Comparison of open and laparoscopic prosthetic repair of large ventral hernias.

BACKGROUND AND OBJECTIVES: Open ventral hernia repair is associated with significant morbidity and high recurrence rates. Recently, the laparoscopic approach has evolved as an attractive alternative. Our objective was to compare open with laparoscopic ventral hernia repairs. METHODS: Fifty laparoscopic and 22 open ventral hernia repairs were included in the study. All patients underwent a tension-free repair with retromuscular placement of the prosthesis. No significant difference between the 2 groups was noted regarding patient demographics and hernia characteristics except that the population in the open group was relatively older (59.4 vs 47.82, P < 0.003). RESULTS: We found no significant difference in the operative time between the 2 groups (laparoscopic 132.7 min vs open 152.7 min). Laparoscopic repair was associated with a significant reduction in the postoperative narcotic requirements (27 vs 58.95 mg i.v. morphine, P < 0.002) and the lengths of nothing by mouth (NPO) status (10 vs 55.3 hrs. P < 0.001), and hospital stay (1.88 vs 5.38 days, P < 0.001). The incidence of major complications (1 vs 4, P < 0.028), the hernia recurrence (1 vs 4, P < 0.028), and the time required for return to work (25.95 vs 47.8, P < 0.036) were significantly reduced in the laparoscopic group. CONCLUSIONS: Laparoscopic ventral hernioplasty offers significant advantages and should be considered for repair of primary and incisional ventral hernias.     

腹腔镜与开放式无张力修补术治疗腹壁疝临床对比研究

目的 评价腹腔镜腹壁疝修补术（LVHR）的安全性与有效性。方法 对2007年1月至2008年8月间上海交通大学医学院附属瑞金医院接受无张力修补术的68例腹壁疝病人（缺损长径≤20cm）的临床资料进行回顾性分析。结果 LVHR 31例,开放式腹壁疝修补术（OVHR）37例。随访时间1～21个月（中位时间11个月）。LVHR与OVHR在年龄、性别比、BMI和疝缺损大小上差异无统计学意义（P>0.05）。LVHR与OVHR的平均手术时间分别为（60.5±17.7）min和（75.5±30.3）min（P＝0.017）,平均术后住院天数分别为（6.2±2.5）d和（9.6±8.0）d（P＝0.026）,术后2周内恢复非限制性活动人数分别为96.8%和78.4%（P=0.026）,差异均有统计学意义。两组术后第1天的疼痛评分VAS分别为5.6±1.2和6.3±1.3,差异有统计学意义（P＝0.018）,术后1周和1个月的VAS差异无统计学意义（P＝0.932,P＝0.056）。两组总并发症发生率分别为19.4%和24.3%（P =0.623）,复发率分别为3.2%和5.6%（P =1.000）,差异无统计学意义。两组的住院总费用分别为（18334±5336）元和（9508±9222）元,差异有统计学意义（P =0.000）。结论 LVHR对于缺损长径<20cm的腹壁疝是安全有效的。     

Comparison of laparoscopic primary and open primary repair of ventral hernias

Prosthetic materials have gained popularity for ventral hernia repair. There are situations when the use of a mesh is either unnecessary or contraindicated. This study compares 51 patients with ventral hernia who underwent laparoscopic or open primary suture repair. Results were determined by a median follow-up of 33 months. Recurrence rates and operative time were the major parameters of outcome. Mean operative time was insignificantly shorter in the laparoscopic group (14.8 ± 4.3 vs. 15.6 ± 3.7 min). There were no short-term complications in groups. One patient in each group had recurrence. Conclusively, laparoscopic primary repair of small ventral hernias is simple and can be performed as an initial approach for small defects. Compared with open repair, it has the advantages of better exposure, reduced pain, and less morbidity. It can also be performed as a component of a combined laparoscopic operation. However, this technique is not recommended for repair of large ventral hernias.     

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目的 评价腹腔镜技术治疗复发性腹股沟疝的安全性和有效性,讨论术式选择.方法 回顾性分析2003年1月至2006年12月上海交通大学医学院附属瑞金医院收治的58例(63例次)复发性腹股沟疝的临床资料.其中腹腔镜腹股沟疝修补术(LIHR)27例(30例次),开放式无张力修补术(OMR)31例(33例次).术后病人均得到随访,随访时间12-36个月(中位时间18个月).结果 两组在手术时间差异(P=0.072)、术后住院天数差异(P=0.076)、术后第2天疼痛分数(VAS)差异(P=0.084)、2周内恢复非限制性活动例数差异(P=1.000)均无统计学意义;LIHR组的住院费用高于OMR组,差异有统计学意叉(P=0.000);两组在随访期内均无复发,总并发症发生率分别为6.7%(2/30)和9.1%(3/33),差异无统计学意义(P=1.000).结论 LIHR在治疗复发性腹股沟疝时与OMR同样安全有效,术式选择取决于前次手术的类型和外科医师的临床经验.     

腹腔镜与无张力疝修补治疗复发性腹股沟疝对比分析

目的评价腹腔镜下治疗复发性腹股沟疝的安全性与有效性,讨论术式的选择。方法回顾性分析2008年1月至2012年1月收治的58例复发性腹股沟疝的临床资料。其中腹腔镜腹股沟疝修补术(LIHR)27例,开放式无张力修补术31例。术后患者均得到随访,随访时间2～42个月(中位时间18个月)。结果二组手术时间差异(P=0.072)、术后住院天数无差异(P=0.067)、术后第二天疼痛分数(VAS)差异(P=0.084)、2周内恢复非限制性活动例数差异(P=1.000)均无统计学意义;二组患者在随访期内均无复发,总并发症发生率分别为6.7%和9.1%,差异无统计学意义(P=1.000)。结论 LIHR在治疗复发性腹股沟疝时与开放式无张力修补术同样安全有效,术式选择取决于前次手术的类型和手术医师的临床经验。     

Pooled data analysis of laparoscopic vs. open ventral hernia repair: 14 years of patient data accrual

BACKGROUND: The purpose of this study was to analyze the published perioperative results and outcomes of laparoscopic (LVHR) and open (OVHR) ventral hernia repair focusing on complications and hernia recurrences. METHODS: Data were compiled from all English-language reports of LVHR published from 1996 through January 2006. Series with fewer than 20 cases of LVHR, insufficient details of complications, or those part of a larger series were excluded. Data were derived from 31 reports of LVHR alone (unpaired studies) and 14 that directly compared LVHR to OVHR (paired studies). Chi-squared analysis, Fisher's exact test, and two-tailed t-test analysis were used. RESULTS: Forty-five published series were included, representing 5340 patients (4582 LVHR, 758 OVHR). In the pooled analysis (combined paired and unpaired studies), LVHR was associated with significantly fewer wound complications (3.8% vs. 16.8%, p < 0.0001), total complications (22.7% vs. 41.7%, p < 0.0001), hernia recurrences (4.3% vs. 12.1%, p < 0.0001), and a shorter length of stay (2.4 vs. 4.3 days, p = 0.0004). These outcomes maintained statistical significance when only the paired studies were analyzed. In the pooled analysis, LVHR was associated with fewer gastrointestinal (2.6% vs. 5.9%, p < 0.0001), pulmonary (0.6% vs. 1.7%, p = 0.0013), and miscellaneous (0.7% vs. 1.9%, p = 0.0011) complications, but a higher incidence of prolonged procedure site pain (1.96% vs. 0.92%, p = 0.0469); none of these outcomes was significant in the paired study analysis. No differences in cardiac, neurologic, septic, genitourinary, or thromboembolic complications were found. The mortality rate was 0.13% with LVHR and 0.26% with OVHR (p = NS). Trends toward larger hernia defects and larger mesh sizes were observed for LVHR. CONCLUSIONS: The published literature indicates fewer wound-related and overall complications and a lower rate of hernia recurrence for LVHR compared to OVHR. Further controlled trials are necessary to substantiate these findings and to assess the health care economic impact of this approach.     

Evaluation of efficacy and indications of surgical fixation for multiple rib fractures: a propensity-score matched analysis

Purpose

The purpose of this study was to assess the effects of recent surgical rib fixation and establish its indications not only for flail chest but also for multiple rib fractures.

Methods

Between 2007 and 2015, 187 patients were diagnosed as having multiple rib fractures in our institution. After the propensity score matching was performed, ten patients who had performed surgical rib fixation and ten patients who had treated with non-operative management were included. Categorical variables were analyzed with Fischer’s exact test and non-parametric numerical data were compared using the Mann–Whitney U test. Wilcoxon signed-rank test was performed for comparison of pre- and postoperative variables. All statistical data are presented as median (25–75 % interquartile range [IQR]) or number.

Results

The surgically treated patients extubated significantly earlier than non-operative management patients (5.5 [1–8] vs 9 [7–12] days: p = 0.019). The duration of continuous intravenous narcotic agents infusion days (4.5 [3–6] vs 12 [9–14] days: p = 0.002) and the duration of intensive care unit stay (6.5 [3–9] vs 12 [8–14] days: p = 0.008) were also significantly shorter in surgically treated patients. Under the same ventilating conditions, the postoperative values of tidal volume and respiratory rate improved significantly compared to those values measured just before the surgery. The incidence of pneumonia as a complication was significantly higher in non-operative management group (p = 0.05).

Conclusions

From the viewpoints of early respiratory stabilization and intensive care unit disposition without any complications, surgical rib fixation is a sufficiently acceptable procedure not only for flail chest but also for repair of severe multiple rib fractures.

     

Usage and survival implications of surgical staging of inguinal lymph nodes in intermediate- to high-risk,clinical localized penile cancer: A propensity-score matched analysis

Objectives

To evaluate the usage of surgical staging of inguinal lymph nodes (SSILNs) in the United States for intermediate to high-risk, clinically localized penile squamous cell cancer (SCC), to explore patient and hospital factors associated with omission of this staging, and to evaluate the effect on survival.

A comparison of outcome and cost of open vs. laparoscopic cholecystectomy.

One hundred elective completed laparoscopic cholecystectomies performed during the period July 1990 to June 1991 were prospectively analyzed for age, sex, and the study variables. A control group of 100 age- and sex-matched patients undergoing elective open cholecystectomy in the year prior to the advent of laparoscopic cholecystectomy was retrospectively analyzed. Both groups were comparable with regard to height, weight, severity of disease, and co-morbidity. The mean operative time for the laparoscopic cholecystectomy group was 107 min vs. 72 min for the open cholecystectomy group. Other significant differences included the use of cholangiography (24% vs. 93%), placement of drains (4% vs. 27%), and morbidity (3% vs. 7%). There was no mortality in either group. The mean length of hospital stay was 1.6 days for the laparoscopic cholecystectomy group vs. 4.8 days in the open cholecystectomy group. The resultant difference in hospital charges to the patient favored laparoscopic cholecystectomy with a mean charge of $6471 vs. $8896 for the open cholecystectomy group. The results of this study support the conclusions that laparoscopic cholecystectomy is a safe and effective alternative to open cholecystectomy and results in a significantly shorter hospital stay with considerable cost savings.     

后腹腔镜与经腰背途径输尿管切开取石手术疗效比较

目的 对后腹腔镜和经腰背部途径治疗输尿管上段结石的疗效指标进行比较,探讨两种术式的技术要点.方法 收治98例上尿路结石病例,其中42例行后腹腔镜输尿管切开取石术,56例行经腰背部直切口输尿管切开取石术.腹腔镜术式采用气管插管全麻,经腰背部途径采用腰硬联合麻.两组术中均留置双J管.结果 98例手术全部成功,两组术中均无需输血.两组在手术时间、术中出血及住院时间有统计学差异,术后复查未见结石残留,随访无并发症发生.结论 对输尿管上段结石的治疗,后腹腔镜输尿管切开取石术微创、安全、有效,较经腰背部途径术中出血少、术后恢复快.但它需要较长的手术时间和一定的腹腔镜外科训练.     

Comparison of long-term outcome and quality of life after laparoscopic repair of incisional and ventral hernias with suture fixation with and without tacks: a prospective, randomized, controlled study

Background

Technique of mesh fixation in laparoscopic incisional hernia repair is a matter of debate. Literature is lacking in randomized trials comparing various methods of mesh fixation. This study was designed to compare the cost-effectiveness and long-term outcomes following the two methods of mesh fixation.

Methods

A total of 110 patients were randomized to tacker mesh fixation or suture mesh fixation. Patients with nonrecurrent hernias with defect size ranging from 2 to 5?cm were included. The cost and incremental cost-effectiveness ratio was calculated. SF-36v2 health survey was used for quality-of-life analysis. Patients were followed up at regular intervals, and return to activity and satisfaction scores were recorded.

Results

Demographic profile and hernia characteristics were comparable between the two groups. Operation time was significantly higher (p?<?0) and early postoperative pain at 1?h, 6?h, and 1?month was significantly lower in the suture group. There was no significant difference in the incidence of chronic pain and seroma formation over a mean follow-up of 32.2?months. Cost of procedure was significantly higher in group I (p?<?0.001). Suture fixation was found to be more cost-effective than tacker fixation. Postoperative quality of life outcomes were similar in the two groups. Among return to activity parameters, time to resumption of daily activities and starting climbing stairs were significantly shorter in the suture group.

Conclusions

The suture fixation method is a cost-effective alternative to tacker fixation in patients with small- to medium-sized defects in laparoscopic incisional and ventral hernia repair. Suture fixation is better than tacker fixation in terms of early postoperative pain and return to activity. The two procedures are equally effective regarding the recurrence rates, complications, hospital stay, chronic pain, quality of life determinants, and patient satisfaction.     

Differences in the outcomes of scrotal vs. lateral vs. medial inguinal hernias: a multivariable analysis of registry data

Hernia - There are hardly any studies on the outcome of scrotal compared with medial and lateral inguinal hernias. Therefore, this present multivariable analysis of data from the Herniamed Registry...     

Similar outcomes after newly implemented rats approach compared to standard vats for anatomical lung resection. A propensity-score matched analysis

IntroductionOutcomes after the introduction of surgical innovations can be impaired by learning periods. The aim of this study is to compare the short-term outcomes of a recently implemented RATS approach to a standard VATS program for anatomical lung resections.MethodsRetrospective review of consecutive patients undergoing pulmonary anatomical resection through a minimally invasive approach since RATS approach was applied in our department (June 01, 2018, to November 30, 2019). Propensity score matching was performed according to patients’ age, gender, ppoFEV1, cardiac comorbidity, type of malignancy, and type of resection. Outcome evaluation includes: overall morbidity, significant complications (cardiac arrhythmia, pneumonia, prolonged air leak, and reoperation), 30-day mortality, and length of hospital stay. Data were compared by two-sided chi-square or Fisher's exact test for categorical and Mann–Whitney U test for continuous variables.ResultsA total of 273 patients (206 VATS, 67 RATS) were included in the study. After propensity score matching, data of 132 patients were analyzed. The thirty-days mortality was nil. Overall morbidity (RATS: 22.4%, VATS: 29.2%; p = 0.369), major complications (RATS: 9% vs VATS: 9.2%; p = 0.956) and the rates of specific major complications (cardiac arrhythmia RATS: 4.5%, VATS: 4.6%, p = 1; pneumonia RATS:0%, VATS:4.6%, p = 0.117; prolonged air leak RATS: 7.5%; VATS: 4.6%, p = 0.718) and reoperation (RATS: 3%, VATS: 1.5%, p = 1) were comparable between both groups. The median length of stay was 3 days in both groups (p = 0.101).ConclusionsA RATS program for anatomical lung resection can be implemented safely by experienced VATS surgeons without increasing morbidity rates.     

腹腔镜下腹壁疝腹膜外补片修补术与腹腔内补片修补术比较的多中心回顾性研究

背景与目的 腹壁疝修补术是最常见的外科手术之一,全球每年有200万例左右的腹壁疝患者接受手术治疗。与开放手术相比,腹腔镜下腹壁疝修补术优势明显。然而腹腔镜下腹腔内补片修补术（IPOM）与腹腔镜下腹膜外补片修补术（ESR）这两种腔镜术式的优缺点及疗效如何,尚无大样本的临床研究证实。因此,本研究通过比较ESR与IPOM两种手术方式治疗腹壁疝的近远期疗效,为临床提供循证参考。方法 回顾性分析2017年1月1日—2022年12月31日湖南省11家医疗机构收治的157例行腹腔镜腹壁疝修补术患者的临床资料,其中124例行ESR（ESR组）,33例行IPOM（IPOM组）,对比分析两组病例的临床特点、手术方式和术后近远期效果。结果 全组无中转开腹病例或围术期死亡病例。两组病例的年龄、性别、BMI、类型差异均无统计学意义（均P>0.05）。两组病例疝环横径、手术时间、术中出血量、疝环闭合概率差异均无统计学意义（均P>0.05）。网片固定方式ESR组以自固定和缝线固定为主（91.1%）,而IPOM组以钉枪固定为主（69.7%）,差异有统计学意义（P<0.05）。ESR组的术后疼痛评分明显低于IPOM组（2.4±0.8 vs. 2.8±1.0,P<0.05）,住院费用明显低于IPOM组（21 001元vs. 38 437元,P<0.05）。两组的术后住院时间和近期并发症发生率差异无统计学意义（均P>0.05）。中位随访10.3个月,ESR组无复发病例,IPOM组2例复发（6.1%）,差异有统计学意义（P<0.05）。结论 ESR是湖南地区腹腔镜下腹壁疝修补的主流术式之一。由于固定方式和网片选择的不同,ESR较之IPOM而言,术后疼痛更轻微、费用更低、复发率更低,且并不明显增加手术时间和术后近期并发症。     

Replacement of expensive, disposable instruments with old-fashioned surgical techniques for improved cost-effectiveness in laparoscopic hysterectomy.

OBJECTIVE: Patients demand that health care and procedures in rural areas be provided by ambulatory surgery centers close to home. However, the reimbursement rate for such procedures in ambulatory centers is extremely low, so a standard classic intrafascial supracervical hysterectomy procedure needs to be more cost effective to be performed there. Instruments and disposable devices can make up > or = 50% of hospital costs for this procedure, so any cost reduction has to focus on this aspect. METHODS: We identified the 3 most expensive disposable devices: (1) an Endostapler, 498 US dollars and 3 staple reloads, 179 US dollars each; (2) a calibrated uterine resection tool 15 mm for encoring of the endocervical canal, 853 US dollars; and (3) a serrated edged macro morcellator for intraabdominal uterus morcellation, 321 US dollars, and substituted them using classic conservative surgical techniques. RESULTS: From September 2001 to September 2002, we performed 26 procedures with this modified technique at an ambulatory surgery center with a follow-up of 6.7 (2 to 14) months. This modified operative technique was feasible; no conversions were necessary, and no complications occurred. Cost savings were 2209 US dollars per procedure; additional costs were 266.33 US dollars for suture material and an Endopouch, resulting in an overall savings of 50 509.42 US dollars. The disadvantage was an increase in operating room time of about 1 hour 20 minutes per case. CONCLUSION: These modifications in the classic intrafascial supracervical hysterectomy technique have proven to be feasible, safe, and highly cost effective, especially for a rural ambulatory surgery center. Long-term follow-up is necessary to further evaluate these operative modifications.     

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.     

Functional outcome and cost-effectiveness of outpatient vs inpatient care for complex hind-foot and ankle surgery. A retrospective cohort study

Study objectiveTo compare the postoperative functional outcome and the total cost associated with outpatient vs inpatient care following complex hind-foot and ankle surgery.DesignRetrospective, cohort study.SettingTertiary care center.PatientsForty patients, American Society of Anesthesiologists 1-3, of either sex undergoing elective complex hind-foot and ankle surgery (fusion, osteotomy, or multiple ligament repair).InterventionsBoth inpatients and outpatients received a continuous perineural infusion of local anesthetic for 48 hours at the core of a multimodal analgesic regimen. Patients were retrospectively identified, and an outpatient cohort was matched to an inpatient cohort in a 1:1 ratio for age, sex, baseline functional score, and type of surgery.MeasurementsThe primary outcome was functional outcome upon discharge of the surgical program as measured by the Lower Extremity Functional Score. Secondary outcomes were the incidence of surgical or anesthetic complications and the total perioperative cost of care.ResultsPatients in both cohorts had similar functional outcome on discharge of the surgical program. Analgesia was effective in both groups, and no complications were reported. The cost of care for outpatients was 54% lower than that for inpatients.ConclusionThis retrospective study suggests that outpatient care including an ambulatory perineural infusion of local anesthetic may be a cost-effective alternative to inpatient care after complex foot and ankle surgery.     

Trimodal therapy vs. radical cystectomy for muscle-invasive bladder cancer: A Canadian cost-effectiveness analysis

IntroductionTrimodal therapy (TMT) is a suitable alternative to neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) for patients with muscle-invasive bladder cancer (MIBC). In this study, we conducted a cost-effectiveness evaluation of RC±NAC vs. TMT for MIBC in the universal and publicly funded Canadian healthcare system.MethodsWe developed a Markov model with Monte-Carlo microsimulations. Rates and probabilities of transitioning within different health states (e.g., cure, locoregional recurrence, distant metastasis, death) were input in the model after a scoped literature review. Two main scenarios were considered: 1) academic center; and 2) populational-level. Results were reported in life-years gained (LYG), quality-adjusted life years (QALY), and incremental cost-effectiveness ratio (ICER). A sensitivity analysis was performed.ResultsA total of 20 000 patients were simulated. For the academic center model, TMT was associated with increased effectiveness (both in LYG and QALY) at a higher cost compared to RC±NAC at five and 10 years. This resulted in an ICER of $19 746/QALY per patient undergoing the TMT strategy at 10 years of followup. For the populational-level model, RC±NAC was associated with higher effectiveness at 10 years, with an ICER of $3319/QALY per patient. This study was limited by heterogeneity within the studies used to build the model.ConclusionsIn this study, TMT performed in academic centers was cost-effective compared to RC±NAC, with higher effectiveness at a higher cost. On the other hand, RC±NAC was considered cost-effective compared to TMT at the populational-level. Further studies are needed to confirm these results.