months.

Methods

A prospective, international European multi-center trial is described. Adult patients with a Ventral Hernia Working Group (VHWG) grade 3 incisional hernia larger than 10 cm², scheduled for elective repair, were included. Biosynthetic mesh was placed in sublay position. Short-term outcomes included 3-month surgical site occurrences (SSO), and long-term outcomes comprised hernia recurrence, reoperation, and quality of life assessments until 24 months.

Results

Eighty-four patients were treated with biosynthetic mesh. Twenty-two patients (26.2%) developed 34 SSOs, of which 32 occurred within 3 months (primary endpoint). Eight patients (11.0%) developed a hernia recurrence. In 13 patients (15.5%), 14 reoperations took place, of which 6 were performed for hernia recurrence (42.9%), 3 for mesh infection (21.4%), and in 7 of which the mesh was explanted (50%). Compared to baseline, quality of life outcomes showed no significant difference after 24 months. Despite theoretical resorption, 10.7% of patients reported presence of mesh sensation in daily life 24 months after surgery.

Conclusion

After 2 years of follow-up, hernia repair with biosynthetic mesh shows manageable SSO rates and favorable recurrence rates in VHWG grade 3 patients. No statistically significant improvement in quality of life or reduction of pain was observed. Few patients report lasting presence of mesh sensation. Results of biosynthetic mesh after longer periods of follow-up on recurrences and remodeling will provide further valuable information to make clear recommendations.

Trial registration

Registered on clinicaltrials.gov (NCT02720042), March 25, 2016.

     

Recurrence rates following local anaesthetic day case inguinal hernia repair by junior surgeons in a district general hospital.

Four hundred and seventy one inguinal hernia repairs were performed by surgeons in training as day cases using local anaesthesia between September 1979 and December 1982. All patients were sent questionnaires relating to the possibility of a recurrence or an unsatisfactory outcome of the operation at a mean of 34 months after surgery. A 96.8% retrieval rate was achieved. As a result of answers received 62 patients were examined. Nineteen recurrences (4.2%) were diagnosed by an independent assessor; a rate of 2.2% for indirect and 8.2% for direct inguinal herniae. No UK series approaches this operation frequency and none has junior surgeons as the sole operators. The recurrence rate is comparable with many in-patient and short stay series. As a result of this day unit, local waiting times for hernia repairs have dropped from 2 years to 6 weeks.     

Management of primary and recurrent inguinal hernia by surgeons from the South West of England

BACKGROUND: The National Institute of Clinical Excellence (NICE) has advocated open mesh repair for primary hernia but suggested laparoscopic repair may be considered for recurrent hernias. AIM: To establish current surgical practice by surgeons from the South West of England. METHODS: A postal survey was distributed to 121 consultant surgeons and a response rate of 75% was achieved. RESULTS: The majority (86%) of the surgeons surveyed performed hernia repairs, and most (95%) of these used open mesh repair as standard for primary inguinal hernia. Only 8% used laparoscopic repair routinely for primary hernias. Few consultants (only 28%) were able to quote formally audited hernia recurrence rates. A total of 90% of respondents still employed open mesh repair routinely for recurrent hernias; however, if mesh had been used for the primary repair, this figure fell to 55%. Some 7% of respondents recommended laparoscopic repair for recurrent hernia, but this increased to 17% if the primary repair was done with mesh. All laparoscopic surgeons in the South West employed the totally extraperitoneal approach (TEP). There was a range of opinion on the technical demands of repair of a recurrent hernia previously mended with mesh; the commonest cause of mesh failure was thought to be a medial direct recurrence (insufficient mesh medially). CONCLUSIONS: Current surgical practice for primary hernias in the South West England reflects NICE guidelines although many surgeons continue to manage recurrent hernias by further open repair. In this survey, there was anecdotal evidence to suggest that hernia recurrence can be managed effectively by open repair.     

Ambulatory inguinal hernia repair with prolene hernia system (PHS)

Study was conducted to evaluate the feasibility and benefits of inguinal hernia repair with prolene hernia system (PHS) mesh under local anaesthesia as a day surgery procedure in a multinational society of United Arab Emirates. One hundred and seventy-eight inguinal hernias in 172 consecutive adults of whom 154 (89.5%) fitted the criteria of inclusion in the day-case surgery settings were operated upon including one early recurrence. Conversion from local to general anaesthesia was required in five (2.8%) patients. The mean operation time was 65 min, including the anaesthesia injection. The mean hospital stay was 2.1 days for all patients and 1.01 days for those who fitted in the ambulatory surgery program. Inguinal hernia repair using the PHS technique under local anaesthesia could be mastered by many of the surgeons in our hospital with minimal morbidity and short hospital stay with a potential to lessen recurrence.