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

Outpatient Surgery and Unplanned Overnight Admission in Bilateral Inguinal Hernia Repair: A Population-based Study

PURPOSE

The use of outpatient surgery in inguinal hernia is heterogeneous despite clinical recommendations. This study aimed to analyze the utilization trend of outpatient surgery for bilateral inguinal hernia repair (BHIR) in Spain and identify the factors associated with outpatient surgery choice and unplanned overnight admission.

METHODS

A retrospective observational study of patients undergoing BIHR from 2016 to 2021 was conducted. The clinical-administrative database of the Spanish Ministry of Health RAE-CMBD was used. Patient characteristics undergoing outpatient and inpatient surgery were compared. A multivariable logistic regression analysis was performed to identify factors associated with outpatient surgery choice and unplanned overnight admission.

RESULTS

A total of 30,940 RHIBs were performed; 63% were inpatient surgery, and 37% were outpatient surgery. The rate of outpatient surgery increased from 30% in 2016 to 41% in 2021 (p < 0.001). Higher rates of outpatient surgery were observed across hospitals with a higher number of cases per year (p < 0.001). Factors associated with outpatient surgery choice were: age under 65 years (OR: 2.01, 95% CI: 1.92-2.11), hospital volume (OR: 1.59, 95% CI: 1.47-1.72), primary hernia (OR: 1.89, 95% CI: 1.71-2.08), and laparoscopic surgery (OR: 1.47, 95% CI: 1.39-1.56). Comorbidities were negatively associated with outpatient surgery. Open surgery was associated (OR: 1.26, 95% CI: 1.09-1.47) with unplanned overnight admission.

CONCLUSIONS

Outpatient surgery for BHIR has increased in recent years but is still low. Older age and comorbidities were associated with lower rates of outpatient surgery. However, the laparoscopic repair was associated with increased outpatient surgery and lower unplanned overnight admission.

Laparoscopic totally extraperitoneal hernia repair in patients with a history of previous abdominopelvic surgery

A retrospective cohort study of patients undergoing laparoscopic inguinal hernia repair compared short- and long-term outcomes between individuals with or without history of previous abdominopelvic surgery, aiming to determine the feasibility of totally extraperitoneal (TEP) repair within this population. All patients who underwent elective TEP inguinal hernia repair by one consultant surgeon across three London hospitals from January 2017 to May 2023 were retrospectively analysed to assess perioperative outcomes. Two hundred sixty-two patients were identified, of whom two hundred forty-three (93%) underwent laparoscopic TEP repair. The most frequent complications were haematoma (6.2%) and seroma (4.1%). Recurrence occurred in four cases (1.6% of operations, 1.1% of hernias). One hundred eighty-four patients (76%) underwent day-case surgery. There were no mesh infections or explanations, vascular or visceral injuries, port-site hernias, damage to testicle, or persisting numbness. There were no requirements for blood transfusion, returns to theatre, or readmissions within 30 days. There was one conversion to open and one death within 60 days of surgery. Eighty-three (34%) had a history of previous AP surgery. There was no significant difference in perioperative outcomes between the AP and non-AP arms. This finding carried true for subgroup analysis of 44 patients whose AP surgical history did not include previous inguinal hernia repair and for those undergoing repair of recurrent hernia. In expert hands, laparoscopic TEP repair is associated with excellent outcomes and low rates of long-term complications, and thus should be considered as standard for patients regardless of a history of AP surgery.

Safety and effectiveness of laparoscopic adult groin hernia repair in Africa: a systematic review and meta-analysis

BACKGROUND

Surgery is the recommended treatment of groin hernia, and laparoscopic approach is increasingly accepted due to lower risk of chronic pain. This systematic review aims to evaluate results of laparoscopic groin hernia repair (LGHR) in Africa.

METHODS

We performed a literature search of published studies using electronic databases. Included African articles reported at least one of outcomes after LGHR in adult population. Newcastle-Ottawa Scale was used for quality assessment. A quantitative meta-analysis was performed to estimate the pooled prevalence of the post-operative outcomes.

RESULTS

We included 19 studies from 6 countries which totalized 2329 hernia cases. Mean age was 44.5 years and male patients were predominant (sex-ratio 19.8). The mean operative time was 69.1 min. The pooled prevalence of conversion to open procedure was 2.578% (95% IC: 1.209-4.443). The pooled prevalence of surgical site infection and Hematoma/Seroma was respectively 0.626% (95%IC: 0.332-1.071) and 4.617% (95% IC: 2.990-6.577). The pooled prevalence of recurrence and chronic pain was respectively 2.410% (95% IC: 1.334-3.792) and 3.180% (95% IC: 1.435-5.580). We found that total morbidity for TAPP procedure was higher than TEP procedure (p = 0.0006; OR 1.8443).

CONCLUSION

These results confirm that LGHR is safe and feasible and would be recommended in our African context.

Primary abandonment of the sac in the management of scrotal hernias: a dual-institution experience of short-term outcomes

PURPOSE

Management of scrotal hernias presents as a common challenge, with operative interventions to address these hernias associated with higher rates of morbidity compared to those of less-complex pathology. Surgeons have advocated for the use of techniques such as primary abandonment of the distal sac as a potential means to reduce complications for operative intervention, with preliminary findings demonstrating feasibility. We sought to assess outcomes related to primary sac abandonment among patients undergoing minimally invasive (MIS) repair of scrotal hernias.

METHODS

A review of prospectively maintained databases among two academic hernia centers was conducted to identify patients who underwent MIS inguinal hernia repairs with primary sac abandonment. Patient demographics, hernia risk factors, intraoperative factors, and postoperative outcomes were evaluated. Short-term outcomes related to patient-reported experiences and surgical-site occurrences requiring procedural intervention were queried.

RESULTS

Sixty-seven male patients [median age: 51.6 years; interquartile range (IQR): 45-65 years] underwent inguinal hernia repair with primary sac abandonment. Anatomic polypropylene mesh was used in 98.5% cases. Rates of postoperative complications were low and included postoperative urinary retention (6%), clinically identified or patient-reported seromas/hematomas within a 30-day follow-up period (23.9%), deep venous thrombosis (1.5%), and pelvic hematoma (1.5%). No seromas or hematomas necessitated procedural interventions, with resolution of symptoms within three months of their operation date.

CONCLUSION

We report a multi-center experience of patients managed with primary abandonment of the sac technique during repair of inguinoscrotal hernias. Utilization of this technique appears to be safe and reproducible with a low burden of short-term complications.

A Long-Term Study on Recurrence, Chronic Pain, and Quality of Life in Obese Patients with Groin Hernia undergoing Laparoscopic Total Extraperitoneal Hernia Repair: Comparison between Mesh Fixation and Nonfixation Techniques

Introduction

"Laparoscopic Total Extraperitoneal (TEP)" repair of hernia is a common surgical procedure for treating groin hernias. This study focused on the long-standing assessment of "quality of life (QoL)," chronic pain, and recurrence to compare the effectiveness of TEP hernia surgery with "mesh fixation (MF)" against "nonfixation (NF)" in patients who are obese with a BMI of 35 kgs/m2 or higher.

Methods

In this study's randomized controlled experiment, 73 obese individuals with groin hernias underwent total extraperitoneal hernia repair with either MF (n = 35) or NF (n = 38). A check-up was conducted 1, 3, and 5 years after the operation. Recurrence, chronic pain, and QoL were assessed using a physical examination and validated questionnaires.

Results

There were no changes between the subjects of either group in baseline characteristics, hernia recurrence rate, chronic pain rate, or QoL. There were neither significant variations in surgical complications nor hospital stay duration.

Conclusion

The results suggest that treating TEP hernias among people with a BMI of 35 kgs/m2 or above with mesh NF may be successful. The recurrence rates among the subject groups were not substantially different; however, NF was linked with reduced rates of chronic pain which would be beneficial for patient satisfaction and recovery. To decide the optimal technique for MF in TEP hernia repair, these findings need to be verified by additional studies.

Management of groin hernias in emergency setting: differences in indications and outcomes between laparoscopic and open approach. A single-center retrospective experience

PURPOSE

The use of minimally invasive groin hernia repair techniques in an emergency setting is still debated and its widespread is limited. The aim of this study is to evaluate the safety and efficacy of the laparoscopic transabdominal preperitoneal (TAPP) technique in the treatment of inguinal and femoral hernias in emergency setting based on our experience, comparing indications and outcomes with the open technique.

METHODS

A retrospective analysis was performed including all patients with incarcerated and/or strangulated groin hernia who underwent emergency surgery from November 2019 to September 2022. Perioperative variables and short- and long-term outcomes were examined. Statistical analysis was performed using chi-square test for nominal variables and Student's t test for continuous ones. A p value < 0.05 was considered statistically significant.

RESULTS

Sixty-six patients were included: 29 patients were treated with TAPP technique (Tapp group) and 37 with open technique plus diagnostic laparoscopy (Open group). Patients in the TAPP group were younger, had less severe clinical scenarios, and had a trend for lower Charlson Comorbidity Index, whereas ASA score and BMI were similar. The small bowel was more frequently herniated in the open group. Bilateral hernia repair was performed in 20.69% of patients in the Tapp group versus 0% in the Open group (p = 0.004). Bowel resection was more frequent in the open group (48.65% vs 0% of the Tapp group, p < 0.001) length of surgery was comparable in the two groups. In the Tapp group, the length of hospitalization was significantly shorter (2.59 ± 2.28 days vs. 9.08 ± 14.48 days; p = 0.023). Postoperative complications, according to Clavien-Dindo, were more severe in Open group where there were two deaths. There were no differences in the number of readmission and re-operations at 30 days and in the recurrence rate.

CONCLUSIONS

Emergency repair of inguinal and femoral hernias using TAPP is a valuable option, safe and feasible in selected patients. In this series, indications for TAPP were reserved to younger patients with less comorbidities and less severe clinical scenario. Future randomized studies are needed to compare TAPP with open emergency hernia surgery in all settings. Potential advantages of TAPP are the reduction of postoperative complications, earlier recovery, and the possibility of bilateral treatment.

Totally extraperitoneal repair of groin hernia in liver transplant patients: a case series study (TOHER)

PURPOSE

The present study aims to describe the feasibility and the postoperative results of groin hernia repair in liver transplant patients using a totally extra-peritoneal (TEP) repair approach.

METHODS

From May 2022 to March 2023, liver transplant patients with groin hernia underwent TEP groin hernia repair, by the single common senior experimented surgeon. Background information, intraoperative findings, postoperative complications, postoperative pain, health, and well-being were registered.

RESULTS

Thirteen TEP approach groin hernioplasties were performed in 10 patients, completing the procedure in all cases without the need for conversion either to open or transabdominal preperitoneal approaches. 70% of surgical explorations revealed multiple hernia defects: lateral hernias in all patients, medial defects in 62%, and femoral defects in 30.8%. Median hospital stay was 1 day [range (0.3)], with 30% treated as outpatients. Post-surgical complications occurred in 30% of cases: 1 hematoma and 2 seromas. Postoperative pain and physical functioning scored 100 (IQR 44) and 90 (IQR 15), respectively.

CONCLUSION

TEP groin hernioplasty is safe and feasible for liver transplant patients, with low complication rates, short hospital stays, and a significant proportion treated as outpatients. The posterior approach allows comprehensive repair of myopectineal defects, crucial due to associated hernial defects.

Lichtenstein versus TIPP versus TAPP versus TEP for primary inguinal hernia, a matched propensity score study on the French Club Hernie Registry

PURPOSE

Groin hernia repair is one of the most frequent operation performed worldwide. Chronic postoperative inguinal pain (CPIP) is the most common and challenging complication after surgical repair with subsequent high socio-economic impact. The aim of this study was to compare the one-year CPIP rates between Lichtenstein, trans-inguinal pre-peritoneal (TIPP), trans-abdominal pre-peritoneal (TAPP) and totally extra-peritoneal (TEP) repair techniques on the French Hernia Registry.

METHODS

Between 2011 and 2021, 15,161 primary groin hernia repairs with 1-year follow-up were available on the register. Using propensity score (PS) matching, matched pairs were formed. Each group was compared in pairs independently; Lichtenstein versus TIPP, TEP and TAPP, TIPP versus TEP and TAPP and finally TEP versus TAPP.

RESULTS

After PS matching analysis, Lichtenstein group showed disadvantage over TIPP, TAPP and TEP groups with significantly more CPIP at one year (15.2% vs 9.6%, p < 0.0001; 15.9% vs. 10.0%, p < 0.0001 and 16.1% vs. 12.4%, p = 0.002, respectively). The 1-year CPIP rates were similar comparing TIPP versus TAPP and TEP groups (9.3% vs 10.5%, p = 0.19 and 9.8% vs 11.8%, p = 0.05, respectively). There was significantly less CPIP rate after TAPP versus TEP repair (1.00% vs 11.9%, p = 0.02).

CONCLUSION

This register-based study confirms the higher CPIP risk after Lichtenstein repair compared to the pre-peritoneal repair techniques. TIPP leads to comparable CPIP rates than TAPP and TEP repairs.

The Role of Imaging in the Pre- and Postoperative Evaluation of Inguinal Hernia

Inguinal hernia repair is the most frequently performed surgical procedure. Imaging has a fundamental role in initial assessment and postoperative evaluation of inguinal hernias. Clinical implications of radiology in the preoperative setting include diagnosis of occult/complicated hernias and enhancement of diagnostic certainty. Postoperatively, imaging may assist the detection and characterization of complications. Familiarity with the normal appearance of the postoperative groin area and surgical techniques is required to avoid misinterpretation. This pictorial essay provides an overview of the expected postoperative imaging findings and highlights the role of imaging in the pre- and postoperative evaluation of inguinal hernias, with emphasis on ultrasonography.

Bilateral inguinal hernia repair by laparoscopic totally extraperitoneal (TEP) vs. laparoscopic transabdominal preperitoneal (TAPP)

BACKGROUND

The guidelines recommend laparoscopic repair for bilateral inguinal hernia. However, few studies compare the totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) techniques in bilateral inguinal hernias. This study aimed to compare the outcomes of TEP and TAPP in bilateral inguinal hernia.

METHODS

We conducted a retrospective cohort study of patients operated on for bilateral inguinal hernia by TEP and TAPP repair from 2016 to 2020. Intraoperative complications, operative time, acute postoperative pain, hospital stay, postoperative complications, chronic inguinal pain, and recurrence were compared.

RESULTS

A total of 155 patients were included in the study. TEP was performed in 71 patients (46%) and TAPP in 84 patients (54%). The mean operative time was longer in the TAPP group than in the TEP group (107 min vs. 82 min, p < 0.001). The conversion rate to open surgery was higher in the TEP group than in the TAPP group (8.5% vs. 0%, p = 0.008). The mean hospital stay was longer in the TAPP group than in the TEP group (p < 0.001). We did not observe significant differences in the proportion of postoperative complications (p = 0.672), postoperative pain at 24 h (p = 0.851), chronic groin pain (p = 0.593), and recurrence (p = 0.471). We did not observe an association between the choice of surgical technique (TEP vs. TAPP) with conversion rate, operative time, hospital stay, postoperative complications, chronic inguinal pain, or hernia recurrence when performing a multivariable analysis adjusted for the male sex, age, BMI, ASA, recurrent hernia repair, surgeon, and hernia size > 3cm.

CONCLUSIONS

Bilateral inguinal hernia repair by TEP and TAP presented similar outcomes in our study.

Sexual dysfunction between laparoscopic and open inguinal hernia repair: a systematic review and meta-analysis

PURPOSE

Sexual dysfunction after inguinal hernia complication is considered rare. However, its consequences impact on quality of life inevitably. Laparoscopic and open inguinal hernia repair may be comparable in terms of recurrent rate, overall complications, and chronic pain. Therefore, its complication is still questionable between these approaches. In this study, we compared sexual dysfunction and related complications between laparoscopic and open inguinal hernia repair.

METHODS

Systematic review and meta-analysis of randomized controlled trials (RCTs) studies were performed to compare laparoscopic and open inguinal hernia repair. Risk ratio (RR) and 95% confidence intervals (95% CI) were used as pooled effect size measures.

RESULT

Thirty RCTs (12,022 patients) were included. Overall, 6014 (50.02%) underwent laparoscopic hernia repair, and 6008 (49.98%) underwent open hernia repair. Laparoscopic approach provided non-significance benefit on pain during sexual activity (RR 0.57; 95% CI 0.18, 1.76), Vas deferens injury (RR 0.46; 95% CI 0.13, 1.63), orchitis (RR 0.84; CI 0.61,1.17), scrotal hematoma (RR 0.99; CI 0.62,1.60), and testicular atrophy (RR 0.46; CI 0.17,1.20). Meanwhile, the open inguinal hernia approach seems to perform better for cord seroma complications and testicular pain.

CONCLUSION

There is no advantage of laparoscopic inguinal hernia repair over an open approach concerning sexual dysfunction. On the contrary, there is an increasing risk of cord seroma after laparoscopic inguinal hernia repair with statistical significance.

Tentacle Mesh for Fixation-Free Spigelian Hernia Repair: Mini-Invasive Approach Granting Broad Defect Overlap

BACKGROUND

Compared to other types of abdominal protrusions, Spigelian hernias are not very common. In prosthetic repair of abdominal protrusions, mesh fixation and defect overlap are an open issue, as they are a source of complications. A newly developed tentacle-shaped mesh has been used to ensure a fixation-free repair with a broader defect overlap in the repair of abdominal hernias. This study describes the long-term results of a fixation-free repair of Spigelian hernias carried out with a tentacle mesh.

METHODS

A proprietary mesh composed of a central body with integrated radiating arms was used for repairing Spigelian hernias in 54 patients. The implant was positioned in preperitoneal sublay, and the straps were delivered across the abdominal musculature with a needle passer, and then, after fascia closure, cut short in the subcutaneous layer.

RESULTS

The friction of the straps passing through the abdominal wall served to hold the mesh in place, guaranteeing a wide overlap over the defect without fixation. In a long-term follow-up of 6 to 84 months (mean 64 months), a very low rate of complications occurred, but no recurrence was reported.

CONCLUSIONS

The tentacle strap system of the prosthesis allowed for an easy, fast and safe fixation-free placement granting a wide overlap, avoiding intraoperative complications. Greatly reduced pain and a negligible amount of postoperative complications characterized the postoperative outcome.

Are Nerves Left In Situ Associated With Less Chronic Pain Than Manipulation During Inguinal Hernia Repair?

INTRODUCTION

Nerve damage has been implicated in chronic groin pain, particularly iliohypogastric, ilioinguinal, and genital branches of genitofemoral nerves. We investigated whether three nerve identification (3N) and preservation is associated with decreased pain 6 mo after hernia repair compared to two common strategies of nerve management: ilioinguinal nerve identification (1N) and two nerve identification (2N).

METHODS

We identified adult inguinal hernia patients within the Abdominal Core Health Quality Collaborative national database. Six-month postoperative pain was defined using the EuraHS Quality of Life tool. A proportional odds model was used to estimate odds ratios (ORs) and expected mean differences in 6-month pain for nerve management while adjusting for confounders identified a priori.

RESULTS

Four thousand four hundred fifty one participants were analyzed; 358 (3N), 1731 (1N), and 2362 (2N) consisting mostly of White males (84%) over the age of 60 y old. Academic centers identified all three nerves more often than ilioinguinal or two nerve identification methods. Median 6-month postoperative pain scores were 0 [interquartile range 0-2] for all nerve management groups (P = 0.51 3N versus 1N and 3N versus 2N). There was no evidence of a difference in the odds of higher 6-month pain score in nerve management methods after adjustment (3N versus 1N OR: 0.95; 95% confidence interval 0.36-1.95, 3N versus 2N OR: 1.00; 95% confidence interval 0.50-1.85).

CONCLUSIONS

Although guidelines emphasize three nerve preservation, the management strategies evaluated were not associated with statistically significant differences in pain 6 mo after operation. These findings suggest that nerve manipulation may not contribute as a significant role in chronic groin pain after open inguinal hernia repair.

Simultaneous Inguinal Hernia Repair with Monofilament Polypropylene Mesh during Robot-Assisted Radical Prostatectomy: Results from a Single Institute Series

Background and Objectives: Inguinal hernia (IH) is a usual finding in men with prostate cancer (PCa) due to their similar risk factors, such as age, gender, and smoking. This study aims to present a single institution's experience with simultaneous IH repair (IHR) and robotic-assisted radical prostatectomy (RARP). Materials and Methods: We retrospectively reviewed 452 patients who underwent RARP between January 2018 and December 2020. A total of 73 patients had a concomitant IHR with a monofilament polypropylene mesh. Patients with bowel in the hernia sac or recurrent hernia were excluded. Results: The median age and the American Society of Anesthesiologists (ASA) score were 67 years (inter-quartile range (IQR) 56-77) and 2 (IQR 1-3), respectively. The median prostate volume and preoperative prostate-specific antigen (PSA) were 38 mL (IQR 25.0-75.2) and 7.8 ng/mL (IQR 2.6-23.0), respectively. The surgery was successfully performed in all cases. The median overall and IHR operative time were 190.0 (IQR 140.0-230.0) and 32.5 (IQR 14.0-40.0) minutes, respectively. The median estimated blood loss and length of hospital stay were 100 mL (IQR 10-170) and 3 days (IQR 2-4), respectively. Only five (6.8%) minor complications occurred after surgery. At the 24-month follow-up, no cases of mesh infection, seroma formation, or groin pain were recorded. Conclusions: This study confirmed the safety and efficacy of performing simultaneous RARP and IHR.

Testicular hydrocele postoperative laparoscopic inguinal hernia repair may be caused lymphatic leakage proved by indocyanine fluorescent dye: A case report

INTRODUCTION AND IMPORTANCE

Indocyanine green (ICG) fluorescent lymphography is reportedly a safe and effective method to diagnosis of lymphatic leakage. We report a case of a patient who underwent ICG fluorescent lymphography during laparoscopic inguinal hernia repair.

CASE PRESENTATION

A 59-year-old man was referred to our department for the treatment of both inguinal hernias, during which laparoscopic ICG lymphography was performed. The patient had a history of open left inguinal indirect hernia repair at the age of 3 years. Following the induction of general anesthesia, 0.25 mg ICG was injected into both testicles, and the scrotum was gently massaged, after which laparoscopic inguinal hernia repair was performed. During the operation, ICG fluorescence was observed in two lymphatic vessels in the spermatic cord. The ICG fluorescent vessels were injured only on the left side due to strong adhesion between lymphatic vessels and the hernia sac, possibly due to a previous operation. ICG leakage was observed on the gauze. Laparoscopic inguinal hernia repair (transabdominal preperitoneal approach [TAPP]) was performed. The patient was discharged 1 day postoperatively. He had a slight postoperative ultrasonic hydrocele only in the left groin that was detected at the follow-up clinic 9 days postoperatively during ultrasonic examination (ultrasonic hydrocele).

CLINICAL DISCUSSION

We report the use of ICG fluorescent lymphography during laparoscopic inguinal hernia repair in a patient who developed a postoperative ultrasonic hydrocele.

CONCLUSION

This case may indicate a relationship between lymphatic vessel injury and hydroceles.

Fascia defect closure versus non-closure in minimal invasive direct inguinal hernia mesh repair: a systematic review and meta-analysis of real-world evidence

PURPOSE

Laparoscopic and robotic inguinal hernia mesh repair are both common surgical procedures worldwide. Postoperative hernia recurrence and seroma formation are important concerns. In ventral hernia, primary defect closure in laparoscopic surgery reduces the recurrence rate. However, there is no synthetic evidence of direct inguinal hernia defect closure versus non-closure in minimal invasive surgery. Therefore, this study investigated the efficacy of defect closure in patients undergoing minimal invasive direct inguinal hernia mesh repair.

METHODS

Eligible studies were identified through a search of PubMed, Embase, Cochrane Library, and CINAHL from their inception until March 2022. Studies examining defect closure in laparoscopic direct inguinal hernia repair were included, and a meta-analysis was performed using the random-effect model. Sensitivity analyses were performed by removing one study at a time. The primary outcomes were hernia recurrence and seroma formation. Acute and chronic postoperative pain, operation time, and length of hospital stay were the secondary outcomes.

RESULTS

Five nonrandomized studies and one randomized controlled trial were included. Pooled analysis revealed defect closure might reduce the hernia recurrence rate (risk difference, - 0.02; 95% confidence interval [CI] - 0.04 to - 0.00; p = 0.02). The result of seroma formation (odds ratio, 0.49; 95% CI 0.17-1.46; p = 0.20) showed no significant difference. Moreover, no significant differences were observed in acute postoperative pain, chronic pain, length of hospital stay, and operation time.

CONCLUSIONS

Our study indicated defect closure seems to be an option to reduce the direct inguinal hernia recurrence rate. No significant benefits were shown in seroma formation and other secondary outcomes. Our study was mostly based on nonrandomized studies and underestimated the effect of defect closure; thus, further high-quality studies are required to draw definitive conclusions.

Bilateral inguinal transabdominal pre-peritoneal laparoscopic hernioplasty associated to bilateral laparoscopic varicocelectomy in the same intervention: a feasibility study

INTRODUCTION

Inguinal hernia and varicocele are common conditions in male population. Laparoscopy brings the opportunity to treat them simultaneously, through the same incision. However, there are different opinions about the risks for testicular perfusion of multiple procedures in the inguinal region. In this study, we assessed the feasibility of simultaneous laparoscopic procedures by studying clinical and surgical outcomes of patients undergoing bilateral inguinal hernioplasty using the transabdominal preperitoneal (TAPP) technique with and without concomitant bilateral laparoscopic varicocelectomy (VLB).

METHODS

a sample of 20 patients from the University Hospital of USP-SP with indirect inguinal hernia and varicocele with indication for surgical correction was selected. Patients were randomized into two groups, 10 undergoing TAPP (Group I) and 10 undergoing simultaneous TAPP and VLB (Group II). Data regarding total operative time, complications and postoperative pain was gathered and analyzed.

RESULTS

there was no statistical difference between groups regarding total operative time and postoperative pain. Only one complication (spermatic cord hematoma) was observed in Group I and no complications were observed in Group II.

CONCLUSIONS

simultaneous TAPP and VLB in was shown to be effective and safe, which provides a basis for conducting studies on larger scales.

Trends and predictors of laparoscopic bilateral inguinal hernia repair in Spain: a population-based study

BACKGROUND

International guidelines currently recommend laparoscopy for bilateral inguinal hernia repair (BIHR). Our study aims to evaluate the trends and factors associated with the choice of laparoscopy for BIHR in Spain.

METHODS

We performed a retrospective analysis of patients undergoing BIHR between 2016 and 2019. We used the national database of the Spanish Ministry of Health: RAE-CMBD. We performed a univariate and multivariable logistic regression analysis to identify the factors associated with the utilization of laparoscopy. We identified perioperative complications and the factors associated with their occurrence through multivariable logistic regression analysis.

RESULTS

A total of 21,795 BIHRs were performed: 84% by open approach and 16% by laparoscopic approach. Laparoscopic approach increased from 12% in 2016 to 23% in 2019 (p < 0.001). The 40% of hospitals did not use laparoscopy, and only 8% of the hospitals performed more than 50% of their BIHRs by laparoscopy. The utilization rate of laparoscopy was not related to the number of BIHRs performed per year (p = 0.145). The main factor associated with the choice of laparoscopy in multivariable logistic regression analysis was the patient's region of residence (OR 2.04, 95% CI 1.88-2.21). Other factors were age < 65 years (OR 1.65, 95% CI 1.52-1.79) and recurrent inguinal hernia (OR 1.31, 95% CI 1.15-1.49). The type of approach for BIHR was not independently associated with perioperative complications.

CONCLUSIONS

Despite a significant increase in recent years, laparoscopic BIHR in Spain remains low. The main factor associated with the utilization of laparoscopy was the patient's region of residence; this factor seems to be related to the presence of hospitals with a high rate of laparoscopic approaches where the patient lives. The type of approach was not independently associated with perioperative complications. More efforts are needed to increase laparoscopic use in patients with bilateral inguinal hernias.

Preoperative Subcutaneous Fat is an Useful Indicator for Learning Totally Extraperitoneal Repair

BACKGROUND

Totally extraperitoneal (TEP) repair is a recommended procedure for inguinal hernia repair in European hernia guidelines. However, technical challenges have limited its uptake in Japan, where transabdominal preperitoneal (TAPP) repair is more common. We evaluated the association of preoperative subcutaneous fat area (preSFA) with surgical outcomes and identified factors associated with the difficulty of TEP repair.

METHODS

Clinical data from 62 patients undergoing TEP repair were collected retrospectively. Using the median for the preoperative subcutaneous fat index (preSFI; 45.9 cm²/m²), we classified patients as having a high SFI (HSFI) (n=31) and low SFI (LSFI) (n=31). Surgical outcomes and perioperative complications were then compared between these groups. Additionally, TEP repair was divided into five phases (e.g., Phase 1: dissection of the caudal side of the preperitoneal space), and operative time was measured during each phase. Phase 1 was divided into two sub-phases (1A: insertion of the first port, 1B: reaching Cooper's ligament).

RESULTS

Operative time was longer (133 min vs 111 min, P = 0.028) and the peritoneal injury rate was higher (35.5% vs 9.7%, P = 0.015) for the HSFI patients. Furthermore, operative time for HSFI patients was significantly longer during Phase 1 (P = 0.014) and Phase 1A (P = 0.022).

CONCLUSIONS

preSFA was associated with a higher peritoneal injury rate and longer operative time in HSFI patients, suggesting that the presence of abundant subcutaneous fat increases the difficulty of TEP repair.

Robotic inguinal hernia repair: is the new Da Vinci single port platform providing any benefit?

BACKGROUND

The utilization of the robot for inguinal hernia repairs has increased in the past years. The new Da Vinci Single Port (SP) system provides the benefits of single-incision procedures and might overcome the technical difficulties of previous single-incision techniques. The aim of this study was to evaluate the safety and feasibility of the SP transabdominal preperitoneal inguinal hernia repair (SP-TAPP) and compare its outcomes to the robotic multiport technique (MP-TAPP).

METHODS

A prospective cohort of patients who underwent a robotic SP-TAPP and MP-TAPP between 2012 and 2022 was analyzed. Primary endpoints were same-day discharge, morbidity, and inguinal recurrence rates. Secondary endpoints included conversion, operative time, port-site incisional hernia, and chronic pain.

RESULTS

MP-TAPP and SP-TAPP were performed in 378 (81.3%) and 87 (18.7%) patients, respectively. Demographics were similar between groups. There were no conversions or intraoperative complications. Mean operative (MP-TAPP: 93.2 vs. SP-TAPP: 78.1 min, p = 0.003) and recovery time (MP-TAPP: 160.8 vs SP-TAPP: 112.6 min, p < 0.001) were significantly shorter in the SP group. Same-day discharge rate was higher (MP-TAPP: 86.5% vs. SP-TAPP: 97.7%, p = 0.001) after SP-TAPP; 30-day morbidity, readmissions, and chronic pain rates were similar between groups. After a mean follow-up of 30.6 months for MP-TAPP and 13.3 months for SP-TAPP, inguinal hernia recurrence and port-site incisional rates were similar between groups.

CONCLUSION

Robotic SP-TAPP is safe and feasible. When compared to MP-TAPP, it showed similar postoperative morbidity, higher same-day discharge rates, and a quicker postoperative recovery. Further studies are needed to confirm the benefits of the SP platform.

Towards automatic verification of the critical view of the myopectineal orifice with artificial intelligence

BACKGROUND

Visualization of key anatomical landmarks is required during surgical Trans Abdominal Pre Peritoneal repair (TAPP) of inguinal hernia. The Critical View of the MyoPectineal Orifice (CVMPO) was proposed to ensure correct dissection. An artificial intelligence (AI) system that automatically validates the presence of key and marks during the procedure is a critical step towards automatic dissection quality assessment and video-based competency evaluation. The aim of this study was to develop an AI system that automatically recognizes the TAPP key CVMPO landmarks in hernia repair videos.

METHODS

Surgical videos of 160 TAPP procedures were used in this single-center study. A deep neural network-based object detector was developed to automatically recognize the pubic symphysis, direct hernia orifice, Cooper's ligament, the iliac vein, triangle of Doom, deep inguinal ring, and iliopsoas muscle. The system was trained using 130 videos, annotated and verified by two board-certified surgeons. Performance was evaluated in 30 videos of new patients excluded from the training data.

RESULTS

Performance was validated in 2 ways: first, single-image validation where the AI model detected landmarks in a single laparoscopic image (mean average precision (MAP) of 51.2%). The second validation is video evaluation where the model detected landmarks throughout the myopectineal orifice visual inspection phase (mean accuracy and F-score of 77.1 and 75.4% respectively). Annotation objectivity was assessed between 2 surgeons in video evaluation, showing a high agreement of 88.3%.

CONCLUSION

This study establishes the first AI-based automated recognition of critical structures in TAPP surgical videos, and a major step towards automatic CVMPO validation with AI. Strong performance was achieved in the video evaluation. The high inter-rater agreement confirms annotation quality and task objectivity.

Postoperative compression in preventing early complications after groin hernia repair

PURPOSE

We conducted this study to investigate the efficacy, safety, and clinical value of postoperative compression in preventing seroma formation, relieving acute pain, and improving QoL after groin hernia repair.

METHODS

This multi-center, prospective, observational real-world study was conducted from March 1, 2022, to August 31, 2022. The study was completed in 53 hospitals in 25 provinces in China. A total of 497 patients who underwent groin hernia repair were enrolled. All patients used a compression device to compress the operative region after surgery. The primary outcome was seroma incidence 1 month after surgery. Secondary outcomes included postoperative acute pain and QoL.

RESULTS

A total of 497 patients [median (IQR) age 55 (41-67) years, 456 (91.8%) male] were enrolled, of whom 454 underwent laparoscopic groin hernia repair and 43 open hernia repair. The follow-up rate was 98.4% 1 month after surgery. Seroma incidence was 7.2% (35 of 489 patients) overall, lower than reported by previous research. No significant differences were found between the two groups (P > 0.05). VAS scores after compression were significantly lower than before compression overall and in both groups (P < 0.001). The laparoscopic group showed a high level of QoL compared with the open group, but there was no significant difference between the two groups (P > 0.05). CCS score correlated positively with VAS score.

CONCLUSION

Postoperative compression, to a certain extent, can reduce seroma incidence, relieve postoperative acute pain, and improve QoL after groin hernia repair. Further large-scale randomized controlled studies are warranted to determine long-term outcomes.

Transinguinal preperitoneal (TIPP) vs endoscopic total extraperitoneal (TEP) procedure in unilateral inguinal hernia repair: a randomized controlled trial

PURPOSE

The Lichtenstein hernioplasty has long been seen as the gold standard for inguinal hernia repair. Unfortunately, this repair is often associated with chronic pain, up to 10-35%. Therefore, several new techniques have been developed, such as the transinguinal preperitoneal patch (TIPP) and the endoscopic total extraperitoneal (TEP) technique. Several studies showed beneficial results of the TIPP and TEP compared to the Lichtenstein hernioplasty; however, little is published on the outcome when comparing the TIPP and TEP procedures. This study aimed to evaluate outcomes after the TIPP vs the TEP technique for inguinal hernia repair.

METHODS

A single-center randomized controlled trial was carried out between 2015 and 2020. A total of 300 patients with unilateral inguinal hernia were enrolled and randomized to the TIPP- or TEP technique. Primary outcome was chronic pain (defined as any pain following the last 3 months) and quality of life, assessed with Carolinas comfort scale (CCS) at 12 months. Secondary outcomes were: wound infection, wound hypoesthesia, recurrence, readmission within 30 days, and reoperation.

RESULTS

A total of 300 patients were randomized (150 per group). After a follow-up of 12 months, we observed significantly less postoperative chronic groin pain, chronic pain at exertion, wound hypoesthesia, and wound infections after the TEP when compared to the TIPP procedure. No significant differences in quality of life, reoperations, recurrence rate, and readmission within 30 days were observed.

CONCLUSION

We showed that the TEP has a favorable outcome compared to the TIPP procedure, leading to less postoperative pain and wound complications, whereas recurrence rates and reoperations were equal in both the groups.

Laparoscopic and robotic inguinal hernia repair are safe and effective after prior pelvic or low abdominal surgery

BACKGROUND

The ideal approach to inguinal hernia repair (IHR) after prior pelvic or low abdominal surgery is not agreed upon. We compared safety and outcomes of IHR between open, laparoscopic, and robotic approaches.

METHODS

This retrospective review of a prospective database analyzed demographic, perioperative, and quality of life data for patients who underwent IHR after pelvic or low abdominal surgery.

RESULTS

286 qualifying patients underwent IHR between 2008 and 2020; 119 open, 147 laparoscopic, and 20 robotic. Laparoscopic repair led to faster cessation of narcotics and return to ADLs than open repair (all p <0.05). Post-operative complications, 30-day readmission, recurrences, and quality of life outcomes were equivalent, except less pain at 3-weeks post-op in the minimally invasive groups, p < 0.01.

CONCLUSION

Minimally invasive IHR after prior pelvic or low abdominal surgery is safe compared to an open approach. Laparoscopic repair provides faster recovery, yet patient satisfaction is equivalent regardless of surgical approach.

Inguinal hernia treatment in Switzerland: inpatient vs. outpatient setting - HerStAmb Study (prospective observational two-centre comparative study)

PURPOSE

Since 01/2018, AVOS (ambulant vor stationär = outpatient to inpatient) regulation has been progressively implemented in hernia surgery in Switzerland. The aim of this prospective, observational, two-centre comparative study was to compare the outcome of outpatient and inpatient post-operative care in terms of AVOS by examining the re-admission rate, complication rate and quality of life in patients with primary unilateral inguinal hernia repair.

METHODS

The study ran between 01/2019 and 04/2020 and included 237 patients with a primary unilateral inguinal hernia. Treatment setting was decided according to AVOS guidelines. Primary endpoint was re-admission rate within 6 weeks postoperatively. Secondary endpoints were the complication rate and patient outcome (quality of life) at 6 weeks follow-up postoperatively, as measured by the Short Form 36 Health Survey Questionnaire (SF-36).

RESULTS

Complications occurred in 11 (14%) inpatient patients, but none required re-admitting for revision until follow-up at 6 weeks after discharge. In the outpatient group, there were 27 (17%) complications reported, while 6 (4%) of these patients crossed over to the inpatient group immediately after surgery. None of the other complications required re-admission until follow-up at 6 weeks. No significant relationship between treatment setting and number of complications/re-admission rate (p=0.458, p=0.061) was observed. The mean outcome (SF-36) between the treatment groups was not significantly different (p=0.16-0.856).

CONCLUSION

In terms of AVOS selection criteria in Switzerland, primary unilateral inguinal hernia can be safely treated in both treatment settings. Re-admission rates, complications and quality of life do not significantly differ. Day surgery in terms of AVOS might be as effective and efficient, both from the patient's perspective and that of the institution.

TRIAL REGISTRATION NUMBER

NCT05234242.

Hernioplastia inguinal pré-peritoneal transabdominal bilateral e varicocelectomia laparoscópica bilateral na mesma intervenção: um estudo de viabilidade

RESUMO Introdução: hérnia inguinal e varicocele são doenças comuns na população masculina. O advento da laparoscopia traz a oportunidade de tratá-las simultaneamente, pelo mesmo acesso. Entretanto, existem divergências sobre os riscos para a perfusão testicular de múltiplos procedimentos na região inguinal. Neste estudo, avaliamos a viabilidade de procedimentos laparoscópicos simultâneos estudando resultados clínicos e cirúrgicos de pacientes submetidos à hernioplastia inguinal bilateral pela técnica transabdominal préperitoneal (TAPP) com e sem varicocelectomia laparoscópica bilateral (VLB) concomitante. Métodos: uma amostra de 20 pacientes do Hospital Universitário da USP-SP com hérnia inguinal indireta e varicocele com indicação de correção cirúrgica foi selecionada. Os pacientes foram randomizados em dois grupos, sendo 10 submetidos à TAPP (Grupo I) e 10 submetidos à TAPP e VLB simultâneas (Grupo II). O tempo operatório total, complicações e dor pós-operatória foram coletados e analisados. Resultados: não houve diferença estatística entre os grupos com relação ao tempo operatório total e à dor pós-operatória. Apenas uma complicação (hematoma do cordão espermático) foi observada no Grupo I e não foram observadas complicações no Grupo II. Conclusões: no mesmo procedimento, submeter pacientes à TAPP e à VLB no mesmo procedimento se mostrou eficaz e seguro, o que fornece embasamento para a realização de estudos em maiores escalas.

Do postoperative complications correlate to chronic pain following inguinal hernia repair? A prospective cohort study from the Swedish Hernia Register

PURPOSE

To analyse if postoperative complications constitute a predictor for the risk of developing long-term groin pain.

METHODS

Population-based prospective cohort study of 30,659 patients operated for inguinal hernia 2015-2017 included in the Swedish Hernia Register. Registered post-operative complications were categorised into hematomas, surgical site infections, seromas, urinary tract complications, and acute post-operative pain. A questionnaire enquiring about groin pain was distributed to all patients 1 year after surgery. Multivariable logistic regression analysis was used to find any association between postoperative complications and reported level of pain 1 year after surgery.

RESULTS

The response rate was 64.5%. In total 19,773 eligible participants responded to the questionnaire, whereof 73.4% had undergone open anterior mesh repair and 26.6% had undergone endo-laparoscopic mesh repair. Registered postoperative complications were: 750 hematomas (2.3%), 516 surgical site infections (1.6%), 395 seromas (1.2%), 1216 urinary tract complications (3.7%), and 520 hernia repairs with acute post-operative pain (1.6%). Among patients who had undergone open anterior mesh repair, an association between persistent pain and hematomas (OR 2.03, CI 1.30-3.18), surgical site infections (OR 2.18, CI 1.27-3.73) and acute post-operative pain (OR 7.46, CI 4.02-13.87) was seen. Analysis of patients with endo-laparoscopic repair showed an association between persistent pain and acute post-operative pain (OR 9.35, CI 3.18-27.48).

CONCLUSION

Acute postoperative pain was a strong predictor for persistent pain following both open anterior and endo-laparoscopic hernia repair. Surgical site infection and hematoma were predictors for persistent pain following open anterior hernia repair, although the rate of reported postoperative complications was low.

Posterior mesh inguinal hernia repairs: a propensity score matched analysis of laparoscopic and robotic versus open approaches

PURPOSE

International guidelines suggest the use of lapro-endoscopic technique for primary unilateral inguinal hernia (IHR) because of lower postoperative pain and reduction in chronic pain. It is unclear if the primary benefit is due to the minimally invasive approach, the posterior mesh position or both. Further research evaluating posterior mesh placement using open preperitoneal techniques is recommended. A potential benefit of open preperitoneal repair is the avoidance of general anesthesia, as these repairs can be performed under local anesthesia. This study compares clinical and patient-reported outcomes after unilateral laparo-endoscopic, robotic, and open posterior mesh IHRs.

METHODS

We performed a propensity score matched analysis of patients undergoing IHR between 2012 and 2021 in the Abdominal Core Health Quality Collaborative registry. 10,409 patients underwent a unilateral IHR via a posterior approach. Hernia repairs were performed via minimally invasive surgery (MIS) which includes laparoscopic and robotic transabdominal preperitoneal (TAPP), laparoscopic totally extraperitoneal (TEP), or open transrectus preperitoneal/open preperitoneal (TREPP/OPP) approaches. Propensity score matching (PSM) utilizing nearest neighbor matching accounted for differences in baseline characteristics and possible confounding variables between groups. We matched 816 patients in the MIS cohort with 816 patients in the TREPP/OPP group. Outcomes included patient reported quality of life, hernia recurrence, and postoperative opioid use.

RESULTS

Improvement was seen after TREPP/OPP as compared to MIS IHR in EuraHS at 30 days (Median(IQR) 7.0 (2.0-16.64) vs 10 (2.0-24.0); OR 0.69 [0.55-0.85]; p = 0.001) and 6 months (1.0 (0.0-4.0) vs 2.0 (0.0-4.0); OR 0.63 [0.46-85]; p = 0.002), patient-reported opioid use at 30-day follow-up (18% vs 45% OR 0.26 [0.19-0.35]; p < 0.001), and rates of surgical site occurrences (0.8% vs 4.9% OR 0.16 [0.06-0.35]; p < 0.001). There were no differences in EuraHS scores and recurrences at 1 year.

CONCLUSIONS

This study demonstrates a potential benefit of open posterior mesh placement over MIS repair in short-term quality of life and seroma formation with equivalent rates of hernia recurrence. Further study is needed to better understand these differences and determine the reproducibility of these findings outside of high-volume specialty centers.

Orchiectomy due to delayed severe scrotal hematocele after laparoscopic transabdominal preperitoneal repair for a giant inguinoscrotal hernia: a case report

BACKGROUND

A giant inguinoscrotal hernia is a rare inguinal hernia that extends below the midpoint of the inner thigh while standing. Although reports of laparoscopic surgery for giant inguinoscrotal hernias have increased, the risk of delayed hematocele has not yet been clarified.

CASE PRESENTATION

A 68-year-old man was evaluated for a left giant inguinoscrotal hernia, and laparoscopic transabdominal preperitoneal repair (TAPP) was performed. In the procedure, the distal hernia sac was not resected. The postoperative course was uneventful for 3 months postsurgery, after which he complained of giant scrotal swelling, which gradually grew to 13 cm. It did not improve with several punctures and caused dysuria because of increased pressure on the urethra. Thus, reoperation was performed 9 months after surgery. The hematocele consisted of a thickened hernia sac, which was tightly adhered to the spermatic cord and testicle. The hernia sac including the hematocele was removed from the scrotum through an anterior approach, preserving the spermatic cord and testicle. On the third postoperative day, an orchiectomy was performed due to poor testicular perfusion caused by spermatic cord injury. There was no hematocele or hernia at the 3-year follow-up. The remnant sac after laparoscopic TAPP for a giant inguinoscrotal hernia possibly caused refractory hematocele. Additionally, the removal of the hernia sac, including hematocele, from the spermatic cord and testicle has a risk of inducing injury, leading to orchiectomy.

CONCLUSION

Surgeons should be aware of the possibility of delayed refractory hematoceles after laparoscopic TAPP for giant inguinoscrotal hernias when the hernia sac is not resected.

Comparison of open preperitoneal and transabdominal preperitoneal hernia repair for primary unilateral femoral hernia: a retrospective cohort study of 132 case

BACKGROUND

Femoral hernia (FH) is traditionally treated by open surgery (OS). Laparoscopic treatment has also shown good results in treating FH. However, there have been few comparative studies of these two techniques. Therefore, our aim was to compare the outcomes of open and laparoscopic surgical FH treatment.

METHODS

Adult patients with primary unilateral FH undergoing OS or transabdominal preperitoneal (TAPP) hernia repair at our hospital from January 2013 to June 2018 were included in this study. Patients with history of abdominal surgery, contraindications to general anesthesia and those not wishing to receive general anesthesia received OS. Demographics, operation details and complications were compared retrospectively between the two groups.

RESULTS

A total of 132 patients were recruited to the study, 62 and 70 of whom underwent OS and TAPP, respectively. Compared to OS group, the TAPP group had a significantly shorter hospital stay (3.0 vs. 2.0 days, respectively, P < 0.05) and a lower postoperative pain score (3.0 vs. 1.0, P < 0.05), and took less time to return to normal activities (13.0 vs. 6.0 days, respectively, P < 0.05). The overall complication rates were equivalent between the groups (10 vs. 9.7%, OR = 1.037, 95% CI 0.329-3.270).

CONCLUSIONS

Both laparoscopic and open surgery appear to be safe and effective in a cohort of patients with femoral hernia and laparoscopic surgery might offer some advantages in reducing length of hospital stay, lower postoperative pain score and quicker return to activities.

Fixation free laparoscopic obliteration of inguinal hernia defects with the 3D dynamic responsive scaffold ProFlor

Laparoscopic TAPP/TEP approaches are well-established options for the cure of inguinal hernias. As in the open approach, mesh fixation and poor-quality biologic response represent controversial questions and are a source of concerns. Furthermore, hernia defect patency represents another problem which seems not well acknowledged among surgeons. These problems are considered the cause of frequent intra and postoperative complications. To overcome these concerns, recently a different concept of cure has emerged. Based on a newly developed dynamic responsive 3D scaffold named ProFlor, a permanent hernia defect obliteration has been finalized. Following its inherent centrifugal expansion due to its dynamic responsivity, this hernia device is positioned fixation free within the defect and induces a probiotic biological response allowing for the re-establishment of the degenerated inguinal barrier. A laparoscopic approach with the 3D scaffold has been tested on 71 patients to demonstrate its effectiveness in reducing intra and postoperative complications. The operated patients presented with bilateral and/or recurrent inguinal hernia. Overall, 122 hernia defects were obliterated with 119 dynamic responsive scaffolds. The procedures were carried out from January 2018 to January 2022 with a defined protocol and detailed procedural steps. The laparoscopic technique with the 3D hernia scaffold allowed for fixation free placement, permanent defect obliteration and dynamically induced regenerative effects. The technique proved effective in reducing intra and postoperative complications. In particular, early postoperative pain and discomfort significantly decreased. No chronic pain and no recurrences were reported during follow up. The results achieved with the described laparoscopic technique seem to embody an innovative concept for inguinal hernia repair. Fixation free, dynamic responsive, permanent defect obliteration, histologically proven regenerative effects are the distinctive features of this 3D scaffold. It seems to embody a more physiological and pathogenetically coherent concept of cure, thus improving treatment results of this widespread disease.

Minimizing complications following transinguinal preperitoneal modified Kugel mesh herniorrhaphy: a double blind prospective randomized clinical trial

Transinguinal preperitoneal (TIPP) single-layer mesh herniorrhaphy has been proven effective. Mesh manufacturers make either a single-unit, two-layer mesh design or a separate optional onlay with the pre-peritoneal mesh. For peace of mind, most surgeons still incorporate the optional onlay. This study evaluated any counterproductive effects of adding the onlay to single-layer TIPP mesh herniorrhaphy and compared the long-term efficacy. This prospective, single-surgeon, single-center, randomized trial compared two groups of 50 consecutive patients at a 1 to 1 ratio. The control group received a single-layer modified Kugel mesh in the preperitoneal space, while the study group received the optional onlay mesh in the inguinal canal with preperitoneal mesh placement. A single surgeon performed the same operation to place the preperitoneal mesh in both groups, the only difference being the placement of the optional onlay mesh in the study group. A blinded researcher performed post-operative interviews using a series of questions at 1, 3, 6, and 12 months after surgery, and another unblinded researcher organized and performed statistical analysis of the peri-operative and post-operative data. The primary endpoints included foreign body sensation, pain, and any other discomfort in the inguinal region following surgery; and the secondary endpoints included recurrence and any complications related to surgery. The patient demographics were similar between the two groups. The average follow-up period was 29 months. Two patients in the 1-layer group and one patient in the 2-layer group were lost to follow-up. Postoperative pain, numbness and soreness were similar between groups. No patients experienced a foreign body sensation after 3 months in the 1-layer group, while five patients still had a foreign body sensation at 12 months in the 2-layer group. No recurrence was noted in either group during the follow-up period. Adequate dissection of the preperitoneal space is the key to a successful single-layer TIPP herniorrhaphy. With decreased materials in the inguinal canal, single-layer TIPP has a lower rate of long-term postoperative discomfort without increasing the risk of future recurrence.

Trial registration: ISRCTN 47111213

Extraperitoneal Laparoscopic Approach in Inguinal Hernia—The Ideal Solution?

Background: After more than 20 years since laparoscopy was proposed as a solution for one of the most common surgical pathologies, inguinal hernia, the choice of an intra- or extraperitoneal approach has remained a highly debated topic. Purpose and objectives: This study aimed at analyzing the feasibility of the extraperitoneal approach, by routine for this team/ and answering the question of whether this type of approach can be considered a safe one. Although indications for an intra- or extraperitoneal approach largely overlap, it may also be a matter of surgeon preference in choosing one technique. Methods: The study was retrospective, conducted on a group of 493 patients operated on for inguinal hernia in the clinic, by a single operating team, between January 2012 and March 2022. Results: It was proven that out of the 493 surgeries for inguinal hernia, 95.1% (n = 469) were operated upon by laparoscopic TEP (total extra peritoneal patch plasty approach); 1.62% (n = 8) by laparoscopic TAPP (transabdominal intraperitoneal); and 3.24% (n = 16) by the open, anterior approach (Lichtenstein). There were no intraoperative complications recorded in any of the procedures, while postoperative complications were found in 10.23% of cases (n = 48) in the extraperitoneal approach, and recurrences after the TEP approach were recorded in 0.40% of cases (n = 2). Conclusions: For correctly selected cases, TEP hernia surgery can be considered a safe and reliable approach.

The transition from open to laparoscopic surgery for bilateral inguinal hernia repair: how we did it

PURPOSE

To describe the transition process from open repair (OR) to laparoscopic repair (LR) of bilateral inguinal hernia in a small basic general hospital METHODS: We describe the technical details and training strategy used to facilitate the transition to systematic LR of bilateral inguinal hernia. We conducted a retrospective analysis of prospectively collected data from all patients undergoing bilateral inguinal hernia repair between January 2017 and December 2020. We analysed the evolution of LR and compared the surgical outcomes: complications, acute pain (24 h), chronic pain (> 3 months), and recurrence (1 year) of the patients operated on by OR and LR.

RESULTS

We performed 132 bilateral inguinal hernia repairs, 55 (41.7%) ORs, and 77 (58.3%) LRs. A significant difference was observed in the choice of LR over time (2017: 9%, 2018: 32%, 2019: 75%, 2020: 91%, p < 0.001). The mean operative time was shorter in the OR group than in the LR group (56 min vs. 108 min, p < 0.001). However, the operative time of the LR decreased over the years. No significant differences were observed in complications or recurrence. LR was associated with lower acute postoperative pain at 24 h (2.2 vs. 3.1 points, p = 0.021) and lower chronic groin pain than OR (1.3% vs. 12.7%, p = 0.009).

CONCLUSION

A structured and systematized training process made the transition from OR to LR of bilateral inguinal hernias feasible and safe in a small basic general hospital. This transition did not increase complications or recurrence. Additionally, LR was associated with a decrease in postoperative pain and chronic groin pain.

Mesh size may not affect recurrence in laparoscopic totally extraperitoneal repair of inguinal hernias

A mesh is usually employed to cover defects when performing laparoscopic totally extraperitoneal repair (TEP) of inguinal hernias. However, there is insufficient evidence for an appropriate mesh size. Therefore, we aimed to compare the recurrence rate between large- and medium-mesh laparoscopic TEP. Patients who underwent laparoscopic TEP for primary inguinal hernias from January 2012 to March 2020 were included. We retrospectively reviewed electric medical records. The primary outcome was the difference in recurrence rate between the large and medium meshes. The large mesh was 10.3 × 15.7 cm, and the medium mesh was 7.9 × 13.4 cm or 9 × 13 cm. In total, 446 patients were included in the study. Of these patients, 177 were in the large-mesh group, and 269 were in the medium-mesh group. The average ages of the large- and medium-mesh groups were 58.4 and 56.9 years, respectively (P = .361). In both groups (large vs medium), males were dominant (93.2% vs 93.6%, P = .850), and indirect hernias (87.0% vs 88.1%, P = .740) were dominant. There was no difference in body mass index (P = .883) or hernia side (P = .770). Peritoneal tearing as an intraoperative complication occurred frequently in the large-mesh group (13.6% vs 3.3%, P < .001). During the mean follow-up period of 28 months, recurrence occurred in 3 (1.7%) and 13 (4.8%) patients in the large- and medium-mesh groups, respectively. However, there was no statistical significance (P = .262). Mesh size may not affect recurrence after laparoscopic TEP of primary inguinal hernias.

Lichtenstein and Total Extraperitoneal Techniques in Inguinal Hernia Surgery: A Comparison of the Intraoperative and Early Postoperative Complications Between the Two Approaches

Background and objective

The Lichtenstein technique (LSt) and total extraperitoneal technique (TEPt) are the most frequently performed surgical procedures for inguinal hernia (IH). This study aimed to compare LSt and TEPt in terms of intraoperative and postoperative complications as well as recurrence rates.

Methods

This retrospective study involved patients hospitalized for IH repair. The study included a total of 262 patients (LSt group: n=125; TEPt group: n=137). 

Results

The follow-up period of the patients ranged between 16 and 30 months (mean: 22.3 months). While intraoperative complications were more commonly reported in the TEPt group, postoperative complications were more common in the LSt group (2.9% vs. 1.6%). Postoperative bleeding/hematoma developed in three (2.4%) patients in the LSt and three (2.2%) in the TEPt group. One of the patients in the LSt group was reoperated due to persistent bleeding. Two patients in the LSt and two in the TEPt group were reoperated for postoperative recurrence (1.6% vs. 2.4%). One patient was reoperated due to chronic persistent pain. Seroma was aspirated in three (2.4%) patients in the LSt and two (1.5%) in the TEPt group.

Conclusion

This study revealed no significant difference between TEPt and LSt groups regarding intraoperative and postoperative complications. We propose that both TEPt and LSt could be safely performed in cases of primary and complex IH by selecting the appropriate method based on the hernia type and patient and with sufficient surgical experience.

Surgical outcomes of laparoscopic total extraperitoneal (TEP) inguinal hernia repair compared with Lichtenstein tension-free open mesh inguinal hernia repair: A prospective randomized study

Inguinal hernia repair is one of the most frequently performed surgery. The ideal procedure for inguinal hernia repair remains controversial. Open Lichtenstein tension-free mesh repair (LMR) is one of the most preferred open techniques with satisfactory outcomes. Laparoscopic approach in inguinal hernia surgery remains controversial, especially in comparison with open procedures. In this study, we have reported a comparison of laparoscopic total extraperitoneal (TEP) inguinal hernia repair with LMR. Postoperative pain, operative time, complications like seroma, wound infection, chronic groin pain, and recurrence rate were parameters to evaluate the outcome. One hundred seventy-four patients were included in the study by consecutive randomized prospective sampling. The patients were divided into 2 groups: group A, laparoscopic TEP inguinal hernia repair, and group B, LMR. The procedures were performed by experienced surgeons. The primary outcomes were evaluated based on postoperative pain and recurrence rate. Secondary outcomes considered for evaluation were operative time, complications like seroma, infection, and chronic groin pain. Severe pain was reported in group A (7.9%) compared to group B (15.1%), which was statistically significant (P < .001). Moderate pain was reported more in group B (70.9%) compared to group A (29.5%) (P < .001). The mean operative time in group A was 84.6 ± 32.2, which was significantly higher than that in group B, 59.2 ± 14.8. There was no major complication in both groups. The chronic pain postoperatively was significantly in higher number of patients in group B vs group A (22.09% vs 3.4%). The postoperative hospital stay period was significantly lesser for group A vs for group B (2.68 ± 1.52 vs 3.86 ± 6.16). Time duration taken to resume normal activities was significantly lower in group A (13.6 ± 6.8) vs (19.8 ± 4.6) in group B (P < .001). Although there is definite evidence of longer operative time and learning curve, laparoscopic TEP has added advantages like less postoperative pain, early resumption of normal activities, less chronic groin pain, and comparable recurrence rate compared to open Lichtenstein repair. Laparoscopic TEP can be performed with acceptable outcomes and less postoperative complications if performed by experienced hands.

Comparison of laparoscopic and open inguinal hernia repair in adults: A retrospective cohort study using a medical claims database

INTRODUCTION

This study aimed to investigate and compare the surgical complications following laparoscopic inguinal hernia repair (LIHR) with those following open inguinal hernia repair (OIHR).

METHODS

This was a retrospective cohort study based on nationwide claims data. We extracted the data of patients aged ≥20 years who underwent inguinal hernia repair (IHR) between 2009 and 2020. The primary outcome was postoperative complications of IHR, and the secondary outcomes were recurrence of hernia and length of hospital stay. Patient characteristics were adjusted with propensity score (PS) matching, the annual proportions of LIHR versus OIHR were summarized, and the surgical outcomes of each IHR were analyzed.

RESULTS

Of the 15 728 eligible patients, 6512 underwent LIHR. The proportion of LIHR increased from 14.7% to 52.8% annually during the study period. From the analysis of 6060 pairs created by PS matching, the risk of surgical site infection (odds ratio [OR] 0.70; 95% confidence interval [CI] 0.56-0.86; P = .0007), and acute postoperative pain (OR 0.69; 95% CI 0.60-0.79; P < .0001), and chronic postoperative pain (OR 0.83; 95% CI 0.70-0.98; P = .0291) were significantly lower with LIHR than with OIHR. The recurrent rate was not significantly different between the LIHR and OIHR groups (OR, 0.68; 95% CI 0.45-1.01; P = .0558). Furthermore, no significant difference was found in the length of hospital stay between the LIHR and OIHR groups (2.91 ± 1.94 days vs 2.97 ± 2.61 days, difference ± SE: 0.06 ± 0.04, P = .1307).

CONCLUSION

LIHR might be superior to OIHR in terms of fewer surgical complications and might be preferred over OIHR in the future.

Laparoscopic approach as a safe and effective option for incarcerated femoral hernias

INTRODUCTION

The laparoscopic approach for elective femoral herniorrhaphy is well established. However, femoral hernias often present as incarcerations and require emergency repair surgery, mainly using the open approach. This study aimed to retrospectively analyze the efficacy of the laparoscopic approach for incarcerated femoral hernias.

METHODS

Data of patients who underwent emergency surgery for incarcerated femoral hernia between April 2016 and August 2021 were retrospectively analyzed. Laparoscopy was performed whenever possible; however, conversion to an open approach remained a fallback option for when laparoscopic repair was not possible. In laparoscopic repair, incarcerated femoral hernias reduced using traction, water pressure, and preperitoneal methods. Data of patients who underwent open repair and laparoscopy were then compared.

RESULTS

During the observation period, 20 patients underwent emergency surgery for incarcerated femoral hernia. Eleven patients subsequently underwent repair using a laparoscopic approach, and eight underwent repair using an open approach. Only one patient underwent intestinal resection without hernia repair due to perforated bowel. Operative time for laparoscopic repair was longer. Mesh repair was performed in 18 patients. Four patients each in the laparoscopic repair and open group required intestinal resection.

CONCLUSION

Incarcerated femoral hernias can be safely repaired using the laparoscopic approach.

Lichtenstein versus transabdominal preperitoneal (TAPP) inguinal hernia repair for unilateral non recurrent hernia: A multicenter short term randomized comparative study of clinical outcomes

Background

The repair of inguinal hernia is still one of the most prevalent surgical procedures done worldwide. Among all repair techniques, open Lichtenstein repair is the most globally conducted. In the past few decades, laparoscopic technique for inguinal hernia repair has increased technical demand. Trans-abdominal pre-peritoneal (TAPP) technique is the main approach, which is featured by less postoperative pain and early recovery.

Objective

The current work is a short-term study to make a comparison between open Lichtenstein repair of inguinal hernia as well as laparoscopic trans-abdominal preperitoneal repair of inguinal hernia (TAPP) for unilateral non recurrent hernia regarding intraoperative, postoperative complications and hospital stay.

Patients and methods

The present prospective randomized study recruited 100 male subjects from General Surgery Department of Al-Azhar University Hospitals and Ain Shams university hospitals suffering from oblique inguinal hernia (unilateral non recurrent hernia) with an age above 18 years and good overall health, who were randomized into two groups: Group A: 49 cases were subjected to laparoscopic trans-abdominal pre-peritoneal repair (TAPP). Group B: 51 cases were subjected to open Lichtenstein repair.

Results

This study detected less post-operative pain day 0, day 1, day 7 and 1 month postoperatively. There was no significant difference at 6 months post-operatively.

Conclusion

Finally, we concluded that TAPP repair for inguinal hernia (unilateral non recurrent hernia) safer with less early post-operative pain. Also, it has fewer complications, with a significantly longer operative time.

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Inguinal hernia can be treated with either open surgical technique (Lichtenstein) or laparoscopic technique (transabdominal preperitoneal repair).

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TAPP repair for inguinal hernia safer with less early post-operative pain.

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There is no statistical difference as regard to surgical complications and post-operative recurrence.

Prevention and management of intraoperative complication during single incision laparoscopic totally extraperitoneal repair

Serious complications related to hernia surgeries have rarely been reported. One meta-analysis comparing laparoscopic and open mesh repair reported that 0.4% of potentially serious operative complications were reported. Previous studies have reported that uncommon serious intraoperative complications more frequently occur during laparoscopic inguinal hernia repairs. One study has shown that patients with history of lower abdominal surgery are at an increased risk of visceral injury during laparoscopic hernia repair. Vascular injuries at dissection and mesh fixation or suturing in the preperitoneal space typically involve the epigastric or aberrant obturator vessels crossing the Cooper’s ligament. However, complications can occur at every step of the operation, although only few are reported. Therefore, we report our experiences of intraoperative complications during single-incision laparoscopic totally extraperitoneal hernia repair and how to prevent and manage intraoperative complications.

Open versus laparoscopic repair of inguinal hernia: an overview of systematic reviews of randomised controlled trials

Background

Inguinal hernia has a lifetime incidence of 27% in men and 3% in women. Surgery is the recommended treatment, but there is no consensus on the best method. Open repair is most popular, but there are concerns about the risk of chronic groin pain. Laparoscopic repair is increasingly accepted due to the lower risk of chronic pain, although its recurrence rate is still unclear. The aim of this overview is to compare the risk of recurrence and chronic groin pain in laparoscopic versus open repair for inguinal hernia.

Methods

We searched Ovid MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews for systematic reviews and meta-analyses. Only reviews of randomised controlled trials (RCTs) in adults published in English were included. Conference proceedings and editorials were excluded. The quality of the systematic reviews was assessed using the AMSTAR 2 checklist. Two outcomes were considered: hernia recurrence and chronic pain.

Results

Twenty-one systematic reviews and meta-analyses were included. Laparoscopic repair was associated with a lower risk of chronic groin pain compared with open repair. In the four systematic reviews assessing any laparoscopic versus any open repairs, laparoscopic repair was associated with a statistically significant (range: 26–46%) reduction in the odds or risk of chronic pain. Most reviews showed no difference in recurrence rates between laparoscopic and open repairs, regardless of the types of repair considered or the types of hernia that were studied, but most reviews had wide confidence intervals and we cannot rule out clinically important effects favouring either type of repair.

Conclusion

Meta-analyses suggest that laparoscopic repairs have a lower incidence of chronic groin pain than open repair, but there is no evidence of differences in recurrence rates between laparoscopic and open repairs.

Safety and Feasibility of Laparoscopic Transabdominal Preperitoneal Hernia Repair for Octo- and Nonagenarians

Background: The feasibility of laparoscopic hernia repair in octo- and nonagenarians has not been investigated in detail. The aim of this retrospective study was to evaluate the safety and feasibility of laparoscopic hernia repair in octo- and nonagenarians. Methods: This study included 607 patients who underwent transabdominal preperitoneal laparoscopic hernia repair at our hospital between April 2014 and October 2020. Patients were divided into an over 80 group (112 patients aged 80 years and older) and a control group (495 patients younger than 80 years). The clinical outcomes were compared between the groups. In addition, among patients aged 80 years and older, those who underwent elective laparoscopic hernia repair (laparoscopic group: 111 patients) were compared with patients who underwent elective open hernia repair during the same study period (open group: 79 patients). Results: The number of patients who underwent bilateral hernia repair was significantly larger in the over 80 group (26.7% versus 11.7%, P < .001). The incidence of postoperative complications was not significantly different between the over 80 group and the control group. Compared with open group, the number of patients who underwent bilateral hernia repair was significantly larger in the laparoscopic group (27.0% versus 2.5%, P < .001). The incidence of postoperative complications (2.7% versus 10.1%) and the incidence of readmission (0.9% versus 6.3%) were significantly greater in the open group. Conclusions: Laparoscopic hernia repair in octo- and nonagenarian patients yields safe and noninferior outcomes. Laparoscopic hernia repair in octo- and nonagenarian patients is considered more suitable for detecting and repairing contralateral hernias simultaneously.

Does Transverse Abdominis Plane Block Increase the Risk of Postoperative Urinary Retention after Inguinal Hernia Repair?

Background and Objective:

Postoperative urinary retention (POUR) is a common adverse event after inguinal hernia repair (IHR), with an incidence of up to 22.2%. The aim of this study is to determine if pre-operative transverse abdominis plane (TAP) block increases the incidence of POUR.

Methods:

A retrospective review was performed for all patients who underwent IHR (open or laparoscopic) at this institution, from January 1, 2016 to December 31, 2017. Patients were divided into two groups: Patients that had a TAP block before surgery (group 1) and patients with no TAP block (group 2). Common demographics and comorbidities were collected along with postoperative outcomes and POUR incidence rates for every group to determine procedural influence.

Results:

From 276 patients reviewed, 28.2% (N = 78) underwent TAP block before surgery. The patient cohort mean age was 61.1 ± 14.4 years. Most the interventions were laparoscopic (81.2%) and an overall POUR incidence rate of 7.6% (N = 21) was observed. Comparatively, common demographics and comorbidities were statistically similar for both groups, with the exception of type 2 diabetes mellitus (p = 0.049). Individually, group 1 and 2 presented POUR incidence rates of 14.1% and 5.05%, respectively. While intraoperative fluid administration, early readmission rate, and length were similar in both groups, there was a significant difference in POUR incidence rates (p = 0.01).

Conclusion:

Patients undergoing TAP block during IHR might have an increased risk of developing POUR. Further larger, prospective, and randomized controlled studies are necessary to better assess these findings.

Prognostic prediction models for chronic postsurgical pain in adults: a systematic review

ABSTRACT

Chronic postsurgical pain (CPSP) affects an estimated 10% to 50% of adults depending on the type of surgical procedure. Clinical prediction models can help clinicians target preventive strategies towards patients at high risk for CPSP. Therefore, the objective of this systematic review was to identify and describe existing prediction models for CPSP in adults. A systematic search was performed in MEDLINE, Embase, PsychINFO, and the Cochrane Database of Systematic Reviews in March 2020 for English peer-reviewed studies that used data collected between 2000 and 2020. Studies that developed, validated, or updated a prediction model in adult patients who underwent any surgical procedure were included. Two reviewers independently screened titles, abstracts, and full texts for eligibility; extracted data; and assessed risk of bias using the Prediction model Risk of Bias Assessment Tool. The search identified 2037 records; 28 articles were reviewed in full text. Fifteen studies reporting on 19 prediction models were included; all were at high risk of bias. Model discrimination, measured by the area under receiver operating curves or c-statistic, ranged from 0.690 to 0.816. The most common predictors identified in final prediction models included preoperative pain in the surgical area, preoperative pain in other areas, age, sex or gender, and acute postsurgical pain. Clinical prediction models may support prevention and management of CPSP, but existing models are at high risk of bias that affects their reliability to inform practice and generalizability to wider populations. Adherence to standardized guidelines for clinical prediction model development is necessary to derive a prediction model of value to clinicians.

Feasibility of modified-TEP technique for large inguinoscrotal and large femoral hernia and its advantages

PURPOSE

To describe the feasibility of modified-TEP technique in reducing dead space in large inguinoscrotal and large femoral hernia to prevent seroma, reduce recurrence and complications.

METHODS

This is a case series of patients who have completed a minimum of 9 months follow-up after undergoing elective endo-laparoscopic inguinal hernia repair with modified-TEP technique for large inguinoscrotal and large femoral hernia in a single institution from June to October 2020.

RESULTS

14 large inguinoscrotal hernia and 4 large femoral hernia were repaired using the modified-TEP technique in 15 patients. These patients reported minimal pain after surgery. There were no reported seroma, complications or recurrences up to 9 months follow-up period.

CONCLUSION

Modified-TEP technique for large inguinoscrotal and large femoral hernia has shown good outcomes and patients reported minimum levels of pain. In experienced hands, it is safe, feasible and effective in reducing seroma formation and hernia recurrence.

Minimally Invasive Hernia Repair in Robot-assisted Radical Prostatectomy

Inguinal hernia is a recognized complication of radical prostatectomy. Previous hernia repair, wound infection, midline incision, low BMI, and preexisting or subclinical hernia contribute to the risk of inguinal hernia following radical prostatectomy. Concomitant hernia repair at the time of pelvic surgery has risks and benefits. Repair during surgery prevents future hernia-related complications and saves the need for an additional procedure. However, hernia repair at the time of radical prostatectomy includes the risk of mesh infection, post-operative pain, adhesions, lack of experience, and overall minimal risk with watchful waiting. The robotic transperitoneal approach is the most commonly used technique for concomitant inguinal hernia repair with a modest addition to operative time and minimal postoperative complications. Recurrence rates following concomitant hernia repair during pelvic surgery are low.

Time-efficiency and hospital costs of open compared with laparoscopic groin hernia repair in a teaching hospital

BACKGROUND

Time efficiency and hospital costs may influence the preferred method of groin hernia repair. Despite growing expertise in laparoscopic hernia repair, knowledge on the actual costs and the potential financial advantages over open hernia repair are limited.

METHODS

A single-center retrospective cohort study comparing hospital costs and time-efficiency of open-mesh (Lichtenstein) and laparoscopic groin hernia repair between 2010 and 2015, including a comparison of surgeons and residents, was conducted. Secondary outcomes were length of hospital stay, complication and recurrence rates.

RESULTS

Nine hundred forty-seven open and 449 laparoscopic groin hernia repairs were included. Unilateral open repair showed a shorter operation theatre occupancy (63.5 min±17.2 vs. 71.9 min±19.9, P<0.001) and lower total costs (€ 974.51±266.67 vs. € 1165.32±285.94, P<0.001) compared with laparoscopic repair. Residents had longer operative times compared with surgeons in the unilateral open procedure (43.8±13.4 min vs. 34.5±16.3 min, P<0.001), in the unilateral laparoscopic procedure (46.9±16.6 min vs. 41.7±18.7 min, P<0.001) and higher total costs in the unilateral open procedure (€ 1007.47±238.58 vs. € 909.35±305.00, P<0.001). There were no significant differences in complication and recurrence rates between residents and surgeons.

CONCLUSIONS

Open-mesh hernia repair appears to be superior in costs for both uni- and bilateral groin hernias when performed by surgeons as well as residents. Residents had higher total costs and longer operation times in the unilateral open groin hernia group when compared with surgeons, yet overall complications and recurrence rates were similar in all groups suggesting that residents are sometimes more expensive and slower, but just as safe.