Totally extraperitoneal repair of recurrent inguinal hernia

Evaluating the complications of adult groin hernia where there is no hernia registry: a systematic review of Nigerian literature

BACKGROUND

Enumerating the complications of groin hernia repair might help to highlight the need for improvement in the quality of care. This is imperative in a country without a strong post-operative complication surveillance mechanism. Hence, this review aims to determine the complications encountered during the surgical treatment of groin hernias among Nigerian subjects.

METHODS

Databases like Google Scholar, Scopus, and PubMed were searched. Out of the 140 papers found during the search, only 20 were included in this review. Bassini repair was the most common type of hernia repair used, and neither laparoscopic repair nor posterior approach was utilized in any of the patients. Emergency presentations constituted about 18.5% of the cases. Meta-analysis of the studies showed that more prevalent complications were wound/scrotal edema (derived from four studies), surgical site infections (derived from 17 studies), and hematoma (from 19 studies). The rates were 23% (CI 0-46%; I2 = 80.9%), 6% (CI 3-10%; I2 = 87.7%), and 5% (CI 2-8%; I2 = 83.7%), respectively. The rate of complication in giant hernias was higher than the non-giant hernias and was statistically significant [p < 0.05; OR 1.5 (CI 0.9-2.4)]. Although the recurrence rate is low, there was insufficient follow-up of patients.

CONCLUSION

This review has shown that one-fifth of the patients had emergency repair of hernias and giant groin hernias have higher odds of complications after repair compared to normal-sized ones. The most common complication noted was wound/scrotal edema. None of the hernias was repaired with laparoscopy. Perhaps, establishing a registry might improve the detection of late complications in patients who had groin hernia repair.

Analysis of risk factors for surgical site infection and postoperative recurrence following inguinal and femoral hernia surgery in adults

OBJECTIVE

We aimed to evaluate the causes of complications following surgery for inguinal and femoral hernia, using surgical site infection (SSI) and recurrence rate as indicators of outcomes to consider appropriate treatments.

METHODS

We retrospectively assessed the medical histories of 1,098 patients with adult inguinal and femoral hernias who underwent herniorrhaphy between July 2010 and March 2019. Using SSI and recurrence rate as indicators of outcomes, we statistically assessed the influence of preoperative and operative conditions on surgical outcomes.

RESULTS

The occurrence of postoperative SSI was significantly more frequent in patients who experienced a long surgical duration, excessive blood loss, and incarceration; underwent emergency surgery and bowel resection; and in whom no mesh sheet insertion was performed. There was no correlation between mesh use and SSI in cases that did not require emergency incarceration repair. For cases involving hernia incarceration, the use of a mesh sheet was avoided to prevent potential infection, which could explain the high incidence of SSI in cases where mesh was not used. The hernia may have recurred due to technical issues during the procedure, as well as failure to ligate the hernia sac.

CONCLUSIONS

Selecting the appropriate surgical method for hernia repair may reduce the incidence of SSI. If manual reduction of inguinal hernias is not possible, an appropriate surgical procedure should be determined based on laparoscopic findings in facilities where laparoscopic hernia surgeries are frequently performed. Moreover, in cases without infection and bowel resection, mesh use may be beneficial. Recurrence can be prevented by ligating the hernia sac during surgery and solving relevant technical problems.

Cost analysis of inguinal hernia repair: the influence of clinical and hernia-specific factors

Introduction

As in the rest of the world, in Germany, inguinal hernia operations are among the most common operations. From an economic standpoint, very little is known about the influence of demographic, clinical or hernia-related parameters on the cost of inguinal hernia repair. We, therefore, evaluated individual patient parameters associated with higher costs with a special focus on multimorbidity.

Methods

A total of 916 patients underwent hernia repair for primary or recurrent inguinal hernia between 2014 and 2017 at a single university center and were included in the analysis. The clinical and financial data of these patients were analyzed to identify cost-increasing parameters.

Results

A majority of patients were male (90.7%), with a mean age of 55 years. The surgical methods utilized were mainly the TAPP (57.2%) and Lichtenstein (41.7%) procedures, with an average duration of surgery of 85 min and an average duration of anesthesia of 155 min. The mean cost of all procedures was 3338.3 € (± 1608.1 €).

Older age, multimorbidity, emergency operations with signs of incarceration, longer hospital stays and postoperative complications were significant cost-driving factors. On the other hand, sex, the side of the hernia (left vs. right) and the presence of recurrent hernias had no influence on the overall direct costs.

Conclusion

From a purely economic point of view, older age and multimorbidity are demographic cost-driving factors that cannot be influenced. The national hospital reimbursement system needs to consider and compensate for these factors. Emergency operations need to be prevented by early elective treatment. Long postoperative stays and postoperative complications need to be prevented by proper preoperative check-ups and accurate treatment.

TEP for elective primary unilateral inguinal hernia repair in men: what do we know?

INTRODUCTION

Based on the new international guidelines for groin hernia management, there is no one surgical technique that is suited to all patient characteristics and diagnostic findings. Therefore, a tailored approach should be used. Here, a distinction must be made between primary unilateral inguinal hernia in men and in women, bilateral inguinal hernia, scrotal inguinal hernia, inguinal hernia following pelvic and lower abdominal procedures, patients with severe cardiopulmonary complications, recurrent inguinal hernias and incarcerated inguinal and femoral hernias. This paper now explores the relevant studies on TEP for elective primary unilateral inguinal hernia in men, which constitutes the most common indication for repair.

MATERIAL

A systematic search of the available literature was performed in February 2019 using Medline, PubMed, Scopus, Embase, Springer Link and the Cochrane Library. Only meta-analyses, systematic reviews, RCTs and comparative registry studies were considered. 117 publications were identified as relevant.

RESULTS

RCTs and comparative registry analyses demonstrated the advantages of TEP with regard to postoperative complications, complication-related reoperations, and postoperative and chronic pain compared with Lichtenstein repair for elective primary unilateral inguinal hernia repair in men. No relevant differences were found compared with TAPP. Mesh fixation is not needed in TEP, but heavyweight meshes result in a lower recurrence rate. Extraperitoneal bupivacaine analgesia vs placebo does not demonstrate any advantages, but drainage is advantageous for seroma prophylaxis. The risk of chronic pain is negatively influenced by small defects, younger patient age, preoperative pain, higher BMI, postoperative complications, higher ASA score and risk factors.

CONCLUSION

For the subgroup of elective primary unilateral inguinal hernia in men, accounting for a proportion of less than 50% of the total collective, advantages were identified for TEP compared with open Lichtenstein repair but not versus TAPP.

An 11-year analysis of reoperated groins after endoscopic totally extraperitoneal (TEP) inguinal hernia repair in a high volume hernia center

BACKGROUND

Developments in inguinal hernia surgery have substantially lowered recurrence rates, yet recurrences remain an important outcome parameter of inguinal hernia repair. The aim of this study was to analyze the characteristics of all reoperated groins after endoscopic totally extraperitoneal (TEP) inguinal hernia repair in a high-volume hernia clinic in the Netherlands.

METHODS

All groins with recurrence-like symptoms reoperated after previous TEP inguinal hernia repair between January 2006 and December 2016 were analyzed. Patient characteristics, imaging findings, primary hernia type, time to recurrence and recurrence type were assessed.

RESULTS

A total of 137 groins were reoperated in 130 patients. The median age at the TEP procedure was 55 years [interquartile range (IQR) 45-64 years]. Fifty-seven groins were initially part of a bilateral procedure (42%). Median time until recurrence was 9 months (IQR 4-26 months). Reoperation findings were a hernia recurrence in 76%, an isolated lipoma in 18%, and no recurrence or lipoma in 6%. The majority of hernias recurred at their initial site (70%), of which the greatest part involved direct hernias. Isolated lipomas were more frequently seen after indirect hernia repair.

CONCLUSIONS

Inguinal hernia recurrences were still observed in this high-volume hernia clinic. Recurrences were most frequently seen at their initial hernia site, the majority involving direct hernias. Isolated lipomas presenting as a pseudorecurrence were most frequently seen after correction of indirect hernias. In accordance with the current guidelines, reducing recurrence rates can be achieved by mesh fixation in bilateral, large and direct defects and by thoroughly reducing lipomas.

International guidelines for groin hernia management

INTRODUCTION

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

METHODS

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

Endo-laparoscopic inguinal hernia repair: What is its role?

Hernia repair techniques vary greatly depending upon the setting, surgeons, insurance reimbursement systems, resources, and logistical capabilities. Open mesh repair is the most frequently used technique. Choosing the best technique for inguinal hernia repair is a challenge. There is no single technique to manage every type of hernia. Today, laparoscopy and robotics are at the forefront of advanced surgical tools and offer a range of options for general surgeons who are critically evaluating new procedures. However, before using a new procedure, such as endo-laparoscopic hernia repair, surgeons often ask the rhetorical question, "Why change?" The common considerations are the availability of equipment, familiarity with the anatomy when using these techniques, operative time, cost to the patient, and the potential need to convert to an open procedure. Additionally, we are now seeing a significant shift away from surgeon-defined benefits to patient-defined benefits. As patients become more aware of their options for hernia procedures and share their experiences, more and more patients are likely to demand a particular technique. Hence, hernia surgeons should be educated on the different techniques available for inguinal hernia repair, including endo-laparoscopic procedures. In this article, we review the existing literature on the current role of endo-laparoscopic inguinal hernia repair.

Inguinal hernia developed after radical retropubic surgery for prostate cancer

PURPOSE

In this retrospective study, we aimed to compare the clinical characteristics of inguinal hernia developed after radical retropubic surgery for prostate cancer to the hernia without previous radical prostatectomy.

METHODS

Twenty-three patients (group A) who had radical retropubic surgery for prostate cancer underwent laparoscopic or open tension-free inguinal hernia repair from March 2007 to February 2011. Nine hundred and forty patients (group B) without previous radical retropubic surgery received laparoscopic or tension-free open hernia operation.

RESULTS

Group A was older than group B (mean ± standard deviation, 69.6 ± 7.2 vs. 54.1 ± 16.1; P < 0.001). Right side (73.9%) and indirect type (91.3%) in group A were more prevalent than in group B (51.5% and 69.4%, respectively) with statistic significance (P = 0.020 and P = 0.023). The rate of laparoscopic surgery in group B (n = 862, 91.7%) was higher than in group A (n = 14, 64.3%, P < 0.001). In comparing perioperative variables between the two groups, operative time (49.4 ± 23.5 minutes) and hospital stay (1.9 ± 0.7 days) in group A were longer than in group B (38.9 ± 16.9, 1.1 ± 0.2; P = 0.046 and P < 0.001, respectively) and pain score at 7 days in group A was higher than in group B (3.1 ± 0.7 vs. 2.3 ± 1.0, P < 0.001). Postoperative recurrence rate was not significantly different between the two groups.

CONCLUSION

Inguinal hernia following radical retropubic surgery for prostate cancer was predominantly right side and indirect type with statistic significance compared to hernias without previous radical prostatectomy.

Laparoscopic or Lichtenstein repair for recurrent inguinal hernia: a meta-analysis of randomized controlled trials

BACKGROUND

There is no clear answer regarding the use of laparoscopic techniques versus the Lichtenstein method for the treatment of recurrent inguinal hernia.

OBJECTIVE

The aim of this study was to compare the outcomes of laparoscopy versus the Lichtenstein repair by a meta-analysis of available randomized controlled trials (RCTs).

METHODS

Databases, including PubMed, EMBASE, the Cochrane Library, and the Science Citation Index updated to May 2012, were searched. The main outcome measures were wound infections and haematoma, urinary retention, post-operative chronic pain and recurrence. A meta-analysis of included RCTs was performed.

RESULTS

Five RCTs, comprising a total of 427 patients, were included. Although most of the analysed outcomes were similar between groups, wound infection rates and post-operative chronic pain occurred less frequently in the laparoscopic group than in the Lichtenstein group (odds ratio: 0.28, 95% CI: 0.08-0.97; P = 0.05; odds ratio: 0.33, 95% CI: 0.17-0.68; P = 0.002, respectively).

CONCLUSION

The laparoscopic approach to the treatment of recurrent inguinal hernia is superior to the Lichtenstein hernioplasty in some aspects that affect patient satisfaction.

Clinical usefulness of laparoscopic total extraperitoneal hernia repair for recurrent inguinal hernia

PURPOSE

Hernia repair after recurrence is a challenging procedure, and many approaches have been suggested for it. Total extraperitoneal (TEP) hernia repair should be considered in recurrent hernia. This study was conducted for the purpose of investigating the clinical usefulness of laparoscopic TEP hernia repair for recurrent inguinal hernia.

METHODS

Among the 191 patients who underwent TEP hernia repair at these authors' center from June 2006 to January 2010, the bilateral-hernia cases and the patients with a history of previous pelvic surgery were excluded. A total of 19 patients (12.5%) were enrolled in the recurrent-inguinal-hernia group (group R), and 133 patients (87.5%) in the primary-hernia group (group P). Data were investigated retrospectively, based on the medical records.

RESULTS

The mean operation time was 97 minutes in group R and 99 minutes in group P (>0.05). In group R, no operation modality change occurred, and temporary urinary retention was developed in four patients (21.1%). In group P, on the other hand, operation modality change from TEP to the transabdominal preperitoneal approach was necessary in four patients (3%). Additionally, in group P, 30 patients (22.6%) had temporary urinary retention and six (4.5%) had testicular edema. No recurrence was identified during the follow-up period in both groups (mean follow-up period: 15.8 months for group R and 18.0 months for group P).

CONCLUSION

Laparoscopic TEP hernia repair seems to be a safe and useful method for correcting recurrent inguinal hernia.

Single-incision laparoscopic transabdominal preperitoneal herniorrhaphy for recurrent inguinal hernias: preliminary surgical results

BACKGROUND

Since the early 1990s, laparoscopy has provided surgeons with new and innovative ways to treat various surgical problems. Many of these minimally invasive techniques have gained universal acceptance by demonstrating improved patient outcomes. Single-incision laparoscopic surgery (SILS) was developed with the aim of reducing the invasiveness of traditional laparoscopy. Laparoscopic transabdominal preperitoneal (TAPP) herniorrhaphy via the three-trocar technique is widely used for recurrent inguinal hernia. To the author's knowledge, this report describes first series of SILS TAPP for recurrent inguinal hernia repair.

METHODS

From April 2009 to March 2010, 15 single-incision laparoscopic TAPP repairs of recurrent inguinal hernia were performed by the same surgical team. The data collected prospectively included patient demographics, type of hernia, operative time, complications, postoperative hospital stay, and recurrence. The umbilicus was the sole point of entry for all patients using a single port, and the same operative technique was used in all cases.

RESULTS

The SILS TAPP procedure was performed successfully for all the patients, and none required conversion to an open procedure or a conventional laparoscopic hernia repair by the addition of more entry ports. The mean operative time was 51 ± 17 min. No intra- or postoperative complications were recorded. There was no evidence of early recurrence during a mean follow-up period of 130 ± 77 days.

CONCLUSION

Based on this experience, the author believes that SILS approach is technically feasible and safe using standard and slightly modified instruments for standard TAPP. The cosmetic benefit is clear, but the advantages of SILS TAPP over conventional laparoscopic surgery during long-term follow-up evaluation will require further randomized clinical trials.

The safety and effectiveness of laparoscopic total extraperitoneal (TEP) repair for recurrent inguinal hernia after open hernioplasty

BACKGROUND

Many studies have reported that laparoscopic total extraperitoneal (TEP) repair for recurrent inguinal hernia after an open hernioplasty was safe and effective. This study was conducted to evaluate TEP repair for recurrent inguinal hernia through a retrospective analysis of our data.

MATERIALS AND METHODS

We performed a retrospective analysis of the medical records of patients who were scheduled for laparoscopic TEP repair from December 2000 to December 2008. A total of 1065 cases of laparoscopic TEP repairs were performed for 944 patients by a single surgeon, and 100 cases of recurrent inguinal hernias were enrolled.

RESULTS

The mean operation time was longer in the recurrent hernia group than that in the primary hernia group (P < 0.001), and peritoneal tearing occurred more frequently in the recurrent hernia group (P < 0.001). Direct hernia was more frequent in the recurrent hernia group (P < 0.001). The mean number of hospital days and complications, such as seroma and postoperative pain, were similar in both groups. Three cases of recurrence occurred (0.28%): 2 occurred in the recurrent hernia group (2%) and the other occurred in the primary hernia group (0.1%).

CONCLUSIONS

Laparoscopic TEP repair is safe and effective for treating recurrent inguinal hernia after an open hernioplasty, because the recurrence rate was low (2%) and other complications were similar for both groups. Direct inguinal hernia was more frequent in patients who had recurrent inguinal hernia.

Serious life-threatening complication 5 years after laparoscopic totally extraperitoneal hernia repair: case report and discussion of the literature

PURPOSE

The purpose of this paper is to report the case of a serious life-threatening infection of the mesh occurring 5 years after totally extraperitoneal (TEP) hernia repair and to highlight the persistent risk of infection that may exist even after a long period following the primary repair. We also aim to raise the awareness of surgeons to the subtle presentation.

METHODS

We have reviewed the clinical presentation, past medical history and relevant pre-operative and post-operative investigations in a case of mesh infection 5 years after primary surgery. We have also reviewed the literature regarding long-term complications that may occur after TEP repair.

RESULTS

A 62-year-old man presented with severe mesh infection 5 years and 4 months after primary bilateral TEP hernia repair. He rapidly progressed into septic shock and had to be managed in the intensive care unit. He is a current smoker of 30 pack years. Post-operative contrast computed tomography (CT) revealed previously undiagnosed diverticuli scattered throughout the colon with points of minor narrowing at the sigmoid and transverse colons.

CONCLUSION

Although the risk of mesh infection following TEP hernia repair is small, it persists for more than 5 years and probably as long as the mesh remains in the body. Our report also raises the question as to whether there is a specific long-term risk of mesh infection following TEP hernia repair in patients with underlying inflammatory bowel disease and/or chronic heavy smoking. This needs to be studied prospectively.

Endoscopic total extraperitoneal repair of recurrent inguinal hernia: a 5-year review

PURPOSE

The experience of endoscopic total extraperitoneal (TEP) repair of recurrent inguinal hernia in a major teaching hospital is reviewed.

METHODS

Between 2003 and 2008, 37 consecutive patients underwent 46 TEP repairs for recurrent inguinal hernia. Patient demographics, hernia characteristics, operating time, conversion rate, intraoperative, postoperative complications and recurrence were measured. Twenty-eight patients had unilateral hernia and nine patients had bilateral hernias. The mean age was 59 years old (range 22-88 years).

RESULTS

The mean operation duration was 88 min (range 60-120 min). Bilateral repairs took 38% longer than for unilateral repairs (108 vs 78 min). Three patients (8.1%) had conversion to open surgery. Seroma developed in two patients, which was subsequently resolved. Within 1 year of follow up evaluation, there was 1 recurrence (2.7%). The mean inpatient hospital stay was 1.6 days, and 24.3% of the operations were performed as outpatients.

CONCLUSION

Repair of recurrent hernia using the TEP approach can be achieved with minimum morbidity, good clinical outcomes and acceptable recurrence rates. Endoscopic repair has become the procedure of choice for the treatment of the majority of recurrent inguinal hernias at our institution.

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.

Total extraperitoneal (TEP) mesh repair of inguinal hernia in the developing world: comparison of low-cost indigenous balloon dissection versus direct telescopic dissection: a prospective randomized controlled study

BACKGROUND

Creation of extraperitoneal space during TEP repair requires an expensive commercially available balloon.

PATIENTS AND METHODS

Fifty-six patients suffering from uncomplicated primary unilateral or bilateral groin hernia were randomized into two groups; group 1--indigenous balloon dissection and group 2--direct telescopic dissection.

RESULTS

There were 55 males and 1 female, with an average age of 49 years; 50% of the inguinal hernias were bilateral. Creation of extraperitoneal space was considered as satisfactory in majority of patients (94.6%) with satisfactory anatomical delineation. Peritoneal breach was noticed during dissection in 36 (64.3%) patients. There was one (3.8%) conversion of TEP to TAPP in group 2. Distance between pubic symphysis to umbilicus was an important factor, which affected the easiness of dissection. In patients with this distance <or=14 cm lateral placement of ports was considered for easy use of graspers. The incidence of scrotal edema was significantly higher in group 2 as compared with group 1 (p < 0.01). Patients with indirect inguinal hernias in group 2 presented with a greater number of scrotal edema. Pain score on VAS at 6 h after surgery was significantly higher in group 2 (p < 0.021). Patients with age <65 years, bilateral hernias, and indirect hernias had a correlation with higher pain score at 6 h. Of the patients, 17.9% developed seroma in group 1 versus 64.3% in group 2 (p < 0.001).

CONCLUSION

Anatomical delineation of inguinal area and dissection in the extraperitoneal space in TEP repair was equally satisfactory with both low-cost indigenous balloon (group 1) and telescopic dissection (group 2). Balloon dissection was associated with significantly reduced postoperative pain at 6 h, scrotal edema, and seroma formation. However at 3 months follow-up balloon dissection did not offer significant advantage over direct telescopic dissection in the overall long-term outcome of TEP repairs. If balloon dissection is considered useful for the beginner, low-cost indigenous balloon may be used to avoid higher cost of commercially available balloon dissector with added early advantages.

Laparoscopic Totally Extraperitoneal Hernia Repair Versus Open Lichtenstein Hernia Repair: Results and Complications

Whereas open Lichtenstein inguinal herniorrhaphy is generally accepted as a safe, well-understood method with a high success rate, the laparoscopic repair of a inguinal hernia is a fairly recent technique. Although the laparoscopic approach to a hernia repair procedure is associated with less pain and faster recovery than open repair, many surgeons are not familiar with this technique owing to technical demands and a long learning curve. This study compares the results and complications between open tension-free mesh (Lichtenstein) repair and laparoscopic total extraperitoneal (TEP) repair. The study cohort was comprised of 345 consecutive patients who underwent an inguinal herniorraphy procedure. An open hernia repair was performed on one group of patients (n = 233), whereas TEP repair was performed on the other (n = 112), and then the comparison of intra- and postoperative complications and results obtained from both techniques was done. The mean hospital stay was similar in both groups. The average operative time in the TEP group was 58.6 +/- 18.1 minutes, and the average operative time in the open group was 58.2 +/- 17.8 minutes. There was no difference in postoperative complication rates between the two groups, except for urinary retention, which patients who underwent TEP repair were more likely to get. The following major complications were recorded: 2 cases of urinary bladder perforation-1 during TEP repair and the other during Lichtenstein repair, but both with good postoperative outcome-and 1 case of pneumothorax, which occurred during the TEP procedure. Despite the fact that TEP is a demanding procedure, it may be performed efficiently with an acceptable operating time and a low complication rate.

A rare complication following laparoscopic TEP repair: case report and discussion of the literature

Transabdominal pre-peritoneal and totally extra-preperitoneal (TEP) are common laparoscopic techniques used to repair inguinal hernias. With better equipment and techniques for creation of pneumoperitoneum serious complications are now infrequent. However, complications from these techniques that are beyond the control of the surgeon do occur. This report details a rare complication related to infection. It is the first such documented complication of TEP hernia repair. There follows a short literature review of rare complications of laparoscopic hernia repair. Surgeons should familiarize themselves with these potential pitfalls for a number of reasons including, counseling when obtaining consent and heightened awareness for infrequent complications during postoperative follow-up.

Laparoscopic Inguinal Hernia Repair—An Unusual Complication

Laparoscopic inguinal hernia repair is associated with minimal postoperative pain, quicker return to normal activities, and very low recurrence rates. We describe an unusual complication after a laparoscopic total extraperitoneal repair.

Treating recurrence after a totally extraperitoneal approach

BACKGROUND

One of today's most highly regarded procedures for treating inguinal hernia is the totally extraperitoneal approach (TEP), but it can on occasion lead to recurrence. This is commonly managed with an open repair, a transabdominal preperitoneal procedure (TAPP), or another TEP. We report here on our years of experience with the latter.

METHODS

The endeavor to a secondary TEP is much the same as to a primary one, but certain differences are encountered as the operation proceeds. For example, many anatomical landmarks found in a first TEP cannot be seen in a second. There can also be a diminished amount of working space, and this occasionally leads to an open conversion.

RESULTS

From September 1991 to September 2005, we repaired 1,526 hernias in 1,156 male patients, using the TEP in every case. Of these, 21 were TEPs after a previous TEP. In 3 cases, the space could not be opened, and they were converted to the open Lichtenstein. One patient had peritoneal tears that led to conversion and another had conversion because of excessive bleeding. There were no complications, no bladder or bowel injuries, no transfusions, no preperitoneal hematomas, and no fatalities. All patients were discharged the same day.

CONCLUSIONS

A secondary TEP, open repair, and TAPP are alternative solutions to the problem of recurrence after TEP. However, any TEP involves a very prolonged learning curve for general surgeons, since they must learn the anatomy as well as the procedure, both at the same time. This is doubly true for the TEP after a previous TEP.

Laparoscopic total extraperitoneal repair versus anterior preperitoneal repair for inguinal hernia

Laparoscopic inguinal hernia repair is still not the gold standard for repair although mesh implantation is unequivocally accepted as an integral part of any groin hernia repair. The aim of the study was to compare the results of anterior preperitoneal (APP) mesh repair with totally extra peritoneal (TEP) repair for inguinal hernias. The prospective study was conducted on 241 patients with 247 hernias (from January 2000 to June 2004). Anterior preperitoneal repair was done in 121 patients and 120 patients were subjected to TEP repair. Repair in both groups was done by using Prolene mesh of size 6x4 in. or 6x6 in. intraoperative and postoperative parameters and complications were recorded and the patients were followed up to 1 year post-surgery. For both unilateral and bilateral inguinal hernias, mean operative time was significantly more in patients of TEP repair as compared to APP repair (P<0.001) and significantly more patients had peritoneal tears in the TEP group (P<0.001). Patients undergoing TEP repair, however, had significantly less postoperative pain (P<0.05) and postoperative hospital stay (P<0.05) and return to work was significantly earlier is this group (P<0.01 and P<0.001). There was no difference in the recurrence rate between the two groups. Patients with inguinal hernias undergoing laparoscopic repair recover more rapidly, and have less incidence of postoperative pain. But it takes significantly more time to perform than APP repair and also the incidence of peritoneal tear is higher.

Recurrent inguinal hernia: a ten-year review

BACKGROUND

This study evaluates the results obtained in recurrent inguinal hernia repair over the past ten years in a general hospital using laparoscopic (LAP) and open tension-free mesh (Lichtenstein) procedures.

METHODS

A prospective controlled study with 258 recurrent inguinal hernias in 235 patients over a ten-year period. The main outcome measurements were recurrence rate, operating time, hospital stay, postoperative complications, and cost.

RESULTS

There were 10 recurrences (4.3%): 7 in the Lichtenstein group (5.7%) and 3 (2.2%) in the LAP group (P = nonsignificant [NS]). There were 15 (12.2%) postoperative complications in the Lichtenstein group and 6 (4.4%) in the LAP group (P =0.04). The operating room costs were higher in the LAP group, but this difference was offset by a significantly shorter hospital stay, shorter operating time, and earlier return to work.

CONCLUSION

Laparoscopic repair is an effective option for the treatment of recurrent inguinal hernia. The TEP approach combines the advantages of minimal invasive surgery and those of tension-free mesh repair, reducing operating time, postoperative morbidity, and recurrence rate.