Fast Track Surgery in laparoscopic treatment of inguinal hernias

Abstract

Background. Minimally invasive surgical techniques for inguinal hernia repair reduce the body’s overall stress response to surgical tissue damage, the risk of complications, the percentage of postoperative acute and chronic pain, recovery time.
 Objective. To improve short-term (acute inguinal pain in the early postoperative period) and long-term (chronic inguinal pain in the long-term follow-up) results of surgical treatment of patients with acquired inguinal hernia by using the modified (sutureless, without mesh fixation) laparoscopic technique of transabdominal preperitoneal hernioplasty (TAPP) with application of Fast Track Surgery guidelines.
 Materials and methods. The retrospective clinical study included 124 patients aged 18 to 88 years (mean age – 46±2.1) with primary unilateral inguinal hernias who were operated on the clinical bases of the Department of Surgery and Vascular Surgery of Shupyk National Medical Academy of Postgraduate Education. The observation period was 3 years. Modified TAPP was performed in 78 patients (spinal anesthesia, local anesthesia of trocar wounds, terminal peritoneal anesthesia, preperitoneal infiltration of affected inguinal region dissection by local anesthetics, using of anatomical 3D mesh, sutureless restoration of peritoneal defect by electric welding method) and Lichtenstein technique was performed in 46 patients. The peritoneal defect in the main group after implant placement was restored by spot welding.
 There was experimental study before proceeding the clinical study. The experimental section of the work included 12 rabbits weighing 1.95-3.75 kg (average weight – 2.30±0.52). Each animal was cut peritoneum in three places on both sides of laparotomy with next reconstruction of the defect on one side by welding, and on the other – by suturing with synthetic suture material.
 Results and discussion. In biological samples from experimental animals, there was decreasing of number of live mesotheliocytes which did not increase the severity of the inflammatory reaction (p˂0.001). A statistically significant difference was observed in the welded scars with higher intensity of collagen formation than in the ligature scars, which provided greater strength of the tissue connection.
 There was a reduction in the patient’s length of stay in the hospital in 4.2 times in the group of modified technique. There was a reduction in the period before the ability to perform professional duties in 3.4 times in the group of new surgical method. There was no significant difference in the levels of postoperative complications (p=0.036) and re-operations due to complications (p=0.023). In the group of modified surgical treatment there were significant lower rates in the indicators of pain at rest (p<0.001), pain during exercise (p<0.001), recurrence rates (p<0.001). There was a decrease in the need for analgetics in the main group in the early postoperative period (p˂0.001) and a reduction in the risk of prolonged inguinodynia (p˂0.001).
 Conclusions. The obtained results demonstrate the effectiveness of the use of modified laparoscopic transabdominal preperitoneal hernia mesh repair for primary unilateral inguinal hernias with using Fast Track Surgery protocols with regard improving quality of life of patients in the early and long postoperative period and reduction of the risk of recurrence.