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

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.

Laparoscopic versus open inguinal hernia repair

Inguinal hernias are common, with a lifetime risk of 27% in men and 3% in women. Inguinal hernia repair is one of the most common operations in general surgery. Despite more than 200 years of experience, the optimal surgical approach to inguinal hernia remains controversial. Surgeons and patients face many decisions when it comes to inguinal hernias: repair or no repair, mesh or no mesh, what kind of mesh, open or laparoscopic, extraperitoneal or transabdominal, and so forth. Inguinal hernia repairs have morbidity and recurrence rates that are not inconsequential. The search for the gold standard of repair continues.

Laparoscopic inguinal hernia repair on a general surgery ward: 5 years' experience

BACKGROUND

Laparoscopic hernia repair has been gaining acceptance as an alternative to open repair. The aim of this study was to present the experience of a general surgery ward with laparoscopic inguinal hernia repair.

MATERIALS AND METHODS

A retrospective search of all laparoscopic inguinal hernia repairs between January 1999 and December 2003 was obtained. Data, including perioperative course, postoperative complication, and long-term follow-up, was documented.

RESULTS

A total of 423 hernias were repaired in 220 patients. Long-term follow-up was performed by questionnaire, clinic visit, or both in 182 of the 220 patients (82.7%). Median follow-up time was 27.5 (range, 4-61) months. Two hundred and three (92.3%) hernias were bilateral. Fifty-seven patients (25.9%) had recurrent hernias. There was no conversion to an open hernia repair. There were 10 recurrences (2.3%). Minor complications (e.g., abdominal wall hematoma, epigastric vessels injury, and urinary retention requiring catheterization) occurred in 17 (7.7%) patients. A bladder injury occurred in 1 patient (0.45%). There was no mortality. Mean postoperative stay was 1.1 days (range, 1-10). Satisfaction with the laparoscopic repair was expressed by using a scoring system of 1 to 5, with 85.2% being very satisfied (score of 4-5) and 8.2% being dissatisfied (score of 1-2).

CONCLUSIONS

The laparoscopic herniorrhaphy offers a safe and effective repair with acceptable complication and recurrence rates. Good results with the total extraperitoneal technique can be achieved by general laparoscopists and not only in highly specialized hernia centers. It is especially suited for bilateral repair and for recurrent hernias.

Robotic implantation of gastric electrical stimulation electrodes for gastroparesis

BACKGROUND

Gastric electrical stimulation (GES) is a low-morbidity treatment option that may be effective for refractory symptoms in patients with gastroparesis of diabetic or idiopathic etiology. During surgery to initiate GES, two electrodes are tunneled in the gastric antrum in a precise location. If these electrodes pass through the mucosa and into the gastric lumen (determined by endoscopy) they must be repositioned, often multiple times. During this procedure, extensive suturing to anchor the electrodes is necessary once properly placed. Robotic surgical systems may provide surgeons with several technical and ergonomic advantages during this procedure when compared with a standard laparoscopic approach.

METHODS

Over a 26-month period, 22 GES systems were implanted. The initial procedures were performed laparoscopically. After the first 15 laparoscopic cases, a technique for robotically implanting leads was developed and employed for the remainder of the series. Demographics, operative time, and endoscopically confirmed electrode mucosal perforations were quantified and compared based on operative approach.

RESULTS

Patients were similar demographically. Total operative time did not differ based on technique (152 +/- 40 min laparoscopic versus 158 +/- 38 min robotic placement; p = 0.6). Mucosal perforations on first attempt at electrode placement occurred more frequently with the laparoscopic than with the robotic technique (15/30 laparoscopic versus 1/14 robotic; p = 0.006). There were no procedure-related complications.

CONCLUSIONS

The robotic approach to GES electrode implantation is feasible and safe. Compared with standard laparoscopic techniques, the accurate insertion and anchoring of these leads can be accomplished more efficiently and comfortably using robotic techniques. Whether robotic GES electrode placement will result in significant clinical advantages for patients will require long-term follow-up.

Laparoscopic inguinal hernia repair

The safest and most effective inguinal hernia repair (laparoscopic versus open mesh) is being debated. As the authors point out, the former accounts for the minority of hernia repairs performed in the United States and around the world. The reasons for this are a demonstration in the literature of increased operative times, increased costs, and a longer learning curve. But the laparoscopic approach has clear advantages, including less acute and chronic postoperative pain, shorter convalescence, and earlier return to work. This article describes the transabdominal preperitoneal and totally extraperitoneal techniques, provides indications and contraindications for laparoscopic repair, discusses the advantages and disadvantages of each technique, and provides an overview of the literature comparing tension-free open and laparoscopic inguinal hernia repair.

[Inguinal hernia repair: results of randomized clinical trials and meta-analyses]

This evidence-based review of the literature aims to answer two questions regarding inguinal hernia repair: 1. should a prosthetic patch be used routinely? 2. Which approach is better - laparoscopic or open surgery? After a comprehensive search of electronic databases we retained only meta-analyses (n=14) and/or randomised clinical trials (n=4). Review of this literature suggests with a good level of evidence that prosthetic hernia repair is the gold standard; the laparoscopic approach has very few proven benefits and may involve more serious complications when performed outside expert centers. The role of laparoscopy for the repair of bilateral or recurrent hernias needs better evaluation.

Recurrence and complications after laparoscopic versus open inguinal hernia repair: results of a prospective randomized multicenter trial

BACKGROUND

The aim of this prospective randomized multicenter trial was to evaluate the recurrence rates and complications of open versus laparoscopic repairs of inguinal hernias.

METHODS

Patients with primary unilateral inguinal hernias were randomized to Shouldice repair, Bassini operation, tension-free hernioplasty (Lichtenstein repair), laparoscopic transabdominal extraperitoneal hernioplasty (TEP), or laparoscopic transabdominal preperitoneal hernioplasty (TAPP). The primary outcome parameter was the rate of recurrence at 3 years. The secondary outcome was the rate of intraoperative, perioperative, and long-term complications. Follow-up comprised of clinical examination after 1, 2, and 3 years.

RESULTS

Three hundred and sixty-five patients were randomly assigned to one of the five procedures. The intention-to-treat analysis showed that the cumulative 3-year recurrence rate was 3.4% in the Bassini group, 4.7% in the Shouldice group, 0% in the Lichtenstein group, 4.7% in the TAPP group, and 5.9% in the TEP group (p = 0.48). Comparing open (Bassini, Shouldice, Lichtenstein) versus laparoscopic (TAPP, TEP) techniques (p = 0.29) and comparing the use of mesh prostheses (Lichtenstein, TAPP, TEP) versus suturing techniques (Bassini, Shouldice) (p = 0.74) showed no significance in the rate of recurrence. The rates of intraoperative (p = 0.15), perioperative (p = 0.09), and long-term complications (p = 0.13) were without significance between the five groups. Comparing mesh techniques (Lichtenstein, TAPP, TEP) versus suturing techniques (Bassini, Shouldice) showed no significance in the rate of complications. The per-protocol analysis for the comparison of mesh (Lichtenstein, TAPP, TEP) versus suturing (Bassini, Shouldice) techniques revealed that recurrences (p = 0.74), intraoperative (p = 0.64), perioperative (p = 0.27), and long-term complications (p = 0.91) were evenly distributed.

CONCLUSIONS

In this multicenter study, no significant difference in the recurrence rate and complications between laparoscopic and open methods of hernia repair was revealed.

Laparoscopic hepatectomy, a systematic review

This systematic review was undertaken to assess the published evidence for the safety, feasibility and reproducibility of laparoscopic liver resection. A computerized search of the Medline and Embase databases identified 28 non-duplicated studies including 703 patients in whom laparoscopic hepatectomy was attempted. Pooled data were examined for information on the patients, lesions, complications and outcome. The most common procedures were wedge resection (35.1%), segmentectomy (21.7%) and left lateral segmentectomy (20.9%). Formal right hepatectomy constituted less than 4% of the reported resections. The conversion and complication rates were 8.1% and 17.6%, respectively. The mortality rate over all these studies was 0.8% and the median (range) hospital stay 7.8 days (2-15.3 days). Eight case-control studies were analysed and although some identified significant reductions in-hospital stay, time to first ambulation after surgery and blood loss, none showed a reduction in complication or mortality rate for laparoscopically carried out resections. It is clear that certain types of laparoscopic resection are feasible and safe when carried out by appropriately skilled surgeons. Further work is needed to determine whether these conclusions can be generalized to include formal right hepatectomy.

Mesh erosion into caecum following laparoscopic repair of inguinal hernia (TAPP): a case report and literature review

Repair of inguinal hernia is the most commonly performed surgical procedure. Both open and laparoscopic methods are accepted modalities of surgical treatment. Transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) are the two types of laparoscopic repair of the inguineal hernia. The main advantages of laparoscopic repair, as compared to open repair, are a shorter hospital stay and a quicker recovery to normal activities. However, laparoscopic repairs are associated with a higher incidence of visceral and vascular injuries. One particular complication is the migration and erosion of mesh into the adjacent viscera. Although the total numbers of cases are small, compared to the total numbers of inguinal hernia repairs, they are important, as they often presented with a diagnostic dilemma. Most of the mesh migrations reported in the literature involves the urinary bladder. In this paper, we present a case of erosion of mesh into the caecum. The patient (a 66-year-old male) underwent TAPP repair of a right inguinal hernia in 1996 with polypropelene mesh. He also underwent an open appendicectomy in 1980. During the laparoscopic repair, he was found to have multiple intra-abdominal adhesions. He presented with intermittent diarrhea, for which he was investigated, and a benign caecal lesion was found. He was initially managed conservatively. However, his symptoms persisted and he underwent a right hemicolectomy in February 2006 in our hospital. The offending lesion was found to be the prolene mesh having eroded into the caecum.

Factors associated with postoperative complications and hernia recurrence for patients undergoing inguinal hernia repair: a report from the VA Cooperative Hernia Study Group

BACKGROUND

We sought to determine perioperative variables predictive of complications or recurrence for patients undergoing surgical repair of inguinal hernias.

PATIENTS AND METHODS

Using data from the Veterans Affairs trial, regression analyses were utilized to identify perioperative factors significantly associated with complications (overall, short-term and long-term), long-term pain, and to develop a risk model for recurrence.

RESULTS

Recurrent and scrotal hernias were predictors for short term and overall complications, regardless of technique. Older age and higher Mental Component Score of the SF-36 were associated with higher risk of long term complications in the open group while prostatism and increased body mass index were the significant predictors in the laparoscopic group. Long-term pain complaints decreased as patient age increased in both groups. Patient and surgeon factors were predictive of recurrence but varied greatly depending on surgical technique.

CONCLUSIONS

Regardless of technique, scrotal and recurrent hernias were associated with a greater risk of complications and younger patients had more long-term pain. Predictors of recurrence vary based on surgical technique.

Routine laparoscopic repair of primary unilateral inguinal hernias--a viable alternative in the day surgery unit?

In September 2004 the NICE institute revised its guidelines on the management of primary inguinal hernias to include laparoscopic repair of unilateral hernias. While published trials have confirmed the equal efficacy of the two approaches, it is not clear what impact a switch to laparoscopic repairs would have on resources and patient throughput in a Day Surgery Unit.

METHOD

All elective hernia repairs performed in a one-year period were considered. Data were obtained from operation notes, discharge summaries and out-patient records. Operating times are routinely documented in theatre.

RESULTS

Of the 351 operations studied, 150 were performed laparoscopically predominantly by an extraperitoneal (TEP)approach. Six required conversion to an open procedure. There was no significant difference in operating times, total theatre time or recovery room times between the two groups (51 min, 75 min and 34 min for the laparoscopic group and 53 min, 74 min and 31 min for the open repair group). Among the laparoscopic repair group there were 48 bilateral hernias and 20 recurrent hernias while 190 of the 201 open repairs were for primary unilateral hernias. Rates of overnight stay and immediate complications were similar between the groups though haematoma was more common following open repair (7 vs 2).

CONCLUSIONS

There is no difference in theatre times, immediate complication rates or rates of overnight stay between open and laparoscopic repair of inguinal hernia. Routine laparoscopic repair of primary unilateral inguinal hernia is a viable alternative within the Day Surgery Unit.

[Inguinal hernia repair. A randomized multicentric study comparing laparoscopic and open surgical repair]

Despite being one of the commonest surgical procedures, few methodologically suitable evaluations of inguinal hernia repair have been conducted in France. Between September 1995 and November 2000 men with inguinal hernias at 7 surgical centers were randomly assigned to open or laparoscopic repair. The primary endpoint was recurrence of hernias at two years and secondary endpoints were complications and postoperative pain (Visual Analogic Score). Of 404 patients assigned to one of the two procedures, 390 were available for the analysis. Median follow-up was 2.8 years for open surgery (Shouldice 98%) and 2.3 years for laparoscopy (TAP 55%; TEP 45%). Two-year follow-up was 66%. Recurrences were more common in the laparoscopic group (15.5%) than in the open group (6%) odds ratio 2.75; 95% confidence interval 1.20-6.85. This difference was statistically significant for direct hernias exclusively. The three severe intraoperative complications were reported in the laparoscopic group. The rate of local complications at 8 and 30 postoperative days were not different between the two techniques, however 8 of 9 patients with testicular pain were in the laparoscopic group. Postoperative pain at one month was less severe in the laparoscopic than in the open group (VAS 1.41.9 and 3.12.6 respectively). The rate of patients with postoperative pain (VAS>2) at one year was not related to the open or laparoscopic technique (overall 8.5%). Mean PREoperative VAS of patients with longterm postoperative pain was higher than PREoperative VAS of patients without postoperative pain, 3.9 and 2.2 respectively. Mean operating room occupation times were 11637 min and 16965 min for open and laparoscopic surgery respectively. Subject to limitations associated with the present study follow-up, open surgery might be superior to laparoscopic surgery for inguinal hernia repair.

Laparoscopic inguinal hernia repair without mesh fixation, early results of a large randomised clinical trial

BACKGROUND

A new persistent groin pain is reported by a significant number of patients following laparoscopic totally extraperitoneal hernia repair (TEP). Mesh fixation has been implicated as a possible cause, but is widely considered essential for mesh stabilization and early recurrence prevention. This study investigates whether any association exists between mesh fixation by metal tacks and the incidence of new groin pain or early hernia recurrence.

METHODS

A prospective multicenter double-blinded randomised trial was conducted between December 2004 and January 2006. Standardized TEP repair was performed with a rectangular 10 x 15cm polypropylene mesh. Hernia were randomized to either mesh fixation by metal tacks or left entirely unfixated. Clinical review by physical examination was performed by a separate blinded surgeon after a minimum of six months, with another review planned after two years. The incidence of new groin pain and recurrence were compared.

RESULTS

Five hundred herniae in 360 patients were entered into the study. At the first wave of clinical follow-up (median eight, range 6-13 postoperative months) a new pain was reported by 38 versus 23% (p = 0.003), occurring at least once a week in 22 versus 15% (p = 0.049), or several times per week in 16 versus 8% (p = 0.009) for fixated versus unfixated repairs, respectively. Patients with bilateral repairs were five times more likely to report the unfixated side being more comfortable (p = 0.006). There was one recurrence in the fixated group (1/247) whilst none have yet occurred in the unfixated group. Fixation increased operative costs by approximately 375 AUD.

CONCLUSION

Mesh fixation in TEP is associated with increased operative cost and chronic pain but no difference in the risk of hernia recurrence at six months was observed.

Postoperative hypoesthesia and pain: qualitative assessment after open and laparoscopic inguinal hernia repair

BACKGROUND

Chronic pain is an important outcome variable after inguinal hernia repair that is generally not assessed by objective methods. The aim of this study was to objectively investigate chronic pain and hypoesthesia after inguinal hernia repair using three types of operation: open suture, open mesh, and laparoscopic.

METHODS

A total of 96 patients were included in the study with a median follow-up of 4.7 years. Open suture repair was performed in 40 patients (group A), open mesh repair in 20 patients (group B), and laparoscopic repair in 36 patients (group C). Hypoesthesia and pain were assessed using von Frey monofilaments. Quality of life was investigated with Short Form 36.

RESULTS

Pain occurring at least once a week was found in 7 (17.5%) patients of group A, in 5 (25%) patients of group B, and in 6 (16.6%) patients of group C. Area and intensity of hyposensibility were increased significantly after open nonmesh and mesh repair compared to those after laparoscopy (p = 0.01). Hyposensibility in patients who had laparoscopic hernia repair was significantly associated with postoperative pain (p = 0.03). Type of postoperative pain was somatic in 19 (61%), neuropathic in 9 (29%), and visceral in 3 (10%) patients without significant differences between the three groups.

CONCLUSIONS

The incidence of hypoesthesia in patients who had laparoscopic hernia repair is significantly lower than in those who had open hernia repair. Hypoesthesia after laparoscopic but not after open repair is significantly associated with postoperative pain. Von Frey monofilaments are important tools for the assessment of inguinal hypoesthesia and pain in patients who had inguinal hernia repair allowing quantitative and qualitative comparison between various surgical techniques.

Inguinal hernia repair

In excess of 100,000 inguinal hernia repairs are performed in the UK each year (Devlin & Kingsnorth 1998). It is the most commonly performed general surgical procedure and is routinely undertaken in patients receiving local anaesthesia in the day case setting. The Royal College of Surgeons has recommended that > 50% inguinal hernias are undertaken on day cases, although at present this figure is only 30% (RCSE 1993). This article defines hernias and describes the aetiology and surgical treatment of inguinal and femoral hernia. The differences between the traditional and laparoscopic repair of hernias are explored as well as the use of materials such as polypropylene mesh to enhance the repair. The need for thromboprophylaxis and antibiotic therapy are outlined together with patient discharge advice.

Current status of minimal access surgery for gastric cancer

BACKGROUND

The aim was to conduct a systematic review of the literature on the subject of laparoscopic gastrectomy (LG) and determine the relative merits of laparoscopic (LG) and open gastrectomy (OG) for gastric carcinoma.

MATERIAL AND METHODS

A search of the Medline, Embase, Science Citation Index, Current Contents and PubMed databases identified individual retrospective and prospective series on LG (proximal, distal and total). Furthermore, all clinical trials that compared LG and OG published in the English language between January 1990 and the end of December 2006 were also identified. A large number of outcome variables were analysed for individual series and comparative trials between LG and OG and results discussed and tabulated.

RESULTS

The majority of the literature is published from Japan showing both oncological adequacy and safety of LG. The majority of early series and comparative studies have utilized laparoscopic resection for early and distal gastric cancer. However, with increasing advanced laparoscopic experience, advancement in digital technology and improvement in instrumentation, more advanced gastric cancers and more extensive procedures such as laparoscopic-assisted total gastrectomy and laparoscopy-assisted D2 dissection are becoming more common. To date lymph node harvesting, resection margins and complication rates seem to be equivalent to open procedures. Furthermore, the earlier fears of port-site metastases have not been borne out.

CONCLUSIONS

The available data suggests that LG seems to be associated with quicker return of gastrointestinal function, faster ambulation, earlier discharge from hospital, and comparable complications and recurrence rate to OG. However, the operating time for LG remains significantly longer compared to its open counterpart, although with experience it is achieving parity with OG. However, the majority of the comparative trials (if not all) probably do not have the power to detect differences in the outcome. As far as the RCT's (LG vs. OG) are concerned, the numbers of patients in such trials are small and the majority of patients were operated upon for early distal gastric cancer and, therefore, any meaningful conclusions regarding the advantages or disadvantages of LG for both the ECGs and extensive and advanced gastric tumours are difficult to justify.

Consolidated five-year experience with laparoscopic inguinal hernia repair

INTRODUCTION

After the introduction of laparoscopic hernia repair to the National Health Service (NHS), we studied the benefits and practicality of carrying out this specialised hernia repair technique in a District General NHS hospital.

METHODS

Patients with groin hernia were stratified into groups for day-surgery or inpatient care based on Trust guidelines. Patients underwent laparoscopic trans-abdominal pre-peritoneal (TAPP) inguinal hernia repair by a single consultant surgeon. Patients were followed-up in the clinic. All data were collected prospectively on a structured proforma. Postal questionnaire was sent to 100 randomly selected patients who had surgery more than two years ago and responses were evaluated.

RESULTS

A total of 830 hernias were operated upon in 572 patients, aged between 16 and 89 years. Three hundred and twelve patients had the operation as a day-case procedure, and the remaining 260 were treated as inpatients. Incidental hernias were discovered in 19.1% of patients, and were treated simultaneously.

CONCLUSION

The laparoscopic tension-free TAPP method of hernia repair, as done here, is cost-effective and efficacious. Most patients can be treated as day-cases. A low recurrence rate (0.36%) with low morbidity makes it an attractive method for routine treatment of groin hernias in the NHS.

Experience of laparoscopic hernia repair in a laparoscopically oriented unit of a large community hospital

We describe a consecutive series of 258 laparoscopic inguinal hernia repairs in 189 patients from January 1997 to December 2004. Early results, complications, and follow-up were collected prospectively. Patients were followed in the outpatient clinic and contacted by phone at the time of this review. Three trocars were employed. The polypropylene mesh was inserted through the periumbilical trocar and fixed in the properitoneal space using titanium clips. There were no conversions and the mean operative time was 88 minutes (including bilateral cases). We had no major intraoperative accidents, and only 12 minor postoperative complications (4 urinary retentions, 6 seromas, and 2 cases of prolonged pain). Walking, hospital discharge, and return to activities were prompt, with a mean hospital stay of 1.7 days, and an average time of absence from work of 16 days. There have been 11 (4%) documented recurrences during long-term follow-up (mean, 62 months). The technique appears safe and efficacious even in a community hospital with a large laparoscopic experience.

Recurrent inguinal hernia: randomized multicenter trial comparing laparoscopic and Lichtenstein repair

BACKGROUND

The optimal treatment for recurrent inguinal hernia is of concern due to the high frequency of recurrence.

METHODS

This randomized multicenter study compared the short- and long-term results for recurrent inguinal hernia repair by either the laparoscopic transabdominal preperitoneal patch (TAPP) procedure or the Lichtenstein technique.

RESULTS

A total of 147 patients underwent surgery (73 TAPP and 74 Lichtenstein). The operating time was 65 min (range, 23-165 min) for the TAPP group and 64 min (range, 25-135 min) for the Lichtenstein group. Patients who underwent TAPP reported significantly less postoperative pain and shorter sick leave (8 vs 16 days). The recurrence rate 5 years after surgery was 19% for the TAPP group and 18% for the Lichtenstein group.

CONCLUSION

The short-term advantage for patients who undergo the laparoscopic technique is less postoperative pain and shorter sick leave. In the long term, no differences were observed in the chronic pain or recurrence rate.

The role of endoscopic extraperitoneal herniorrhaphy: where do we stand in 2005?

Inguinal hernia repair is a common surgical procedure, but the most effective surgical technique remains controversial. The evolution of laparoscopic techniques has allowed reproduction of open preperitoneal repair via an endoscopic total extraperitoneal (TEP) approach. More recently, the advent of comprehensive training in laparoscopy has allowed TEP to continue evolving as the feasibility of this approach gains recognition as a preferable technique. Once considered very difficult to learn, TEP currently is adequately taught in many surgical training programs. This report reviews the fundamentals and details various modifications that make this procedure more desirable than open procedures and other laparoscopic techniques. A resultant decrease in operative time, cost of the procedure, and morbidity to the patient is routine. In addition, the authors review their institutional experience and examine other current evidence-based data.

Open or endoscopic total extraperitoneal inguinal hernia repair? A systematic review

BACKGROUND

Although a large number of surgeons currently perform endoscopic hernia surgery using a total extraperitoneal (TEP) approach, reviews published to date are based mainly on trials that compare laparoscopic transabdominal preperitoneal (TAPP) repair with various types of open inguinal hernia repair.

METHODS

A qualitative analysis of randomized trials comparing TEP with open mesh or sutured repair.

RESULTS

In this review, 4,231 patients were included in 23 trials. In 10 of 15 trials, TEP repair was associated with longer surgery time than open repair. A shorter postoperative hospital stay after TEP repair than after open repair was reported in 6 of 11 trials. In 8 of 9 trials, the time until return to work was significantly shorter after TEP repair. Hospital costs were significantly higher for TEP than for open repair in all four trials that included an economic evaluation. Most trials (n = 14) reported no differences in subsequent recurrence rates between TEP and open repair.

CONCLUSIONS

The findings showed that endoscopic TEP repair is associated with longer surgery time, shorter postoperative hospital stay, earlier return to work, and recurrence rates similar to those for open inguinal hernia repair. The procedure involves greater expenses for hospitals, but appears to be cost effective from a societal perspective. The TEP technique is a serious option for mesh repair of primary hernias.

Surgical management of inguinal hernia

The Lichtenstein repair is now the gold standard for open hernia repairs. This repair is easier to learn and easy to implement for the average general surgeon. Open mesh repairs are not the end-all in hernia operations, however, and surgeons must retain the knowledge for open tissue-based procedures. Laparoscopic inguinal hernia repair is a safe alternative to open repair for inguinal hernias but is much more operator dependent. Open mesh repair has a lower recurrence rate when compared with TEP or TAPP repairs for less experienced laparoscopists. Laparoscopic repair has a quicker return to work, is associated with less postoperative pain, and has a better cosmetic result. It is more difficult to learn, however, and hospital costs are higher. Surgeons need to look at their own numbers and experience to decide which approach is better given the clinical situation based on their proficiency with the various techniques.

Is minimally invasive surgery less invasive in total hip replacement? A pilot study

It has been suggested that minimally invasive surgery (MIS) in total hip replacement (THR) is less traumatic than standard techniques. This study was designed to address the question of whether an anterior MIS approach generates less inflammation and muscle damage than the standard posterolateral (PL) approach. Inflammation parameters such as interleukin-6 (IL-6), muscle damage parameters like heart type fatty acid binding protein (H-FABP), and haemoglobin (Hb) levels were determined pre-operatively and at five consecutive points post-operatively in 10 patients operated through a MIS anterior approach and in 10 patients operated through a PL approach. The mean IL-6 concentration increased from 3 pg/ml in both groups pre-operatively to 78.5 pg/ml (PL group) vs 74.8 pg/ml (MIS group) at 6 hours post-operatively and reached a maximum of 100 pg/ml (PL group) vs 90.5 pg/ml pg/ml (MIS group) after 24 hours. Up to this time point, there was a decrease in both groups. The post-operative mean H-FABP concentration increased to 10.7 microg/l in the PL group vs 15.8 microg/l in the MIS group. It formed a plateau and decreased after 24 hours post-operatively. The Hb levels were 14.5 g/dl before surgery and decreased to 10.7 g/dl (PL group) and 10.0 g/dl (MIS group) at 72 hours post-operatively. No significant differences were found between the two approaches either in inflammation and muscle damage or blood loss. Although the absence of a learning curve may explain the lack of a difference between both techniques, we speculate that the term MIS is at least doubtful in terms of being less traumatic.

Is the Lichtenstein Operation of Strangulated Groin Hernia a Safe Procedure?

BACKGROUND

In spite of many published articles describing the hernia repairs, there are only a few original reports concerning the polymer mesh application during emergency procedures for strangulated inguinal hernias. The aim of our study was to evaluate the results of the Lichtenstein and Bassini operations for strangulated groin hernias and to show the changing number of the tension-free repairs.

METHODS

From 1997 to 2004, the Bassini procedure was performed in 21 patients, 6 of whom underwent small intestine resection and 2 others required resection of the necrotic omentum. The strangulated intestinal loop or omentum were released in 13 cases. After the repair 1 patient died of shock caused by intestinal necrosis. Of 56 patients who underwent an emergency Lichtenstein procedure, 55 were followed-up. A small intestine resection was performed in 2 cases to correct segmental necrosis. The gangrenous omental appendix of the sigmoid colon was excised in 1 patient, and necrotic omental fragments were resected in 2 cases. The strangulated intestinal loop or omentum was released in 51 patients. All patients were given wide-spectrum antibiotics intravenously.

RESULTS

Between 1997 and 2000 tension-free procedures were performed in half of the patients undergoing emergency operation for strangulated hernia; between 2001 and 2004 such procedures were employed in more than 90% of the cases. In 2 patients we observed a small inflammatory infiltration of the wound that resolved within several days after Lichtenstein repair. A serous fluid collection was present in 2 cases. The treatment consisted of puncture and was successful in both cases.

CONCLUSIONS

The use of monofilament polypropylene mesh for strangulated inguinal hernia repair is safe, and the risk of the local infectious complications is low.

Laparoscopic vs conventional tension free inguinal herniorrhaphy: 2005 Society of American Gastrointestinal Endoscopic Surgeons (SAGES) annual meeting debate

This report summarizes the 2005 Society of American Gastrointestinal and Endoscopic Surgeons' inguinal herniorrhaphy debate. Most inguinal herniorrhaphies in the United States are performed using one of several prosthesis-based, tension-free (TFR) procedures. Approximately 15% of the procedures used are laparoscopic inguinal herniorrhaphies (LIH). Technical ease, lower cost, and local anesthesia are the major advantages attributed to TFR, whereas superior cosmesis, less perioperative pain, and a faster return to normal activity is attributed to LIH. The overall cost-benefit ratio, incidence of chronic pain syndromes, and relevance of a recent major trial could not be entirely settled in this debate. The importance of adequate training for surgeons undertaking LIH cannot be overemphasized. Experienced surgeons displaying equivalent results for LIH and TFR are justified in offering LIH to patients with primary unilateral inguinal hernias.

A comparison of heterogeneity variance estimators in combining results of studies

For random effects meta-analysis, seven different estimators of the heterogeneity variance are compared and assessed using a simulation study. The seven estimators are the variance component type estimator (VC), the method of moments estimator (MM), the maximum likelihood estimator (ML), the restricted maximum likelihood estimator (REML), the empirical Bayes estimator (EB), the model error variance type estimator (MV), and a variation of the MV estimator (MVvc). The performance of the estimators is compared in terms of both bias and mean squared error, using Monte Carlo simulation. The results show that the REML and especially the ML and MM estimators are not accurate, having large biases unless the true heterogeneity variance is small. The VC estimator tends to overestimate the heterogeneity variance in general, but is quite accurate when the number of studies is large. The MV estimator is not a good estimator when the heterogeneity variance is small to moderate, but it is reasonably accurate when the heterogeneity variance is large. The MVvc estimator is an improved estimator compared to the MV estimator, especially for small to moderate values of the heterogeneity variance. The two estimators MVvc and EB are found to be the most accurate in general, particularly when the heterogeneity variance is moderate to large.

Open, preperitoneal hernia repair with the Kugel patch: a prospective, multicentre study of 450 repairs

BACKGROUND

The Kugel patch inguinal hernia repair is a relatively new, open, minimally invasive procedure using a preperitoneal approach.

METHOD

Prospective multicentre case series of 450 consecutive Kugel patch repairs. Recurrence rates and persistent inguinal pain after at least 1 year as well as short-term outcomes were studied.

RESULTS

After a follow-up of 18 months, eight recurrences (1.9%) were found, and persisting inguinal pain was reported in 15 patients (3.5%). The mean operation time and hospital stay were 20 +/- 9 min and 19 +/- 1.3 h respectively. Less than 1% of patients planned for an ambulatory treatment needed prolonged hospitalisation. Analgesics were used for 3 +/- 2 days. Paracetamol was the only painkiller used in 69% of patients, and 13% did not take any painkiller at all. Half of all patients returned to their daily activities after 9 days and half of the employed patients returned to work after 14 days.

CONCLUSION

The Kugel patch repair is a quick technique with a low recurrence rate and good patient comfort. It offers the advantages of a preperitoneal inguinal hernia repair without the need for general anaesthesia or expensive laparoscopic equipment.

Comparison of laparoscopic and open tension-free repair of recurrent inguinal hernias: a prospective randomized study

BACKGROUND

The current prospective randomized controlled clinical study aimed to assess the short- and long-term results of recurrent inguinal hernia repair, and to compare the results for transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) procedures with those for open tension-free repair.

METHODS

For this study, 82 patients were randomly assigned to undergo TAPP (group A, n = 24), TEP (group B, n = 26), or open Lichtenstein hernioplasty (group C, n = 32). All the patients with recurrent inguinal hernias had undergone previous repair using conventional open procedures. Physical examination showed Nyhus type II hernia in the vast majority of the patients (59%). High-risk patients (American Society of Anesthesiology [ASA] III or IV); coagulation disorders; previous abdominal or pelvic surgery; and irreducible, congenital, and massive scrotal or sliding hernias were excluded from the study.

RESULTS

There was a statistically significant difference (p = 0.001) in operating time favoring the open procedure. The intensity of postoperative pain was greater in the open hernia repair group 24 h, 48 h, and 7 days after surgery (p = 0.001), with a greater consumption of pain medication among these patients (p < 0.004). The median time until return to work was 14 days for group A, 13 days for Group g, and 20 days for group C. The comparison was in favor of laparoscopically treated patients. Nine recurrences (4 in the laparoscopic groups and 5 in the open group) were documented within 3 years of follow-up evaluation.

CONCLUSION

Laparoscopic inguinal hernia repair (TAPP or TEP) is the method of choice for dealing with recurrent inguinal hernia.

Laparoscopic Inguinal Hernia Repair

As a consequence of the development of laparoscopic cholecystectomy in the late 1980s, diagnostic and therapeutic laparoscopy has now become an integral part of the average general surgeon's practice. Many conventional operations have been successfully adapted for the laparoscopic approach. A laparoscopic operation is unquestionably the surgical procedure of choice for gastroesophageal reflux disease and removal of the gallbladder, spleen, or adrenal gland unless specific contraindications are present. However, the value of laparoscopic techniques for other operations remains controversial within the surgical community. Laparoscopic inguinal herniorrhaphy (LIH) is a case in point. Frequent reanalysis of the controversial procedures such as laparoscopic herniorrhaphy is especially important because videoscopic operations remain in their developmental stages and thus continue to evolve. With this in mind, the purpose of this review was to examine the current state of the art of laparoscopic inguinal herniorrhaphy in relationship to its conventional counterparts.

Cure chirurgicale des hernies inguinales de l’adulte

Inguinal hernia repair is the most commonly performed surgical procedure. Nearly one out of three men between 20 and 60 years of age will undergo hernia repair. Multiple surgical techniques are available which have comparable clinical outcomes but which differ in their functional results and economic impact. Despite an extensive surgical literature, no consensus exists regarding an optimal technique. This review aims to compare the indications for the three most common techniques: 1) the Shouldice repair, 2) the Lichtenstein repair, and 3) the laparoscopic hernia repair. To begin with, we present the operative principals of each repair along with criteria for evaluation of outcomes. Evidence-based outcomes data are then presented. We then address the choice of a surgical technique for everyday practice based on these factors. Finally, we propose avenues for future clinical research which may improve clinical, functional, and economic results in the repair of inguinal hernia of the adult.

Systematic review and meta-analysis of the effectiveness of antibiotic prophylaxis in prevention of wound infection after mesh repair of abdominal wall hernia

BACKGROUND

The aim was to determine whether systemic antibiotic prophylaxis prevented wound infection after repair of abdominal wall hernia with mesh.

METHODS

This was a systematic review of the available literature identified from multiple databases using the terms 'hernia' and 'antibiotic prophylaxis'. Randomized placebo-controlled trials of antibiotic prophylaxis in abdominal wall mesh hernia repair with explicitly defined wound infection criteria and a minimum follow-up of 1 month were included. After independent quality assessment and data extraction, data were pooled for meta-analysis using a random-effects model.

RESULTS

The search process identified eight relevant trials. Two papers on umbilical, incisional or laparoscopic hernias, and six concerning inguinal and femoral (groin) hernias were suitable for meta-analysis. The incidence of infection after groin hernia repair was 38 (3.0 per cent) of 1277 in the placebo group and 18 (1.5 per cent) of 1230 in the antibiotic group. Antibiotic prophylaxis did not significantly reduce the incidence of infection: odds ratio 0.54 (95 per cent confidence interval 0.24 to 1.21); number needed to treat was 74. The number of deep infections was six (0.6 per cent) in the placebo group and three (0.3 per cent) in the antibiotic prophylaxis group: odds ratio 0.50 (95 per cent c.i. 0.12 to 2.09).

CONCLUSION

Antibiotic prophylaxis did not prevent the occurrence of wound infection after groin hernia surgery. More trials are needed for complete evidence in other areas of abdominal wall hernia.

Coagulation, inflammatory, and stress responses in a randomized comparison of open and laparoscopic repair of recurrent inguinal hernia

BACKGROUND

In previous comparisons of inflammatory and stress responses to open (OR) and laparoscopic (LR) hernia repair, all operations were performed under general anesthesia. Since local anesthesia is widely used for OR, a comparison of this approach with LR seemed relevant.

METHODS

Patients with recurrent inguinal hernia were randomized to OR under local anesthesia (n = 30) or LR under general anesthesia (n = 31). The magnitude of the surgical trauma was assessed by measuring markers of coagulation (prothrombin fragment 1 + 2), endothelial activation (von Willebrand factor), inflammation [leukocytes, interleukin-6, -8 and -10, granulocyte macrophage colony-stimulating factor, and C-reactive protein (CRP)], and endocrine stress (cortisol) in blood collected before operation, 4 h postincision, and on postoperative day 2.

RESULTS

Leukocyte counts and interleukin-6 and CRP levels increased in both groups, with the CRP increase being significantly greater in the OR group. The other markers did not increase significantly.

CONCLUSION

The acute phase response was more pronounced after OR, even when this was done under local anesthesia. Both techniques seemed rather atraumatic.