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

BACKGROUND

For the scientific evaluation of the endoscopic and open mesh techniques for the repair of inguinal hernia, meta-analyses of randomized controlled trials (RCT) are necessary. The Lichtenstein repair is one of the most common open mesh techniques and therefore of special interest.

METHODS

After an extensive search of the literature and a quality assessment, a total of 34 RCT comparing endoscopic procedures both transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP)--with various open mesh repairs were deemed to be suitable for a formal meta-analysis of the relevant parameters. These studies included data for 7,223 patients. Trials that used the Lichtenstein repair for the control group (23 of 34 trials) were analyzed-separately.

RESULTS

Significant advantages for the endoscopic procedures compared with the Lichtenstein repair include a lower incidence of wound infection (Peto odds ratio, 0.39; 95% confidence interval, 0.26, 0.61), a reduction in hematoma formation (0.69 [0.54, 0.90]) and nerve injury (0.46 [0.35, 0.61]), an earlier return to normal activities or work (-1.35[-1.72, -0.97]), and fewer incidences of chronic pain syndrome (0.56[0.44, 0.70]). No difference was found in total morbidity or in the incidence of intestinal lesions, urinary bladder lesions, major vascular lesions, urinary retention and testicular problems. Significant advantages for the Lichtenstein repair include in a shorter operating time (5.45[1.18, 9.73]), a lower incidence of seroma formation (1.42[1.13, 1.79]), and fewer hernia recurrences (2.00[1.46, 2.74]). Similar results are seen when endoscopic procedures are compared with other open mesh repairs. However, in this comparison, total morbidity was lower with the endoscopic operations (0.73[0.61, 0.89]). The incidence of seroma formation, chronic pain syndromes, and hernia recurrence was not significantly different.

CONCLUSION

Endoscopic repairs do have advantages interms of local complications and pain-associated parameters. For more detailed evaluation further well-structured trials with improved standardization of hernia type, operative technique, and surgeons' experience are necessary.

Insufflation profile and body position influence portal venous blood flow during pneumoperitoneum

BACKGROUND

We investigated changes in portal venous blood flow (PVBF) during carbon dioxide (CO2) pneumoperitoneum to evaluate the effects of different insufflation profiles and body positions.

METHODS

An established rat model was extended by implanting a portal vein flow probe that would enable us to measure PVBF for 60 min [t0-t60] in animals subjected to a CO2 pneumoperitoneum with an intraabdominal pressure (IAP) of 9 mmHg. Forty-eight male Sprague-Dawley rats were randomized into the following four experimental and two control groups: decompression group D1 ( n = 8), desufflation for 1 min every 14 min; decompression group D2 ( n = 8), desufflation for 5 min, after 27 min; position group P1 ( n = 8), 35 degrees head-up position; position group P2 ( n = 8), 35 degrees head-down position; negative control group C1 ( n = 8), no insufflation; positive control group C2 ( n = 8), constant IAP of 9 mmHg for 60 min.

RESULTS

Pneumoperitoneum and body positions, respectively, reduced PVBF [t1-t60] significantly ( p < 0.001) by 32.0% C2, 32.8% D1, 31.1% D2, 40.8% P1, and 48.5% P2, as compared to PVBF at t0 in each group. There was a significant difference in PVBF reduction between P1 and P2 and also between C2 and both P1 and P2 ( p < 0.04).

CONCLUSIONS

CO2 pneumoperitoneum reduces PVBF significantly (>30%). Extreme body positions (35 degrees tilt) significantly intensify PVBF reduction. PVBF reduction is significantly more dramatic in subjects placed in a 35 degrees head-down position. Short desufflation periods did not improve mean PVBF, but it may have beneficial immunological and oncological effects that warrant further investigation.

Laparoscopic transperitoneal hernia repair of incarcerated hernias: Is it feasible? Results of a prospective study

BACKGROUND

Laparoscopic transperitoneal hernia repair (TAPP) has proved its efficiency in elective surgery. However, TAPP results with incarcerated hernias still are unknown.

METHODS

Data from a prospective study were evaluated with regard to TAPP repair for both chronically and acutely incarcerated hernias.

RESULTS

During a 6-year period, 220 incarcerated hernias were repaired (194 via TAPP). The median operation time for TAPP was 55 min. An accompanying resection therapy became necessary for only four of the emergency cases (11.1%) and two of the chronically incarcerated cases (1.3%) in the TAPP group. Postoperative morbidity was 2.8% in the emergency group and 3.8% in the chronically incarcerated group, which does not differ from the rate for TAPP used on reducible hernias. One recurrence was found 26 months after TAPP reconstruction (0.5%).

CONCLUSION

Laparoscopic inguinal hernia repair (TAPP) represents an efficient therapeutic concept in the treatment of both chronically and acutely incarcerated inguinal hernias.

Update: what is left for laparoscopic hernia repair?

The risks, benefits and costs of laparoscopic hernia repair are still being debated. According to a current survey on the situation of hernia surgery in Germany in 1996, laparoscopic hernioplasty was done in about 60% of the answering hospitals; about a quarter of all hernia repairs are done laparoscopically. Since April 1993, about 2, 700 laparoscopic hernia repairs were done at Marienhospital Stuttgart. The operating time was on the average 50 min. The rate of complications was about 3%. The postoperative period of disablement was a median of 20 days; included in this time was the postoperative hospital stay. The recurrence rate was about 1%. It is remarkable that laparoscopic hernia repair was equally efficient in repairing unilateral primary hernias, recurrent hernias or bilateral hernias. The cost analysis showed that the application of multipath articles will make the operation costs of laparoscopic hernia repair only about DM 100 higher than for a conventional operation.

[Laparoscopic hernia therapy (TAPP) as a teaching operation]

INTRODUCTION

Because of an increasing number of endoscopic hernia procedures, it is important to look into the possibility of standardizing these techniques helping surgeons to acquire the operative skills necessary.

MATERIAL AND METHODS

To discuss these aspects, the documented data on TAPP operations that have been carried out in this department since 1993 were analyzed. The results of teaching procedures were compared with those of experts after they had gotten past the learning and development curve.

RESULTS

A total of 778 teaching procedures were performed by 10 surgeons with an individual experience of 30.5 operations (median). Before starting the first procedure, 89 were done by assistants operating the camera. The morbidity of teaching operations was 1.9% compared to 1.4% for those performed by experts. After a median follow-up of 23 months there were two recurrences (0.23%) in the expert group and none in the teaching group (follow-up 16 months).

CONCLUSION

Because of the potentials of standardization of the TAPP technique, the results of teaching were equal to expert operations. Therefore, TAPP is suitable for application in a routine setting.

Recurrence after endoscopic transperitoneal hernia repair (TAPP): causes, reparative techniques, and results of the reoperation

BACKGROUND

Even though the introduction of endoscopic surgical techniques to inguinal hernia therapy dates back 10 years, only a few data exist concerning the problem of development of a recurrence after endoscopic repair. Similarly there are only anecdotal reports on the feasibility of an endoscopic reintervention for this situation. For the first time we are able to present data of a prospective study on both issues.

STUDY DESIGN

We analyzed the data of a prospectively documented series of 46 transperitoneal hernia repair reinterventions after endoscopic hernia repair. In 33 patients from our own clinic we evaluated the cause of recurrence after transperitoneal hernia repair. Together with these and 13 more patients sent to us from external clinics we examined the efficiency of an endoscopic reoperation.

RESULTS

When implanting a 13 x 8-cm mesh with an incision (phase I) we found the main cause of recurrence to be that the mesh was too small (47.4%) and the region of the mesh incision was insufficient (42.1%). After a change to a 15 x 10-cm implant without incision (phase II) the main cause of recurrence was found to be a mesh dislocation (38.9%) and the rate of recurrence dropped from 2.8% (phase I) to 0.36% (phase II). The transperitoneal reoperation lasted for a median of 75 minutes (range 45 to 170 minutes) for the medial recurrence and a median of 110 minutes (range 65 to 190 minutes) for the lateral recurrence (p = 0.009). The total rate of complications was 10.9%, and the rate of re-recurrence was 0% after a median followup of 26 months (range 2 to 72 months).

CONCLUSIONS

To avoid hernia recurrence after transperitoneal hernia repair operations a sufficiently large mesh (at least 15 x 10 cm) has to be implanted, preferably without an incision, after an extensive parietalization. The endoscopic reoperation for recurrence can be done only in a transperitoneal way and is effective with comparably low complication rates. The procedure is significantly easier for a medial recurrence compared with a lateral recurrence. This method of reoperation should be reserved for endoscopically experienced surgeons.

Long-term results of a randomized clinical trial between laparoscopic hernioplasty and shouldice repair

BACKGROUND

At present only short-term follow-up data are available to compare endoscopic and conventional hernia surgery. This paper presents data from a randomized study 6 years after initial recruitment.

METHODS

In 1993 a randomized comparative study of transabdominal preperitoneal (TAPP) and Shouldice repair was commenced. Endpoints were rate of recurrence, late complications, complaints and patient satisfaction.

RESULTS

The rate of recurrence in the TAPP group was one (2 per cent) of 48 patients and in the Shouldice group two (5 per cent) of 43. Only five patients in the Shouldice and three in the TAPP group reported slight discomfort in the inguinal region at 6-year follow-up. In neither group was chronic pain syndrome observed. Altogether, 46 (96 per cent) of 48 patients in the TAPP group and 35 (81 per cent) of 43 of those having the Shouldice procedure stated complete satisfaction with the hernia repair.

CONCLUSION

Long-term evaluation demonstrated greater satisfaction with the result of the repair in the endoscopic group. The difference between the groups in the recurrence rate was not significant, because of the small numbers. The TAPP method appears to be an effective surgical alternative in patients with inguinal hernia.

Scrotal hernias: a contraindication for an endoscopic procedure? Results of a single-institution experience in transabdominal preperitoneal repair

INTRODUCTION

Endoscopic repair was introduced for use with inguinal hernia therapy more than 10 years ago. The technique as well as the indications for this method are debated, however. As a borderline inguinal hernia situation, the scrotal hernia in particular evokes vehement objections to an endoscopic procedure because of the anticipated problems and complications in dissecting the extended hernia sac. The efficiency of the laparoscopic transabdominal preperitoneal (TAPP) technique in the treatment of scrotal hernia therefore is discussed in this article.

METHODS

Laparoscopic hernia repair (TAPP) has been performed in our department since 1993. Data are collected by a prospective documentation of operative and follow-up results. For evaluation, a comparison of scrotal and normal hernia repair was performed.

RESULTS

Between April 1993 and June 1998 the TAPP technique was used to treat 191 scrotal hernias, 42 (22%) of which were recurrent hernias. The median operating time for a normal inguinal hernia repair was 45 min, whereas scrotal hernias required a median of 65 min and irreducible scrotral hernias a median of 68.5 min. Major complications were observed in 1.6% of scrotal and 0.6% of normal inguinal hernia repairs. The most frequent scrotal hernia repair problem was the formation of a seroma, 10.5% of which had to be evacuated. During a follow-up period of 30 months, we found a total of two recurrences (1.05%).

CONCLUSION

In scrotal hernia repair, TAPP is not associated with higher complication rates and can be performed with efficiency comparable with that in normal inguinal hernia repair.

[Surgical therapy of colonic diverticulitis--how reliable is primary anastomosis?]

INTRODUCTION

The aim of the study was to evaluate the modern principles of surgery in diverticulitis, e.g. early elective resection and primary anastomosis.

METHODS

The data of 445 consecutive patients were retrospectively analysed after classifying all cases in four subgroups according to a modified Hinchey classification (stages 0-III).

RESULTS

Within our study group the morbidity was 26.5% (n = 118) and the mortality was 1.6% (n = 7). In 96% (n = 425) of all cases and in 64% (21/33) of patients with perforated diverticulitis and peritonitis (stage III), a primary anastomosis was performed. Four patients of the study group showed insufficient anastomosis (0.9%). No leakage was observed from any of the anastomoses performed in stage III diverticulitis. Stage of inflammation and age of patient correlate with morbidity and mortality. Some 53% (94/177) of the patients in stage II and 67% (22/33) of the patients in stage III had never showed symptoms of diverticulitis before.

CONCLUSION

Prophylactic surgery to avoid life-threatening situations, including abscess formation or perforation, is not possible in many cases. However, especially patients at risk (age, coexisting illness) should undergo early surgery. Primary anastomosis can be performed safely even at an advanced stage.

Laparoscopic hernia repair -- the facts, but no fashion

BACKGROUND

For about 10 years now, laparoscopic hernia surgery has been introduced as an additional mode of therapy in the treatment of inguinal hernias. This method is being reproached with higher costs of surgery and rate of complications, as well as missing long-term results.

MATERIALS AND METHODS

Within a literature research, data from 25 randomised trials and 16 prospective observational studies on endoscopic and conventional hernia surgery were evaluated. Statistics were calculated using the chi2 test.

RESULTS

Compared with the conventional suture technique and tension-free surgery, the endoscopic repair proved to be advantageous with regard to postoperative pain and period of disablement. There was no significant difference between the methods when evaluating the rate of complications. In two randomised trials, there was a significant difference in favour of endoscopic repair with regard to the recurrence rates, whereas in the other studies a significant difference could not be shown. In the prospective series, recurrence rates were 0.71% for totally preperitoneal repair (TEP) and 1.06% for transabdominal preperitoneal repair (TAPP) repair.

CONCLUSION

Endoscopic hernia surgery (TAPP and TEP) represents an efficient method of treatment in the therapy of inguinal hernias. Recurrent and bilateral hernias can be seen as an absolute indication for endoscopic repair.

Laparoscopic surgery complications associated with trocar tip design: review of literature and own results

In the last 10 years, there has not been an abdominal surgical procedure that has not been performed by laparoscopic means. The enthusiasm of surgeons active in this field often neglects problems, especially with basic instruments which are important vehicles for the laparoscopic technique. The purpose of this study was to focus on trocar-related problems with special respect to the tip design. On the basis of a prospective study of laparoscopic transperitoneal hernia repair (TAPP) and laparoscopic Nissen fundoplication, we evaluated our data concerning trocar-related complications at the abdominal wall. We compared two groups of patients treated in a nonrandomized design with either sharp cutting single-use trocars or cone-shaped non-cutting reuseable trocars. The evaluation of our own data showed an incisional hernia in 1.83% of patients treated with a sharp trocar tip, a complication which could be significantly lowered, to 0.17%, with a conic tip design. Similar results could be seen with trocar-related bleeding events at the insertion site in the abdominal wall. In most publications, trocar design and related complications are unmentioned. Our data demonstrate a reasonable benefit for a conic tip design, which enables atraumatic insertion through the abdominal wall. The reuseable steel version furthermore holds a considerable cost-saving potential.

[Risks and benefits of laparoscopic hernia-plasty (TAPP). 5 years experiences with 3,400 hernia repairs]

In the present study, for the first time the aspects of risk, benefit and the costs of laparoscopic hernioplasty in the transabdominal technique with preperitoneal placement of a polypropylene mesh are examined prospectively in a very large group of patients with 3,400 hernia repairs. The median operation time was 45 min for unilateral primary hernias, 50 min for unilateral recurrent hernias and 76 min for bilateral hernias. The frequency of complications showed a significant dependence on the individual steps in the development of the method and the individual learning curve. The same is true for the rate of recurrency. Whereas initially the rate of serious complications was 2.75%, the rate of minor complications 11% and the rate of recurrences 4.5% the corresponding figures are at present 0.4%, 4.4% and 0.5%. Laparoscopic hernioplasty proved to be equally as effective in the treatment of primary hernias, recurrent hernias and bilateral hernias. The large number of 11 surgeons participating proves that laparoscopic hernioplasty can be learned and that even in a teaching hospital it can be performed safely, efficiently and cost-effectively.

A single institution's experience with transperitoneal laparoscopic hernia repair

BACKGROUND

Previous evaluations of endoscopic hernia surgery mostly are based on small prospectively documented series or on a few randomized comparative studies. In the following, results of a large single-institution experience concerning the transabdominal preperitoneal patch (TAPP) technique with regard to the development of methods and the routine use are described.

METHODS

From April 1993 to March 1997, 2,700 TAPP procedures were performed at the Department of General and Visceral Surgery, Marien-hospital, Stuttgart, Germany. The follow-up was documented prospectively in all cases by use of computed data base.

RESULTS

The majority of patients (83.8%) were operated because of primary hernias. In 17.2% a first or multiple recurrence of an inguinal hernia was indicated. At a median postoperative observation period of presently 20 months and a follow-up rate of 86.5%, 28 recurrences have been determined so far (total recurrence rate 1.03%), 6 of which occurred after a recurrent hernia reparation (1.33%) and 22 after primary hernia repair (0.97%). The most common cause for recurrence was in 39.3% a mesh (12 x 8 cm) being too small. The total complication rate was 4.6%; as an expression of the learning curve it was reduced from 7.8% (operations 1 to 500) to 2.8% (operations 2,200 to 2,700).

CONCLUSIONS

According to our experience, the TAPP technique is sufficiently applicable as a standard method for an unselected group of patients in a routine setting. It is especially suited to the repair of recurrent and bilateral hernias as well as for patients with a high risk for recurrence that can profit from a tension-free endoscopic procedure, particularly in case of obesity.

[Follow-up results of laparoscopic cholecystectomy]

Following a laparoscopic cholecystectomy 400 patients have been interviewed with a questionnaire on the late results of the surgery (15 to 40 months postop.). The cholecystectomies had been performed within the time from March 7, 1990 to April 30, 1992 in Tübingen. After a mean of 16.8 days the patients returned to work, while they themselves felt reduced for an average of 10.6 days. 11.9% of the patients complained of slight wound healing problems and in 3.1% wound infections have been registered. Although 97% of the patients were satisfied with the results of surgery, 8.7% still complained of upper abdominal trouble. Slight persistent problems like light pain or flatulence have been reported by 19%.