Factors that affect recurrence after incisional herniorrhaphy with prosthetic material.

OBJECTIVE: To evaluate the risk factors for recurrence after prosthetic incisional herniorrhaphy. DESIGN: Retrospective study. SETTING: Tertiary referral centre, Spain. PATIENTS: 246 patients who had incisional herniorrhaphy with a prosthetic material (polypropylene) between 1990 and 1997 INTERVENTIONS: A reinforcement mesh was inserted when the hernia was more than 5 cm. In incisional hernias less than 5 cm the reinforcement mesh was inserted when the repair was under tension or when tissues were noted to be weak during the operation. MAIN OUTCOME MEASURES: Age, sex, obesity, the presence of bronchial disease, previous repair of the incisional hernia, type of surgery, size and site of hernia and presence of local complications during the immediate postoperative period. RESULTS: Mean (SD) follow-up was 77 (6) months (minimum follow up two years). The hernia recurred in 43 cases (17%) (mean time of recurrence 10 (8) months). Age over 60 years, previous herniorrhaphy, size of hernia, and postoperative local complications were significant risk factors (p < 0.01) in both the univariate and multivariate analyses. CONCLUSIONS: Patients at the greater risk of recurrence are those aged over 60 years, with large, recurrent hernias and who develop local complications during the postoperative period.     

Umbilical hernia in adults

Background: There is no consensus on the best technique for the repair of umbilical hernia in adults. The role of laparoscopic hernioplasty of umbilical hernia remains controversial. This study was undertaken to compare the outcomes of open and laparoscopic onlay patch repair of umbilical hernia in adults. Methods: From January 1996 to December 2002, 102 patients underwent elective repair of umbilical hernia. Operative techniques included Mayo repair (n = 43), laparoscopic onlay Gore-Tex patch hernioplasty (n = 26), suture herniorrhaphy (n = 24), and mesh hernioplasty (n = 9). Results: Demographic features and risk factors were similar among the four groups. The operative time of laparoscopic hernioplasty (median, 66 min) was significantly longer than those for patients who underwent Mayo repair (60 min) or sutured herniorrhaphy (50 min) (p < 0.05). None of the patients who underwent laparoscopic patch repairs required conversion to open repair. The median pain score at rest on postoperative day 1 was significantly lower in patients who underwent laparoscopic repair compared to those who had Mayo repair. A significantly shorter hospital stay and a lower wound morbidity rate were also observed in patients who underwent laparoscopic repair. With a mean follow-up of 2 years, suture herniorrhaphy had a relatively high recurrence rate (8.7%), whereas no recurrence was documented for the other techniques. Conclusions: Laparoscopic onlay patch hernioplasty is a safe and efficacious technique for the repair of umbilical hernia. Compared to Mayo repair, the laparoscopic approach confers the advantages of reduced postoperative pain, shorter hospital stay, and a diminished morbidity rate.     

腹腔镜脐内侧襞瓣加强内环口疝修补术在儿童及青少年腹股沟斜疝中的应用

目的 探讨腹腔镜脐内侧襞瓣加强内环口疝修补术在治疗儿童和青少年腹股沟斜疝中的可行性及优越性.方法 从2001年10月至2005年1月,我院对110例(140侧)儿童实施了疝囊高位结扎术(A组).2005年1月至2011年2月,对于300例(405侧)患儿疝囊高位结扎术(B组)中,对有疝复发危险因素的47例患儿,加做脐内侧襞瓣覆盖加强内环口.结果 B组具有疝复发危险因素患儿47例,经腹腔镜脐内侧襞腹膜瓣加强内环口疝修补术均顺利完成.A组随访2～122个月,平均56个月,4例复发(2.8%).B组随访5～74个月,平均34个月,尚未见复发.二组患者随访期间均未见睾丸萎缩等并发症.结论 腹腔镜疝囊高位结扎合并脐内侧襞瓣覆盖内环口疝修补术是安全可靠的,对有选择的腹股沟斜疝患儿以及青少年腹股沟斜疝有进一步降低疝复发的作用.     

Comparative study of tailor-made mesh plug herniorrhaphy versus Lichtenstein herniorrhaphy versus Bassini operation: a prospective clinical trial

OBJECTIVE: Operations to cure inguinal hernia are among the most common surgical procedures. However, the most effective surgical technique for inguinal hernia repair is unknown, and the recurrence at 5 years varies between 1% and 10%. Surgical techniques and implanted materials are crucial to the result of and costs associated with hernia repair. The objective of this study was to determine whether the tailor-made mesh plug for inguinal hernia repair was as effective and safe as other methods of herniorrhaphy. METHODS: Of 94 patients who had a primary diagnosis of inguinal hernia prospectively included in the study, 25 were treated with tailor-made mesh plug herniorrhaphy, 26 with Lichtenstein herniorrhaphy and 36 with the Bassini operation. The primary outcome was the recurrence of hernia at 1 year, and secondary outcomes included surgical complications and hospital stay. RESULTS: There was no postoperative mortality in this study. Three patients had recurrence after Bassini operation, but there was no recurrent hernia after Lichtenstein or mesh plug herniorrhaphy. Groin swelling and ecchymosis were found in two patients (1 tailor-made mesh plug, 1 Lichtenstein herniorrhaphy). No surgical site infection occurred. Mean operating time was 60 minutes (range, 45-75 minutes) for tailor-made mesh plug herniorrhaphy, 82 minutes (range, 30-120 minutes) for Lichtenstein herniorrhaphy, and 82 minutes (range, 30-135 minutes) for the Bassini operation. CONCLUSION: Tailor-made mesh plug herniorrhaphy is a safe operation. The mesh plug material (Mersilene) was cheap. The recurrence rate was lower with tailor-made mesh plug herniorrhaphy than with the Bassini operation, but equal to that with Lichtenstein herniorrhaphy. Postoperative complications did not differ among all operations.     

Transperitoneal robotic-assisted laparoscopic radical prostatectomy and inguinal herniorrhaphy

Patients undergoing radical prostatectomy are at increased risk of development of post-operative inguinal hernias (IH). We present the largest series of transperitoneal combined robotic-assisted laparoscopic prostatectomy (RALP) and IH. After IRB approval, data from patients undergoing RALP at two centers were prospectively entered into a database and analyzed. IH were repaired robotically via a transperitoneal route with mesh. Between June 2002 and May 2007, 837 RALPs were performed, 80 of which included combined IH repair (9.6%), by two surgeons, T.A. and D.S. Forty-two patients (52.5%) had IH on pre-operative exam. Twenty-four hernias were left, 32 right, and 24 bilateral. Twenty-two patients had prior ipsilateral or contralateral herniorrhaphy. After dissection of the hernia sac, a swatch of flat Marlex mesh (n = 22), a polypropylene mesh plug (n = 19), an Ultrapro hernia system (n = 7), a Proceed coated mesh (n = 19), a 3D-Max (n = 37), a combination of both umbrella and flat mesh (n = 3), or suture alone (n = 2) was used. Inguinal herniorrhaphy added approximately 15 min of operative time in all cases. There was one hernia recurrence over an average follow-up period of 12.5 months (0.2–52 months). There was one complication attributable to IH repair—a urine leak which was attributed to anastomotic stretch due to reperitonealization. Urological surgeons should perform a thorough inguinal exam during preoperative evaluation and intraoperatively to detect subclinical inguinal hernias. Inguinal herniorrhaphy at the time of RALP is safe and should be routinely performed.     

腹腔镜疝修补术中网片是否固定与开放式无张力疝修补术的疗效比较

目的对比腹腔镜疝修补术网片固定、网片免固定与开放式无张力疝修补术治疗腹股沟疝的有效性及安全性,以期为未来腹股沟疝治疗术式的选择提供依据。 方法回顾性分析2015年1月至2018年1月,宝应县人民医院收治的腹股沟疝93例患者的临床资料,根据手术方法分为3组：A组,腹腔镜疝修补术网片固定（34例）;B组,腹腔镜疝修补术网片免固定组（31例）;C组,开放式无张力疝修补术（28例）。术后随访1年,对比3组患者手术实施情况、术后并发症发生情况及复发率。 结果B组术中失血量、手术时间、术后下床活动时间、进食时间、疼痛持续时间、住院时间、术后2 d疼痛评分与A组比较,差异无统计学意义（P>0.05）;A、B组术中失血量少于C组,术后下床活动时间、进食时间、疼痛持续时间、住院时间短于C组,术后2 d疼痛评分低于C组,差异有统计学意义（P<0.05）;3组手术时间两两比较,差异无统计学意义（P>0.05）;3组术后并发症发生率、复发率比较,差异均无统计学意义（P>0.05）。 结论腹腔镜与开放式无张力疝修补术治疗腹股沟疝疗效相当,且患者术后均无较多并发症,安全性均理想。但因腹腔镜手术无需作较大切口,患者受到创伤小,术后恢复快,其应用价值优于开放式手术。腹腔镜术中补片在不固定的情况下仍能获得与补片固定后相似的效果,故腹腔镜网片免固定疝修补术操作简单,并发症少,临床推广价值更高。     

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.     

Mesh configurations in laparoscopic extraperitoneal herniorrhaphy

Background: Laparoscopic total extraperitoneal (TEP) hernia repair utilizes slit mesh that is placed around the spermatic cord to secure the prosthesis and prevent recurrence. Because of concern that encircling of the cord might increase pain and morbidity, we compared patients with mesh repairs using encircled and nonencircled techniques. Methods: The 191 male patients who underwent bilateral TEP repairs were divided into three groups. In 100 consecutive patients (group A), the slit mesh was closed around both spermatic cords; in 56 patients (group B), the slit mesh was tucked under the spermatic cords but not closed; in 35 consecutive patients (group C), the slit was closed around one cord and tucked under the other, in a randomized fashion. Results: The groups had similar operative times (A: 83 ± 25 min; B: 79 ± 21; C; 77 ± 24), use of pain medication (A: 2.7 ± 2.5 days; B: 2.4 ± 1.9; C: 3.1 ± 2.4), and recovery before return to work (A: 7.9 ± 7.0 days; B: 8.2 ± 6.1; C: 6.7 ± 4.8). The incidence of indirect hernias was similar in all groups. Complication rate was 20% in A, 20% in B, and 14% in C (p= NS). Chronic pain was more frequent in A (A: 6, B: 0, p= 0.06). In group C, fluid collections were more common on the closed side (closed: 3, tucked: 0; p= 0.08). There were no recurrences in any group. Conclusions: Closing the slit around the spermatic cord in laparoscopic inguinal hernia repair is not essential for prevention of early recurrence. Fluid collections tended to be more frequent when the mesh was closed around the cord, and chronic pain was more frequent in the group with closed mesh bilaterally. Received: 3 April 1997/Accepted: 3 July 1997     

脐环充填式无张力疝修补术在治疗成人脐疝中的应用

目的探讨脐环充填式无张力疝修补术在治疗成人脐疝中的优越性。方法总结2002年1月至2009年12月间41例成人脐疝患者的治疗经验。其中Mayo法23例,无张力疝修补术18例。结果全组手术过程顺利。脐环充填式无张力疝修补术的平均手术时间(58±11 min)稍长于Mayo组(50±12 min),但术后疼痛感较轻及术后住院时间缩短(P0.05);两组均无切口感染病例。术后随访发现Mayo手术组有2例复发,无张力疝修补术组无复发。结论脐环充填式无张力疝修补术是治疗成人脐疝较好的术式,具有安全、术后恢复快、复发率低等优点。     

Laparoscopic completely extraperitoneal repair of inguinal hernia in children: a single-institute experience with 1,257 repairs compared with cut-down herniorrhaphy

Background  Conventional open herniorrhaphy in children has been reported to have 0.3–3.8% recurrence and 5.6–30% postoperative contralateral hernia rates. We developed a unique technique to achieve completely extraperitoneal ligation of PPV without any skip areas under laparoscopic control. This report introduces our technique and results compared with the cut-down herniorrhaphy. Methods  A consecutive series of 1,585 children with inguinal hernia/hydrocele (1996–2006) was analyzed. In laparoscopic patent processus vaginalis (PPV) closure (LPC), an orifice of PPV was encircled with a 2–0 suture extraperitoneally by a specially devised Endoneedle and tied up from outside of the body achieving completely extraperitoneal ligation of the ring. The round ligament was included in the ligation, whereas the spermatic cord and testicular vessels were excluded by advancing the needle across them behind the peritoneum. Cut-down herniorrhaphy (CD), with or without diagnostic laparoscopy, or LPC was selected according to parental preference under informed consent. Results  Parents gave more preference to LPC (LPC in 1,257 children, CD in 308, and miscellaneous in 20). Age ranges were equal for both groups. Sex distribution showed female preponderance in the LPC group (44.8% vs. 26.6%, p < 0.001) and umbilical hernia/cysts were predominantly included in the LPC group (11.9% vs. 2.9%, p < 0.001). Mean operation times were equal for both groups for unilateral repair (28.2 ± 9.2 for LPC vs. 27.8 ± 13.5 for CD) and were shorter for bilateral repair in the LPC group (35.8 ± 11.6 vs. 46.7 ± 17.7). The incidence of postoperative hernia recurrence and contralateral hernia in the LPC group was 0.2% and 0.8%. Two children in the CD group had injuries to their reproductive system during the operation (0.6%). Conclusions   The advantages of our technique include following: technically simple, short operation time, inspection of bilateral IIRs with simultaneous closure of cPPV, reproductive systems remain intact, routine addition of umbilicoplasty if desired, and essentially indiscernible wounds.     

Laparoscopic repair of recurrent inguinal hernias after endoscopic herniorrhaphy

Background: Although the recurrence rate for endoscopic herniorraphy is low (0–3%), it is still debatable whether these recurrences should be corrected laparoscopically or by the conventional method. The aim of this study was to investigate whether these recurrences can be repaired by means of the laparoscopic approach with acceptable complication and recurrence rates. Methods: From October 1992 to December 1997, 34 patients with recurrent inguinal hernias at physical examination underwent surgery at our institutions. All the recurrences occurred following endoscopic inguinal hernia repair with mesh prostheses. The recurrences were repaired endoscopically using a transabdominal approach. Depending on the size of the defect, a new polypropylene mesh was used. Results: Mean surgery time was 69 min. There were no conversions to the anterior approach. After a mean follow-up of 35 months, no recurrences had been diagnosed. Conclusion: The transabdominal preperitoneal approach is a reliable technique for recurrent inguinal hernia repair after previous endoscopic herniorrhaphy. Received: 7 September 1998/Accepted: 13 October 1998     

腹腔镜食道裂孔疝修补术的临床效果分析：附51例报告

目的:探讨腹腔镜食道裂孔疝修补术的安全性和疗效。方法:回顾分析2012年7月—2016年7月51例行腹腔镜食道裂孔疝修补术的患者临床资料。结果:51例患者均顺利接受腹腔镜食道裂孔疝修补术。术中裂孔缝合修补后均采用补片加强固定。对无明显禁忌证患者,同时行Dor胃底折叠术。平均时间(100±15.4)min,术中出血量平均(28±15.4)mL,术后平均住院时间2d。术后胸痛、进食后哽噎等疝囊压迫症状明显缓解,反酸,烧心等反流症状也得到明显改善。无严重并发症发生,均在4周内恢复正常饮食。平均随访32个月,未见裂孔疝复发及补片相关并发症。结论:腹腔镜食道裂孔疝修补术是安全有效的手术方式,食道裂孔缝合关闭后使用补片加强修补可以降低裂孔疝的复发率。     

Controlled multicenter trial of laparoscopic transabdominal preperitoneal hernioplasty vs Shouldice herniorrhaphy

Background: In February 1993 a prospective randomized multicenter trial was initiated to compare laparoscopic transabdominal preperitoneal hernioplasty to Shouldice herniorrhaphy as performed by surgeons of nonspecialized clinics. Methods: Until January 1994, 87 patients with 108 hernias took part in the trial (43 Shouldice and 44 laparoscopic repairs). Results: The laparoscopic procedure took significantly longer than did the open operation but caused less pain as measured by pain analogue score and consumption of paracetamol and narcotics. The postoperative complication rate was 26% in the open and 16% in the laparoscopic group. The patients in the laparoscopic group were discharged earlier and their convalescence was shorter than after open hernia repair. There has been one early recurrence in the laparoscopic and two in the open group to date with a mean follow-up of 201 days. Conclusions: Laparoscopic hernia repair causes less pain than the conventional operation and enables the patient to return to full work and usual activities earlier. The recurrence rate will not be known for 5 years.     

Patient-reported outcomes after inguinal herniorrhaphy

BACKGROUND: Patient-reported outcomes (PRO) reflect the functional outcomes of inguinal herniorrhaphy. We studied the effect of hernia recurrence and complications on PRO for participants in the Veterans Affairs trial of Open or Laparoscopic Repair of Inguinal Hernia. METHODS: Analyzed PRO included (1) the Medical Outcomes Study Short Form 36, version 2, (2) the Surgical Pain Scale, (3) the Activities Assessment Scale, and (4) patient satisfaction. Recurrences and complications were recorded at follow-up visits. Complications were categorized by (1) hematoma/seroma, (2) orchitis, (3) neuralgia, and (4) other. Univariate and multivariable regression analyses identified variables significantly associated with postoperative PRO. RESULTS: Of the 1603 patients with PRO data, 105 had a recurrence and 342 had a complication at 2 years. Multivariable analyses showed neuralgia (P < .0005) adversely affected all PRO, and recurrence (P < .05) affected patient-reported pain, activity, and satisfaction, but not the score for the Medical Outcomes Study Short Form 3. Patients with a recurrence after open repair had more pain than those with a recurrence after laparoscopic repair (P = .0001). Patients with other complications after laparoscopic repair reported more pain and less activity than those with other complications after open repair (P = .003 and P = .009, respectively). CONCLUSIONS: The effectiveness of inguinal herniorrhaphy should be measured by the rate of recurrence and neuralgia. Postoperative neuralgias have a deleterious effect on all patient-reported outcomes.     

Laparoscopic vs open herniorrhaphy in the management of pediatric inguinal hernia: a systemic review and meta-analysis

Purpose

Laparoscopic herniorrhaphy (LH) has been evolved as a minimally invasive technique for pediatric inguinal hernias (PIHs). Considerable debate exists regarding the benefits of LH over conventional open herniorrhaphy (OH). The aim of this review was to critique the current literature to determine the efficacy of LH.

Methods

Published studies until July 30, 2010, were searched from Medline, Embase, Ovid, Web of Science, and Cochrane databases. Randomized controlled trials (RCTs) and observational clinical studies (OCSs) with a comparison of LH and OH were included. A systemic review and meta-analysis were performed using the odds ratios (ORs) for dichotomous variables and weighted mean differences (WMDs) for continuous variables.

Results

Of 138 studies, 3 RCTs and 4 OCSs were eligible for inclusion criteria, comprising 1543 cases of LH and 657 cases of OH. Compared with OH, shorter operative time for bilateral hernias (WMD = −11.14; 95% confidence interval [CI], −20.61 to −1.68; P = .02) and lower rate of metachronic contralateral hernia (OR, 0.26; 95% CI, 0.09-0.76; P = .01) were noted in LH. However, no significant difference was observed between LH and OH in patients' age, sex, affected side, operative time for unilateral hernias, duration of hospital stay, time to resume full activity, recurrence, and complications.

Conclusions

Laparoscopic herniorrhaphy is superior to OH in the repair of bilateral PIH and lower rate of metachronic contralateral hernia, with similar operative time for unilateral hernias, length of hospital stay, recurrence, and complication rates. Because of the publishing bias, a series of RCTs with standard report format and uniform unit are necessary to explore the efficiencies of LH in the management of PIH.     

Kugel自膨式补片与Perfix网塞治疗成人原发腹股沟疝的对比研究

目的与传统Perfix网塞修补腹股沟疝比较,探讨Kugel补片的优点。方法Kugel补片修补组（下称Kugel组）39例,Perfix网塞修补组（下称Perfix组）48例。对两组患者术前基本情况,手术时间,术后早期反应,住院时间,术后并发症及复发率进行比较。结果Kugel组患者平均年龄显著高于Perfix组（P〈0．05）,Kugel组伤口疼痛、恢复活动时间以及伤121异物感、阴囊水肿例数显著低于Peffix组（P〈0．01）,手术时间显著低于Perfix组（P〈0．05）。术后随访平均12个月（5—16个月）,均未见复发。结论与Perfix网塞修补术相比,Kugel补片修补术具有伤口疼痛轻、异物感轻、恢复快的优点,Kugel补片修补手术是一种具有良好发展潜力的无张力疝修补术。     

Laparoscopic herniorrhaphy.

Laparoscopic inguinal hernia repair could represent an attractive alternative to conventional inguinal herniorrhaphy if it can be shown to result in less perioperative morbidity (primarily postoperative pain) or a decreased long-term recurrence rate. The data addressing either of these concerns will be forthcoming in ensuing years. The variations in the laparoscopic approach to the preperitoneal space and the differences in dissection and fixation techniques outlined in this article reflect the fact that the procedure is still evolving, and there is not yet a consensus on the best laparoscopic herniorrhaphy. It is likely that there will not be one laparoscopic technique applicable to all inguinal hernias. Rather, the patient's body habitus and the type of hernia encountered at laparoscopy will persuade the surgeon to use one of several techniques. Once a consensus is reached among surgeons as to the optimal laparoscopic hernia repair(s), it will be possible to begin gathering data concerning perioperative morbidity and recurrence rates. Only then can the question be answered whether laparoscopic inguinal herniorrhaphy has any advantages over the conventional extraperitoneal operation. A multicenter prospective nonrandomized trial has been initiated by our group in an attempt to determine whether laparoscopic inguinal herniorrhaphy has efficacy. The exact technique employed by the individual centers has not been strictly regulated, but general guidelines have been given. It is hoped that this project will provide information on whether laparoscopic inguinal herniorrhaphy is a useful alternative to conventional repair. Most of the laparoscopic inguinal herniorrhaphy techniques described in this article expose the patients to the inherent risks of initial laparoscopic penetration of the abdomen and the long-term possibility of adhesions to the sites where the peritoneum has been breached. Because these risks are not present in a conventional repair, the laparoscopic technique must have other advantages if it truly is to obtain a place in the armamentarium of general surgeons.     

Inguinal herniorrhaphy. Reduced morbidity by service standardization

To ascertain if service specialization and procedure standardization would improve the complication rate of inguinal herniorrhaphy, the results of all inguinal herniorrhaphies performed during a 3-year period by board-certified general surgeons who also performed a variety of other procedures common to the field of general surgery, assisted by general surgical residents (group B, 390 patients), were compared in the same institution with the results of inguinal herniorrhaphy when performed during 3 years under protocol by a Hernia Service directed by a senior faculty member assisted by junior surgical residents (group C, 442 patients). Group B patients had essentially no follow-up until they reappeared for care at the Hernia Service, whereas patients in group C achieved an 82% 7-year follow-up. The infection and recurrence rates of group C patients (0.45% and 0.9%, respectively) were significantly better than those of group B patients (5.9% and 4.6%, respectively). These results suggest that in our institution, the concentration of patients with hernias in a hernia service, manned by a specialized surgeon, produced better short- and long-term results than those obtained by general surgeons not dedicated to the field of hernia repair. Further studies will be necessary to confirm these findings.     

无张力疝修补术在腹股沟嵌顿疝中的应用

目的探讨无张力疝修补术治疗腹股沟嵌顿疝的可行性和有效性。方法回顾性分析2010年1月至2013年6月,芜湖市第二人民医院收治腹股沟嵌顿疝35例患者的临床资料,其中行无张力疝修补术14例（包括Lichtenstein术3例和Rutkow术11例）,传统疝修补术6例（Bassini术）,高位结扎疝囊15例,观察手术后的局部疼痛、切口感染以及术后复发等情况。结果35例患者手术均顺利完成,术后无切口感染、手术死亡。所有患者术后门诊随访3～6个月,未见复发。结论无张力疝修补术治疗腹股沟嵌顿疝安全、有效,值得临床应用。