A prospective, randomized study of open vs laparoscopic inguinal hernia repair. An assessment of postoperative pain

Open Mesh Repair for Inguinal Hernia is Safer than Laparoscopic Repair or Open Non-mesh Repair: A Nationwide Registry Study of Complications

BACKGROUND

Inguinal hernia repair is the most common elective procedure in general surgery. Therefore, the number of patients having complications related to inguinal hernia surgery is relatively large. The aim of this study was to compare complication profiles of inguinal open mesh (OM) hernioplasties with open non-mesh (OS) repairs and laparoscopic (LAP) repairs using retrospective nationwide registry data.

METHODS

The database of the Finnish Patient Insurance Centre (FPIC) was searched for complications of inguinal and femoral hernia repairs during 2002-2010. Complications of OM repairs were compared to complications of OS repairs and LAP repairs.

RESULTS

Over 75 % of all inguinal hernia procedures during the study period in Finland were OM hernioplasties. FPIC received 245 complication reports after OM repairs, 40 after OS repairs, and 50 after LAP repairs. Reported complications were significantly more severe after LAP and OS repairs than OM surgery (p<0.001). Visceral complications (p<0.001), deep infections (p<0.001), and deep hemorrhagic complications (p<0.001) were overrepresented in the LAP group. In the OS group, visceral complications (p<0.001), recurrences (p<0.001), and severe neuropathic pain (p<0.001) predominated.

CONCLUSION

LAP and OS repairs of inguinal hernia were associated with more severe complications than open surgery with mesh in this study.

Preperitoneal surgery using a self-adhesive mesh for inguinal hernia repair

Background and Objectives:

Laparoscopic preperitoneal hernia repair with mesh has been reported to result in improved patient outcomes. However, there are few published data on the use of a totally extraperitoneal (TEP) approach. The purpose of this study was to present our experience and evaluate early outcomes of TEP inguinal hernia repair with self-adhesive mesh.

Methods:

This cohort study was a retrospective review of patients who underwent laparoscopic TEP inguinal hernial repair from April 4, 2010, through July 22, 2014. Data assessed were age, sex, body mass index (BMI), hernia repair indications, hernia type, pain, paresthesia, occurrence (bilateral or unilateral), recurrence, and patient satisfaction. Descriptive and regression analyses were performed.

Results:

Six hundred forty patients underwent laparoscopic preperitoneal hernia surgery with self-adhesive mesh. The average age was 56 years, nearly all were men (95.8%), and the mean BMI was 26.2 kg/m². Cases involved primary hernia more frequently than recurrent hernia (94% vs 6%; P < .05). After surgery, 92% of the patients reported no more than minimal pain, <1% reported paresthesia, and 0.2% had early recurrence. There were 7 conversions to an open procedure. The patients had no adverse reactions to anesthesia and no bladder injury. Postoperative acute pain or recurrence was not explained by demographics, BMI, or preoperative pain. There were significant associations of hernia side, recurrence, occurrence, and sex with composite end points. Nearly all patients (98%) were satisfied with the outcome.

Conclusion:

The use of self-adhesive, Velcro-type mesh in laparoscopic TEP inguinal hernia repair is associated with reduced pain; low rates of early recurrence, infection, and hematoma; and improved patient satisfaction.

Factors affecting unused remaining volume of intravenous patient-controlled analgesia in patients following laparoscopic gynecologic surgery

PURPOSE

This study was undertaken to evaluate the factors affecting the unused remaining volume of intravenous patient-controlled analgesia (IV PCA) in patients who had undergone laparoscopic gynecologic surgery.

METHODS

We retrospectively collected patient records from pre-existing PCA log sheets from 98 patients. Surgical factors and IV PCA-related data including remaining volume, administration duration, early discontinuation (yes or no), and adverse reactions were recorded. Chi-square test, one-way analysis of variance, and multiple linear regression were applied for data analysis.

RESULTS

The average age of the 98 patients was 40.0 ± 8.24 years. The incidence of postoperative nausea and vomiting (PONV) and early discontinuation were not statistically significant among the different surgical groups (p = .540 and p = .338, respectively). Twenty-eight patients wanted discontinuation of IV PCA and the remaining volume was 33.6 ± 7.8 mL (range 20-55 mL). The significant determinants of remaining volume were whether IV PCA was discontinued due to PONV and duration of surgery (p < .001). The surgical duration was inversely correlated with the remaining volume.

CONCLUSION

Early discontinuation of IV PCA due to PONV is a major contributing factor to wastage of medicine. Prevention and treatment of PONV is needed to encourage patients to maintain PCA use for pain control.

Early pain after laparoscopic inguinal hernia repair. A qualitative systematic review

BACKGROUND

Early post-operative pain after laparoscopic groin hernia repair may, as in other laparoscopic operations, have its own individual pain pattern and patient-related predictors of early pain. The purpose of this review was to characterise pain within the first post-operative week after transabdominal pre-peritoneal repair (TAPP) and total extraperitoneal repair (TEP), and to identify patient-related predictors of early pain.

METHODS

A qualitative systematic review was conducted. Pubmed, Embase, CINAHL, and the Cochrane database were searched for studies on early pain (first week) after TAPP or TEP.

RESULTS

We included 71 eligible studies with 14,023 patients. Post-operative pain is most severe on day 0 and mainly on a level of 13-58 mm on a visual analogue scale and decreases to low levels on day 3. There seems to be no difference in pain intensity and duration when TEP and TAPP are compared. Deep abdominal pain (i.e. groin pain/visceral pain) dominates over superficial pain (i.e. somatic pain) and shoulder pain (i.e. referred pain) after TAPP. Predictors of early pain are young age and pre-operative high pain response to experimental heat stimulation. Furthermore, evidence supported early pain intensity as a predictive risk factor of chronic pain after laparoscopic groin hernia repair.

CONCLUSION

Early pain within the first week after TAPP and TEP is most severe on the first post-operative day, and the pain pattern is dominated by deep abdominal pain. Early post-operative pain is most intense in younger patients and can be predicted by pre-operative high pain response to experimental heat stimulation.

The preperitoneal memory-ring patch for inguinal hernia: a prospective multicentric feasibility study

PURPOSE

To evaluate the feasibility, the reproducibility, the safety and the efficacy of a recently introduced preperitoneal memory-ring patch (Polysoft, Davol Inc., C.R. Bard Inc., Crawley, UK) by a prospective multicentric observational study.

METHODS

We performed 235 unilateral groin hernia repairs in 200 consecutive patients during a 12-month period. Patients were operated by three different surgeons in two different centres. Pre- and intraoperative data, as well as postoperative complications, were prospectively recorded.

RESULTS

Two hundred patients, with a mean age of 55.4 years, were operated for primary or recurrent unilateral groin hernias. The mean operation time for unilateral hernia repair was 22 min (range 14-37 min). Seventy-one patients (35.5%) were operated in an ambulatory setting. Considering pain scores, we observed a preoperative visual analogue scale (VAS) score of 1.4 (range 0-3.7). After 24 h, 3 weeks and 6 months, VAS was 4.2 (0.5-6.9), 1.7 (0-2.0) and 0.1 (0-1.5), respectively. The follow-up was more than 18 months in all patients (range 19-31 months). In total, three patients were diagnosed with a recurrence and were reoperated by an anterior Lichtenstein repair with large-pore mesh.

CONCLUSION

This transinguinal minimally invasive preperitoneal mesh repair is reproducible, easy to perform and safe with acceptable mid-term results. These elements, together with a minimal superficial dissection in the inguinal canal, preperitoneal mesh placement and the absence of fixation, are possible elements to reduce acute and chronic postoperative pain compared to other open and also laparoscopic techniques that have to be proven in larger (randomised) trials.

Open vs. laparoscopic pyloromyotomy--a retrospective analysis

Laparoscopic pyloromyotomy has obtained increasing importance in the last years. However, there is no proof of an obvious advantage of the laparoscopic over the open approach. This retrospective analysis of 157 infants with pyloromyotomies (129 open and 28 laparoscopic procedures) should settle the benefit of one of these procedures. The duration of the operation in the laparoscopic procedure was significantly shorter than in open pyloromyotomy (median 25 versus 34 min; p = 0.025). Complete oral feeding was reached after similar postoperative time in both groups, but the postoperative hospital length of stay in the laparoscopic group was significantly shorter than in the open group (3.5 versus 7 days, p = 0.008). The postoperative requirements for analgetics were low and showed no difference in both groups. In our clinic the laparoscopic pyloromyotomy was successfully introduced as standard operating procedure. There was no difference in the complication rate as compared to the open procedure. The recovery time was shorter in the laparoscopic group. A superiority of the laparoscopic pyloromyotomy over the open procedure is suggested by the ascertained data.

Postoperative pain and quality of life after laparoscopic and open inguinal hernia repair: results of a prospective randomized trial

BACKGROUND

As part of a large prospective randomized Austrian multicenter trial evaluating recurrence rates and complications of open and laparoscopic unilateral inguinal hernia repairs we assessed postoperative pain and quality of life.

METHODS

Approximately 151 patients were randomized to Shouldice repair, Bassini operation, or laparoscopic transabdominal preperitoneal hernioplasty (TAPP). Pain was recorded preoperatively and on the first four postoperative days. Quality of life was recorded preoperatively and 1 month postoperatively.

RESULTS

Patients having Shouldice repairs had significantly higher visual analog-scale scores for pain on the fourth postoperative day (P=0.048) and significantly higher scores in McGill pain questionnaires on the first four postoperative days (P=0.046) compared with the other groups. Apart from a significantly lower score in postoperative bodily pain in the Shouldice group (P=0.039), no significant differences in quality of life were apparent among the three methods.

CONCLUSIONS

The TAPP and Bassini repairs result in less short-term postoperative pain.

Day case laparoscopic herniorraphy. A NICE procedure with a long learning curve

BACKGROUND

The aim of this study was to evaluate day case laparoscopic herniorraphy (LH) and to ascertain the impact of trainee surgeons on its performance.

METHODS

We performed a prospective study of ambulatory laparoscopic transabdominal preperitoneal herniorraphies performed in a dedicated day surgical unit between March 1996 and October 2003.

RESULTS

A total of 840 herniorraphies were performed in 706 consecutive patients. Surgery was performed by 15 higher surgical trainees and three consultant surgeons. The mean operating times for trainees were longer for unilateral (48.4 +/- 0.98 vs 41.4 +/- 0.87 min, p < 0.05) and bilateral (69.0 +/- 3.24 vs 53.0 +/- 1.68 min, p < 0.05) repairs than for consultants. Subgroup analysis demonstrated that after an experience of 40 procedures, trainee times approached those of the consultants (41.39 +/- 1.17 vs 41.4 +/- 0.87 min, p= 0.31). LH repair was well tolerated and associated with minimal postoperative pain and nausea. Mean pain scores postoperatively and at 24 h were 2.69 +/- 0.11 and 2.07 +/- 0.09, respectively. Mean nausea scores postoperatively and at 24 h were 0.34 +/- 0.06 and 0.22 +/- 0.06, respectively. Ninety-three percent of patients (n = 657) were discharged within 8 h. There were two conversions to an open procedure (0.1%) and two significant complications (0.1%). Ninety-five percent of patients who responded to our questionnaire (n = 398/419) were satisfied with surgery and would undergo day case laparoscopic herniorraphy again.

CONCLUSIONS

Laparoscopic herniorraphy is a safe technique suitable for day case surgery. Operator experience dictates duration of surgery. Trainees' operating times approach those of consultants after 40 procedures. Prolonged operating times and increased cost are not justifiable reasons for not recommending LH.

Laparoscopic Versus Open Myomectomy: A Double-Blind Study to Evaluate Postoperative Pain

The advantages of laparoscopic over open surgery have been documented in nonblinded settings. Our prospective, double-blind setting evaluated pain scores 72 h after surgery by comparing patients who underwent laparoscopic myomectomy or with laparotomy. Forty women referred for conservative myomectomy were included in the study. After stratification (myoma size, number of myomas, and surgeon), patients were randomized to either laparoscopy (n = 19) or laparotomy (n = 21) and received a standardized anesthesia and patient-controlled analgesia for 24 h after surgery. Identical wound dressings were applied to blind the patient and the observer to the surgical approach. The postoperative pain scores were documented on a visual analog scale (VAS; 0 = no and 10 = unbearable pain) at 24, 48, and 72 h after surgery. As the primary outcome variable, we calculated the mean overall VAS-score at these time points. P < 0.05 (t-test and analysis of covariance) was considered statistically significant. There were no differences in patient characteristics among the groups. The mean overall VAS score at 24, 48, and 72 h was statistically significantly lower in the laparoscopic group compared with the laparotomy group (2.28 +/- 1.38 versus 4.03 +/- 1.63; P < 0.01). Our data demonstrate, for the first time in a double-blind setting, that laparoscopic myomectomy reduces postoperative pain for 72 h after surgery compared with laparotomy.

"Sports" hernia: treatment with biologic mesh (Surgisis): a preliminary study

BACKGROUND

Groin pain in athletes is caused by a wide range of musculoskeletal disorders. Occasionally, a palpable bulge at the external ring or ultrasound may not demonstrate a hernia. When athletes do not respond to conservative treatment, a "sports" hernia should be considered.

METHODS

A retrospective review of 750 laparoscopic preperitoneal hernias was performed. A sports hernia was defined as a tear in the transversalis fascia that was not evident by preoperative physical exam. A 7 x 10-cm biologic mesh, Surgisis, was placed, uncut, over the myopectinate orifice and fixed with five tacks or fibrin glue. Patients were followed up at 2 and 6 weeks, 6 months, and 1 year.

RESULTS

Ten professional and amateur athletes were found to have sports hernias. Operative time averaged 32 min. There were no major complications. All athletes returned to full activities in 4 weeks. Only one patient did not show improvement in his symptoms. No patient developed a recurrent hernia.

CONCLUSIONS

Laparoscopic exploration should be considered in athletes with chronic groin pain that does not improve after conventional treatments have failed. Furthermore, biologic mesh (Surgisis) should be considered for the repair of inguinal sports hernias.

Kugel herniorrhaphy: clinical results of 124 consecutive operations

PURPOSE

Due to its recent clinical application, the results of Kugel herniorrhaphy have not yet been well documented. We analyzed our experience in performing 124 consecutive Kugel herniorrhaphies at a single institute.

METHODS

Since the first introduction of Kugel herniorrhaphy in Japan in September 2001, a total of 117 patients (124 hernias) have undergone this procedure at our institute. The operative technique of Kugel herniorrhaphy was directly obtained through two hands-on training courses that were given by Dr. Kugel. The clinical results of the 124 hernias were analyzed, and to understand the feasibility of performing Kugel herniorrhaphy for various types of hernias, the operation time and the necessity for dividing the hernia sac were compared among each type based on the Nyhus classification.

RESULTS

The operation times in types 2, 3A, 3B, 3C, and 4 were 48.5 +/- 19.5, 45.9 +/- 19.9, 54.2 +/- 24.8, 52.5 +/- 10.6, and 64.4 +/- 56.7 min, respectively, and the differences between each group were not statistically significant. In type 3A, no patient required a division of the hernia sac (0%), in contrast to 43% in type 3B. Peritoneal injury during operation and local hematoma/seroma were the most common complications (8.1% and 8.9%, respectively). Postoperatively the patients' quality of life factors, such as the analgesics needed, number of days before a return to normal activity, number of days before a return to work, and the recurrence rate of 0.9%, were comparable with other tension-free herniorrhaphy findings reported in the past.

CONCLUSION

Our results suggest that Kugel herniorrhaphy is equally feasible for all types of Nyhus classifications, including femoral and recurrent hernias.

Kugel hernia repair: open “mini-invasive” technique. Personal experience on 620 patients

A large monoinstitutional series adopting the Kugel retroparietal technique for inguinal hernia surgery is analysed. Our aim is to assess the "mini-invasiveness" of this technique. Six hundred and twenty patients (pts) affected by monolateral inguinal hernia were treated with a preperitoneal alloplasty with a posterior approach (Kugel hernia repair, KHR) between January 2002 and September 2004. The surgical incision extension was 3.5 cm on average (range 2-4.5). The mean operation time was 33 min (range 20-45). Spinal anaesthesia and ambulatory procedure were applied in 595 cases (96%). Postoperative complications affected 20 pts (3%). The postoperative pain was well controlled. No chronic neuropathic pain was registered at follow-up. Patients resumed work after an average of 9 days (range 7-12) from operation. Recurrence rate was 0.8%. Conclusions. The Kugel hernia repair satisfies the standards to be awarded as a "mini-invasive" technique.

Comparison of endoscopic techniques vs Shouldice and other open nonmesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials

BACKGROUND

We performed a scientific evaluation of the efficacy of different surgical techniques for inginual hernia repair and supported our findings by conducting a systematic review of randomized studies comparing endoscopic with open nonmesh suture techniques.

METHODS

After an extensive search of the literature, a total of 27 studies (41 publications) with evidence level lb were identified. These studies randomly compared endoscopic with open nonmesh suturing techniques. The quality of data sufficed to enable a quantitative meta-analysis of various parameters using the original software of the Cochrane Collaboration. Due to its superiority in comparison to other open nonmesh suturing techniques, the Shouldice repair technique was analyzed separately.

RESULTS

The systematic comparison of endoscopic techniques with the Shouldice repair showed that these techniques had significant advantages in terms of the following parameters: total morbidity, hematoma, nerve injury, and pain-associated parameters such as time to return to work, and chronic groin pain. The Shouldice operation has the advantages of a shorter operating time and a lower incidence of wound seroma. There was no difference regarding the incidence of major complications, wound infection, testicular atrophy, or hernia recurrence. Open non-Shouldice suturing techniques are associated with higher recurrence rates and more wound infections than endoscopic operations.

CONCLUSION

In comparison to open nonmesh suture repair techniques, endoscopic repair techniques have significant advantages in terms of pain-associated parameters. For the revaluation of long-term complications such as hernia recurrence and chronic groin pain, further clinical examination of the existing study collectives is needed.

Comparison of endoscopic procedures vs Lichtenstein and other open mesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials

BACKGROUND

For the scientific evaluation of the endoscopic and open mesh techniques for the repair of inguinal hernia, meta-analyses of randomized controlled trials (RCT) are necessary. The Lichtenstein repair is one of the most common open mesh techniques and therefore of special interest.

METHODS

After an extensive search of the literature and a quality assessment, a total of 34 RCT comparing endoscopic procedures both transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP)--with various open mesh repairs were deemed to be suitable for a formal meta-analysis of the relevant parameters. These studies included data for 7,223 patients. Trials that used the Lichtenstein repair for the control group (23 of 34 trials) were analyzed-separately.

RESULTS

Significant advantages for the endoscopic procedures compared with the Lichtenstein repair include a lower incidence of wound infection (Peto odds ratio, 0.39; 95% confidence interval, 0.26, 0.61), a reduction in hematoma formation (0.69 [0.54, 0.90]) and nerve injury (0.46 [0.35, 0.61]), an earlier return to normal activities or work (-1.35[-1.72, -0.97]), and fewer incidences of chronic pain syndrome (0.56[0.44, 0.70]). No difference was found in total morbidity or in the incidence of intestinal lesions, urinary bladder lesions, major vascular lesions, urinary retention and testicular problems. Significant advantages for the Lichtenstein repair include in a shorter operating time (5.45[1.18, 9.73]), a lower incidence of seroma formation (1.42[1.13, 1.79]), and fewer hernia recurrences (2.00[1.46, 2.74]). Similar results are seen when endoscopic procedures are compared with other open mesh repairs. However, in this comparison, total morbidity was lower with the endoscopic operations (0.73[0.61, 0.89]). The incidence of seroma formation, chronic pain syndromes, and hernia recurrence was not significantly different.

CONCLUSION

Endoscopic repairs do have advantages interms of local complications and pain-associated parameters. For more detailed evaluation further well-structured trials with improved standardization of hernia type, operative technique, and surgeons' experience are necessary.

Retrospective comparison of open versus laparoscopic pyloromyotomy

BACKGROUND

Laparoscopic pyloromyotomy is gaining popularity in the management of pyloric stenosis. However, there is no unequivocal evidence in favour of the laparoscopic over the open approach. This paper reports an experience with laparoscopic pyloromyotomy and an attempt to identify any benefit over the open procedure.

METHODS

This was a retrospective review of all 87 pyloromyotomies performed at this institution for pyloric stenosis over the 39 months since the first laparoscopic pyloromyotomy was performed.

RESULTS

Data for 39 infants who underwent laparoscopic pyloromyotomy were compared with those for 38 infants who underwent pyloromyotomy via a periumbilical incision. Patient demographics were similar between the two groups. The duration of operation was longer for laparoscopic pyloromyotomy than for the open procedure (median 50 versus 30 min; P = 0.001). There were no differences in recovery time, postoperative length of hospital stay, complication rates and postoperative analgesia requirements between the two groups.

CONCLUSION

Laparoscopic pyloromyotomy has been incorporated successfully into the authors' standard working practice. Complication rates recovery times were similar to those achievable with the open procedure. There was no clear benefit of one approach over the other.

Outcome and Cost Comparison of Laparoscopic Transabdominal Preperitoneal Hernia Repair versus Open Lichtenstein Technique

Laparoscopic hernia repair has all the advantages of a tension free repair. This study compares the laparoscopic transabdominal preperitoneal (TAPP) approach with tension-free open hernia repair in terms of operative time, postoperative pain, hospital stay, complications, and cost. Open and TAPP repairs using polypropylene mesh were performed in two groups of 25 male patients. The difference in operative times between the groups was not significant. Mean pain scores (0-100) for the open group were 54.12 +/- 13.06 at 12 hours and 37.24 +/- 11.38 at 24 hours, significantly higher than the corresponding scores of 38.36 +/- 8.21 at 12 hours and 20.92 +/- 8.73 at 24 hours for the TAPP group (P < 0.05). The mean postoperative analgesic dose was 6.72 +/- 2.72 in the TAPP group, which was insignificantly lower than 7.52 +/- 2.00 in the open group. Mean hospital stay was 2.24 +/- 0.97 days in the open group and 1.52 +/- 0.51 in the TAPP group, which was significant (P < 0.05). Twenty patients (80%) in the TAPP group rated themselves highly satisfied with the surgery as compared to 11 patients (44%) in the open group (P < 0.05). There was no recurrence in either group during a mean followup period of 13.5 months (range, 8-28 months). Laparoscopic hernia repair was significantly more expensive than open (1100 US dollars versus 629 US dollars). TAPP repair is superior to open repair in terms of shorter hospital stay, lower postoperative pain, and better patient satisfaction. It is also safe, with no recurrence in a short-term period. This technique will be the operation of choice for the treatment of groin hernia after long-term results have been established in our center.

Carcinogenic potential of commonly used hernia repair prostheses in an experimental model

Background

The purpose of this study was to assess the carcinogenic potential of commonly used hernia repair prostheses in an animal model.

Methods

Three types of prosthetic material (monofilament polypropylene, multifilament polypropylene and expanded polytetrafluoroethylene) were implanted in CBA/H mice. Flat (1 cm2) and rolled pieces of the same material were placed subcutaneously in either flank, and a further flat piece was placed in the preperitoneal space. Owing to a high incidence of mesh extrusion in the polypropylene groups, the study protocol was modified to allow only preperitoneal placement of the material. A fourth, control, group had the pockets for the prostheses created but no material implanted. After modification of the protocol there were approximately 60 mice in each group. The mice were followed for 2 years, then killed and assessed histologically for tumour development.

Results

No sarcoma developed at the site of mesh implantation in any of the groups.

Conclusion

This study indicates that the risk of sarcoma formation at the site of hernia repair prostheses is very low.

Meta-analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair

BACKGROUND

The aim was to conduct a meta-analysis of the randomized evidence to determine the relative merits of laparoscopic (LIHR) and open (OIHR) inguinal hernia repair.

METHODS

A search of the Medline, Embase, Science Citation Index, Current Contents and PubMed databases identified all randomized clinical trials that compared OIHR and LIHR and were published in the English language between January 1990 and the end of October 2000. The meta-analysis was prepared in accordance with the Quality of Reporting of Meta-analyses (QUOROM) statement. The six outcome variables analysed were operating time, time to discharge from hospital, return to normal activity and return to work, postoperative complications and recurrence rate. Random effects meta-analyses were performed using odds ratios and weighted mean differences.

RESULTS

Twenty-nine trials were considered suitable for meta-analysis. Some 3017 hernias were repaired laparoscopically and 2972 hernias were repaired using an open method in 5588 patients. For four of the six outcomes the summary point estimates favoured LIHR over OIHR; there was a significant reduction of 38 per cent in the relative odds of postoperative complications (odds ratio 0.62 (95 per cent confidence interval (c.i.) 0.46 to 0.84); P = 0.002), 4.73 (95 per cent c.i. 3.51 to 5.96) days in time to return to normal activity (P < 0.001), 6.96 (95 per cent c.i. 5.34 to 8.58) days in time to return to work (P < 0.001) and 3.43 (95 per cent c.i. 0.35 to 6.50) h in time to discharge from hospital (P = 0.029). There was a significant increase of 15.20 (95 per cent c.i. 7.78 to 22.63) min in the mean operating time for LIHR (P < 0.001). The relative odds of short-term recurrence were increased by 50 per cent for LIHR compared with OIHR, although this result was not statistically significant (odds ratio 1.51 (95 per cent c.i. 0.81 to 2.79); P = 0.194).

CONCLUSION

LIHR was associated with earlier discharge from hospital, quicker return to normal activity and work, and significantly fewer postoperative complications than OIHR. However, the operating time was significantly longer and there was a trend towards an increase in the relative odds of recurrence after laparoscopic repair.

Outcomes analysis for groin hernia repairs

Outcomes studies after inguinal hernia operations show a pattern of continued improvement throughout the last decade. OHRs are intrinsically less costly and less complicated to perform than LHR. The most recent modification in OHR has been the improvement of the mesh prostheses for insertion into the preperitoneal space. The earlier return to work seen in the early 1990s with LHR has been offset by comparable recuperation in the late 1990s associated with improvements in prosthetic repair in OHR. Both behavioral and technical factors must be evaluated to improve outcomes with hernia surgery.

The effect of preincisional periportal infiltration with ropivacaine in pain relief after laparoscopic procedures: a prospective, randomized controlled trial

BACKGROUND AND OBJECTIVES

It is essential to minimize pain after laparoscopic surgery. This study examined the effect of wound infiltration by a long-acting local anesthetic.

METHODS

This prospective, randomized study includes 190 laparoscopic procedures carried out by the same surgeon. The patients were randomly allocated into 2 groups. The control group comprised 75 cases of laparoscopic cholecystectomy (LC) and 20 cases of laparoscopic inguinal hernia repair (LIHR) without the use of a local anesthetic; only saline was used. The study group comprised 75 cases of LC and 20 cases of LIHR with preincisional periportal infiltration with 20 mL of ropivacaine (10 mg/mL). The postoperative pain scores at 3, 6, 12, and 24 hours determined with a visual analogue scale (VAS), nausea, and the kind and amount of analgesic drugs were assessed.

RESULTS

In the study group in 41% of LC cases and 85% of LIHR cases, no analgesia was required at all; likewise, in the control group in 20% of LC cases and 44% of LIHR cases, no analgesia was required. The difference was statistically significant (P<0.05). In the remainder, pain at 3 and 6 hours and total analgesic requirements in the study group were less than that in the control group (P<0.05). The postoperative nausea and shoulder pain remained statistically unchanged (P>0.05).

CONCLUSIONS

It seems that wound infiltration with ropivacaine in laparoscopy provides satisfactory postoperative analgesia, diminishing or reducing the need for opioids.

Prospective randomized trial of laparoscopic (transabdominal preperitoneal) vs open (mesh) repair for bilateral and recurrent inguinal hernia

BACKGROUND

Laparoscopic hernia repair excites controversy because its benefits are debatable and critics claim it is attended by serious complications. The one group of patients in whom benefits may outweigh the perceived disadvantages are those with bilateral or recurrent inguinal hernias.

METHOD

One hundred twenty patients with bilateral or recurrent hernias were randomized to either laparoscopic transabdominal preperitoneal (TAPP) or open mesh repair. Patients completed a well-being questionnaire prior to and following surgery together with a visual analog pain score. Patients were followed up clinically at 1 and 3 months and thereafter by their general practitioner.

RESULTS

Age and sex distribution was similar in the two groups. Laparoscopic TAPP hernia was quicker (40 vs 55 min; p < 0.001), less painful (visual analog pain score, 2.8 vs 4.3; p = 0.003) and allowed earlier return to work (11 vs 42 days; p < 0.001) compared to open mesh repair.

CONCLUSION

This trial demonstrates that laparoscopic hernia repair via the TAPP route offers significant benefit to patients undergoing bilateral or recurrent inguinal hernia repair.

Laparoscopic totally extraperitoneal versus Lichtenstein herniorrhaphy: cost comparison at teaching hospitals

Laparoscopic hernia repair is safe and effective and may result in less postoperative pain and faster recuperation compared with traditional open hernia repairs. Controversy exists as to the increased cost associated with laparoscopic repairs. The purpose of this study was to quantify and compare the cost of the totally extraperitoneal (TEP) laparoscopic repair and the tension-free Lichtenstein repair at teaching hospitals. The records of consecutive TEP (n = 28) and Lichtenstein (n = 28) repairs performed at Parkland Memorial Hospital and Zale-Lipshy University Hospital were reviewed. A detailed cost analysis was performed. Total patient charge (5,509 US dollars vs. 3,999 US dollars) and total cost (2,861 US dollars vs. 2,009 US dollars) were higher for TEP versus Lichtenstein repairs, respectively (P < 0.05). Operative time and complications were similar for both groups. Return to full activity (15 vs. 34 days) was faster for TEP versus Lichtenstein repairs, respectively (P < 0.05). Of 9 patients in the TEP group who had previously undergone an open hernia repair, 8 (89%) preferred the laparoscopic approach. The laparoscopic TEP repair costs 852 US dollars more than the Lichtenstein repair. The TEP repair results in faster recuperation. Patient preference and faster recuperation may offset the increased cost associated with laparoscopic hernia repair.

Randomized clinical trial comparing laparoscopic totally extraperitoneal approach with open mesh repair in inguinal hernia

The aim of this study was to compare laparoscopic totally extraperitoneal approach (TEP) repair with tension-free open mesh repair in inguinal hernia. One hundred thirty-four patients were allocated randomly to undergo TEP repair (n = 67) or open mesh repair (n = 67). Operative and postoperative outcomes were determined. The mean of operating time (49.67 +/- 14.11 vs. 56.64 +/- 12.32; P = 0.001), visual analog scale score (2.73 +/- 1.69 vs. 4.61 +/- 1.77; P = 0.001), hospital stay (1.8 +/- 0.7 vs. 2.7 +/- 1.6; P = 0.001), and duration of recovery (10.8 +/- 7.4 vs. 15.2 +/- 8.5; P = 0.001) was significantly less for TEP repair when compared with open mesh repair. The incidence of complications (13.4% vs. 16.4%; P = 0.631) and recurrence (2.9% vs. 5.9%; P = 0.407) was approximately equal in each group. Our results showed that laparoscopic TEP repair is superior to open mesh repair.

Extraperitoneal endoscopic groin hernia repair under epidural anesthesia

We performed a prospective study to evaluate the feasibility of performing endoscopic total extraperitoneal repair of groin hernia (TEP) under epidural anesthesia in selected patients considered to be at high risk or unfit for general anesthesia. Fifty-eight endoscopic total extraperitoneal hernia repairs were performed in 36 patients between January 1997 and December 1999 under epidural anesthesia since they were considered a high risk or unfit for general anesthesia. All patients received intramuscular diclofenac sodium for preemptive analgesia. Intraoperatively, all were sedated with intravenous midazolam and fentanyl. Endoscopic TEP repair was successful under epidural anesthesia in 33 of 36 patients. In the remaining three patients, the procedure had to be converted to Lichtenstein's repair due to shoulder discomfort experienced by the patients as a result of pneumoperitoneum, which was produced by incidental peritoneal tears during extraperitoneal dissection. Intraoperatively, one patient had bleeding from the inferior epigastric artery, which was controlled with clipping of the artery. The mean operative time was 48 minutes (range, 28-72 minutes) in the TEP group and 94 minutes (range, 84-102 minutes) in the converted group. All the patients received an epidural top-up dose at the end of surgery for postoperative analgesia. All patients were ambulatory the same day. Postoperative pain was assessed by a visual analogue scale (VAS). The mean pain score was 1.2 (+/- 0.8) on discharge in the TEP group. During follow-up, seven patients developed scrotal swelling with cord induration, which was treated conservatively with scrotal support and analgesics. In all patients, resolution was observed within 6 weeks. One patient was detected to have a recurrence 4 months after surgery. Endoscopic TEP repair under epidural anesthesia appears to be safe, technically feasible, and an acceptable alternative in patients who are at high risk or unfit for general anesthesia.

Laparoscopic extraperitoneal inguinal hernia repair versus open mesh repair: a prospective randomized controlled trial

BACKGROUND

This study was designed to compare an open tension-free technique (Lichtenstein repair) with a laparoscopic totally extraperitoneal hernia repair (TEP).

METHODS

One hundred sixty-eight men aged 30 to 65 years with primary or recurrent inguinal hernia were randomized to TEP or open mesh technique in the manner of Lichtenstein. Follow-up was after 1 and 6 weeks, and 1 year.

RESULTS

Eighty-one patients were randomized to TEP, and 87 to open repair. For 1 patient in each group, the operation was converted to a different type of repair. No difference was seen in overall complications between the 2 groups. However, 1 patient in the TEP group underwent operation for small bowel obstruction after surgery. A higher frequency of postoperative hematomas was seen in the open group (P <.05). Patients in the TEP group consumed less analgesic after surgery (P <.001), returned to work earlier (P <.01), and had a shorter time to full recovery (P <.01). Two recurrences occurred in the TEP group 1 year after surgery.

CONCLUSION

The TEP technique was associated with less postoperative pain, a shorter time to full recovery, and an earlier return to work compared with the open tension-free repair. No difference was seen in overall complications. However, 2 recurrences did occur after 1 year in the TEP group.

Tension-free inguinal hernia repair: the design of a trial to compare open and laparoscopic surgical techniques

BACKGROUND

Inguinal hernia is a common condition in men and represents a large component of health-care expenditures. Approximately 700,000 herniorrhaphies are performed each year in the United States. The most effective method of repair of an inguinal hernia is not known.

STUDY DESIGN

A multicenter, randomized, clinical trial was designed to compare open tension-free inguinal hernia repair with laparoscopic tension-free repair on recurrence rates, complications, patient-centered outcomes, and cost. The study design called for randomization of 2,200 men over a period of 3 years. These men will be followed for a minimum of 2 years. This will allow determination of as little as a 3% absolute difference in recurrence rates with 80% power. Randomization is stratified by hospital, whether the hernia is unilateral or bilateral and whether the hernia is primary or recurrent.

RESULTS

This is a report of the study design and current status. The study involves 14 Veterans Affairs medical centers with previous experience in laparoscopic hernia repair. After 35 months of enrollment, 2,165 men were randomized and recruitment was then closed. The majority of the patients (82.3%) had unilateral hernias and 90.6% of the hernias were primary. Sixty-seven percent of the patients had an outpatient operation.

CONCLUSIONS

We report successful recruitment into a large multicenter trial comparing open and laparoscopic hernia repair. When followup is complete, this study will provide data regarding both clinical (recurrence rates) and patient-centered outcomes.

Recurrent hernia following endoscopic total extraperitoneal repair

BACKGROUND AND PURPOSE

A retrospective study was conducted to identify the reasons for recurrence following endoscopic total extraperitoneal (TEP) repair of inguinal hernias and to develop a strategy to prevent recurrence.

METHOD

Between January 1996 and December 2001, 1193 TEP hernia repairs were performed in 694 patients. Following reduction of the hernia sac and dissection of the preperitoneal space up to the psoas muscles laterally, a Prolene mesh (15 x 15 cm) was placed. The mesh was fixed medially to the Cooper ligament with two or three spiral tacks. In six patients, the hernia recurred following endoscopic TEP repair within the same period. Four of these patients elected to undergo laparoscopic transabdominal preperitoneal (TAPP) repair of the recurrent hernia.

RESULTS

Medial recurrences developed in three of the four patients because of medial displacement of the mesh. One patient was found to have a missed indirect hernia sac. All the patients who underwent laparoscopic TAPP repair had an uneventful recovery and are well at follow-up.

CONCLUSION

In addition to medial fixation of the mesh to the Cooper ligament, complete proximal dissection of the peritoneum from the spermatic cord and additional fixation of the mesh to the anterior abdominal wall, with careful avoidance of possible injury to the adjacent nerves, may prevent recurrences.

Laparoscopic techniques versus open techniques for inguinal hernia repair

BACKGROUND

Inguinal hernia repair is the most frequently performed operation in general surgery. The standard method for inguinal hernia repair had changed little over a hundred years until the introduction of synthetic mesh. This mesh can be placed by either using an open approach or by using a minimal access laparoscopic technique. Although many studies have explored the relative merits and potential risks of laparoscopic surgery for the repair of inguinal hernia, most individual trials have been too small to show clear benefits of one type of surgical repair over another.

OBJECTIVES

The objective of this review was to compare minimal access laparoscopic mesh techniques with open techniques. Comparisons of open mesh techniques versus open non-mesh techniques have been considered in a separate Cochrane review.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, and The Cochrane Central Controlled Trials Registry for relevant randomised controlled trials. The reference list of identified trials, journal supplements, relevant book chapters and conference proceedings were searched for further relevant trials. Through the EU Hernia Trialists Collaboration (EUHTC) communication took place with authors of identified randomised controlled trials to ask for information on any other recent and ongoing trials known to them. Specialists involved in research on the repair of inguinal hernia were contacted to ask for information about any further completed and ongoing trials. The world wide web was also searched.

SELECTION CRITERIA

All published and unpublished randomised controlled trials and quasi-randomised controlled trials comparing laparoscopic groin hernia repair with open groin hernia repair were eligible for inclusion. Trials were included irrespective of the language in which they were reported.

DATA COLLECTION AND ANALYSIS

Individual patient data were obtained, where possible, from the responsible trialist for all eligible studies. All reanalyses were cross-checked by the reviewers and verified by the trialists before inclusion. Where IPD were unavailable additional aggregate data were sought from trialists and published aggregate data checked and verified by the trialists. IPD were available for 25 trials, additional aggregated data for seven and published data only for nine. Where possible, time to event analysis for hernia recurrence and return to usual activities were performed on an intention to treat principle. The main analyses were based on all trials. Sensitivity analyses based on the data source and trial quality were also performed. Pre-defined subgroup analyses based on recurrent hernias, bilateral hernias and femoral hernias were also carried out.

MAIN RESULTS

41 published reports of eligible trials were included involving 7161 participants. Sample sizes ranged from 38 to 994, with follow-up from 6 weeks to 36 months. Duration of operation was longer in the laparoscopic groups (WMD 14.81 minutes, 95% CI 13.98 to 15.64; p<0001). Operative complications were uncommon for both methods but more frequent in the laparoscopic group for visceral (Overall 8/2315 versus 1/2599) and vascular (Overall 7/2498 versus 5/2758) injuries. Length of hospital stay did not differ between groups (WMD -0.04 days, 95% CI -0.08 to 0.00; p=0.05, but return to usual activity was earlier for laparoscopic groups (HR 0.56, 95%CI 0.51 to 0.61; p<0.0001 - equivalent to 7 days). The data available showed less persisting pain (Overall 290/2101 versus 459/2399; Peto OR 0.54, 95% CI 0.46 to 0.64; p<0.0001), and less persisting numbness (Overall 102/1419 versus 217/1624; Peto OR 0.38, 95% CI 0.4286 to 0.49; p<0.0001) in the laparoscopic groups. In total, 86 recurrences were reported amongst 3138 allocated laparoscopic repair and 109 amongst 3504 allocated to open repair (Peto OR 0.81, 95% CI 0.61 to 1.08; p = 0.16). The use of mesh during laparoscopic hernia repair is associated with a reduction in the risk of hernia recurrence, significantly so for the transabdominal preperitoneal repair (TAPP) versus open non-mesh repair (overall 26/1440 versus preperitoneal repair (TAPP) versus open non-mesh repair (overall 26/1440 versus 47/1119; Peto OR 0.45, 95% CI 0.28 to 0.72; p=0.0009). However, no difference was detected when comparing laparoscopic methods with open mesh methods of hernia repair.

REVIEWER'S CONCLUSIONS

The use of mesh during laparoscopic hernia repair is associated with a relative reduction in the risk of hernia recurrence of around 30-50%. However, there is no apparent difference in recurrence between laparoscopic and open mesh methods of hernia repair. The data suggests less persisting pain and numbness following laparoscopic repair. Return to usual activities is faster. However, operation times are longer and there appears to be a higher risk of serious complication rate in respect of visceral (especially bladder) and vascular injuries.

The effects of different hernia repair methods on postoperative pain medication and CRP levels

Although tension-free techniques of hernia repair using synthetic meshes have yielded encouraging results, the best method of inguinal hernia repair is still unclear. The aim of this study was to compare the responses of inflammatory mediators and postoperative pain relief following laparoscopic total extraperitoneal (TEP) hernioplasty, open tension-free mesh hernioplasty (Lichtenstein), posterior preperitoneal mesh hernioplasty (Nyhus procedure), and Bassini procedure. Patients with primary inguinal hernia were randomized in the operating room to undergo one of these repair techniques. Group I comprised 24 patients treated by Lichtenstein procedure; Group II comprised 21 patients treated by Nyhus procedure; Group III comprised 19 patients treated by Bassini procedure; and Group IV comprised 20 patients treated by laparoscopic TEP mesh hernioplasty. Postoperative pain levels following hernia repair were compared by measuring the use of patient-controlled analgesia (PCA) during the 24 hours after surgery. Serum samples withdrawn before surgery and 48 hours after surgery were assayed for C-reactive protein (CRP) content. Patient characteristics, operating time, and operative and early complications were noted. Serum CRP levels rose markedly following Nyhus (184.5 +/- 41.6 mg/L), Lichtenstein (138.4 +/- 72.5 mg/L), and Bassini repair (137.2 +/- 55.9 mg/L) compared with that of patients who underwent TEP mesh hernioplasty (55.5 +/- 41.2 mg/L). There were also significant differences in the postoperative need for analgesics via PCA among patients undergoing Nyhus (382.9 +/- 189.1 mg), Bassini (303.2 +/- 173.7 mg), and Lichtenstein (253.9 +/- 129.3) procedures compared with 196.6 +/- 148.8 mg for the TEP mesh hernioplasty group. Patients in the Lichtenstein group also had significantly less need of analgesics than those in the Nyhus and Bassini groups. In conclusion, TEP mesh hernioplasty is less traumatic and yields less postoperative pain than the Nyhus, Lichtenstein, and Bassini procedures.

Meta-analysis of laparoscopic inguinal hernia trials favors open hernia repair with preperitoneal mesh prosthesis

BACKGROUND

This meta-analysis was performed to determine the degree to which improvements in open hernia repair (OHR) in the last decade have altered the relative benefit of laparoscopic hernia repair (LHR).

METHODS

Twenty-seven comparative trials including 4,688 randomized patients were evaluated.

RESULTS

Within the control OHR, patients with routine mesh repair returned to work earlier than a sutured repair (16.4 versus 27.3 days, P = 0.010). During the study period, the increased use of mesh in OHR (3 of 12 initially versus 9 of 15 subsequent studies) was associated with an earlier return to work (25.9 to 16.8 days, P = 0.017); there was no significant improvement with corresponding LHR.

CONCLUSIONS

Although LHR was associated with an earlier return to work compared with conventional sutured OHR, more recent mesh OHRs provide equivalent outcomes but at lower costs and potentially less severe complications, supporting an open technique using preperitoneal mesh prostheses as the optimal hernia repair.

Repair of groin hernia with synthetic mesh: meta-analysis of randomized controlled trials

OBJECTIVE

To measure the effects of laparoscopic and open placement of synthetic mesh on recurrence and persisting pain following groin hernia repair.

SUMMARY BACKGROUND DATA

Synthetic mesh techniques are claimed to reduce the risk of recurrence but there are concerns about costs and possible long-term complications, particularly pain.

METHODS

Electronic databases were searched and experts consulted to identify randomized or quasi-randomized trials that compared mesh with non-mesh methods, or laparoscopic with open mesh placement. Individual patient data were sought for each trial. Aggregated data were used where individual patient data were not available. Meta-analyses of hernia recurrence and persisting pain were based on intention to treat.

RESULTS

There were 62 relevant comparisons in 58 trials. These included 11,174 participants: individual patient data were available for 6,901 patients, supplementary aggregated data for 2,390 patients, and published data for 1883 patients. Recurrence and persisting pain were less after mesh repair (overall recurrences: 88 in 4,426 vs. 187 in 3,795; OR 0.43, 95% CI 0.34-0.55; P <.001) (overall persistent pain: 120 in 2,368 vs. 215 in 1,998; OR 0.36, 95% CI 0.29-0.46; P <.001), regardless of the non-mesh comparator. Whereas the reduction in recurrence was similar after laparoscopic and open mesh placement (OR 1.26, 95% CI 0.76-2.08; P =.36), persistent pain was less common after laparoscopic than open mesh placement (OR 0.64; 95% CI 0.52-0.78; P <.001).

CONCLUSIONS

The use of synthetic mesh substantially reduces the risk of hernia recurrence irrespective of placement method. Mesh repair appears to reduce the chance of persisting pain rather than increase it.

Extraperitoneal laparoscopic hernia repair with local anesthesia

BACKGROUND

This review aimed to compare laparoscopic preperitoneal herniorrhaphy (LPPH) using a laryngeal mask airway and local anesthesia with conventional open herniorrhaphy using similar anesthetic conditions.

METHODS

A retrospective review of 238 hernia operations was conducted from October 1996 through September 1998. Laparoscopic preperitoneal hernia repairs with the patient under laryngeal mask airway anesthesia were performed initially using 10 ml of 0.5% bupivacaine (LPPH+10 group). This was compared with hernia repair using 30 ml of 0.5% bupivacaine (LPPH+30 group). Both LPPH groups were compared with a plug and patch "Gilbert" hernia repair group. Postoperative pain was compared in the recovery room and outpatient suite.

RESULTS

The LPPH+30 group required significantly less postoperative pain medication than the LPPH+10 group. The LPPH+30 group required slightly more pain medication in the recovery room than the open hernia repair group, but in the postanesthesia care unit (PACU) unit, the LPPH+30 group used less pain medication. A similar number of LPPH+30 patients, and open hernia repair patients required no pain medication.

CONCLUSIONS

The use of a long-acting local anesthetic, (30 ml of 0.5% bupivacaine via laryngeal mask airway) for laparoscopic preperitoneal hernia repair compared favorably with conventional open hernia repair using similar anesthetic techniques.

Hernioplasty and simultaneous laparoscopic cholecystectomy: a prospective randomized study of open tension-free versus laparoscopic inguinal hernia repair

BACKGROUND

The laparoscopic repair of unilateral primary groin hernia remains controversial. This randomized study evaluates the outcome of the laparoscopic technique in hernia repair in patients undergoing simultaneous laparoscopic cholecystectomy (LC) and compares laparoscopic repair with tension-free open groin hernia repair.

METHODS

Sixty-four low-risk patients with symptomatic chronic calculous cholecystitis and synchronous unilateral primary inguinal hernia were randomized to undergo either laparoscopic transabdominal preperitoneal mesh hernia repair (TAPP) and LC or LC and open tension-free hernia repair.

RESULTS

The operating time was longer in the TAPP and LC group (mean +/- SD = 121 +/- 32 minutes) than in the LC and open group (95 +/- 27 minutes) (P <.01). The mean operating costs were higher in the TAPP and LC group ($1235 versus $1080) (P <.03). The intensity of postoperative pain at rest was greater in the LC and open group at 24 hours (P <.01) and 48 hours (P <.05), with a greater consumption of pain medication (P <.01). No differences between the 2 groups were found in terms of postoperative complications, disability period before return to work, or hernia recurrences.

CONCLUSIONS

The totally laparoscopic procedure does not result in a significant benefit other than improved comfort in the first 2 postoperative days. However, laparoscopic hernia repair is considerably more difficult to perform than open tension-free hernioplasty. Thus, the totally laparoscopic approach should be performed only by experienced laparoscopic surgeons with special expertise in hernia surgery.

Assessing risks, costs, and benefits of laparoscopic hernia repair

Laparoscopic inguinal herniorrhaphy (LIHR) was introduced with the following potential advantages: less postoperative discomfort and pain, reduced recovery time that allows earlier return to full activity, easier repair of a recurrent hernia, the ability to treat bilateral hernias concurrently, the performance of a simultaneous diagnostic laparoscopy, ligation of the hernia sac at the highest possible site, improved cosmesis, and decreased incidence of recurrence. Potential disadvantages include complications, such as bowel, bladder, and vascular injuries; potential adhesive complications at sites where the peritoneum has been breached or prosthetic material has been placed; the apparent need, at least at the present, for a general anesthetic; and the increased cost because of expensive equipment needs. Most surgeons agree that LIHR has a role in the management of patients with a recurrent hernia after a conventional inguinal herniorrhaphy (CIHR), bilateral inguinal hernia, or a need for laparoscopy for another procedure, such as laparoscopic cholecystectomy. The routine use of LIHR for the unilateral, uncomplicated hernia is a more contentious issue.

Laparoscopic repair of incisional and parastomal hernias after major genitourinary or abdominal surgery

BACKGROUND AND PURPOSE

Abdominal wall or parastomal hernias following major genitourinary or abdominal surgery are a significant surgical problem. Open surgical repair is difficult because of adhesion formation and poor definition of the hernia fascial edges. Laparoscopic intervention has allowed effective correction of these abdominal wall hernias.

PATIENTS AND METHODS

From November 1997 to June 2000, 14 male and 3 female patients underwent laparoscopic abdominal wall herniorrhaphy at our institution. Of these, 13 patients received incisional and 4 parastomal hernia repair. All hernia defects were repaired using a measured piece of Gore-Tex DualMesh. A retrospective review of each patient's history and operative characteristics was undertaken.

RESULTS

All repairs were successful. No patient required conversion to an open procedure, and there were no intraoperative complications. The average operative time was 4 (range 2.5-6.5) and 4.3 (range 3.75-5.5) hours in the incisional and parastomal group, respectively. The average hospital stay was 4.9 days (range 2-12) for the incisional group and 3.8 (range 3-4) days for the parastomal group. To date, two patients experienced a recurrence of incisional hernias, at 5 and 8 months postoperatively. No recurrences have developed in the parastomal hernia repairs at 2 to 33 months.

CONCLUSION

Laparoscopic repair of abdominal wall incisional or parastomal hernias provides an excellent anatomic correction of such defects. Adhesions are lysed under magnified laparoscopic vision, and the true limits of the fascial defects are clearly identified. The DualMesh is easy to work with and has yielded excellent results. A comparison with open repair with respect to perioperative factors and long-term success is currently under way.

Surgical aspects and future developments of laparoscopy

Laparoscopy has revolutionized surgery and in the process influenced the practice of anesthesiology. This article reviews several minimal access procedures that have been accepted into practice, are gaining acceptance, or remain investigational. Absolute contraindications to laparoscopy have been emphasized. As the threshold for primary care physicians to refer sicker and sicker patients for surgery decreases, it is crucial for the anesthesiologist to understand physiologic stresses of pneumoperitoneum and the nuances of laparoscopic surgery. The anesthesiologist also can be recruited to adjust insufflation pressures, tweak images on monitors, rotate and position the patient, or pass balloons and bougies. With patient and surgeon expectation of no pain or nausea and early discharge, anesthetic choices become vital for the ultimate success of the procedure.

Prospective Comparison between Laparoscopic Preperitoneal Herniorrhaphy and Open Mesh Herniorrhaphy

Controversy persists regarding the most effective inguinal hernia repair. The purpose of this study is to compare the complications, charges, patient satisfaction, and recovery time between laparoscopic (LH) and open mesh herniorrhaphy (OH). A nonrandomized prospective analysis of 233 consecutive inguinal hernia repairs was performed over a 12-month period by 27 surgeons. The type of repair was determined by surgeon preference. Cost analysis was performed using anesthesia records and hospital cost. Patient satisfaction and recovery time were evaluated by third-party interview. A total of 113 OHs and 120 LHs were performed; 11 OHs and 42 LHs were bilateral. Patient demographics were equivalent for the two groups. No statistical difference was noted when comparing anesthesia/operating room time between the two groups. The LHs accrued an additional charge of $2254 per case. Complication rates were 4.4 per cent for the OHs and 8.3 per cent for the LHs. All complications were considered minor. No infectious complications or recurrences were noted in either group. Satisfaction rates and pain indices were nearly identical for both OHs and LHs. The LHs had a shorter recovery time by 5.5 days. We conclude that LH is associated with a higher complication rate and cost than OH. Pain indices are similar, but LH has a shorter recovery time.

Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized controlled trials

BACKGROUND

The place of laparoscopic groin hernia repair remains controversial. Individual randomized controlled trials alone have not provided statistically reliable results when considering recurrence, potentially serious complications and chronic pain.

METHODS

A rigorous systematic review was performed of published data from all relevant randomized or quasi-randomized trials. Electronic databases were searched and members of the EU Hernia Trialists Collaboration consulted to identify trials. Prespecified data items were extracted from reports and, where possible, quantitative meta-analysis was performed.

RESULTS

Thirty-four published reports of eligible trials were included, involving 6804 participants. Sample sizes ranged from 20 to 1051, with follow-up from 6 weeks to 36 months. Duration of operation was longer in the laparoscopic groups (P < 0.001, Sign test). Operative complications were uncommon for both methods, but visceral and vascular injuries were more frequent in the laparoscopic group (4.7 per 1000 versus 1. 1 per 1000). Postoperative pain was less among laparoscopic groups (P = 0.08). Length of hospital stay did not differ significantly between groups (P = 0.50), but return to usual activity was earlier for laparoscopic groups (P < 0.001). Chronic pain and numbness were reported for only a small minority of trials. Overall, recurrences did not differ between groups, but comparison of laparoscopic with open non-mesh repair favoured laparoscopic methods, significantly so for transabdominal preperitoneal repair (Peto odds ratio 0.56 (95 per cent confidence interval 0.33-0.93); P = 0.026).

CONCLUSION

Although the rigorous search maximized trial identification, variation in trial reporting made formal meta-analysis difficult. Laparoscopic repair was associated with less postoperative pain and more rapid return to normal activities, but it takes longer to perform and may increase the risk of rare, but serious, complications.

Long-term results of a randomized clinical trial between laparoscopic hernioplasty and shouldice repair

BACKGROUND

At present only short-term follow-up data are available to compare endoscopic and conventional hernia surgery. This paper presents data from a randomized study 6 years after initial recruitment.

METHODS

In 1993 a randomized comparative study of transabdominal preperitoneal (TAPP) and Shouldice repair was commenced. Endpoints were rate of recurrence, late complications, complaints and patient satisfaction.

RESULTS

The rate of recurrence in the TAPP group was one (2 per cent) of 48 patients and in the Shouldice group two (5 per cent) of 43. Only five patients in the Shouldice and three in the TAPP group reported slight discomfort in the inguinal region at 6-year follow-up. In neither group was chronic pain syndrome observed. Altogether, 46 (96 per cent) of 48 patients in the TAPP group and 35 (81 per cent) of 43 of those having the Shouldice procedure stated complete satisfaction with the hernia repair.

CONCLUSION

Long-term evaluation demonstrated greater satisfaction with the result of the repair in the endoscopic group. The difference between the groups in the recurrence rate was not significant, because of the small numbers. The TAPP method appears to be an effective surgical alternative in patients with inguinal hernia.