Bilateral Inguinal Hernia Repair Research Articles

Laparoscopic repair of inguinal hernia in infants: Comparison with open hernia repair

PurposeThis study aimed to evaluate the usefulness of laparoscopic repair of inguinal hernia (LR) in infants in comparison with open hernia repair (OR). MethodsWe retrospectively analyzed the clinical data of 465 infants treated for inguinal hernia from January 2006 to December 2015. Among them, 124 underwent LR and 341 underwent OR. ResultsIn the OR group, 16.1% (55/341) primarily underwent bilateral inguinal hernia repair and 13.6% (42/308) subsequently developed metachronous contralateral inguinal hernia during follow-up. In the LR group, 75.8% (94/124) underwent primary bilateral inguinal hernia repair and only 1.6% (2/123) developed metachronous contralateral inguinal hernia. The mean operation times of unilateral inguinal hernia repair showed no statistical differences between LR and OR. However, the mean operation times of bilateral inguinal hernia repair were shorter in LR (39.8±10.4 vs. 51.1±14.4min, p<0.001). Postoperative recurrence and wound infection showed no statistical differences between the groups, but postoperative scrotal swelling was more common in OR (0.0% vs. 4.0%, p=0.006). ConclusionLR in infants showed a lower incidence of metachronous hernia, shorter operation times, and better postoperative course than OR. LR could be considered the primary operation method in infants with inguinal hernia. Levels of EvidencePrognosis Study, Retrospective Study, Level III.

Systematic review and simulation study of ignoring clustered data in surgical trials.

Multiple surgical procedures in a single patient are relatively common and lead to dependent (clustered) data. This dependency needs to be accounted for in study design and data analysis. A systematic review was performed to assess how clustered data were handled in inguinal hernia trials. The impact of ignoring clustered data was estimated using simulations. PubMed, Embase and the Cochrane Library were reviewed systematically for RCTs published between 2004 and 2013, including patients undergoing unilateral or bilateral inguinal hernia repair. Study characteristics determining the appropriateness of handling clustered data were extracted. Using simulations, various statistical methods accounting for clustered data were compared with an analysis ignoring clustering by assuming 100 hernias, with a varying percentage of patients having bilateral hernias. Of the 50 eligible trials including patients with bilateral hernias, 20 (40 per cent) did not provide information on how they dealt with clustered data and 18 (36 per cent) avoided clustering by assessing the outcome by patient and not by hernia. None of the remaining 12 trials (24 per cent) considered clustering in the design or analysis. In the simulations, ignoring clustering led to an increased type I error rate of up to 12 per cent and to a loss in power of up to 15 per cent, depending on whether the patient or the hernia was the randomization unit. Clustering was rarely considered in inguinal hernia trials. The simulations underline the importance of considering clustering as part of the statistical analysis to avoid false-positive and false-negative results, and hence inappropriate study conclusions.

Unfixed Mesh Plug Migration from Inguinal Ring to Urinary Bladder

A 65-year-old man presented to a clinic with a chief complaint of macrohematuria and frequent urination. The computed tomographic scan and cystoscopy revealed a dome of bladder tumor. He was referred to our hospital with the diagnosis of bladder tumor. He had undergone bilateral inguinal hernia repair and magnetic resonance imaging suggested mesh plug migration on the urinary bladder inserted into the right inguinal lesion 11 years previously. Under the diagnosis of mesh plug migration, partial cystectomy with extraction of the foreign body was performed. After the surgery he was well and symptoms had disappeared.

Prospective randomized study comparing single-incision laparoscopic versus multi-trocar laparoscopic totally extraperitoneal (TEP) inguinal hernia repair at 2 years.

Inguinal hernia repair via multi-trocar laparoscopy (MTL) has gained an increasing popularity worldwide. Single-incision laparoscopy (SIL) has been introduced to reduce the port-related complications and to improve the cosmetic results. The authors report a prospective randomized study comparing SIL versus MTL totally extraperitoneal (TEP) inguinal hernia repair. Between January 2013 and May 2015, 113 versus 97 patients were prospectively randomized between SILTEP and MTLTEP. Perioperative, short-term, and mid-term outcomes have been assessed. The primary endpoint was the mid-term outcomes (late postoperative complications, late inguinal hernia recurrence, surgical and cosmetic satisfactions). Secondary endpoints were perioperative outcomes (operative time, mesh fixation, operative complications, postoperative pain, and hospital stay) and short-term outcomes (early postoperative complications, early inguinal hernia recurrence, and days to return to normal activities). After a mean follow-up of 27 ± 8months, a statistically significant difference was found between the two groups in terms of mean operative time for both unilateral and bilateral inguinal hernia repair (p = 0.016; p = 0.039) and cosmetic satisfaction (p = 0.003). Perioperative, short-term, and mid-term outcomes were comparable between the two groups. At 2-year follow-up, a significant shorter operative time after MTLTEP and a greater cosmetic satisfaction after SILTEP have been found.

A Study of 50 Cases of Stoppa’s Pre-Peritoneal Repair of Bilateral Inguinal Hernia

A Study of 50 Cases of Stoppa’s Pre-Peritoneal Repair of Bilateral Inguinal Hernia

Evaluation of open hernioplasty in bilateral inguinal hernia repair

Background Inguinal hernia occurs in ∼1.5% of the general population and in 5% of male individuals. The bilateral type affects about 12% of patients, the direct and the combined ones being more frequent than the indirect. Simultaneous or sequential repair has been debated especially after tension-free repairs. Aim This study was carried out to compare Stoppa procedure with bilateral Lichtenstein hernioplasty for the treatment of primary bilateral inguinal hernia. Patients and methods This trial included 80 male patients with primary bilateral inguinal hernias. They were divided randomly into two equal groups. Group A underwent bilateral Lichtenstein hernioplasty and group B underwent Stoppa repair. Preoperative, operative, and postoperative characteristics were recorded for each patient in the study. Patients were followed up at 3, 6, and 12 months postoperatively. Results As regards preoperative data, there was no statistically significant difference between both groups. The Stoppa operation took a significantly shorter time than the bilateral Lichtenstein technique; the mean operative time for Stoppa and bilateral Lichtenstein was 84.0±8.6 and 96.4±6.2 min, respectively. Visual analogue scoring of pain 12 h postoperatively was significantly lower in the Stoppa group than in the bilateral Lichtenstein group. As regards operative and postoperative complications, there was no significant difference between both groups. Hospital stay, return to normal daily activities, and inguinodynia rates were similar in both groups. There was no recorded recurrence in both groups up to 1 year of follow-up. Conclusion Bilateral primary inguinal hernias can be operated upon in one setting without an increase in morbidity or recurrence rate. The Stoppa technique can be a good alternative to bilateral Lichtenstein procedure for the treatment of bilateral inguinal hernia, with comparable outcome.

Variation in the use of laparoscopy with inguinal hernia repairs in a sample of pediatric patients at children's hospitals

Metachronous contralateral inguinal hernias (MCH) occur in approximately 10% of pediatric patients following unilateral inguinal hernia repairs (UIHR). Laparoscopic evaluation of the contralateral internal ring is a method of identifying high-risk individuals for prophylactic contralateral exploration and repair. The objective of this study was to assess variation in utilization of diagnostic laparoscopy, and report costs associated with the evaluation of a contralateral patent processus vaginalis during hernia repair in pediatric hospitals. The Pediatric Health Information System database was searched to identify outpatient surgical encounters for pediatric patients with a diagnosis of inguinal hernia during a 1-year period (2014). Records were identified that contained diagnostic codes for unilateral or bilateral inguinal hernia in combination with a procedure code for open hernia repair with or without diagnostic laparoscopy. After exclusions there were 3952 hernia repairs performed at 30 hospitals; median age was 4 years (IQR 1-7), 78.8% were male, and 64.9% Caucasian. Three-quarters (76.7%) had UIHR, 8.6% had unilateral repairs with laparoscopy (UIHRL), 12.2% had bilateral inguinal hernia repairs (BIHR), and 2.4% had bilateral repairs with laparoscopy (BIHRL). Where laparoscopy was used, 78% resulted in a unilateral repair and 22% in a bilateral procedure. The percent of patients undergoing laparoscopy varied from 0 to 57% among hospitals, and 0-100% among surgeons. Pediatric surgeons were more than three times more likely to perform a diagnostic laparoscopy compared with pediatric urologists. Median adjusted costs were $2298 (IQR 1659-2955) for UIHR, $2713 (IQR 1873-3409) for UIHRL, $2752 (IQR 2230-3411) for BIHR, and $2783 (IQR 2233-3453) for BIHRL. Median costs varied over two-fold among hospitals ($1310-4434), and over four-fold among surgeons ($948-5040). Data suggested that <10% of patients with clinically unilateral inguinal hernias developed MCH. A negative diagnostic laparoscopy ensured that 0.9-1.31% developed MCH. However, up to 30% of patients underwent contralateral exploration/repair when diagnostic laparoscopy was used. The current study found increased costs associated with the use of laparoscopy, with considerable variation in costs among surgeons and hospitals. These data elucidate competing financial and clinical consequences associated with the use of diagnostic laparoscopy with clinically unilateral hernias. Variation existed in the use of laparoscopy during inguinal hernia repairs and associated costs within the current sample from children's hospitals in the United States. The additional costs of laparoscopic evaluation must be considered against the clinical utility and therapeutic consequences of identifying individuals with a higher risk of metachronous contralateral inguinal hernia.

Bilateral endoscopic totally extraperitoneal (TEP) inguinal hernia repair does not impair male fertility.

Endoscopic totally extraperitoneal (TEP) hernia repair with polypropylene mesh has become a well-established technique. However, since the mesh is placed in close contact with the spermatic cord, mesh-induced inflammation may affect its structures, possibly resulting in impaired fertility. The aim of this observational prospective cohort study was to assess fertility after bilateral endoscopic TEP inguinal hernia repair in male patients. Fifty-seven male patients (22-60years old) with primary, reducible, bilateral inguinal hernias underwent elective bilateral endoscopic TEP hernia repair with use of polypropylene mesh. The primary outcome was testicular perfusion; secondary outcomes were testicular volume, endocrinological status, and semen quality. All patients were assessed preoperatively and 6months postoperatively. Follow-up was completed in 44 patients. No statistically significant differences in measurements of testicular blood flow parameters or testicular volume were found. Postoperative LH levels were significantly higher [preoperative median 4.3IU/L (IQR 3.4-5.3) versus postoperative median 5.0IU/L (IQR 3.6-6.5), p=0.03]. Levels of inhibin B were significantly lower postoperatively [preoperative median 139.0ng/L (IQR 106.5-183.0) versus postoperative median 27.0ng/L (IQR 88.3-170.9), p=0.01]. No significant changes in FSH or testosterone levels were observed. There were no differences in semen quality. Our data suggest that bilateral endoscopic TEP hernia repair with polypropylene mesh does not impair fertility, as no differences in testicular blood flow, testicular volume, or semen quality were observed. Postoperative levels of LH and inhibin B differed significantly from preoperative measurements, yet no clinical relevance could be ascribed to these findings.

Two mesh technique in lieu of single mesh in giant prosthetic reinforcement of the visceral sac for bilateral inguinal hernias

Background: Posterior wall strengthening is the essential aim of Bilateral Inguinal hernia repair. The two methods for it are tissue repair and tension free repair. Tension free repair have become the gold standard. The preperitoneal repair for Bilateral Inguinal hernia is performed by wrapping the lower part of the parietal peritoneum with a large chevron shape polypropylene mesh.Methods: This study presents a modification of stoppas repair using a polypropylene mesh of size 15×9 cm to cover the myopectineal ostium of fruchaud on each side. The direct hernia sac was inverted with a purse string suture. Indirect hernia was opened and margins approximated with a 2-0 polyglycolic acid suture. No drainage was used.Results: Post-operative period was uneventful in all the patients. This new technique uses less post-operative time and the cost of surgery is reduced. There was one post-operative recurrence on one side only on follow up at one week, three weeks and three months.Conclusions: The use of two small size mesh covering both Fruchaud’s myopectineal orifices for bilateral inguinal hernia repair instead of a large size mesh is a promising technique. It saves the operative time and shortens the hospitalization time.

The International Pediatric Endosurgery Group Evidence-Based Guideline on Minimal Access Approaches to the Operative Management of Inguinal Hernia in Children.

Introduction: Minimally invasive surgery (MIS) for inguinal hernia repair (IHR) in children has been reported for more than two decades. The International Pediatric Endosurgery Group (IPEG) Evidence-Based Review Committee chose MIS IHR as the inaugural topic for review and presentation at the 2016 IPEG annual meeting. Materials and Methods: English language articles published between January 1, 2009, and December 31, 2015, were reviewed and included in this evidence-based review after searching PubMed, Cochrane Reviews, ClinicalTrials.gov, Google Scholar, and EMBASE. Results: Level 1a and 1b evidence supports the recommendations that operative time for bilateral IHRs should be considered shorter and postoperative complications rates should be considered lower in MIS repair over open. Recurrence rates are similar between the two methods (level 1a and 1b evidence). No level 1 evidence exists to support one MIS technique over another or that operating on a detected contralateral patent processus vaginalis during laparoscopy makes any difference in long-term outcome to the patient. Conclusions: The advantages of lower postoperative complications and shorter operative times have been found in studies of surgeons experienced in MIS repair and differences were small. The evidence in this review supports that MIS repair is a safe, effective method of IHR with proper training and mentorship.

Bilateral primary inguinal hernia repair in Taiwanese adults

Objective: The objective of this study was to identify the long-term rates of and treatment options for recurrence of bilateral primary inguinal hernias following various hernia repair methods, namely, open inguinal hernia repair (OIHR) without mesh, OIHR with mesh (OIHR-M), and laparoscopic inguinal hernia repair (LIHR). Materials and Methods: Data in this retrospective study were retrieved from the Taiwan's National Health Insurance Research Database. All adult patients who underwent primary bilateral inguinal hernia repair were selected from this database using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedure codes. Results: From 2000 to 2010, 13,636 adult patients underwent elective bilateral inguinal hernia repair, with a median follow-up of 63.95 months. The risk of recurrence was significantly lower in the LIHR group than in the OIHR group (hazard ratio [HR] =0.691,P = 0.003) and was similar to that in the OIHR-M group (HR = 1.187,P = 0.184). The median recurrence-free period was 28.93 months. After recurrence, 52.6% of patients underwent repair at the same hospital, and 35.5% of patients were operated on by the same surgeons. The LIHR group had a significantly shorter median recurrent period than did the other groups (OIHR, OIHR-M, and LIHR: 33.83, 23.33, 16.56 months, respectively;P Conclusions: In this large cohort study, the recurrence risk was significantly lower in the LIHR group than in the OIHR group and was similar to that in the OIHR-M group, for primary bilateral hernia repair. In addition, the LIHR group experienced similar mortality as the other groups but lower readmission rates. Moreover, the proportion of LIHR patients treated by the same doctor was significantly higher than that of traditional hernia repair patients. In short, LIHR is a reliable procedure and may offer an improved surgical experience for bilateral primary inguinal hernia repair.

Managing bilateral inguinal hernia laparoscopically: is it gold standard?

Background:Even after many studies done in recent years, no consensus has been achieved on the surgical technique of inguinal hernia repair. It was believed that in bilateral inguinal hernia cases laparoscopic surgery is very much advantageous as it can be done through same incisions as unilateral laparoscopic inguinal hernia repair (no additional incision required), whereas in open surgery for bilateral case separate groin incision for each side required. Aim of this study is to evaluate and compare results of bilateral inguinal hernia patients operated by laparoscopic (transabdominal preperitoneal) or open (lichenstein) repair.Methods: A prospective comparative study was conducted in a tertiary care teaching hospital over the period of two years. 60 patients with bilateral inguinal hernia were taken up and randomly divided into two groups. Group I (study group) includes patients operated by bilateral laparoscopic hernia repair (TAPP) and Group II (control group) includes patients operated by open hernia repair (lichenstein tension free hernioplasty). All patients were followed up for 18 months post-operatively. All patients of both groups were monitored for operative time, conversion rate, length hospital stay, post-operative complications and recurrence, time to return to work.Results:Statistically there was significant difference between both groups in terms of length of hospital stay and time to return to work. Group I patients where TAPP surgery performed, 22 patients (73.33%) were discharged within 36 hours of surgery, whereas in Group II patients - control group where open surgery performed, only 4 patients (13.33%) discharged within 36 hours. All 30 patients (100%) in group I had joined their routine work within 10 days of surgery; whereas in Group II patients only 4 cases (13.33%) joined duties on or before 10 days and most of the patients 26 (86.67%) had taken more than 10 days to resume their duties. But there was no significant difference between operative time, complication rates and recurrence rates. All cases in group I were completed laparoscopically (no conversion to open repair).Conclusions:Simultaneous bilateral inguinal hernia repair laparoscopically does not increase the risk for the patient and has an equal morbidity compared with unilateral repair, length of hospital stay, and return to normal work and over all recovery after laparoscopic repair is faster than after open bilateral simultaneous repair. Laparoscopic inguinal hernia repair of bilateral hernias should be recommended as the gold standard.

Vedolizumab: A Peek into the Future of Autoimmune Enteropathy

Autoimmune enteropathy (AIE) is characterized by protracted diarrhea and malnutrition. Vedolizumab; a humanized monoclonal antibody that inhibits adhesion and migration of leukocytes into the gastrointestinal tract and has never been used to treat autoimmune enteropathy in the past, but in this case has given us glimpse of a new modality that can be further established with research. We present to you a case of a 72-year-old Caucasian male with history of bilateral inguinal hernia repair. He was admitted to an outside hospital with diarrhea and weight loss for 6 months, without a recognizable etiology. He reported having 10-15 watery bowel movements daily along with small amount of blood and mucus associated with diffuse abdominal pain. Physical examination showed cachectic appearing male with normal vital signs, hyperactive bowel sounds and mild diffuse tenderness on deep palpation. Pertinent laboratory work showed: hemoglobin of 10 g/dl; ESR 19 mm/hr; albumin 2.7 g/dl and antinuclear antibodies with a titer of 1:320. Comprehensive stool studies were negative for enteric pathogens. Serological tests for celiac disease were also non contributory. Esophagogastroduodenoscopy demonstrated normal stomach, duodenum and proximal jejunum with unremarkable biopsies. Evidence of ileitis and right sided colitis was found on colonoscopy. Due to concerns for Crohn's disease he was initially started on mesalamine, azathioprine, prednisone to which his symptoms didn't respond. Later Infliximab was added only to worsen his condition. He presented to our hospital for further evaluation after significant weight loss. Repeat colonoscopy showed severe inflammation of terminal ileum, ascending and transverse colon. Random biopsies from terminal ileum and colon suggested changes consistent with autoimmune enteropathy or graft versus host disease. It was decided to switch infliximab to Vedolizumab in hope to treat his refractory symptoms. To our pleasant surprise one month on treatment he started showing signs of improvement. In three months on Vedolizumab, his stool frequency reduced to one bowel movement daily with documented weight gain with overall clinical improvement. Autoimmune enteropathy is exceedingly rare, treatment options are still being explored. Vedolizumab, which was used to treat this disorder for the first time has shown a very promising result. Further research with this drug would give us more insight into this immune milieu.

Efficacy of Local Anesthetic With Dexamethasone on the Quality of Recovery Following Total Extraperitoneal Bilateral Inguinal Hernia Repair

Quality of recovery (directly associated with patient satisfaction) is an important clinical outcome measurement and a surrogate of anesthetic/surgical care quality. To compare the efficacy of a transversus abdominis plane (TAP) block with dexamethasone sodium phosphate and preperitoneal instillation of local anesthetic (PILA) with dexamethasone vs control on postoperative quality of recovery following a bilateral total extraperitoneal inguinal hernia repair (TEP-IHR) (>24 hours). Secondary objectives included efficacy of this technique on postoperative opioid use, nausea and vomiting, and pain scores. Conducted from November 2013 to August 2015, this randomized, prospective, single-blinded study compared 2 groups (a TAP block and PILA) with a standard anesthetic technique with no regional technique (control) following bilateral TEP-IHR. This study at the Veterans Affairs Medical Center (Indianapolis, Indiana) included patients ages 18 to 80 years with an American Society of Anesthesiologists physical status of 1 to 3 scheduled for an outpatient bilateral TEP-IHR. Nurses assigning pain scores and administrating opioids for pain and staff anesthesiologists administering the Quality of Recovery-40 (QoR-40) questionnaire were blinded. Patients randomized to receive a TAP block with local anesthetics and dexamethasone, PILA with dexamethasone, or no regional technique (3 groups). Patient's response to the QoR-40 questionnaire following a TEP-IHR surgery. The mean (SD) ages in the TAP block (n = 19), PILA (n = 24), and control (n = 23) groups were 58.2 (9.4) years, 62.5 (8.1) years, and 62.9 (7.8) years, respectively. The global QoR-40 scores on postoperative day 1 for the TAP block group (median [interquartile range (IQR)], 178 [173-188]) were comparable with the control group (median [IQR], 174 [150-181]), while the PILA group had better global QoR-40 scores (median [IQR], 184 [175.5-190.75]) (P = .002). The effects of the TAP block and PILA on pain in the postoperative care unit (PACU) (median [IQR], 1 [0-5] and 3.5 [0-6.8], respectively), pain after discharge (median [IQR], 3 [2-5] and 3 [1-5.5], respectively), opiate use after discharge (median [IQR], 6.7 [5-10] and 6.7 [3.3-10], respectively), and incidence of nausea and vomiting in the PACU (4 of 19 [21.1%] and 6 of 24 [25%], respectively) were not significantly different from the control group (median [IQR], 4 [3-6] for pain scores in the PACU; 4 [3-7] for pain scores after discharge; 6.7 [3.3-10] for opioid use after discharge; and 6 of 23 [26.1%] for incidence of nausea/vomiting in the PACU). While there was a significant reduction of opioid use in the PACU in the TAP block group (median [IQR], 0 [0-1.3]) when compared with the control group (median [IQR], 4 [1.3-6.7]) (P = .001), this was not seen in the PILA group (median [IQR], 2 [0-6.4]). This study demonstrates a better quality of recovery in patients' receiving PILA with dexamethasone compared with control for a TEP-IHR surgery. clinicaltrials.gov Identifier: NCT02036983.

Obturator hernia as a frequent finding during laparoscopic pelvic exploration: A retrospective observational study.

Hernia through the obturator canal is usually unsuspected and hence undiagnosed. Patients with obturator hernias present as acute cases of intestinal obstruction secondary to strangulation or incarceration, with high rate of morbidity and mortality due to delayed diagnosis and treatment. The know incidence of obturator hernia is low, representing 0.073% (11 of 15,098) of all hernias repaired at the Mayo Clinic in a retrospective study of 15 years. In this study, we conducted a retrospective analysis of laparoscopic extraperitoneal hernia repairs that were performed between the years 2003 and 2007. All procedures were undertaken by 2 experienced surgeons who performed more than 150 previous surgeries. In 293 patients who underwent repair of bilateral or recurrent inguinal hernia, exploration of the obturator foramen was conducted looking for obturator hernia, which was found in 20 cases (6.82% of patients). The true incidence of obturator hernia is greater than that reported in the literature, and the chances of detecting hernia are greater if an equal number of men and women are scanned could be higher if pelvic scanning was performed.

Pseudorecurrence following female laparoscopic inguinal hernia repair in children

Laparascopic repair of inguinal hernias in female children can be achieved using the inversion and ligation technique in which the hernia sac is inverted into the peritoneal cavity and ligated using endoloops. This technique has been shown to reduce operative time and post-operative complications such as missed contralateral hernia, wound infection and hernia recurrence. We describe a case of a 3-month old female who underwent laparoscopic repair of bilateral inguinal hernias, and presented one year post-operatively with bilateral groin bulges. On re-operation the bulges were determined not to be true hernia recurrences, but rather pseudorecurrences of accumulated fluid distal to the ligation point after incomplete inversion. They were successfully repaired in an open fashion, without subsequent development of groin bulges.

Hybrid TAPP/TEP Repair of Bilateral Obturator and Inguinal Hernias

Hybrid TAPP/TEP Repair of Bilateral Obturator and Inguinal Hernias

Early assessment of bilateral inguinal hernia repair: A comparison between the laparoscopic total extraperitoneal and Stoppa approaches

BACKGROUND:The present clinical trial was designed to compare the results of bilateral inguinal hernia repair between patients who underwent the conventional Stoppa technique and laparoscopic total extraperitoneal repair (LTE) with a single mesh and without staple fixation.PATIENTS AND METHODS:This controlled, randomised clinical trial was conducted at General Surgery and Trauma of the Clinics Hospital, Medical School, the University of São Paulo between September 2010 and February 2011. Totally, 50 male patients, with a bilateral inguinal hernia, older than 25 years were considered eligible for the study. The following parameters were analysed during the early post-operative period: (1) The intensity of surgical trauma, operation time, C-reactive protein (CRP) levels, white blood cell count, bleeding and pain intensity; (2) quality of life assessment; and (3) post-operative complications.RESULTS:LTE procedure was longer than the Stoppa procedure (134.6 min ± 38.3 vs. 90.6 min ± 41.3; P < 0.05). The levels of CRP were higher in the Stoppa group (P < 0.05) but the number of leucocytes, haematocrit, and haemoglobin were similar between the groups (P > 0.05). There was no difference in pain during the 1st and 7th post-operative, physical functioning, physical limitation, the impact of pain on daily activities, and the Carolinas Comfort Scale during the 7th and 15th post-operative (P > 0.05). Complications occurred in 88% of Stoppa group (22 patients) and 64% in LTE group (16 patients) (P < 0.05).CONCLUSION:The comparative study between the Stoppa and LTE approaches for the bilateral inguinal hernia repair demonstrated that: (1) The LTE approach showed less surgical trauma despite the longer operation time; (2) Quality of life during the early post-operative period were similar; and (3) Complication rates were higher in the Stoppa group.

The Use of Caudal/Epidural Catheter as the Primary Anesthetic with Dexmedetomidine Secondary to High Risk of Post-Operative Apnea in Premature Infants

Life threatening post-operative apnea is a known complication of general anesthesia in premature infants. Neuraxial anesthesia has been associated with reduced risk of post-operative apnea. We report two cases, presenting for bilateral inguinal hernia repair, where we used a caudal/epidural catheter for the neuraxial block combined with dexmedetomidine for sedation in preterm infants at high risk for postoperative respiratory complications. Dexmedetomidine assisted in providing both favorable surgical conditions via its well proven sedative effects without respiratory comprised and decreased the discomfort and stress to the child during placement of the epidural catheter and the neuraxial anesthesia provided excellent analgesia and surgical conditions.

Intra‐operative bilateral otorrhagia during laparoscopic inguinal hernia repair: a case report and review of the literature

SummaryAn 81‐year‐old male developed intra‐operative bilateral otorrhagia during a laparoscopic bilateral inguinal hernia repair performed in a steep Trendelenburg position, associated with subcutaneous emphysema. Haemorrhagic blistering was found on both tympanic membranes and in the acoustic meatus, however the tympanic membranes were intact. We believe the combination of a prolonged steep Trendelenburg position, raised intra‐abdominal pressure, hypercarbia due to the pneumoperitoneum and subcutaneous emphysema, was responsible for the bilateral otorrhagia.