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

Novel local anaesthesia technique 'NATURE' (Nerves And Transversalis-fascia Using RopivacainE) to improve outcomes during endo-laparoscopic inguinal hernia repair

BACKGROUND

The use of local anaesthesia infiltration techniques may attenuate pain following endo-laparoscopic inguinal hernia surgery. We aim to reduce post-operative pain and the subsequent need for analgesia using a novel technique of local anaesthesia infiltration 'NATURE' (Nerves And Transversalis-fascia Using RopivacainE).

METHODS

This is a retrospective study of patients who underwent endo-laparoscopic inguinal hernia repair in two institutions in Singapore. Patients who received the local anaesthesia according to the new technique (intervention group) were compared to patients who received local anaesthesia only over their surgical incisions (control group).

RESULTS

Data on 97 patients were analysed. There were 50 (51.5%) patients in the intervention group and 47 (48.5%) patients in the control group. No significant differences were observed in the two patient population's baseline characteristics, operative time and cumulative need for medications. The intervention group reported lower pain levels immediately after surgery (1.4 ± 1.7 versus 2.4 ± 1.9, p<0.01) and at 4 hours post-surgery (0.9 ± 1.1 versus 1.4 ± 1.2, p = 0.02). They also had lower levels of post-operative complications (4% versus 21.3%, p = 0.03).

CONCLUSION

Infiltration of local anaesthesia at specific anatomical locations during endo-laparoscopic inguinal hernia surgery can be effective in minimising post-operative pain. Prospective randomised controlled trials are needed to further substantiate this technique.

Elective "True Day Case" Laparoscopic Inguinal Hernia Repair in a District General Hospital: Lessons Learned from 1000 Consecutive Cases

Introduction

Laparoscopic inguinal hernia repair (LIHR) is ideal for day case surgery. It is recommended that at least 70% should be day cases as a measure of cost-effectiveness. The aims of this study were to (i) assess the rate of true day case (TDC) surgery and (ii) identify predictors associated with unexpected overnight stay (UOS).

Methods

Data was collected prospectively on 1000 consecutive elective LIHR performed in a District General Hospital (DGH) over a 7-year period. Data was collected on baseline patient demographics, ASA grade, and intraoperative details. A multivariate analysis was performed in order to identify predictors of UOS.

Results

1000 patients (927 males) underwent elective LIHR. Mean age was 57.3±15.2 years. 915 patients were planned as day case procedures. 822/915 day cases (89.8%) were discharged on the same day and 93 (10.2%) stayed overnight unexpectedly. Patient age, duration of procedure, and patient slot in the operating list were found to be independent predictors (p<0.05) of UOS.

Conclusion

Our results demonstrate that LIHR is a "true" day case procedure in a DGH. Although some factors associated with UOS cannot be altered, careful patient selection and operating list planning are of paramount importance in order to minimise the burden on healthcare resources.

Guidelines on pediatric day surgery of the Italian Societies of Pediatric Surgery (SICP) and Pediatric Anesthesiology (SARNePI)

The Italian Society of Pediatric Surgery (SICP) together with The Italian Society of Pediatric Anesthesia (SARNePI) through a systematic analysis of the scientific literature, followed by a consensus conference held in Perugia on 2015, have produced some evidence based guidelines on the feasibility of day surgery in relation to different pediatric surgical procedures. The main aspects of the pre-operative assessment, appropriacy of operations and discharge are reported.

Laparoscopic totally extraperitoneal inguinal hernia repair: twenty-seven serious complications after 4565 consecutive operations

OBJECTIVE

To identify and assess the complications of laparoscopic inguinal hernia treatment with totally extraperitoneal mesh placement (TEP).

METHODS

We included patients who had undergone the TEP procedure in a consecutive series of 4565 laparoscopic hernia repairs between January 2001 and January 2011. Inclusion criteria were diagnosis with symptomatic inguinal hernia, including recurrence after inguinal hernia repair and previous surgery in the lower abdomen and pelvis. All patients were 18 years of age or above. Patients with incarcerated hernia in emergency were excluded from the study.

RESULTS

A total of 4565 hernias were included in the study. In the group, there were 27 severe complications (0.6%): 12 bleedings (0.25%), two bladder lesions (0.04%), five intestinal obstructions (0.11%), four intestinal perforations (0.09%) one injury to the iliac vein (0.02%), one femoral nerve injury (0.02%), two lesions of vas deferens (0.04%) and two deaths (0.02%) (pulmonary embolism, peritonitis).

CONCLUSION

The rate of complications with the TEP procedure is low. Laparoscopic hernia repair technique is reproducible and reliable. In our experience, there are contraindications to the TEP procedure. TEP technique must be meticulous to avoid intraoperative complications (bipolar diathermy). Complications can occur even after the surgeon has gained substantial experience.

Laparoscopic totally extraperitoneal hernioplasty with nonfixation of three-dimensional mesh: Dulucq's technique

INTRODUCTION

The inguinal hernia repair has been a controversial area in the surgical practice ever since it has been conceived. The fact that numerous different procedures are in use reflects the complexity of inguinal hernia and its repair.

AIM

The purposes of this study were to describe Dulucq's technique and the modifications of using 3-D mesh in laparoscopic totally extraperitoneal inguinal hernia repair.

METHODS

Surgical technique of laparoscopic totally extraperitoneal hernia repair is detailed on the text.

CONCLUSION

Laparoscopic totally extraperitoneal is preferred over transabdominal preperitoneal hernia as the peritoneum is not violated. The dissection must always be done with the same stages, without monopolar diathermy and the patient in a slight Trendelenburg position. Following these recommendations, the laparoscopic totally extraperitoneal hernioplasty is feasible with fewer intra-abdominal complications.

Ambulatory laparoscopic fundoplication for gastroesophageal reflux disease: a systematic review

BACKGROUND

Ambulatory laparoscopic fundoplication for gastroesophageal reflux disease (GERD) has been developed in order to increase patients' satisfaction and to save bed costs. The aim of this systematic review was to assess the advantages and disadvantages of ambulatory surgery in patients undergoing elective fundoplication for GERD.

METHODS

Two reviewers independently searched and identified 15 prospective or retrospective nonrandomized studies dealing with ambulatory laparoscopic fundoplication for GERD in the Medline, Cancerlit, and Embase databases between January 1990 and July 2010. Outcomes were postoperative mortality, morbidity, conversion and reoperation rates, mean operative time, hospital admission or readmission, unexpected consultation, and patient satisfaction. Because only one comparative study was identified, data compilation and relative risk evaluation through meta-analysis were not possible.

RESULTS

A total of 1459 adult patients underwent an ambulatory laparoscopic fundoplication for GERD, 876 in a day-case setting and 583 in an outpatient setting. The procedure appears feasible for selected patients and expert surgeons, and it has a very low mortality rate and conversion, reoperation, and overall morbidity rates of 3.6, 0.6, and 11.1%, respectively. Hospital admission, nonprogrammed consultation, and hospital readmission rates were as high as 20, 11, and 12%, respectively. No study looked at comparative long-term functional results between ambulatory and inpatient procedures. Patient satisfaction rates based on self-evaluation were high.

CONCLUSION

The data available to date in the literature, mostly of level 4 evidence, suggest that laparoscopic fundoplication for GERD appears to be safe and feasible in a day-surgery setting, subject to careful patient selection and surgeon expertise. Randomized control trials are urgently needed to better evaluate this promising care management.

NICE guidance and current practise of recurrent and bilateral groin hernia repair by Scottish surgeons

BACKGROUND

NICE (National Institute of Health and Clinical Excellence) in England recommended laparoscopic repair for recurrent and bilateral groin hernias in 2004. The aims of this survey were to evaluate the current practise of bilateral and recurrent inguinal hernia surgery in Scotland and surgeons' views on the perceived need for training in laparoscopic inguinal hernia repair (LIHR).

METHODS

A postal questionnaire was sent to Scottish consultant surgeons included in the Scottish Audit of Surgical Audit database 2007, asking about their current practice of primary, recurrent and bilateral inguinal hernia surgery. A response was considered valid if the surgeon performed groin hernia surgery; further analysis was based on this group. Those who did not offer LIHR were asked to comment on the possible reasons, and also the perceived need for training in laparoscopic hernia surgery. Only valid responses were stored on Microsoft Excel (Microsoft Corporation, USA) and analysed with SPSS software version 13.0 (SPSS, Chicago, Illinois).

RESULTS

Postal questionnaires were sent to 301 surgeons and the overall all response rate was 174/301 (57.8%). A valid response was received from 124 of 174 (71.2%) surgeons and analysed further. Open Lichtenstein's repair seems to be the most common inguinal hernia repair. Laparoscopic surgery was not performed for 26.6 and 31.5% of recurrent and bilateral inguinal hernia, respectively. About 15% of surgeons replied that an LIHR service was not available in their base hospital. Lack of training, financial constraints, and insufficient evidence were thought to be the main reasons for low uptake of LIHR. About 80% of respondents wished to attend hands-on training in hernia surgery.

CONCLUSIONS

Current practice by Scottish surgeons showed that one in three surgeons did not offer LIHR for bilateral and recurrent inguinal hernia as recommended by NICE. There is a clear need for training in LIHR.

Current indications for laparoscopy in day-case surgery

Day-surgery setting allows to combine patients' satisfaction to cost-saving policies that seems to be more and more important for a modern hospital management. Minimally invasive surgery seems to be the ideal surgical approach for day-case procedures since, reducing trauma to a minimal level, allows patients to return quick to a normal life with minimal nursing assistance. Extensive review of the most recent article has been performed in this article in order to define the current evidences that support the use of laparoscopic surgery in a day-case setting. Laparoscopic cholecystectomy, anti-reflux procedure and hernia repair seems to be justified according to the results of the published data. Patients' selection and hospital organization seem to be mandatory in order to obtain successful results.

Laparoscopic hernia repair

The laparoscope was first invented in the early 20th century. The first laparoscopic hernia repair was in 1990. Despite almost 20 years of laparoscopic hernia repair experience, open hernia surgery remains the main stay of hernia surgery today. This review looks at current evidence and guidelines on the use of laparoscopic hernia repair surgery.