Single-port access in laparoscopic bilateral inguinal hernia repair: first clinical report of a novel technique

Laparoendoscopic single-site surgery in inguinal hernia repair

Laparoendoscopic single-site surgery (LESS) for laparoscopic inguinal hernia repair (IHR) offers the potential for excellent cosmetic outcomes and maximization of the inherent advantages of minimally invasive surgery. LESS IHR is associated with a steep learning curve, which is attributable to both the IHR technique itself and the single-site technique. The technical obstacles in the single-site technique may be mitigated by employing certain maneuvers and strategies that minimize clashing between instruments and improve freedom of movement. The current literature consistently points out the inherent challenges in LESS IHR, with its longer operative time compared to that of conventional laparoscopic IHR. LESS IHR performed by capable operators has comparable complication rates, duration of hospital stay, and incidence of recurrence as conventional laparoscopic IHR. LESS IHR is both feasible and safe. Given its excellent cosmetic outcome, it is likely to be sought by younger patients who are concerned with scar formation. The use of robotics may bypass the technical challenges in LESS, but cost considerations in their usage will likely persist.

Clinical outcomes of single incision laparoscopic surgery and conventional laparoscopic transabdominal preperitoneal inguinal hernia repair

BACKGROUND:

Laparoscopic surgery has been a frequently performed method for inguinal hernia repair. Studies have demonstrated that the laparoscopic transabdominal preperitoneal (TAPP) approach is an appropriate choice for inguinal hernia repair. Single-incision laparoscopic surgery (SILS) was developed to improve the cosmetic effects of conventional laparoscopy. The aim of this study was to evaluate the safety and feasibility of SILS-TAPP compared with TAPP technique.

MATERIALS AND METHODS:

A total of 148 patients who underwent TAPP or SILS-TAPP in our surgery clinic between December 2012 and January 2015 were enrolled. Data including patient demographics, hernia characteristics, operative time, intraoperative and postoperative complications, length of hospital stay and recurrence rate were retrospectively collected.

RESULTS:

In total, 60 SILS-TAPP and 88 TAPP procedures were performed in the study period. The two groups were similar in terms of gender, type of hernia, and American Society of Anesthesiologists (ASA) classification score. The patients in the SILS-TAPP group were younger when compared the TAPP group. Port site hernia (PSH) rate was significantly high in the SILS-TAPP group, and all PSHs were recorded in patients with severe comorbidities. The mean operative time has no significant difference in two groups. All SILS procedures were completed successfully without conversion to conventional laparoscopy or open repair. No intraoperative complication was recorded. There was no recurrence during the mean follow-up period of 15.2 ± 3.8 months.

CONCLUSION:

SILS TAPP for inguinal hernia repair seems to be a feasible, safe method, and is comparable with TAPP technique. However, randomized trials are required to evaluate long-term clinical outcomes.

Single incision laparoscopic TAPP with standard laparoscopic instruments and suturing of flaps: A continuing study

BACKGROUND:

Single incision laparoscopic surgery, especially transumbilical, should be the closest to replicate the minimal access results achieved by natural orifice endoscopic surgery (NOTES). This study of single incision transabdominal preperitoneal (SITAPP) inguinal hernia repair is a continuing study exploring the peroperative variables and short and long term complications of this procedure.

PATIENTS AND METHODS:

All the 183 patients were operated by the same surgeon through a horizontal transumbilical incision positioned across the lower third of the umbilicus. Port access was through three separate transfacial punctures. Routine rigid instruments were used and the peritoneal flaps were either tacked or sutured into place. Patients with irreducible hernia and obstructed hernia were included, while those with strangulated hernia were excluded.

RESULTS:

All the patients were male with an average age of 41.4 years. Twenty four patients had bilateral hernia, 15 patients had irreducible and 6 patients had obstructed hernia. The mean operating time was 38.3 mins for unilateral hernias completed with tackers and 42.8 mins in those with intracorporeal suturing. The corresponding operating time for bilateral hernias was 53.2 and 62.7 minutes. There was minimal serous discharge from the umbilicus in 8 patients, port site infection in 1 patient and recurrence in 2 patients over a 36 months period.

CONCLUSIONS:

SITAPP for groin hernias, performed with conventional instruments is feasible, easy to learn, has a very high patient acceptance and is cosmetically superior to conventional TAPP. The use of tackers reduces the operating time significantly.

The role of the laparoendoscopic single site totally extraperitoneal approach to inguinal hernia repairs: a review and meta-analysis of the literature

BACKGROUND

Laparoendoscopic single site (LESS) surgery may have perceived benefits of reduced visible scarring compared to conventional laparoscopic (LAP) totally extraperitoneal (TEP) hernia repairs. We reviewed the literature to compare LESS TEP inguinal hernia repairs with LAP TEP repairs.

METHODS

We searched electronic databases for research published between January 2008 and January 2012.

RESULTS

A total of 13 studies reported on 325 patients. The duration of surgery was 40-98 minutes for unilateral hernia and 41-121 minutes for bilateral repairs. Three studies involving 287 patients compared LESS TEP (n = 128) with LAP TEP (n = 159). There were no significant differences in operative duration for unilateral hernias (p = 0.63) or bilateral repairs (p = 0.29), and there were no significant differences in hospital stay (p > 0.99), intraoperative complications (p = 0.82) or early recurrence rates (p = 0.82). There was a trend toward earlier return to activity in the LESS TEP group (p = 0.07).

CONCLUSION

Laparoendoscopic single site surgery TEP hernia repair is a relatively new technique and appears to be safe and effective. Advantages, such as less visible scarring, mean patients may opt for LESS TEP over LAP TEP. Further studies with clear definitions of outcome measures and robust follow-up to assess patient satisfaction, return to normal daily activities and recurrence are needed to strengthen the evidence.

Single-incision laparoscopic transabdominal preperitoneal herniorrhaphy for bilateral inguinal hernias using conventional instruments

PURPOSE

Inguinal hernia repair is a common surgical procedures performed worldwide. Although surgical technology is advancing rapidly in this era, surgeons have a chance to make modifications in laparoscopic surgery by reducing the number and size of incisions. The aim of this study is to assess the safety and feasibility of a single-incision laparoscopic surgical (SILS) approach for transabdominal preperitoneal mesh hernioplasty (TAPP) of bilateral inguinal hernia.

METHODS

Ten patients with bilateral inguinal hernia admitted to our department and underwent TAPP were retrospectively evaluated. Data regarding patient demographics, type of hernia, operating time, complications, and postoperative hospitalization were prospectively collected. SILS TAPP was performed using conventional instruments and, surgical techniques similar to standard 3-port TAPP were used, except that it was conducted through a single umbilical port.

RESULTS

All the patients had a bilateral inguinal hernia. All patients were male, and the mean age of the patients was 45 years (range=28 to 62 y). The mean duration of surgery was 63 minutes (range=55 to 80 min). The procedures were completed successfully on all the patients without requiring conversion to the traditional laparoscopic surgery or the use of additional trocars. There was no evidence of early recurrence during a mean follow-up period of 67 days (range=30 to 105 d).

CONCLUSIONS

SILS TAPP for bilateral hernia is feasible and seems to be safer. However, follow-up and analysis are required to establish long-term clinical outcomes and recurrence rate.

Laparoendoscopic single-site extraperitoneal inguinal hernia repair: initial experience in 10 patients

BACKGROUND AND PURPOSE

Recent technical advances and a trend toward laparoscopic single incision surgery have led us to explore the feasibility of laparoendoscopic single-site (LESS) hernia repair.

PATIENTS AND METHODS

We present our technique and initial experience with LESS extraperitoneal inguinal hernia repair in 10 consecutive men with unilateral inguinal hernias. Age range was 43.7 (28-64) years. Mean body mass index was 28 (range 24-30). Six were left inguinal hernias. There were six indirect and four direct hernias. Three patients had undergone previous open appendectomy. Incarcerated or bilateral hernias were excluded from our initial series. All cases were performed by three surgeons who were experienced in conventional totally extraperitoneal laparoscopic hernia repair as well as experienced in LESS. A literature review of current single-port inguinal hernia repair data is also presented.

RESULTS

The mean operative time was 53 minutes (range 45-65  min). The average length of skin incision was 2.8  cm (range 2.3-3.2  cm). No drain was necessary in any of the patients, while no recordable bleeding was observed. There were no intraoperative or immediate postoperative complications. Hospitalization period was 2 days for all patients. After a limited follow-up of 1 month, there have been no recurrences and no complaints of testicular pain. The results of the current series compare favorably with those found in a literature review.

CONCLUSION

LESS extraperitoneal inguinal hernia repair is both feasible and safe, although more technically demanding than its conventional laparoscopic counterpart. Although the cosmetic result with the former approach may prove superior, there are standing questions regarding the complications and long-term outcome. Randomized and if possible blinded trials that compare conventional and single-incision laparoscopic hernia repair may help to distinguish the most advantageous technique.

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.

Single-Port Cholecystectomy Through the Lateral Ring of the Left Inguinal Hernia

Background: Single-port surgery was developed by the evolution of the laparoscopy. The advantage of this new method is mainly cosmetic, but the risk of the hernia—owing to the larger port—increased. Case report: A 71-year-old man was admitted with a left lateral inguinal hernia and gallbladder stones. After preparation of the sac of the hernia, a single-port was inserted into the lateral ring and a cholecystectomy was performed. The operation was completed by the reconstruction of the abdominal wall using a polypropylene mesh. The total operating time was 85 minutes. Conclusion: In the case of the combined operation, the defect of the abdominal wall could be used as a location of the single port, and the trauma of the abdominal wall could be avoided. This is the first publication about single-port cholecystectomy where the ring of the inguinal hernia was used as a placement site of the single port.

Single-incision laparoscopic transabdominal preperitoneal inguinal hernia repair using only conventional instruments: an initial report

INTRODUCTION

Notes is the logical answer to scarless surgery, but despite being around for almost 4-5 years, it has to still garner a major support because of a number of limitations. Single-incision laparoscopic surgery, especially when done through the umbilicus, should be the perfect answer as far as the absence of any visible scar is concerned.

MATERIALS AND METHODS

All the 67 patients were operated by the same surgeon through a transversely placed umbilical incision in the lower half of the umbilicus. Three conventional ports, 10, 5, and 5  mm, were introduced through the same skin incision but separate transfacial punctures. The instruments included 10-mm and 5-mm 30° rigid telescopes and rigid instruments as in standard laparoscopic cholecystectomy. Patients with irreducible hernia and obstructed hernia were included, and those with strangulated hernia were excluded.

RESULTS

All the patients were men, with an average age of 38.6 years. Three patients had bilateral hernia and 2 each had irreducible and obstructed hernia. The mean operating time was 42.8 minutes for unilateral hernias when tackers were used and 51.7 minutes in those in whom intracorporeal suturing was done. The operating time for bilateral hernias was 71.7 minutes. There was minimal flap discharge, without infection, in 3 patients. There were no other complications. There were no conversions and no recurrences upto 9 months of follow-up.

CONCLUSIONS

Transumbilical single-skin-incision laparoscopic transabdominal preperitoneal repair for groin hernias, performed solely with conventional instruments, is feasible, easy to learn, and probably the future of laparoscopic inguinal hernia repair.

Single-incision Laparoscopic Surgery (SILS) in general surgery: a review of current practice

Single-incision laparoscopic surgery (SILS) aims to eliminate multiple port incisions. Although general operative principles of SILS are similar to conventional laparoscopic surgery, operative techniques are not standardized. This review aims to evaluate the current use of SILS published in the literature by examining the types of operations performed, techniques employed, and relevant complications and morbidity. This review considered a total of 94 studies reporting 1889 patients evaluating 17 different general surgical operations. There were 8 different access techniques reported using conventional laparoscopic instruments and specifically designed SILS ports. There is extensive heterogeneity associated with operating methods and in particular ways of overcoming problems with retraction and instrumentation. Published complications, morbidity, and hospital length of stay are comparable to conventional laparoscopy. Although SILS provides excellent cosmetic results and morbidity seems similar to conventional laparoscopy, larger randomized controlled trials are needed to assess the safety and efficacy of this novel technique.

Single-port laparoscopic surgery

Laparoscopic surgery performed through a single-incision is gaining popularity. The demand from the public for even less invasive procedures will motivate surgeons, industry, and academic centers to explore the possibilities and refine the technology. Although the idea seems quite attractive, there are several technological obstacles that are yet to be conquered by improved technology or additional training. The question of safety has yet to be answered and will require well-designed randomized control trials. Opponents to the approach argue that the size of the single incision (see Table 1) is frequently larger than all the standard laparoscopy incisions combined. On the other hand, proponents remember a similar argument from traditional open surgeons during the initial development of laparoscopy. That argument was quickly discredited when the immediate benefits oflaparoscopy were compared with patients undergoing surgery with small laparotomy incisions. During the development of a new technique, the learning curve exposes patients to risk and society to expense. LESS pioneers appear to have reached a level of comfort with technology and techniques that paves the way for scientific scrutiny. Perhaps, the surgical community will capitalize on this situation with randomized, controlled studies and sound evidence to support or refute the benefits of LESS. If we do not seize this opportunity, patient demand and industry's dual edge message of financial success versus fear of losing referrals will lead to a scenario similar to the development of laparoscopic cholecystectomy in the 1990s. Regardless of its future, the surgical community will still benefit from a renewed excitement as surgeons aim to continually reduce the amount of pain and trauma our patients must endure. In addition, technological advances on instrumentation will benefit the field of laparoscopy and improve patient care.