Meta-analysis and review of prospective randomized trials comparing laparoscopic and Lichtenstein techniques in recurrent inguinal hernia repair

Efficacy of totally extraperitoneal endoscopic hernioplasty (TEP) versus Lichtenstein hernioplasty: a systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy and safety of totally extraperitoneal endoscopic hernioplasty (TEP) compared to the Lichtenstein hernioplasty in adult patients with uncomplicated inguinal hernia.

METHODS

A systematic review and meta-analysis were conducted following PRISMA guidelines. We included 27 randomized controlled trials (RCTs) identified through comprehensive searches in Embase, Web of Science, PubMed, Scopus, and Cochrane Library. Studies comparing TEP and Lichtenstein techniques in adult patients with uncomplicated inguinal hernias were selected. Primary outcomes included hernia recurrence and chronic postoperative pain. Secondary outcomes assessed were surgical wound infection, seroma, hematoma, scrotal edema, operative time, hospital stay (in hours and days), and time to return to daily activities.

RESULTS

A total of 27 RCTs with 7,658 patients were analyzed. No significant difference was found in hernia recurrence between TEP and Lichtenstein (RR 1.03; 95% CI [0.62-1.72]; p = 0.90). However, TEP significantly reduced the risk of chronic postoperative pain by 62% (RR 0.38; 95% CI [0.28-0.51]; p < 0.00001), surgical wound infection by 52% (RR 0.48; 95% CI [0.31-0.75]; p = 0.001), and hematoma formation by 37% (RR 0.63; 95% CI [0.41-0.97]; p = 0.04). No significant differences were found for seroma formation (RR 1.17; 95% CI [0.98-1.40]; p = 0.08) or scrotal edema (RR 0.62; 95% CI [0.35-1.10]; p = 0.10). Operative time showed no significant difference (MD 7.78 min; 95% CI [-2.77-18.33]; p = 0.15). Regarding hospital stay, TEP reduced the duration in days (MD -0.83; 95% CI [-1.24 to -0.41]; p < 0.0001), while no difference was observed when measured in hours (MD 0.01; 95% CI [-0.29-0.31]; p = 0.95). Furthermore, TEP was associated with a faster return to daily activities by approximately 5 days (MD -4.74; 95% CI [-6.78 to -2.70]; p < 0.00001).

CONCLUSION

The TEP technique is more effective in terms of chronic pain, risk of surgical wound infection, and reduction of hematoma formation than the Lichtenstein technique.

Transabdominal preperitoneal (TAPP) repair for emergency groin hernia: a systematic review

PURPOSE

Laparoscopic groin hernia repair has evolved and gained popularity and laparoscopic transabdominal preperitoneal (TAPP) procedure provides an opportunity to evaluate the peritoneal cavity and both inguinal areas without the need for additional dissection. There is still a paucity of evidence to support TAPP repair in the emergency setting. In this systematic review, we aim to evaluate the feasibility and safety of TAPP repair for incarcerated and strangulated groin hernias.

METHODS

PRISMA guidelines were followed for literature search and established inclusion and exclusion criteria were applied. Data were extracted and analyzed for the outcomes of interest.

RESULTS

Overall, 8 studies were included in the review, comprising 316 patients. Patients characteristics and outcomes were limitedly reported. Only 3 cases of conversion to open approach were reported and 2 recurrences were diagnosed. Postoperative complications are inconsistently reported but mostly refer to minor complications. There were no mortality cases. Visceral resections were performed in 25 cases due to ischemia, mostly extracorporeally.

CONCLUSION

Laparoscopy is a game changer and TAPP approach is a feasible, safe, and effective technique for the emergent repair of groin hernias. Further studies and prospective randomized data are needed to establish its role in the emergent groin hernia management.

Comparative analysis of different surgical approaches for recurrent inguinal hernia: a single-center observational study

Purpose

Managing recurrent inguinal hernias is complex, and choosing the right surgical approach (laparoscopic vs. open) is vital for patient outcomes. This study compared the outcomes of using the same vs. different surgical approaches for initial and subsequent hernia repairs.

Methods

We retrospectively analyzed patients who underwent recurrent inguinal hernia repair at Seoul National University Bundang Hospital between January 2014 and May 2023. Patients were divided into the "concordant" and "discordant" groups, comprising patients who underwent same and different approaches in both surgeries, respectively. Preoperative baseline characteristics, index surgery data, postoperative outcomes, and recurrence rates were analyzed and compared.

Results

In total, 131 patients were enrolled; the concordant and discordant groups comprised 31 (open, n = 19; laparoscopic, n = 12) and 100 patients (open to laparoscopic, n = 68; laparoscopic to open, n = 32), respectively. No significant differences were observed in the mean operation time (50.5 ± 21.7 minutes vs. 50.2 ± 20.0 minutes, P = 0.979), complication rates (6.5% vs. 14.0%, P = 0.356), or 36-month cumulative recurrence rates (9.8% vs. 9.8%; P = 0.865). The mean postoperative hospital stay was significantly shorter in the discordant than in the concordant group (1.8 ± 0.7 vs. 1.4 ± 0.6, P = 0.003).

Conclusion

Most recurrent inguinal hernia repairs were performed using the discordant surgical approach. Overall, concordance in the surgical approach did not significantly affect postoperative outcomes. Therefore, the selection of the surgical approach based on the patient's condition and surgeon's preference may be advisable.

Outcomes from Early Experience with Laparoscopic Inguinal Hernia Repair Versus Open Technique: Navigating the learning curve

Objectives

This study aimed to evaluate the outcomes of laparoscopic inguinal hernia repair (LIHR) regarding postoperative pain, recurrence rates, duration of hospital stay and other postoperative outcomes within the context of a tertiary care teaching hospital in South India, and the initial experience of laparoscopic repairs. The current consensus in the literature often suggests LIHR as superior to open inguinal hernia repair (OIHR).

Methods

This single-centre, retrospective, observational study was conducted at the Jawaharlal Institute of Postgraduate Education and Research, Puducherry, India, from January 2011 to September 2020. All patients who underwent elective OIHR and LIHR were included. Data on the patients demographics, comorbidities, hernia type, mesh characteristics, surgery duration, hospital stay and immediate postoperative complications were collected and analysed.

Results

A total of 2,690 OIHR and 158 LIHR cases were identified. The demographic profiles, hospital stay and complication rates were similar in both groups. However, surgical site infection was present exclusively in the OIHR group (3.55% versus 0.0%; P <0.05). The timeline for returning to normal activities was statistically shorter for the LIHR group (6 versus 8 days; P <0.05). The most frequent immediate complication in the LIHR group was subcutaneous emphysema (6.54% versus 0.0%; P <0.05). Recurrence (9.23% versus 3.61%; P = 0.09) and chronic pain (41.53% versus 13.55%; P <0.05) were higher in the LIHR group.

Conclusion

Lower recurrence and chronic pain rates were observed with OIHR in the initial experience with LIHR in the hospital. However, LIHR had significant advantages concerning faster patient recovery and lower rates of surgical site infections. While the results contribute an interesting deviation from the standard narrative, they should be interpreted within the context of a learning curve associated with the early experience of the research team with LIHR.

Comparing Laparoscopic Total Extraperitoneal and Lichtenstein Mesh Repair for Inguinal Hernias: A Focus on Patient Outcomes

BACKGROUND

This study aimed to evaluate post-operative outcomes by comparing factors such as post-operative pain, duration of hospitalization, time needed to resume normal and full activities, and complications between laparoscopic total extraperitoneal (TEP) and Lichtenstein tension-free mesh hernioplasty or repair (LMR) for inguinal hernias.

MATERIALS AND METHODS

A prospective study was conducted involving male patients undergoing either LMR or laparoscopic TEP mesh repair, with 30 patients in each group. The study assessed post-operative pain, duration of hospital stay, return to normal activities, and complications. Pain scores were monitored at regular intervals using a visual scale. Before discharge, patients' ability to perform self-care activities was evaluated using the Katz index of independence in activities of daily living. Outpatient follow-up was conducted on day 14, one month, three months, and six months post-surgery.

RESULTS

Post-operative pain scores were significantly higher among LMR patients compared to TEP patients until the 14th day post-surgery (p < 0.001). However, pain levels became comparable after that. There were no notable differences in pain scores between unilateral and bilateral hernias. TEP patients experienced significantly shorter hospital stays (p < 0.001) and quicker resumptions of self-care (p < 0.001), light work (p < 0.02), and full work (p < 0.03) compared to LMR patients.

CONCLUSION

Laparoscopic TEP repair offers advantages over Lichtenstein mesh repair in terms of reduced postoperative pain, shorter hospital stays, and faster recovery to normal activities. These findings can guide clinicians and patients in making informed decisions regarding hernia repair techniques.

A comparative study between open pre-peritoneal approach versus laparoscopic trans-abdominal pre-peritoneal approach in recurrent inguinal hernia repair: a prospective cohort study

BACKGROUND

The repair of recurrent inguinal hernias after prosthetic mesh repair is challenging due to the technical complexity and complications associated with it. As well as the increased risk of recurrence due to weakened tissues and distorted anatomy. The Posterior Pre-Peritoneal Approach yields significantly better results than the anterior approach due to its distance from previously scarred tissue.

OBJECTIVE

To compare the open pre-peritoneal approach and Laparoscopic trans-abdominal pre-peritoneal approach in the management of recurrent inguinal hernia which was previously managed through an open anterior approach regarding their intra-operative time, the postoperative outcomes in the form of hematoma, wound infection and finally the recurrence within 1-year follow-up.

PATIENTS AND METHODS

The current study is a prospective cohort study, a single-center trial conducted from June 2021 to June 2022 in the general surgery department in Ain Shams University Hospitals, which included 74 patients presented with recurrent inguinal hernia who had previous open anterior approach 68(91.8%) males and 6(8.1%) females including a 1-year follow-up postoperative.

RESULTS

There were 74 patients in our study with 37 patients in each group. Group (I) underwent an open pre-peritoneal approach and group (II) underwent a Laparoscopic trans-abdominal pre-peritoneal approach. The mean age of the group (I) is 39.51 with a standard deviation of  ± 3.49. While in group (II) the mean age is 39.37 with standard deviation  ± 3.44 (p = 0.881). From the included 74 patients 67(91.8%) were males and 6(8.1%) were females. As regards the co-morbidities, in group (I) 17(45.9%) patients have no co-morbidities, 11(29.7%) patients have diabetes mellitus, 6(16.2%) patients have hypertension, and 3(8.1%) patients have diabetes and hypertension. Andin group (II) 26(70.3%) patients have no co-morbidities, 6(16.2%) patients have diabetes mellitus, 3(8.1%) patients have hypertension, and 2(5.4%) patients have diabetes and hypertension (p = 0.207). Regarding intra-operative time, the mean time in minutes in the group (I) is 63.33 with a standard deviation of  ± 11.95. While in group (II) the mean time in minutes is 81.21 with a standard deviation of  ± 18.03 (p = 0.015). The postoperative outcomes were assessed for 1-year follow-up in the form of hematoma, wound infection, and recurrence within 1 year. Regarding the hematoma occurred in 4(10.8%) patients in group (I). While in 2(5.4%) patients in group (II) (p = 0.674). The wound infection was found in 5(13.5%) patients in group(I) and zero patients in group (II) (p = 0.021). Finally, we followed up with the patients for about 1 year to detect the recurrence. Which was found in 3(8.1%) patients in group (I) and 1(2.7%) patient in group (II) (p = 0.615).

CONCLUSION

The results of this study demonstrate that both the laparoscopic approach and the open posterior approach are effective for recurrent inguinal hernia following anterior approach mesh hernioplasty, with comparable results. Laparoscopy has been associated with a lower rate of recurrence and overall complications compared to open technique, however, it is difficult to draw definitive conclusions about the preferred option due to its lengthy learning curve and difficulty to perform. Furthermore, the results of this study confirm the previously reported positive results of the posterior pre-peritoneal for recurrent inguinal hernia, particularly when performed by experienced surgeons. Therefore, further prospective randomized population-based trials are necessary to better assess the decision-making for recurrent hernia management and the impact of specialization in abdominal wall surgery in terms of recurrence and complications.

Inguinal hernia: Lichtenstein VS Shouldice technique repair: A randomized controlled trial

Background

Inguinal hernia repair is the most frequent operation in general surgery. The chance of a person having to undergo an inguinal hernia operation during his/her life is quite high, 27 % in men and 3 % in women. European Hernia Society guidelines state that the Lichtenstein technique (mesh-based repair) is the standard treatment of elective inguinal hernia in adults. Some authors consider the Shouldice technique (tissue-based repair) the best conventional method for open hernia repair. In this study, we compared these two methods.

Methods

In This randomized study, 452 patients were randomly allocated into 2 groups. 51 patients were lost during follow-up period and were excluded from further analysis in the study. Finally, the analyzed patients were 183 patients in Shouldice technique group and 218 patients in Lichtenstein technique group. All patients were examined after 1 week, 1, 3 months, 1, 2, and 3 years after the operation date.

Results

After 3 years follow up Recurrence of hernia in Shouldice technique group was 7.1 % and in Lichtenstein technique group was 3 % with significant differences (p-value 0.006). No statistically significant differences were found between the groups in wound infection, Seroma, hematoma, Hydrocele, Bladder damage, chronic pain in the inguinal region, and Patient Satisfaction level after surgery.

Conclusion

It seems that inguinal hernia treatment by the Lichtenstein technique is better than the Shouldice technique in elective patients.

Single-incision laparoscopic surgery transabdominal preperitoneal approach for recurrent inguinal hernia: A case series of long-term follow-up

INTRODUCTION AND IMPORTANCE

Laparoscopic surgery is recommended to treat recurrent inguinal hernia (IH). Single-incision laparoscopic surgery transabdominal pre-peritoneal (SILS-TAPP) has been an option for IH repair but few studies on the application of this method for recurrent IH was conducted. We aimed to report our experience of SILS-TAPP for recurrent IH and the long-term outcomes of this technique.

CASE PRESENTATION

Ten patients of recurrent IH, including three multiple recurrences, were successfully treated with SILS-TAPP. Previous surgeries were Bassini and Lichtenstein's procedures. No perioperative complications were observed; neither additional trocar nor conversion to open surgery was needed. Median operation time was 65 (range: 45-95) minutes. Post-operative pain lasted for two to three days. Neither long-term complications nor recurrence was seen until the median follow-up time of 37 (range: 16-53) months.

CLINICAL DISCUSSION

Although the surgical procedure of hernia repair of SILS-TAPP was the same as conventional TAPP, the manipulation of the instrument was technically challenging. This surgical method should be done by an SILS expert with application of several surgical tips to overcome difficulties adhering to single-port surgery. Also, meticulous and patient dissection of the inguinal site is suggested.

CONCLUSION

SILS-TAPP is safe and feasible to repair recurrent inguinal hernia. However, it should be done by experienced surgeons.

Giant inguinal hernia repair using standard transverse inguinal incision with mesh. A retrospective case control study

BACKGROUND

Giant inguinal hernia (GIH) is a rare condition in the developed world, and the literature is scarce. Case reports describe different techniques in an attempt to prevent abdominal compartment syndrome (ACS). We aimed to review our experience with GIH repair.

METHOD

A retrospective review of the medical records of all consecutive patients who underwent a tension-free mesh GIH repair using a transverse inguinal incision between 2014 and 2021 at a tertiary university referral center. In brief, the technique included head-down positioning, maximal pre-incision reduction of hernia contents, and repair with mesh. Follow-up was conducted in outpatient clinic. We compared the results to a time-based open standard inguinal hernia repair group (control group).

RESULTS

During the study period, 58 patients underwent an open GIH repair with mesh without abdominal preparation. 232 patients were included in the control group. The mean surgery duration was 125.5 min in the GIH group and 84 min in the control group (p < 0.001). Bowel resection was not necessary in any case. In-hospital complication rates were 13.8% vs. 5.6% in the GIH and control groups, respectively (p = 0.045). Early complication rates (up to 30 days post-operatively) were 62.1% vs. 14.7% in the GIH and control groups, respectively (p < 0.001). Late complications rate was similar (p = 0.476). ACS and mortality were not reported. No recurrence event was reported in the GIH group.

CONCLUSION

Tension-free mesh repair for GIH using a standard transverse inguinal incision is feasible and safe and there is no need for abdominal cavity preparation. Early complications are more common than in the control group, but there were no higher rate of late or severe complications and no recurrence event.

Laparoscopic TAPP to treat inguinal hernia. Is the robot preferable? A review and cohort-study on anatomical landmarks of robotic-assisted transabdominal preperitoneal groin hernia repair (r-TAPP)

In this review, the advantages of the robotic platform in rTAPP are presented and discussed. Against the background of the unchanged results of conventional TAPP for decades (approx. 10% chronic pain and approx. 3.5% recurrence), a new anatomy-guided concept for endoscopic inguinal hernia repair with the robot is presented. The focus is on the identification of Hesselbach's ligament. The current results give hope that the results of TAPP can be improved by rTAPP and that rTAPP is not just a more expensive version of conventional TAPP. To support the rationale presented here, we analyzed 132 video recordings of rTAPP's for the anatomical structures depicted therein. The main finding is, that in all cases (132/132 or 100%) Hesselbach's ligament was present and following its lateral continuity with the ileopubic tract offered a safe framework to develop all the critical anatomical structures for clearing the myopectineal orifice, repair the posterior wall of the groin and perform a flawless mesh fixation. Future studies are needed to integrate all the resources of the robotic platform into an rTAPP concept that will lead out of the stalemate of the indisputably high rate of chronic pain and recurrences.

Return to Work in Patients With Unilateral Inguinal Hernia Surgery: A Comparative Study Between Laparoscopic Transabdominal Preperitoneal Approach and Lichtenstein Tension-Free Mesh Repair

Objective The objective of this prospective cohort study was to compare the time to return to work between patients who underwent laparoscopic transabdominal preperitoneal (TAPP) hernia repair and those who underwent Lichtenstein tension-free hernia repair with mesh for unilateral inguinal hernia. Methodology Patients were registered for unilateral inguinal hernia review at Aga Khan University Hospital, Karachi, Pakistan, from May 2016 to April 2017 and followed till April 2020. All patients aged 16-65 planned for unilateral transabdominal preperitoneal hernia repair or Lichtenstein tension-free hernia mesh repair were included. Patients with bilateral inguinal hernia repair, limited activity, or above retirement age were excluded. A non-probability consecutive sampling technique was implemented, and patients were divided into two cohort groups: Group A underwent laparoscopic transabdominal preperitoneal hernia repair, while Group B underwent Lichtenstein tension-free mesh repair. Patients were followed up at one week to inquire about the resumption of activities and then at one and three years for recurrence. Results Sixty-four patients met the inclusion criteria; three patients opted out of research, and 61 patients agreed to participate; one patient was excluded due to the conversion of the procedure. The remaining 30 in Group A and 30 in Group B were followed for the study period. The mean time to return to work in Group A was 5.33 ± 4.46 days; in Group B, it was 6.83 ± 4.58 days, with a p-value of 0.657. One recurrence was observed at three years in Group A. Conclusion Although the time to return to work at our hospital was slightly shorter in laparoscopic hernia repair than in the open technique, the results were not statistically significant. In addition, there was no significant difference in hernia recurrence at the one-year follow-up between laparoscopic transabdominal preperitoneal hernia repair and Lichtenstein tension-free hernia mesh repair for unilateral inguinal hernia.

Comparison of mesh fixation and non-fixation in transabdominal preperitoneal (TAPP) inguinal hernia repair: a randomized control trial

INTRODUCTION

Mesh fixation in inguinal hernia repair, has been a controversial subject for many years. Therefore, in this study, we evaluated and compared fixation and non-fixation of mesh in Transabdominal Preperitoneal (TAPP) Inguinal hernia repair.

METHODS

In this randomized control trial, 100 patients diagnosed with unilateral inguinal hernia were included. We divided the study population into two groups of fifty. For both groups, a 15 × 13 cm Prolene(polypropylene) mesh was used for repair. In the fixation group, mesh was fixed to the abdominal wall by endoscopic tacks, while in the non-fixation group, mesh was secured at the proper place without any fixation. Postoperative outcomes were complications, recurrence, and pain intensity after 1-, 3- and 6-months.

RESULTS

Postoperative pain intensity in the 1st month [Median of 2 and 0, (P < 0.001)], and 3rd month [Median of 0.5 and 0, (P < 0.001)], in the fixation group were significantly higher than the non-fixation group. However, 6 months after surgery, pain intensity was almost similar for both groups. In the 6th postoperative month, only one patient experienced recurrence who was in the fixation group. The rate of recurrence and urinary retention between the groups was not significant.

CONCLUSION

It was observed that until 6 months after surgery patients who received the non-fixating method of TAPP repair experienced lower levels of pain in comparison to the fixation group while other complications did not differ between the two groups. This trail was registered at www.irct.ir with Trial Registration Number of IRCT20210224050491N1.

Utilization of laparoscopic and open inguinal hernia repair at a large hernia center in China: a single-center observational study

BACKGROUND

The utilization of laparoscopic and open inguinal hernia repair in China remains unclear. We aim to investigate the rates of laparoscopic and open inguinal hernia repairs and its associated factors at a large hernia center.

METHODS

Data were obtained from the front sheet of medical records of Beijing Chaoyang hospital. Adult inguinal hernia inpatients who underwent hernia repairs between 2013 and 2020 were included. We calculated the overall rates of laparoscopic and open inguinal hernia repairs and compared the rate of laparoscopic repairs between different sex, age groups, types, and sides of inguinal hernias. Multivariable logistic regression was used to examine factors associated with the rate of laparoscopic repairs.

RESULTS

14,481 inpatients with inguinal hernia were included. 91.78% were male, 75.43% were more than 50 years, 75.20% were unilateral inguinal hernia, and 64.57% were indirect inguinal hernia. Overall, 49.47% underwent laparoscopic repairs and 50.53% underwent open repairs. Women had lower rate of laparoscopic repair than men, especially in those with unilateral hernias. Bilateral and direct inguinal hernia had higher rates of laparoscopic repair than unilateral and indirect inguinal hernia. Multivariable logistic regression showed that inpatients who were women, > 70 years, pantaloon inguinal hernia, with obstruction, and more comorbidities were less likely to have laparoscopic repairs.

CONCLUSION

Around 50% of inguinal hernia patients at a large hernia center underwent laparoscopic repairs, which was more commonly performed in male, young, bilateral inguinal hernia, and inpatients without comorbidities. More efforts were needed to increase the safe and effective laparoscopic utilization among female patients with inguinal hernias.

Comparison of perioperative and mid-term outcomes between laparoscopic and robotic inguinal hernia repair

BACKGROUND

Although the advantages of laparoscopic inguinal hernia repair (LIHR) have been described, guidelines regarding robotic inguinal hernia repair (RIHR) have yet to be established, despite its increased adoption as a minimally invasive alternative. This study compares the largest single-center cohorts of LIHR and RIHR and aims to shed light on the differences in outcomes between these two techniques.

METHODS

Patients who underwent LIHR or RIHR over an 8-year period were included as part of a retrospective analysis. Variables were stratified by preoperative, intraoperative, and postoperative timeframes. Complications were listed according to the Clavien-Dindo classification system and comprehensive complication index (CCI®). Study groups were compared using univariate analyses and Kaplan-Meier's time-to-event analysis.

RESULTS

A total of 1153 patients were included: 606 patients underwent LIHR, while 547 underwent RIHR. Although demographics and comorbidities were mostly similar between the groups, the RIHR group included a higher proportion of complex hernias. Operative times were in favor of LIHR (42 vs. 53 min, p < 0.001), while RIHR had a smaller number of peritoneal breaches (0.4 vs. 3.8%, p < 0.001) as well as conversions (0.2 vs. 2.8%, p < 0.001). The number of patients lost-to-follow-up and the average follow-up times were similar (p = 0.821 and p = 0.304, respectively). Postoperatively, CCI® scores did not differ between the two groups (median = 0, p = 0.380), but Grade IIIB complications (1.2 vs. 3.3%, p = 0.025) and recurrences (0.8% vs. 2.9%, p = 0.013) were in favor of RIHR. Furthermore, estimated recurrence-free time was higher in the RIHR group [p = 0.032; 99.7 months (95% CI 98.8-100.5) vs. 97.6 months (95% CI 95.9-99.3).

CONCLUSION

This study demonstrated that RIHR may confer advantages over LIHR in terms of addressing more complex repairs while simultaneously reducing conversion and recurrence rates, at the expense of prolonged operation times. Further large-scale prospective studies and trials are needed to validate these findings and better understand whether RIHR offers substantial clinical benefit compared with LIHR.

Nationwide analysis of laparoscopic groin hernia repair in Italy from 2015 to 2020

Since its introduction, the minimally invasive treatment of groin hernias has become widely accepted as a viable alternative to open surgery. Still, the rates and reasons for its adoption vary highly among countries and the regions within a country. After almost thirty years since its introduction, its spread is still limited. The present study, conducted under the auspices of AGENAS (Italian National Agency for Regional Services), aims at giving a snapshot of the spreading of minimally invasive and robotic techniques for the treatment of groin hernia in Italy. This study is retrospective, with data covering the period from 1st January 2015 to 31st December 2020. AGENAS provided data using the operation and diagnosis codes used at discharge and reported in the International Classification of Diseases 9th revision (ICD9 2002 version). Admissions performed on an outpatient basis, i.e., without an overnight stay of at least one night in hospital, were excluded. A total of 33,925 laparoscopic hernia repairs were performed during the considered period. Overall, a slight increase in the number of procedures performed was observed from 2015 to 2019, with a mean annual change of 8.60% (CI: 6.46-10.74; p < 0.0001). The number of laparoscopic procedures dropped in 2020, and when considering the whole period, the mean annual change was - 0.98% (CI: - 7.41-5.45; p < 0.0001). Urgent procedures ranged from 335 in 2015 to 508 in 2020 referring to absolute frequencies, and from 0.87% to 9.8% in relative frequencies of overall procedures in 2017 and 2020, respectively (mean = 4.51%; CI = 3.02%-6%; p < 0.001). The most relevant observation that could be made according to our analysis was that the adoption of the laparoscopic approach knew a slow but steady increase from 2015 onward.

Minimally Invasive Repair of Recurrent Inguinal Hernia: Multi-Institutional Retrospective Comparison of Robotic Versus Laparoscopic Surgery

Introduction: Inguinal hernia repair is one of the most commonly performed surgical procedures in general surgery. Despite surgical advances, recurrence and chronic pain are still major issues after this intervention. Aim of our study was to retrospectively assess and compare outcomes of robotic versus laparoscopic repair of recurrent inguinal hernia. Methods: All patients who underwent recurrent inguinal hernia repair between 2014 and 2021 in five different institutions were included in our study. Baseline data on age, gender, body mass index, comorbidities, smoking habit, and anticoagulant therapy were retrospectively collected from prospectively maintained databases. Operative time, length of stay, and early and late complications were compared between the robotic and the laparoscopic approach. Results: Forty-eight patients underwent recurrent inguinal hernia repair between January 2014 and December 2021. Twenty-three patients underwent a robotic procedure, whereas 25 were submitted to the laparoscopic intervention. Overall mean follow-up was 26.2 months. There was no significant difference in the baseline characteristics of the two groups. Acceptable and comparable rates of peri- and postoperative outcomes were recorded. However, postoperative visual analog scale score and incidence of chronic pain were lower after the robotic rather than after the laparoscopic approach. (2.9 versus 3.8 P = .002; 20% versus 0%; P = .02, respectively). Conclusions: Minimally invasive repair of recurrent inguinal hernia is safe and feasible; robotic surgery is associated with low rate of postoperative and chronic pain without a significant increase in operative time.

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.

Indications and Outcomes of a Hybrid Method Combining Laparoscopic and Anterior Approaches for Inguinal Hernia Repair

Introduction

Surgery for complex inguinal hernia (IH) (recurrent IH or IH after radical prostatectomy (RP)) may be difficult because of the presumed scar or adhesion in the retropubic space. A hybrid method combining the laparoscopic and anterior approaches (HLAA) in a bidirectional surgical technique may be an option in complex IH cases.

Methods

Patients at our institution who underwent IH repair for complex IH using HLAA from April 2018 to November 2019 were included. We retrospectively evaluated the patient characteristics, IH diagnosis, intraoperative variables, complications, and hernia recurrence during the follow-up period.

Results

Twenty patients were involved in this study. Seven patients underwent hLAA for recurrent IH, whereas the remaining 13 underwent hLAA for IH after RP. Five patients had bilateral IH, all of whom had IH after RP. The type of IH was lateral in 21 patients, medial in six patients, and lateral and medial in two patients. Hernia repair was performed using a patch alone in two patients and a plug and patch in 18 patients. Seroma or hematoma was observed in five patients, and one patient experienced chronic pain. No hernia recurrence was observed during the median follow-up period of 24 months.

Conclusion

hLAA could facilitate precise diagnosis and intraoperative confirmation of repair for recurrent IH and IH after RP. The intraoperative findings and the cause of recurrence can be easily shared among surgeons in hLAA. Further investigations are necessary to determine the long-term efficacy of hLAA in a larger cohort.

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.

Inguinal Hernia Mesh Repair: The Factors to Consider When Deciding Between Open Versus Laparoscopic Repair

Inguinal hernia repair is one of the most commonly performed surgical procedures worldwide. An inguinal hernia occurs due to a defect in the abdominal wall, which allows the abdominal contents to pass through it. Although the placement of mesh over the defect is the gold standard to close the defect, there are various approaches to achieving it, out of which two of the most widely accepted techniques are laparoscopic inguinal hernia repair (LIHR) and open inguinal hernia repair (OIHR). However, the approach of choice widely fluctuates with regards to various factors such as patient history, type of hernias, and surgeons' preference. It is imperative to understand the variations in outcomes of different approaches and how best they fit an individual patient in deciding the technique to be undertaken. This article has reviewed many studies and compared the two techniques in terms of chronic pain, the time required to return to activity, rate of recurrence, and cost-effectiveness.

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.

Inguinal hernia repair: a global perspective

BACKGROUND

Inguinal hernia repair is one of the most common operations performed worldwide with most of the burden of these occurring in low- or middle-income countries (LMICs). There has been much research investigating the most effective method of hernia repair in resource-rich countries, however very little has been done to determine the most cost-beneficial method of hernia repair in LMICs.

METHODS

A systematic review of the English literature through PubMed and Scopus was conducted according to the PRISMA statement.

RESULTS

Twenty-eight studies met the inclusion criteria of which 17 were randomised controlled trials and 11 were systematic reviews. Three areas of investigation were established from the literature search, namely operative method and type of mesh used (where applicable). Open-mesh procedures were shown to be less costly and have shorter operative times than laparoscopic methods. People who underwent laparoscopic hernia repair regularly returned to normal activities earlier than those who had open-mesh procedures. However, there was no other difference in complication rates between these two methods. Recent investigations have revealed that sterilised synthetic mosquito net was similar to hernia-specific meshes whilst significantly reducing cost.

CONCLUSION

We postulate that the most cost-beneficial method of hernia repair for implementation in LMICs is using open-mesh procedures with sterilised mosquito net under local anaesthetic. Further cost-benefit research is required in this area.

Healthcare Resource Utilization in Inguinal Hernia Repair: A Three-Year Cost Evaluation of Truven Health Marketscan Research Databases

BACKGROUND

Inguinal hernia repair is the most commonly performed elective operation in the United States, with over 800,000 cases annually. While clinical outcomes comparing laparoscopic versus open techniques have been well documented, there is little data comparing costs associated with these techniques. This study evaluates the cost of healthcare resources during the 90-d postoperative period following inguinal hernia repair.

METHODS

We analyzed data from the Truven Health MarketScan Research Databases. Adult patients with an ICD-9 or CPT code for inguinal hernia repair from 2012 to 2014 were included. Patients with continuous enrollment for 6 mo prior to surgery and 6 mo after surgery were analyzed. Related healthcare service costs (readmission and/or ER visit and/or outpatient visit) were calculated by clinical classification software and generalized linear modeling was used to compare healthcare utilization between groups.

RESULTS

124,582 cases were identified (open = 84,535; lap = 40,047). Index surgery cost was 41% higher in laparoscopic cases. The cost for readmission was close to $25,000 and similar between both groups, but the laparoscopic group were 12% less likely to be readmitted for surgical complications within 90-d when compared to the open group. Cost of bilateral laparoscopic repair is less than that of serial unilateral open repairs.

CONCLUSION

Laparoscopic inguinal hernia repair carries a higher index surgery cost than open repair. However, open repair has an increased rate of readmission. To maximize value, efforts should be directed at minimizing readmissions and improving identification of bilateral hernias at the time of initial presentation.

Tension-free mesh repair of inguinal hernia in patients on continuous ambulatory peritoneal dialysis

BACKGROUND

Peritoneal dialysis (PD) is the first-line renal replacement therapy for end-stage renal failure patients in Hong Kong. Abdominal wall hernia is a common mechanical complication of PD, and early surgical repair has been advocated to reduce complications. This study aims to review the outcomes of tension-free mesh repair of inguinal hernia in PD patients.

METHODS

All PD patients who underwent elective repair of inguinal hernia from 2009 to 2015 were identified from a single centre for retrospective analysis. Primary outcomes included surgical complications, perioperative dialysis technique and recurrence.

RESULTS

Twenty-one patients with a total of 26 inguinal hernia repairs were included in this 7-year retrospective study. All were males, and the mean age was 68 ± 10 years. Diabetic nephropathy (n = 9, 42.9%) and glomerulonephritis (n = 7, 33.3%) were the two most common causes of renal failure. All hernias were detected after the initiation of PD, and the mean duration of PD to hernia detection was 16 months (range 1-65 months). Lichtenstein open mesh repair was performed in all patients. Complications included seroma (n = 3, 11.5%) and ischaemic orchitis (n = 1, 3.8%). There were no mesh infection or recurrence. Twenty patients (95.2%) received intermittent peritoneal dialysis post-operatively and returned to continuous ambulatory PD in 15 to 30 days. Only one patient (4.8%) required bridging haemodialysis due to Tenckhoff catheter blockage.

CONCLUSIONS

Tension-free mesh repair is associated with low morbidity and low recurrence rates in PD patients. Timely management and close collaboration with renal physicians are essential to continue PD after repair.

Ten-year trends in minimally invasive hernia repair: a NSQIP database review

BACKGROUND

Utilization of minimally invasive techniques for ventral and inguinal hernia repairs continues to rise. The purpose of this study was to provide updates on national utilization trends and wound complications of minimally invasive versus open ventral and inguinal hernia repairs.

METHODS

Data were accessed from the 2006 to 2017 National Surgical Quality Improvement Program database. All CPT codes that correlated to laparoscopic and open inguinal and ventral hernia repairs were queried. The total number of cases and wound complications, including superficial surgical site infection (SSI), deep SSI, organ space SSI, and wound dehiscence, was collected for each respective CPT code and compared for each year. IBM SPSS Statistics Software and Microsoft Excel were used to collect and analyze the data.

RESULTS

Between 2009 and 2017, the percentage of minimally invasive inguinal hernia repairs increased from 23.1 to 37.8%, whereas the percentage of minimally invasive ventral hernias only increased from 31.5 to 36.6%. Open inguinal hernia repairs had a wound complication rate ranging from 0.60 to 0.74%, which was double the rate of minimally invasive repairs (0.24 to 0.49%) for nearly each respective year. Minimally invasive ventral hernia repairs had total wound complication rates ranging from 0.91 to 1.37%, whereas open ventral hernias had the highest total wound complication rates ranging from 5.07 to 6.26%.

CONCLUSIONS

Over the last ten years, the utilization of minimally invasive inguinal and ventral hernia repair has increased by nearly two-fold. A larger proportion of this increase has been secondary to minimally invasive inguinal compared to ventral hernia repairs. Wound complications across all techniques remained stable or improved, and remained significantly less in the minimally invasive compared to open approaches. This study highlights the continued growth of minimally invasive techniques in hernia repair over the last decade.

Laparoscopic treatment (reTAPP) for recurrence after laparoscopic inguinal hernia repair

PURPOSE

For inguinal hernia recurrences, the European Hernia Society guidelines recommend laparo-endoscopic repair (LR) following a previous open surgery (OS) and, conversely, OS following previous laparo-endoscopic repair. Laparoscopic treatment of recurrences after previous LR is controversial. The purpose of this study was to determine the safety, feasibility, and reliability of a repeated transabdominal preperitoneal laparoscopic repair (reTAPP) for a recurrent hernia.

METHODS

We analyzed and compared a series of patients with recurrent inguinal hernia after LR who underwent repair by a conventional approach with similar patients who underwent reTAPP between January 2010 and December 2018.

RESULTS

Between January 2010 and December 2018, 2488 transabdominal preperitoneal laparoscopic inguinal hernia (TAPP) repairs were performed. Recurrence was observed in 46 (1.8%). Of these patients, 18 (39%; Group 1; G1) underwent conventional open repair (Lichtenstein technique) and 28 (61%; Group 2; G2) reTAPP. In G2, repair was successful in 24 patients (86%); however, four cases (14%) needed conversion to OS because of technical difficulties. Two patients re-recurred (4.3%), one in G1 which was resolved in a third approach with a reTAPP and the other in G2 which was resolved with OS.

CONCLUSION

ReTAPP surgery for recurrences after previous TAPP repair proved to be safe and was associated with a shorter length of hospital stay and morbidity and recurrence rates comparable to OS at a highly specialized center. Randomized studies with a larger number of cases are necessary to confirm these findings and draw more robust and objective conclusions.

Laparoscopic repair of recurrent inguinal hernia offers similar outcomes and quality of life to primary laparoscopic repair

OBJECTIVE

Open repair of recurrent inguinal hernias has been shown to result in significantly poorer perioperative outcomes when compared to open primary hernia repair. However, limited data exist comparing primary and recurrent laparoscopic inguinal hernia repair (LIHR). The aim of our study was to compare quality of life and clinical outcomes between these two groups.

METHODS

Patients undergoing LIHR at a single institution from 2012 to 2018 were reviewed from a prospectively managed quality database. Quality of life outcomes were measured using the surgical outcomes measurement system and Carolinas Comfort Scale surveys administered preoperatively and at 3 weeks, 6 months, 1 year, and 2 years postoperatively.

RESULTS

A total of 1298 patients undergoing LIHR were analyzed (1139 primary, 159 recurrent). There were older and more male patients in the recurrent group. There were no major complications, and recurrence rates were not significantly different between primary and recurrent groups (1.3% vs 2.4% p = 0.56), while hematoma occurred more commonly in the recurrent group (1.5% vs 4.4% p = 0.0205). Short- and long-term quality of life were similar between the groups except lower (worse) physical function at 3 weeks (32.9 ± 4.2 vs 31.9 ± 4.4: p = 0.0186) and 6 months (34.6 ± 2.8 vs 33.8 ± 3.0: p = 0.0175) and increased sensation of mesh (3 weeks) in the recurrent group (2.3 ± 5.4 vs 3.3 ± 5.3: p = 0.0160).

CONCLUSION

Recurrent inguinal hernia repair using laparoscopic totally extraperitoneal approach is as safe and effective as primary repair with similar quality of life.

Quadratus Lumborum Block As A Single Anesthetic Method For Laparoscopic Totally Extraperitoneal (Tep) Inguinal Hernia Repair: A Randomized Clinical Trial

Minimally invasive surgery for inguinal hernia repair is advantageous in terms of return to usual activities and lower rates of chronic pain; however, it requires general anesthesia. This study sought to analyze the benefits of ultrasound guided locoregional anesthesia of the quadratus lumborum muscle (QL block) as a single anesthetic technique for endoscopic totally extraperitoneal (TEP) inguinal hernia repair with regard to postoperative pain, length of hospital stay, and hospital cost. A total of 46 patients, aged 18 to 80 years, with unilateral inguinal hernia, one group that received general anesthesia and one that received sedation and QL block for TEP inguinal hernia repair. In the 46 patients the median pain score 6 hours after surgery was significantly lower (2 versus 4) among the QL block group than among the group receiving general anesthesia. Consequently, the former group showed a briefer median hospital stay (6 versus 24 hours, respectively). The anesthesia and hospital costs were also lower for the QL block group, with median reductions of 64.15% and 25%, respectively. QL block is a safe and effective option for patients undergoing TEP inguinal hernia repair, given the observed reduction in early postoperative pain, briefer hospital stay, and decreased anesthesia and hospital costs.

Re-recurrence and pain 12 years after laparoscopic transabdominal preperitoneal (TAPP) or Lichtenstein's repair for a recurrent inguinal hernia: a multi-centre single-blinded randomised clinical trial

BACKGROUND

Long-term clinical outcome after a recurrent inguinal hernia repair may be associated with the type of repair, that is, laparoscopic or open. The results from previous randomised controlled trials are inconclusive regarding the long-term risk of re-recurrence chronic pain. Accordingly, this trial compared laparoscopic transabdominal preperitoneal repair (TAPP) with Lichtenstein's repair. The primary outcome was repair for a re-recurrence. The secondary outcome was chronic pain.

METHODS

Multi-centre single-blinded, randomised trial on TAPP vs Lichtenstein's repair in male patients operated for a recurrent inguinal hernia after a primary open inguinal hernia repair. Follow-up for repair for a re-recurrence was registered in the Danish Hernia Database. Prospective follow-up data were achieved by a structured questionnaire on pain-related functional impairment using the Activities Assessment Scale (AAS-pain).

RESULT

A total of 360 patients were randomised, 297 were mailed the follow-up questionnaire (63 excluded) after median 12 years (range 9-15). A total of 265 patients responded to the questionnaire (response rate 89%). The cumulative rate of repair for re-recurrence after 12 years was 10% (95% confidence interval (CI) 5.3-15.1%) vs 10% (5.6-14.7%) after TAPP or Lichtenstein, respectively (p = 0.764). Moderate/severe AAS-pain was reported by 4% (95% CI 1-8%) vs 7% (95% CI 3-11%) patients after TAPP or Lichtenstein, respectively (p = 0.698) CONCLUSION: Long-term re-recurrence rate and incidence of chronic pain was surprisingly high respectless of surgical approach and neither TAPP nor Lichtenstein's procedure was superior to improve surgical results.

Comparison of endoscopic surgery and Lichtenstein repair for treatment of inguinal hernias: A network meta-analysis

BACKGROUND

This study aimed to identify the best procedure for addressing inguinal hernias by comparing results after transabdominal preperitoneal (TAPP), totally extraperitoneal (TEP), and Lichtenstein repairs using a network meta-analysis.

METHODS

We conducted a systematic search of MEDLINE, Web of Science, the Cochrane Central Library, and ClinicalTrials.gov up to September 1, 2018 for randomized controlled trials (RCTs) comparing the TAPP, TEP, and Lichtenstein procedures. The study outcome were the hernia recurrence, chronic pain, hematoma, seroma, wound infection, operation time, hospital stay, and return-to-work days.

RESULTS

Altogether, 31 RCTs were included in the meta-analysis. The results of this network meta-analysis showed there were no significantly differences among the 3 procedures in terms of hernia recurrence, chronic pain, hematoma, seroma, hospital stays. Lichtenstein had a shorter operation time than TAPP+TEP [MD (95%Crl)]: 12 (0.51-25.0) vs 18 (6.11-29.0) minutes, respectively) but was associated with more wound infections than TEP: OR 0.33 (95%Crl 0.090-0.81). Our network meta-analysis suggests that TAPP and TEP require fewer return-to-work days [MD (95%CI)]: - 3.7 (-6.3 to 1.3) vs -4.8 (-7.11 to 2.8) days.

CONCLUSION

Our network meta-analysis showed that there were no differences among the TAPP, TEP, and Lichtenstein procedures in terms of safety or effectiveness for treating inguinal hernias. However, TAPP and TEP could decrease the number of return-to-work days. A further study with more focus on this topic for inguinal hernia is suggested.

Laparoscopic totally extra-peritoneal groin hernia repair with self-gripping polyester mesh: a series of 780 repairs

BACKGROUND

Laparoscopic groin hernia repair is an increasingly common procedure with benefits of reduced post-operative pain and infection. Post-operative chronic pain remains an ongoing concern in about 10% of patients. Parietex ProGrip™, a polyester self-gripping mesh, has a theoretical benefit of avoiding tacks for mesh-fixation. This case series reflects our long-term experience of this technique.

METHODS

We conducted a retrospective case series from November 2011 to December 2017. Patients were identified through an operative Medicare Benefits Schedule item number search. Clinical documentation was reviewed with length of stay, mesh infection, chronic pain, recurrence and re-operation as primary data points.

RESULTS

A total of 514 patients underwent 780 laparoscopic inguinal hernia repairs with self-gripping polyester mesh during this period. There were 53 female (10.3%) and 461 male patients (89.7%). Unilateral hernia repair was performed in 248 patients (48.2%) and bilateral repair in 266 patients (51.8%). Almost all repairs (779, 99.8%) were primary hernias. There were no mesh infections. Four recurrences were noted (0.51%) and three of these subsequently underwent open redo-hernia repairs (0.38%). Post-operative follow-up was up to 4.4 years.

CONCLUSIONS

Our series of laparoscopic groin hernia repair with self-gripping mesh demonstrate this is a safe and reliable mesh and effective technique with low recurrence rates.

Comparison between single-incision and multiple-incision laparoscopic surgery for totally extraperitoneal inguinal hernia repair

Introduction: We compared the clinical outcomes of single-incision laparoscopic surgery (SILS) and multiple-incision laparoscopic surgery for totally extraperitoneal (TEP) inguinal hernia repair.Material and methods: This retrospective study included 134 consecutive patients undergoing single-incision or multiple-incision laparoscopic surgery for inguinal hernia between January 2012 and December 2016 at our hospital.Results: In total, 62 patients undergoing SILS-TEP and 72 receiving multiple-incision laparoscopic surgery were included in this study. No significant differences in patients' characteristics between the two groups were noted. No patient required conversion to open surgery in either group. No significant differences were noted between the two groups in operative time, bleeding volume, post-operative hospital stay, and analgesics used. Postoperative complications were observed in 5.7% (4 of 62) of patients in the SILS group and 3.2% (2 of 72) of patients in the control group. Among the few patients who experienced complications, most had hematomas. No major complications or hernia recurrences were observed during the follow-up period in either group.Conclusions: SILS-TEP produced good cosmetic outcomes for patients regardless of previous surgery, and it could be safely performed with acceptable morbidity. It also does not increase the possibility of conversion to open surgery.

[Endoscopic surgery and laparoscopy are new insights of evolution of inguinal hernia repair (in Russian only)]

This article is devoted to general and particular problems of inguinal hernia repair through the analysis of statistical data and comparison of advantages and disadvantages of various methods of inguinal hernia repair. Particular attention is paid to the analysis of current options of mesh implant fixing during endoscopic hernia repair: TAPP, TER, e-TER. Long-term outcomes are essential to determine surgical technique. The authors consider that careful adherence to the basic principles of minimally invasive surgery can reduce the incidence of complications, recurrences and chronic pain syndrome after inguinal hernia repair. The main advantages of current surgical technologies are accelerated rehabilitation, earlier restoration of social activity, improvement of the quality of life.

Successful mesh plug repair using a hybrid method for recurrent inguinal hernia after laparoscopic transabdominal preperitoneal approach: A case report

INTRODUCTION

The HerniaSurge Group and the European Hernia Society guidelines recommend an anterior approach to treat recurrent inguinal hernias after a failed posterior approach. The hybrid method combining explorative laparoscopy and anterior open approach can provide the benefits of both approaches.

PRESENTATION OF CASE

A 79-year-old man presented with a recurrent inguinal hernia after primary repair for an indirect hernia using the laparoscopic transabdominal preperitoneal approach (TAPP) 5 years ago. The indirect hernia formed inferior to the lower edge of the previous mesh was diagnosed under laparoscopy. The hernia defect (2 cm) was fixed using a mesh plug via the anterior approach. Appropriate mesh overlap was confirmed using laparoscopy.

DISCUSSION

This minimally invasive method enabled us to choose the best treatment for recurrent hernia and prevent chronic pain due to possible nerve damage caused by extended dissection of the scar tissue. Furthermore, the final confirmation step using laparoscopy assures complete coverage of all defects within the myopectineal orifice.

CONCLUSION

This hybrid method facilitates the choice of an optimal approach for the treatment of recurrent hernia and may reduce surgical complications and re-recurrence rate.

Prevention and Treatment of Chronic Postsurgical Pain: A Narrative Review

Chronic postsurgical pain affects between 5 and 75% of patients, often with an adverse impact on quality of life. While the transition of acute to chronic pain is a complex process-involving multiple mechanisms at different levels-the current strategies for prevention have primarily been restricted to perioperative pharmacological interventions. In the present paper, we first present an up-to-date narrative literature review of these interventions. In the second section, we develop several ways by which we could overcome the limitations of the current approaches and enhance the outcome of our surgical patients, including the better identification of individual risk factors, tailoring treatment to individual patients, and improved acute and subacute pain evaluation and management. The third and final section covers the treatment of established CPSP. Given that evidence for the current therapeutic options is limited, we need high-quality trials studying multimodal interventions matched to pain characteristics.

Meta-analysis of patient-reported outcomes after laparoscopic versus open inguinal hernia repair

BACKGROUND

Inguinal hernia repair is a common low-risk intervention. Patient-reported outcomes (PROs) are being used increasingly as primary outcomes in clinical trials. The aim of this study was to review and meta-analyse the PROs in RCTs comparing laparoscopic versus open inguinal hernia repair techniques in adult patients.

METHODS

A systematic review and meta-analysis was carried out in accordance with PRISMA guidelines. Only RCTs in peer-reviewed journals were considered. PubMed, Ovid Embase, Scopus and the Cochrane Library were searched. In addition, four trial registries were searched. The search interval was between 1 January 1998 and 1 May 2018. Identified publications were reviewed independently by two authors. The review was registered in the PROSPERO database (CRD42018099552). Bias was assessed using the Cochrane Collaboration risk-of-bias tool.

RESULTS

Some 7192 records were identified, from which 58 unique RCTs were selected. Laparoscopic hernia repair was associated with significantly less postoperative pain in three intervals: from 2 weeks to within 6 months after surgery (risk ratio (RR) 0·74, 95 per cent c.i. 0·62 to 0·88), 6 months to 1 year (RR 0·74, 0·59 to 0·93) and 1 year onwards (RR 0·62, 0·47 to 0·82). Paraesthesia (RR 0·27, 0·18 to 0·40) and patient-reported satisfaction (RR 0·91, 0·85 to 0·98) were also significantly better in the laparoscopic repair group.

CONCLUSION

The data and analysis reported in this study reflect the most up-to-date evidence available for the surgeon to counsel patients. It was constrained by heterogeneity of reporting for several outcomes.

Laparoscopic versus Lichtenstein hernioplasty for inguinal hernias: a systematic review and Meta-analysis of randomized controlled trials

Background: This meta-analysis aimed to explore the safety and efficacy of Lichtenstein versus laparoscopic hernioplasty for inguinal hernias based on eligible randomized controlled trials (RCTs).Material and methods: We searched several electronic databases to identify eligible studies based on the index words updated to March 2018.We also searched related publication sources and only included eligible RCTs in the current analysis. Relative risk (RR) or mean difference (MD) along with 95% confidence interval (95% CI) were used for the main outcome of our analysis.Results: In total, 21 studies were included with 3772 patients in the laparoscopic group and 3910 patients in the Lichtenstein group. The results indicated that compared with the Lichtenstein group, the laparoscopic surgery group had significantly increased operative time. Besides, there was no significant difference in the rate of hematoma or seroma and complications between the two groups. However, compared with the Lichtenstein group, the laparoscopic group had a higher hernia recurrence rate, a lower incidence of chronic pain and a lower rate of wound infection, but no significant difference was found.Conclusion: The results demonstrated that laparoscopic repair reduced chronic pain and wound infection compared with Lichtenstein repair. But Lichtenstein could reduce the operative time and hernia recurrence.

Laparoscopic Versus Conventional Open Surgery for the Treatment of Bilateral Inguinal Hernias

Objective: To evaluate and compare laparoscopic and conventional open procedures for bilateral inguinal hernia surgical repair, using clinical, intraoperative, and postoperative criteria.

Methods: Forty-three patients with bilateral inguinal hernia were included in a retrospective study, between 2014–2017. All patients underwent conventional open or laparoscopic bilateral hernioplasty, and were divided into two groups: a conventional open group (COG) and a laparoscopy group (LG). Clinical, intraoperative, and postoperative outcomes were reviewed.

Results: In the laparoscopic hernioplasty group, there was a significantly shorter hospitalization period (p = 0.026), less postoperative pain (p = 0.03), and a prompt return to work (p = 0.043) compared to the conventional open procedure. On the other hand, patients who underwent hernioplasty with the Progrip-type synthetic mesh developed a lower pain score, an earlier return to work, and a quick start to normal physical activities in comparison with other mesh types used for the treatment of bilateral inguinal hernias. For patients who underwent conventional open procedure, there was a significantly shorter operating time (p = 0.042).

Conclusion: Laparoscopic bilateral inguinal hernioplasty is a time-consuming and technically demanding procedure. However, the current study underlines the benefits of this type of surgery. This technique presents comparable clinical, intraoperative, and postoperative results with the conventional open surgery.

Laparoscopic total extraperitoneal inguinal hernia repair: Retrospective study on prosthetic materials, postoperative management, and quality of life

Laparoscopic inguinal hernia repair is one of the most frequently performed operations. However, the search for the most appropriate prosthetic materials continues to occupy the surgical community. The purpose of this study was to evaluate the postoperative short- and mid-term effects (like duration of stay, number and type of complications, and inguinal pain) of laparoscopic inguinal hernia repair using the total extraperitoneal (TEP) approach. The evaluation encompassed different types of mesh and fixation devices, as well as medications prescribed during hospitalization.This retrospective study was conducted at the General, Laparoendoscopic, Bariatric, and Robotic Surgical Clinic of the Athens Medical Center. Clinical data from 524 patients were evaluated. The answers from an appropriately designed questionnaire completed from each individual were used to obtain information about their postoperative course. The statistical analysis was implemented in SPSS v 23.Analysis revealed that pain sensation on discharge decreased with increasing age (P < .05). No clear relationship was found between surgical clips and pain (P = .292), as well as mesh absorbability and chronic pain (P = .539). The major postoperative complications were annoyance and discomfort (15.9%). The recurrence rate was 1.7%.Postoperative complications following the TEP approach were mostly found to be minor; chronic pain, as an aspect of impaired quality of life, was not experienced in the majority (89.08%). The properties of prosthetic materials used and the type of medications prescribed were not found to exert a significant role in satisfactory postoperative outcomes.

Long-term follow-up of endoscopic totally extraperitoneal direct inguinal hernia repair using the Endoloop technique

INTRODUCTION

The pre-tied suture Endoloop™ technique for plication of the weakened transversalis fascia is efficient in post-operative seroma prevention, after laparoscopic/endoscopic direct inguinal hernia repair. No studies have evaluated long-term tolerability of this new technique in regards to chronic pain and hernia recurrence.

METHODS

Prospective longitudinal evaluation study of consecutive patients treated with Endoloop™ for M2 or M3 direct defects, during endoscopic totally extraperitoneal approach. Meshes were secured with fibrin sealant only. All patients had a minimum 2.8 years (median 5.9 years) follow-up. First outcome was chronic groin/testicular pain; secondary outcome parameters included hernia recurrence and Quality of Life (QoL). Patients were assessed by phone interview using the validated Carolinas Comfort Scale (CCS), questioned regarding recurrence and asked to present for clinical review as needed.

RESULTS

112 patients (median age 57 years) with 141 direct hernia defects were included during the study period of 2008-2014. An Endoloop™ was used on 127 occasions-79 M2 and 48 M3 direct hernias. One patient had an early recurrence requiring an open repair and was therefore excluded. Thirty-three of the remaining one hundred and eleven patients (29.7%) were lost to long-term follow-up. According to their CCS range, 70 patients (88.6%) were very satisfied with their results, 8 (10.1%) were satisfied, and only one patient (1.3%) who reported chronic groin pain was unsatisfied. There was no reported long-term hernia recurrence.

CONCLUSION

The PDS Endoloop™ technique for closure of direct inguinal hernia defects is well tolerated with low risk of hernia recurrence, chronic pain, and excellent QoL. This reliability persists to long-term follow-up.

Recurrent groin hernia surgery after primary open inguinal procedures: a reappraisal of the open preperitoneal (Ugahary) technique

PURPOSE

There are several methods for repairing recurrent inguinal hernia, depending on the type of initial repair. Our aim was to analyze our long follow-up results on the open preperitoneal repair for patients with recurrent inguinal hernia.

METHODS

Our retrospective survey included 135 consecutive recurrent inguinal hernia patients, operated on during 1999-2010, with a mean follow-up time of 8.7 years.

RESULTS

During the mean follow-up time of 8.7 years, only four (3%) patients developed a re-recurrence. Two of these patients were asymptomatic, and the two other were operated on. Early postoperative complications occurred in four (3%) patients. The complications comprised one hematoma, one seroma, and two infections. Chronic pain was diagnosed in five (3.7%) patients, but their symptoms disappeared spontaneously within a few years.

CONCLUSIONS

We conclude that in competent hands, the open preperitoneal repair (Ugahary) is a good surgical option in operating recurrent inguinal hernias.

A Comparison of Outcomes between Lichtenstein and Laparoscopic Transabdominal Preperitoneal Hernioplasty for Recurrent Inguinal Hernia

There remain concerns about the optimal technique for repairing recurrent inguinal hernias because of the high risks of complications and recurrence. The aim of this study was to compare Lichtenstein hernioplasty with the transabdominal preperitoneal (TAPP) laparoscopic technique in the treatment of recurrent inguinal hernias. One hundred twenty-two patients who underwent surgery for recurrent inguinal hernia were prospectively randomized to receive either Lichtenstein (n = 63) or TAPP (n = 59) hernioplasty between January 2010 and December 2014. Baseline characteristics, intraoperative complications, and short- and long-term postoperative factors were evaluated. Preoperative factors were comparable between the two groups. The average follow-up period was 46.2 ± 8.5 months. The two groups had similar intraoperative and short-term postoperative complication rates, whereas the rate of long-term postoperative complications was lower for the TAPP group than the Lichtenstein group (6.8% vs 23.8%, respectively, P = 0.012). The TAPP group had significantly lower visual analogue scale scores, fewer analgesics consumption, and faster recovery than the Lichtenstein group ( P < 0.05). Chronic pain was more prevalent in the Lichtenstein group than the TAPP group (15.9% vs 3.4%, respectively, P = 0.031). The recurrence rate was 4.8 per cent for the Lichtenstein group and 1.7 per cent for the TAPP group, with no significant difference ( P = 0.62). Both the Lichtenstein and TAPP procedures are safe and effective methods for repairing recurrent inguinal hernia with low incidence rates of life-threatening complications and recurrence. The TAPP procedure is superior to the Lichtenstein repair in terms of reduced postoperative pain, shorter sick leave, faster recovery, and better cosmetic results. Careful selection of the surgical procedures and implementation of technical essentials are necessary.

Case series of recurrent inguinal hernia after primary TREPP repair: re-TREPP seems feasible and safe

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Recurrent inguinal hernias are preferably treated via an alternative route, e.g. posterior after anterior.

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Endoscopic preperitoneal repair techniques are common for groin hernias after Lichtenstein’s plasty.

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The TREPP technique is a minimal access, open variant of these preperitoneal techniques.

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The TREPP technique seems to be a safe and feasible technique to use for recurrence after previous TREPP for inguinal hernia repair.

Introduction

The Trans REctussheath PrePeritoneal (TREPP) mesh repair was introduced in 2006 to decrease the risk of postoperative inguinal pain in hernia surgery. For the repair of a recurrent inguinal hernia after a primary TREPP an alternative open anterior route (Lichtenstein) may seem the most logical option, but coincides with an increased risk of chronic postoperative inguinal pain. Therefore, this study aimed to evaluate the feasibility of a second TREPP procedure to repair a recurrent inguinal hernia after an initial TREPP repair.

Methods

Consecutive patients with a recurrent inguinal hernia after a primary TREPP, repaired by a re-TREPP were retrospectively included in the study. Data, retrieved from the electronic patient files, were combined with the clinical findings at the outpatient department where the patients were physically investigated according to a priorly written and registered protocol.

Results

Overall about 1800 TREPPs were performed between 2006 and 2013. Since the introduction of TREPP in 2006, 40 patients presented with a recurrence in our center. From this group 19 patients were re-operated with the TREPP technique. No intraoperative complications occurred. There was one conversion from re-TREPP to Lichtenstein and no re-recurrences occurred to date. Ten out of 19 patients could be clinically evaluated with a mean follow-up period of 37 months (range 11–95). None of these patients (n=10) complained of chronic postoperative inguinal pain. Two patients reported discomfort. One patient died non procedure related, three weeks after re-TREPP of sudden cardiac death.

Conclusion

These first experiences with re-TREPP for secondary inguinal hernia repair are encouraging for the aspects of feasibility and safety, particularly in experienced surgical hands.

Current Concepts of Inguinal Hernia Repair

With more than 20 million patients annually, inguinal hernia repair is one of the most often performed surgical procedures worldwide. The lifetime risk to develop an inguinal hernia is 27-43% for men and 3-6% for women. In spite of all advances, 11% of all patients suffer from a recurrence and 10-12% from chronic pain following primary inguinal hernia repair. By developing evidence-based guidelines and recommendations, the international hernia societies aim to improve the outcome of inguinal hernia repair due to standardization of care. From a total of more than 100 different repair techniques for inguinal and femoral hernias, classified as tissue repair, open mesh repair, and laparo-endoscopic mesh repair, the new International Guidelines of the Hernia-Surge Group only recommend the totally extraperitoneal patch plasty (TEP), transabdominal preperitoneal patch plasty (TAPP), and Lichtenstein techniques. Since a generally accepted technique suitable for all inguinal hernias does not exist, surgeons should provide both an anterior open (Lichtenstein) and a posterior laparo-endoscopic (TEP or TAPP) approach option. The guidelines strongly recommend that surgeons tailor the treatment of inguinal hernias based on expertise, local/national resources, and patient- and hernia-related factors. A tailored approach in inguinal hernia repair should pay heed to the patient- and hernia-related factors, unilateral hernia in men and women, bilateral hernia, recurrent hernia, scrotal hernia, previous pelvic and lower abdominal surgery, severe cardiac or pulmonary comorbidities, and incarcerated hernia.